Pharmacology Test 1

The nurse has administered several oral medications to the patient. Which factors will influence the absorption of these medications? (Select all that apply.) A. Presence of food in the stomach B. pH of the stomach C. Patient position upon intake of medication D. Form of drug preparation E. Pain

A. Presence of food in the stomach B. pH of the stomach D. Form of drug preparation E. Pain

ways drugs can be excreted (elimination)

•Kidneys (kidney function is measured by BUN/Creatinine, GFR) •Liver •Lungs •Saliva •Sweat •Breast milk

A patient has been taking aspirin for chronic pain. The patient states that the pain is not relieved with 650 mg of aspirin every 4 hours. What is the best instruction for the nurse to give the patient? A) Increase your dose to 1000 mg every 4 hours. B) Alternate aspirin and a narcotic analgesic every 4 hours. C) Take aspirin and a COX-1 inhibitor at the same time. D) Notify your health care provider that the medication is not effective.

D) Notify your health care provider that the medication is not effective.

Definition of onset, duration of action, peak and trough

Onset: The time it takes for a drug to reach the minimum effective concentration after administration Duration of action: length of time the drug exerts a therapeutic effect. Peak: drug reaches its highest plasma concentration in the blood and identifies the body's rate of absorption; if peak is too low, effective concentration has not been reached. Trough: lowest plasma concentration of a drug; identifies rate of drug elimination

Pharmacodynamic interaction: Antagonistic effect

One drug reduces or blocks the effects of the other when two drugs are administered together. Example: naloxone administration for opioid overdose. ***educate patient that prescription drugs, over the counter drugs, and herbal products can interact with each other.

Opioid analgesic: Morphine sulfate: (Action, indication, assessment, contraindications)

***Antidote: Naloxone Action: used to relieve moderate to severe pain; depression of pain impulses by binding with opiate receptors on the CNS; Also suppresses respirations and coughing by acting n the respiratory and cough centers in the medulla. Indications: effective against acute pain from heart attacks or cancer, relieves dyspnea from pulmonary edema, can relieve preoperative anxiety. Assessment: Obtain medical and drug history, check for drug allergies, Evaluate for drug-drug interaction to prevent further respiratory depression, Assess vital signs (rate and depth of respirations and blood pressure), evaluate pupil size prior to administration, validate dose prior to administration Contraindications: CNS or respiratory depression, status asthmaticus, sleep apnea, increased intracranial pressure/head injury, shock, ileus, alcohol abuse, dysrhythmias

Liquids

**note if diluting or shaking is required prior to administration Page 85

Vaginal Medications

*Usually inserted via applicator. Medication forms: suppositories, foams, jellies, or creams -void before administration -Patient should be in lithotomy position. -patient can administer with nurse close by. -patient should remain lying down for at least 20 min -medications can stain clothing, so a pad or panty liner is recommended Page. 88

Protein binding

-Acidic drugs (aspirin and methotrexate) and neural drugs (nortriptyline) bind with albumin and lipoproteins. -Basic drugs (morphine and amantadine) bind to AGP -Highly protein-bound drugs: more than 90% bound to protein (Warfarin, glyburide, sertraline, furosemide, and diazepam) -Weakly protein-bound drugs: less than 10% bound to protein (gentamicin, metformin, metoprolol, lisinopril) Portion that is bound is inactive and unable to exert pharmacologic effect. Portion that is unbound is free, active drug (able to exit blood vessels and reach their site of action)

Receptor response: agonists vs Partial agonists vs antagonists

-Agonists: drugs that activate receptors and produce desired response -Partial agonists: drugs that elicit only moderate activity when binding to receptors; prevent receptor activation by other drugs. -Antagonists: drugs prevent receptor activation and block response, decreasing or increasing cellular action.

Administering medications through nasogastric tubes and gastrostomy tubes

-Always check for proper placement and gastric residual before administering drugs. Return any aspirated gastric fluid to the stomach -Place patient in high Fowler position or elevate the head of the bed at least 30 degrees to avoid aspiration -Make sure is drugs can be crushed or capsule can be opened and administered through the tube (enteric coated and extended released drugs cannot be crushed). Crushed drug should be placed into a plastic dosing cup and a small amount of water is added to liquify the dry medication -Remove the plunger from the syringe and attach the syringe to the feeding tube. Poor liquified medication into the syringe, release the clamp, and allow the medication to flow in properly by gravity. -ensure proper identification of each drug up until the time of administration by administering one drug at at time, and flush with 10-15 mL of water between each administration to maintain patency of the tubing. -When drug administration is complete, flush with 30 mL of water; Always record the amount of water used with administration of drug on the patient's input sheet. -Clamp the tube and remove the syringe. **If NG tube is set for suction, clamp tube for 30 minutes to allow medications to be absorbed before restarting suction. Page. 88

A patient has been advised to take Ibuprofen. When teaching the patient about Ibuprofen, which instructions should you include? -Avoid taking Aspirin with Ibuprofen -Take with food to reduce GI upset -Monitor for bleeding gums, nosebleeds, black tarry stools -Take herbs, ginkgo and garlic, with ibuprofen -Take NSAIDs 2 days before menstruation to decrease discomfort.

-Avoid taking Aspirin with Ibuprofen -Take with food to reduce GI upset -Monitor for bleeding gums, nosebleeds, black tarry stools

eye ointment administration

-Hand hygiene and wear gloves; patient positioned laying on their back or looking up at the ceiling. -Wipe inner to outer canthus to clean any discharge, new cloth used for each eye. -pull skin below the lower lid downward to expose conjunctiva. -Squeeze 1/4 inch wide strip of ointment on to conjunctiva sac -Instruct patient to close eyes for 2-3 minutes; if possible, apply at bedtime **tip should never touch eyelids or eyelashes to prevent contamination Page 86

Nonspecific and nonselective drug effects

-Nonspecific: drugs that affect multiple receptor sites (bethanechol is prescribed for post op urinary retention and increases bladder contraction, but also decreases heart rate and blood pressure, and increases gastric acid secretion) -Nonselective: Affect multiple receptors (Epinephrine acts on multiple receptors, affecting multiple body systems)

Use of Metered Dose Inhaler (MDI)

-Shake inhaler vigorously 5-6 times; If it is being used for the first time, spray into the air prior to administration. -Patient should exhale through the mouth -Mouth closes around the MDI with the opening toward the back of the throat. (If spacer is being used, the patient closes the mouth around the mouth piece of the spacer, MDI is placed into the other end). Patient will hold device with thumb at the mouthpiece, and index finger and middle finger at the top. -Instruct patient to take a slow, deep breath through the mouth and to push the top of the medication canister once during inhalation. -Hold breath for 10 seconds then exhale slowly through pursed lips -Wait 1-2 minutes before another dose. Repeat steps, shake MDI with cap on ***If different inhalers are being used together, space administration between them by 5 minutes. ***Always rinse mouth after use to prevent irritation and secondary infection ***Use of spacer improves drug delivery to lungs Page 87

Mechanisms of drug action

-Stimulation-enhances intrinsic activity (adrenergic drugs-increase heart rate, sweating, and respiratory rate) -Depression-decrease neural activity and bodily functions (barbiturates and opiates) -Irritation-noxious effect (astringents) -Replacement-replace essential body compounds (insulin, thyroid medications) -Cytotoxic action-kill invading parasites or cancers -Antimicrobial action-prevent, inhibit, or kill infectious organisms -Modification of immune status-modify, enhance, or depress immune system (Methotrexate)

Nose spray administration

-hand hygiene and gloves; patient should blow their nose prior -If patient is using a nasal spray to reach the sinuses, proper head position is with the patient looking down at the feet with the spray tip aimed toward the eye. Some sprays have instructions to close one nostril, tilt the head to the closed side, and hold the breath or breathe through the nose for 1 minute. **tip should not touch the nasal passages. Page 87

Eyedrop administration

-hand hygiene and wear gloves; patient is positioned laying on their back or head tilted upwards, looking at the ceiling -wipe from inner to outer canthus to remove discharge (separate cloth should be used for each eye) -pull skin below the lower lid downward to expose conjunctiva. -Eye drops should be administered in the center of the sac; gently press on lacrimal duct with sterile cotton ball or tissue for 1-2 minutes to prevent systemic absorption through the lacrimal canal. -Patient should keep eye closed for 1-2 minutes to promote absorption **dropper should never touch eyelids or eyelashes to prevent contamination Page 86

Administering ear drops

-hand hygiene and wear gloves; patient should be sitting up with their head tilted slightly toward the unaffected side -Drops hold be aimed at the side of the ear canal and should be allowed to run down into the ear. -Patient maintains current position for 2-3 minutes for drops to reach affected area. **Infants: auricle pulled down and back **Adults: auricle pulled up and back **Medication should be room temperature prior to administration **Tip of dropper should not touch the ear to prevent contaminiation

Nose drop administration

-hand hygiene and wear gloves; patient should blow their nose prior -patient should either tilt their head back if drops need to reach the frontal sinus, or tilt head to the affected side to reach the ethmoid sinus. -Head should remain tilted back for 5 minutes after installation **Do not touch applicator to the nasal passages. Page 87

Safety/verification measures related to drug orders and administration

-verify identity of the patient (compare wristband and MAR) -Always use 2 patient identifiers (name and date of birth) -be familiar with patient's health history, preform head-to-toe assessment on the patient, and obtain set of vitals -review labs and diagnostic imaging prior to administration -Assess patient's ability to swallow -read drug order and obtain clarity, if needed, from the prescriber prior to administration -review and confirm patient's allergies -understand the reason why medication is being given; know the expected effect and possible interactions, including any OTC medications and herbal preperations -confirm order with drug label (drug name, dose, and suitability for administration by the intended route) -check dose calculations; double check with high alert medications and avoid distractions during drug preparation -know date ordered and ending date of medication -Refuse to give a medication if you believe it is unsafe or patient expresses concern, and notify healthcare provider -Inform patient of potential side effects and expected results from taking medication. Document instructions. -Reassess patient's response in timely fashion (time frame depends on route and medication administered) **Never administer medications prepped by another nurse **Stay with the patient until medication is taken **Always timely document medication administration; document patient refusal or medication holding and notify provider. page: 81-Clinical Judgement box

Preventative treatment for migraines

1. beta-adrenergic blockers (prolonged propranolol and atenolol) 2. anticonvulsants (valproic acid and gabapentin) 3. TCAs (amitriptyline and Imipramine)

Loading dose

A higher dose of a drug given initially at the start of drug therapy so therapeutic effects can be reached sooner

The nurse is caring for a patient on valproic acid for seizures. Which statement made by the client requires follow-up from the nurse? A) "I have a cold and will stop by the drugstore on my way home for something to help." B) "I do not drink alcohol anymore." C) "I take my medicine at the same time every day." D) "I am still using birth control."

A) "I have a cold and will stop by the drugstore on my way home for something to help." Cold medicines and antihistamines should not be taken with valproic acid because they can increase the sedative effects. Patients on anti-seizure drugs should avoid alcohol and pregnancy and be consistent with how they take their medication.

A client who has received some traumatic news is panicking and asks for some medication to help settle down. The nurse anticipates giving which drug that is most appropriate for this situation? A) diazepam B) zolpidem C) phenobarbital D) cyclobenzaprine

A) Diazepam Benzodiazepines such as diazepam are used as anxiolytics, or sedatives. Zolpidem is used as a hypnotic for sleep. Phenobarbital is not used as an anxiolytic but is used for seizure control. Cyclobenzaprine is a muscle relaxant and is not used to reduce anxiety.

Which drug is commonly used for conscious sedation A) Midazolam B) Halothane C) Isoflurane D) Lidocaine

A) Midazolam

What should for a nurse to teach a patient on sumatriptan? A) Take as soon as symptoms appear. B) Stop taking if you develop nausea and vomiting. C) You should be able to maintain normal activities while taking this medication. D) This medication is safe for people on MAOIs or SSRIs.

A) Take as soon as symptoms appear.

The patient's bioavailability of a drug is altered. The nurse interprets this to mean that (USLO 1, 2) A) The drug's metabolism is affected B) The drug's absorption is affected C) The drug's distribution is affected D) The drug's excretion is affected

A) the drug's metabolism is affected

A patient has been diagnosed with neuroleptic malignant syndrome. The nurse anticipates administration of which medication to treat this patient? A) Dantrolene B) Tentrabenzaine C) Propranolol D) Lorazepam

A. Dantrolene Treatment of NMS involves immediate withdrawal of antipsychotics, adequate hydration, hypothermic blankets, and administration of antipyretics, benzodiazepines, and muscle relaxants such as dantrolene (Dantrium). Tetrabenazine (Xenazine), used to improve symptoms of Huntington's disease, seems to be effective in treating tardive dyskinesia. Propanolol (Inderal) has been found to be effective in the treatment of akathisia. Acute dystonia may be treated with lorazepam (Ativan).

A patient has liver and kidney disease. He is given a medication with a half-life of 30 hours. The nurse expects the duration of this medication to A. Increase B. Decrease C. Remain unchanged D. Dissipate

A. Increase Metabolism and elimination affect the half-life of a drug. With liver or kidney dysfunction, the half-life of the drug is prolonged, and less drug is metabolized and eliminated.

The nurse realizes that a drug administered by which route will require the most immediate evaluation of therapeutic effect? A. Intravenous B. Oral C. Subcutaneous D. Topical

A. Intravenous

A patient is complaining of pain rated "10" on a scale of 1 to 10. The nurse has several choices of pain medication to administer. Which order is the best for the nurse to administer at this time? A. Morphine sulfate 1 mg IV (intravenous) B. MS Contin 2 tablets PO (by mouth) C. Transdermal patch D. Tylenol suppository

A. Morphine sulfate 1 mg IV (intravenous)

Phases of pharmacokinetics

Absorption Distribution Metabolism Excretion

Metabolism (biotransformation)

the process by which the body chemically changes drugs into a form that can be excreted

Opioid antagoinists: Narcan/Naloxone (Action/how it works, Indications, side effects, adverse effects)

Action/how it works: Blocks receptor and displaces opioid; reverses effects of opiates including respiratory depression, sedation, and hypotension, however also reverses analgesic effect Indications: suspected opiate overdose Side effects: Sweating, flushing, agitation, nausea, vomiting, bleeding (elevates partial thromboplastin time) Adverse effects: pain returns due to analgesia reversal; can precipitate withdrawal in patients physically dependent.

Mood Stabilizer: Lithium

Action: Alteration of ion transport in muscle and nerve cells; increased receptor sensitivity to serotonin Indication: Bipolar disorder manic episodes. Therapeutic: > 1.5 mEq/L may lead to toxicity Assessment: assess for mental status and suicidal ideation; baseline vital signs, health and drug history (neuro and cardiac status), Lithium level, sodium level Contraindication: Liver/renal disease, pregnancy, hyponatremia, dehydration, cardiac disease Interactions: Lithium level increases with NSAIDS and haloperidol; St. John's Wort and Kava Kava Safety: Fall precautions, seizure precautions Side effects: drowsy, dizziness, memory impairment, headache, dry mouth GI distress. Adverse effects: Hypotension, dysrhythmias, edema of hands and ankles, increased urination, hyponatremia, nephrotoxicity Monitoring: : Monitor vital signs (risk of orthostatic hypotension), evaluate lithium and sodium levels, monitor cardiac status, is the drug effective? **Signs of toxicity: persistent nausea and vomiting, severe diarrhea, blurred vision, tinnitus, ataxia, increasing tremors, confusion, dysrhythmias, seizures. Teaching: maintain adequate fluid and sodium intake, take medication with food, may take several weeks to take effect, prevent pregnancy.

Selective serotonin receptor agonist, Antimigraine: Sumatriptan (Action, indication, assessment, contraindications, and interactions_

Action: Causes vasoconstriction of cranial arteries. Indications: acute treatment of migraine and cluster headaches Assessment:Assess pain location, intensity, duration, and associated symptoms during migraine attack Contraindications: CAD, peripheral vascular disease, hypertension, cerebrovascular disease **Caution: intracranial bleeding, smoking, obesity, seizures, renal or hepatic dysfunction Interactions: antidepressant medications, increased risk of serotonin syndrome or neuroleptic malignant syndrome with SSRI's

Antigout, Xanthine Oxidate inhibitor: Allopurinol (Action, indications, assessment, contraindications)

Action: Decreases uric acid synthesis and prevents gout attacks Indications: prevention of attack from gouty arthritis Assessment: Obtain medical history of any gastric, renal, cardiac, or liver disorders; Check labs (BUN, creatinine, ALT and AST, Alkaline phosphatase, and LDH) and compare with future lab results; Assess serum uric acid value for future comparisons; Assess pain level and swelling associated with uric crystal formation Contraindications: dehydration, renal impairment

Anticonvulsant, Benzodiazepine, anxiolytics: Diazepam and Lorazepam

Action: Enhances the activity of GABA, decreases excitability of the brain Indications: Status epilepticus, partial seizures, tonic clonic seizures, muscle spasm, sedation induction, alcohol withdrawal, anxiety Therapeutic response: must be administered IV; short term effect. Other anti-seizure drug must be given immediately after. Safety precautions: Seizure precautions, do not drive or operate machinery Side effects: Fatigue, dizziness, drowsiness, urinary retention/incontinence, menstrual cycle irregularity, headache Adverse effects: respiratory depression, hypotension Monitoring and Safety: Monitor liver enzymes, renal function, and CBC; Monitor vital signs (BP, Respirations, and O2); patient should stay on bedrest for at least 3 hours after parenteral medication administration. Teaching: Cannot be stopped abruptly, seizure and fall precautions; Avoid alcohol and other CNS depressants

Anticonvulsant, Valproate: Valproic Acid (Action, indication, theraputic response, contradictions, safety precautions, side effects, Adverse effects, monitoring/safety, Teaching)

Action: Enhances the activity of GABA, decreases excitability of the brain Indications: tonic-clonic seizures, absence seizures, and partial seizures; bipolar disorder; migraine prophylaxis Therapeutic response: Therapeutic range 50-100 mcg/mL Contraindications: Children <2 years of age, liver disorders, decreases effectiveness of oral contraceptives. Safety precautions: Seizure precautions, do not drive or operate machinery Side effects: dizziness, drowsiness, insomnia, double vision, weakness, GI distress (abdominal pain, nausea/vomiting/diarrhea) Adverse effects: Hepatotoxicity, suicidal ideation, thrombocytopenia Monitoring and Safety: Monitor liver enzymes, renal function, and CBC Teaching: Cannot be stopped abruptly, can be taken with food to minimize GI irritation; seizure and fall precautions; Avoid alcohol and other CNS depressants

Anticonvulsant, Barbiturate: Phenobarbital (action, indications, therapeutic response, contraindications, safety precautions, side effects, adverse effects, monitoring/safety, teaching)

Action: Enhances the activity of GABA, decreases excitability of the brain Indications: tonic-clonic seizures, partial seizures, and myoclonic seizures; status epilepticus Therapeutic response: Therapeutic range 15-40 mcg/mL Contraindications: use with caution with other CNS depressants, severe respiratory disease, hepatic dysfunction or renal impairment. Safety precautions: Seizure precautions, do not drive or operate machinery Side effects: dizziness, drowsiness, weakness, headaches, confusion, nausea/vomiting, constipation, erectile dysfunction. Adverse effects: CNS depression, sedation, respiratory depression, Hypotension, tolerance Monitoring and Safety: monitor renal and liver function, monitor CBC; seizure and fall precautions Teaching: Cannot be stopped abruptly, can be taken with food to minimize GI irritation; seizure and fall precautions;

Anti-inflammatory (NSAID): Ibuprofen (Action, indication, Assessment, contraindications, interactions)

Action: Inhibits COX 1 and COX 2 Indication of use: to reduce inflammation and relieve pain; Anti-inflammatory effect for arthritic conditions (osteoarthritis, rheumatoid arthritis), reduces fever, dysmenorrhea, headaches. Assessment: check history for allergy to NSAID drugs, obtain a drug and herbal history and report any possible drug-drug interactions, assess for GI distress and peripheral edema, review labs and medical history for renal disease, liver disease, bleeding disorder, or peptic ulcer Contraindications: Bleeding disorders, recent CABG, cardiac disease or dysrhythmias, pregnancy, peptic ulcer disease, anticoagulant therapy, renal or hepatic disease, ulcerative colitis or Crohn's disease, history of GI bleeding/perforation/ulcers. Interactions: Increased bleeding time with anticoagulants, decreased effect with aspirin, may increase severe side effects of lithium.

Desvenlafaxine-Serotonin Norepinephrine Reuptake inhibitors (SNRIs)

Action: Inhibits the reuptake of serotoninin and norepinephrine, which increases these substances in nerve fibers. Assessment: obtain health history of depression episodes, assess for mental status and suicidal ideation; receive medicine history, evaluate liver and renal function. Indication: Major depression, anxiety disorder (generalized and social) Contraindication: Pregnancy and breast feeding, Anticoagulation therapy (increased bleeding risk), suicidal ideation. Interactions: St. Johns Wort, CNS depressants and alcohol, MAOIs Side effects: drowsiness, dizziness, insomnia, headache, photosensitivity, ejaculation dysfunction Adverse effects: Nephrotoxicity, tachycardia, hypertension, orthostatic hypotension, suicidal ideation, seizures, Stevens-johnson syndrome Monitoring: Monitor weight and vital signs, compare to baseline; Observe patients mood and signs of decreased depression Teaching: avoid alcohol or other CNS depressant concurrently; Take medications as prescribed and do not stop abruptly

Methylphenidate (Action, indication, assessment, contraindications)

Action: Modulates serotonergic pathways by affecting changes in dopamine transport. Indications: ADHD and Narcalepsy; increases attention spam and cognitive performance; decreases impulsiveness, hyperactivity, and restlessness Assessment: determine medical history of heart disease, hypertension, hyperthyroidism, Parkinson's disease, or glaucoma; Assess vital signs for baseline, assess baseline mental status **EVALUATE HEIGHT, WEIGHT, AND GROWTH OF CHILDREN Contraindications: Anxiety, Tourette syndrome, glaucoma, recent heart attack, use of MAOIs, dysrhythmia, hyperthyroidism · Caution: kids under 6, psychosis, depression, alcohol abuse, bipolar disorder, hypertension, and seizures.

Analgesic, Anti-inflammatory: Aspirin (Action, indication, Assessment, contraindications, interactions)

Action: Prostaglandin inhibitor that decreases the inflammatory response; also considered an antiplatelet drug (decreases platelet aggregation) Indication: Analgesic, antipyretic, and anti-inflammatory-reduces pain and inflammatory symptoms, reduces fever, decreases inflammation for osteoarthritis and rheumatoid arthritis, and decreases platelet aggregation (MI and stroke prophylaxis) Assessment: : check history for allergy to NSAID drugs, obtain a drug and herbal history and report any possible drug-drug or drug-herb interactions, assess for GI distress and peripheral edema, review labs and medical history for renal disease, liver disease, bleeding disorder, or peptic ulcer Contraindications: Hypersensitivity, renal or hepatic disorders, gout, alcohol abuse, current anticoagulant therapy, GI bleeding history, head trauma, pregnancy Interactions: Aspirin should not be taken with anticoagulants or other NSAIDs because it increases bleeding risk; decreases the effectiveness of ACE inhibitors, loop diuretics, and probenecid; increased gastric ulcer risk with glucocorticoids; Increased risk of bleeding if using the following herbs: garlic, ginseng, ginko biloba, and green tea. -Lab: decreased cholesterol, potassium, thyroid levels; increased uric acid level, PT, and bleeding time.

Anti-inflammatory, NSAID: Celecoxib (Action, indication, Assessment, contraindications)

Action: Selectively inhibits COX-2 enzyme, which normally promotes prostaglandin synthesis and inflammatory response, without inhibiting COX-1 Indication: relief of moderate to severe pain; pain relief from osteoarthritis, rheumatoid arthritis, and ankylosing spondylitis; relieve dysmenorrhea; migraine relief. Assessment: Assess range of motion, degree of swelling, and pain in affected joints before and throughout therapy; Assess patient for allergies to sulfonamides, aspirin, or NSAIDs Contradictions: § renal or hepatic dysfunction, dehydration, peptic ulcer disease, GI bleeding or perforation, anticoagulant therapy, alcohol abuse, and older adults (due to comorbidities) *** Avoid in patients with recent MI or heart failure; patient's with a hx of angina, hypertension, dysrhythmias, heart failure, cardiac disease, CABG surgery, and peripheral vascular disease are very important to note as a contradiction. Use of this drug can increase risk of serious cardiovascular thrombolytic events, myocardial infarction, and stroke.

Antipsychotic, neuroleptic: Haloperidol (who can and can't take it, indication, Common presentation, therapeutic response, contraindications, interactions)

Action: alters the effects of dopamine on the CNS by blocking dopamine receptors; sedation and EPS may occur. Who can't take it: Older adults with dementia and people with Parkinson's disease should not have this drug. Indication: Control psychosis and agitation in adults and children, control schizophrenia, and control Tourette syndrome. Therapeutic response: Long acting, slow release is given via injection every 2-4 weeks (use of large needle due to viscosity, do not massage after administration, and rotate sites) Contraindication: Parkinson's disease, CNS depression, Coma; Caution for alcohol abuse, CAD, liver damage, seizures, and glaucoma. Interactions: Increased sedation with alcohol and other CNS depressants

Amitriptyline: Tricyclic Antidepressents

Action: block the uptake of the neurotransmitters norepinephrine and serotonin in the brain Indication: Major depression; elevates mood, increases interests in daily living and activity, decreases insomnia. Assessment: obtain health history of depression episodes, assess for mental status and suicidal ideation; receive medicine history, evaluate liver and renal function. Contraindication: Cardiovascular disease, hypertension; Do not take St. John's Wort or gingko biloba, concurrent use with MAOIs Interactions: Alcohol and other CNS depressants potentiate CNS depression, sedatives Side effects: Orthostatic hypotension, sedation, tachycardia, urinary retention, constipation, dry mouth Adverse effects: cardiotoxicity, suicidal ideation, blood dyscrasias, and seizures Monitoring: : Monitor weight and vital signs, compare to baseline; Observe patients mood and signs of decreased depression Teaching: Clinical response occurs 2-4 weeks after therapy, rise slowly to upright position

Antipsychotic, nonphenothiazine: Aripiprazole

Action: interferes with the binding of dopamine to dopamine and serotonin receptors. Indication: manages schizophrenia, bipolar disorder, autism, depression, and Tourette syndrome. Assessment: obtain health history of depression episodes, assess for mental status and suicidal ideation; receive medicine history, evaluate liver and renal function. Contraindication: antidiabetic agents decrease drug levels and increase risk for hyperglycemia, CNS depressants increase sedation and orthostatic hypotension, SSRIs increase risk for serotonin syndrome. Interactions: Grapefruit juice and St. John's wort Side effects: drowsiness, memory impairment, headache, fatigue, peripheral edema, insomnia, anxiety and agitation, dizziness, erectile dysfunction Adverse effects: tachycardia, palpitations, hypokalemia, diabetes, rhabdomyolysis, dysrhythmia, seizures, hyponatremia, EPS, Suicidal ideation, NMS Monitoring: : Monitor weight and vital signs, compare to baseline; Observe patients mood and signs of decreased depression Teaching: Inform patients that medication may take 6 weeks or longer to achieve full effect, avoid combining with alcohol and other CNS depressants, Do not drive, Medication should not be abruptly stopped

MAOIs

Action: monoamine oxidase enzyme inactivates norepinephrine, dopamine, epinephrine, and serotonin; by inhibiting this enzyme, these four neurotransmitter levels are increased. Indication: depression not controlled by other antidepressants Assessment: obtain health history of depression episodes, assess for mental status and suicidal ideation; receive medicine history, evaluate liver and renal function. Contraindication: Do not take St. John's Wort or gingko biloba Interactions: CNS stimulants such as vasoconstrictors and cold medications that contain phenylephrine and pseudoephedrine cause hypertensive crisis; Food interactions, possibly fatal: some cheese, cream, yogurt, coffee, chocolate, bananas, raisins, Italian green beans, liver, pickled foods, sausage, soy sauce, yeast, beer, red wines. Safety: Do not abruptly stop; Side effects: Agitation, restlessness, insomnia, anticholinergic effects, orthostatic hypotension Adverse effects: hypertensive crisis from tyramine interaction, suicidal ideation. Monitoring: Monitor weight and vital signs, compare to baseline; Observe patients mood and signs of decreased depression Teaching: provide list of foods to avoid, avoid alcohol or other CNS depressant concurrently; Take medications as prescribed and do not stop abruptly, take at bedtime (once level is built up, can switch and take in the morning), Therapeutic effect can take several weeks

Anticonvulsant, Hydantoin: Phenytoin (indication, therapeutic response, assessment questions, contraindications, interactions, dietary restrictions)

Action: reduces motor cortex activity and alters in transport by acting on sodium channels on neuronal cell membranes. Indications: prevention/ treatment of tonic-clonic seizures, partial seizures, and status epilepticus Therapeutic response: Theraputic serium level is 10-20 mcg/mL Assessment questions: description of seizures, current medications and herbs taking, medical history Contraindications: Pregnancy Interactions: decreased effects with folic acid, calcium, antacid, sucralfate, and cisplatin; decreased effects of anticoagulants and oral contraceptives; decreased absorption of calcium and vitamin D; Antipsychotics and herbs can lower seizure threshold increasing seizure activity. Dietary restrictions: dairy foods, spinach (green, leafy vegetables), citrus fruits, dried beans and peas, enriched and whole wheat bread and cereals, pastas

Subcutaneous

Administered for systemic effect; absorbed mainly through the capillaries. Location: chosen for adequate fat-pad size: upper outer aspect of the arms, abdomen 2 inches away from umbilicus, anterior thighs Needle: 25-27 gauge, 3/8-5/8 inch long Syringe: 1-3 mL (solution is usually 0.5-1 mL. If 2 mL is ordered, medication will have to be divided and administered at two different sites to prevent discomfort and better absorption) -hand hygiene, wear gloves, clean area. -Grasp or pinch are of the patient's loose fatty tissue with the fingers of your nondominent hand. -Insert needle quickly; shorter needle will be inserted at 90 degrees, longer needle will be inserted at 45 degrees. -Release pinch to stabilized syringe -Inject medication slowly -remove needle quickly and apply pressure over injection site to prevent bleeding or oozing into the tissue. -Can apply bandage if needed Page. 90

Benzodiazepines: Alprazolam (reasons it is prescribed, assessment, monitoring/safety, nursing interventions/teaching)

Alprazolam (Xanax)-typically given for anxiety, panic disorders, and some sleep disorders (has a relatively long half life) Assessment: Determine patient history of insomnia and anxiety disorders, review drug history and medical history (are they taking other CNS depressents), assess baseline patient's mental status, evaluate baseline vital signs for future comparison, and review labs (kidney function especially; renal impairment can prolong drug action by increasing the half-life of the drug) Monitoring/Safety: continue to monitor vital signs (especially respirations and blood pressure), observe for adverse reactions (especially in older or debilitated people), Use of bed alarm to prevent injury or falls (if in the hospital, especially for older adults or those using drug for the first time) Nursing interventions/teaching: teach non-pharmacologic methods to induce sleep, advise on adverse reactions to report (depression, respiratory depression), and strongly instruct patent that drugs should not be stopped abruptly, instruct to not drive or operate machinery while taking medication

drug prototype: Tricyclic antidepressants

Amitriptyline

A patient has been taking aripiprazole for 2 weeks. The client reports drowsiness and headache. What will the nurse do? A) Counsel the patient to request changing to something else. B) Explain to the patient that these are common side effects of the medication. C) Suggest that the patient have serum glucose testing. D) Suggest that these may be signs of agranulocytosis.

Aripiprazole is commonly known as Abilify. It is an antipsychotic drug used to manage and treat schizophrenia, mania associated with bipolar I disorder, irritability associated with an autism spectrum disorder, disjunctive therapy in major depressive disorder, and Tourette syndrome. side effects include: extreme tiredness and sleepiness, dry mouth, strange movements and twitches of muscles, dizziness, increased appetite and weight gain, restlessness, pain in the abdomen, fast heartbeat.

Right route

Assess patient's ability to swallow prior to administering oral medications; if there are any issues, new route needs to be ordered by provider for proper administration Do not crush or mix medications without validation or consultation Offer water for patient to take with medications, not juice (Iron can be taken with orange juice.) Use aseptic technique

Local Anesthesia: Lidocaine (Assessment, Monitoring and safety, nursing interventions and teaching)

Assessment: Assess degree of numbness of affected part, ensure gag reflex is intact before allowing patient to eat or drink Monitoring and safety: Monitor for pain intensity in affect area periodically during therapy; If mucosal lidocaine used, avoid food or chewing for 60 minutes after administration. Nursing intervention/teaching: -for topical application (Patch)-apply to intact skin to cover most painful area (can be cut smaller prior to removing release liner). Avoid contact with water because it will loosen the adhesive. Remove patch if develop irritation or burning. Wash hands immediately after application and avoid contact with eyes. Mucosal: administer only as directed; can cause numbness and will impair swallowing. Do not administer food or chew gum for at least 60 minutes after administration

Opioid analgesics (assessment, desired response, adverse effects, need for intervention/safety)

Assessment: Pain assessment (used to treat moderate-severe pain), Assess vital signs (BP, O2 saturations, respiration rate and depth) Desired response: suppress pain impulses and suppresses respiration and cough by acting on the respiratory and cough centers in the medulla of the brain stem; also possess antidiarrheal effects adverse effects: respiratory depression, urinary retention, hypotension need for intervention: safety: Respirations <10 and shallow, pinpoint pupils, cyanosis, absent bowel sounds, decreased level of consciousness **Opioids taken with kava, valerian, and St. John's wort may increase sedation

Local Anesthetic: Spinal anesthesia/Epidural (Assessment, monitoring, teaching)

Assessment: obtain a drug and health history, noting drugs that affect the cardiopulmonary system; note reason for administration Monitoring and Safety: Monitor vital signs post op due to risk of hypotension and respiratory depression, monitor post op mental status, and observe urine output. Teaching: Encourage patient to remain flat after surgery with spinal anesthesia and to take increased fluids decreases the likelihood of leaking spinal fluid

A client who has been diagnosed with depression calls the office and says, "It's been an entire week since I started my new medicine and I feel the same. Why isn't it working?" What is the nurse's best response? A) "The medication may not be effective for him. He may need to try another type." B) "It may take up to 4 weeks to notice any therapeutic effects. Let's wait a little longer to see how he does." C)"It sounds like the dose is not high enough. I'll check about increasing the dosage." D) "Some patients never recover from depression. He may not respond to this therapy."

B) "It may take up to 4 weeks to notice any therapeutic effects. Let's wait a little longer to see how he does." Patients and family members need to be told that antidepressant drugs commonly require several weeks before full therapeutic effects are noted. The other answers are incorrect.

The nurse is teaching a patient about using high-dose aspirin to treat arthritis. What information will the nurse include when teaching this patient? A) "A normal serum aspirin level is between 30 and 40 mg/dL." B) "You may need to stop taking this drug a week prior to surgery." C) "You will need to monitor aspirin levels if you are also taking warfarin." D) "Your stools may become dark, but this is a harmless side effect."

B) "You may need to stop taking this drug a week prior to surgery." Aspirin thins blood, increasing risk for bleeding.

The nurse realizes more medication teaching is necessary when the 30-year-old patient taking lorazepam states: A) I must stop drinking coffee and colas B) I can stop this drug after 3 weeks if I feel better C) I must stop drinking alcoholic beverages D) i should not become pregnant while taking this drug

B) I can stop this drug after 3 weeks if I feel better. You can not stop Benzodiazepines abruptly. This needs to be titrated slowly.

A patient on antipsychotics may be at increased risk for injury due to A) increased potential for aspiration due to sedation B) Increased risk for falls due to orthostatic hypotension C) Increased risk for infection due to neutropenia D) Increased risk for suicide due to changes in thought processes.

B) Increased risk for falls due to orthostatic hypotension Orthostatic hypotension is the most common adversereaction seen in patients treated with antipsychotics

The nurse is preparing to administer an injection of morphine to a patient and notes a respiratory rate of 10 breaths/min. What is the nurse's best action? A) Administer a smaller dose and record the findings. B) Notify the health care provider and delay drug administration. C) Administer the prescribed dose and notify the health care provider. D) Hold the drug, record the assessment, and recheck in 1 hour.

B) Notify the health care provider and delay drug administration.

A 6-year-old boy has been started on methylphenidate hydrochloride for the treatment of attention deficit hyperactivity disorder (ADHD). During a follow-up visit, his mother tells the nurse that she has been giving the medication at bedtime. What is the nurse's appropriate evaluation of the mother's actions? A) She is giving him the medication dosage appropriately. B) The medication should not be taken until he is at school. C) The medication should be taken with meals for optimal absorption. D) The medication should be given 4 to 6 hours before bedtime to diminish insomnia

B) The medication should not be taken until he is at school. Methylphenidate hydrochloride is a stimulant to help patient's with ADHD focus on one task at a time. A common side effect includes insomnia, so this medication should not be administered at bedtime. Taking the stimulant with food can decrease the absorption of the drug. The best time for the child to take this medication would be just prior or while in school to provide better focus.

An older adult complains of insomnia. Which suggestion would be most appropriate for the nurse to provide as an initial method to deal with this issue? A. "Take Benadryl pills each evening before bedtime." B. "Drink warm milk or chamomile tea before bedtime." C. "Develop an exercise regimen for the evening hours." D. "Take naps during the day whenever you feel drowsy."

B. "Drink warm milk or chamomile tea before bedtime."

The nurse administers 650 mg of aspirin at 7 PM. The drug has a half-life of 3 hours. The nurse interprets this information to mean that 325 mg of the medication will have been eliminated from the patient's system by what time? A. 7 AM B. 10 PM C. 1 AM D. 10 AM

B. 10 PM

Which statement by a patent indicates that more teaching on phenothiazine therapy for the treatment of psychosis is needed? A) it might take 6 weeks or more for the drug to take effect B) I will get up slowly from a seated position C) When I start to feel better, I will cut the dose of the medication in half D) I will avoid direct sun exposure.

C) When I start to feel better, I will cut the dose of the medication in half The drug should be taken exactly as ordered. Antipsychotics do not cure the mental illness but doalleviate symptoms. Compliance with drug regimen is extremely important.

A patient sustains significant burns to the skin and is experiencing fluid shift associated with edema in the fluid overload phase. The nurse would anticipate that this will interfere most with which phase of pharmacodynamics? A. Absorption B. Distribution C. Metabolism D. Excretion

B. Distribution Distribution is the process by which the drug becomes available to body fluids and body tissues. Drug distribution is influenced by blood flow, the drug's affinity to tissue, and the protein-binding effect. This distribution can be affected by the effects of edema in the fluid overload phase.

A young woman is being treated for psychosis with haloperidol. Which would indicate the need to add an anticholinergic to the patient's medication regimen? A. A decrease in pulse and respiratory rate B. Facial grimacing and tongue spasms C. An increase in hallucinations D. A decrease in the patient's level of orientation

B. Facial grimacing and tongue spasms Pseudoparkinsonism, which resembles symptoms of Parkinson's disease, is a major side effect of typical antipsychotic drugs such as haloperidol. Anticholinergic medications may be used to control this side effect.

Which medication should the nurse be concerned about for a patient taking venlafaxine? A) Garlic B) St. John's Wort C) Gingko Biloba D) Vitamin C

B. St. John's Wort Both St. John's Wort and Venlafaxine increase seritonin levels, which can be detrimental.

A nurse caring for a patient in an outpatient setting notes that the patient is currently taking lorazepam for anxiety, and her breath smells like alcohol. The nurse reports this to the healthcare provider because A. taking alcohol with Ativan can be fatal. B. taking alcohol with Ativan may increase sedative effects. C. all patients using alcohol should be referred for assistance. D. Ativan and alcohol antagonize one another

B. Taking alcohol with Ativan may increase sedative effects Alcohol and other CNS depressants should not be taken with benzodiazepines because respiratory depression could result

BUN and Creatinine definition and normal values

BUN (blood urea nitrogen) is the metabolic breakdown product of protein metabolism -normal BUN: 10-20 Creatinine: Metabolic by-product of muscle excreted by the kidneys -normal creatinine: 0.6-1.2 ***kidney function is important to follow to ensure correct drug dosing.

The nurse is aware that benzodiazepines mimic which neurotransmitter A) Dopamine B) Serotonin C) GABA D) Melatonin

C) GABA

The nurse is reviewing the food choices of a patient who is taking a monoamine oxidase inhibitor (MAOI). Which food choice would indicate the need for additional teaching? A) Orange juice B) Fried eggs over-easy C) Salami and Swiss cheese sandwich D) Biscuits and honey

C) Salami and Swiss cheese sandwich Aged cheeses, such a Swiss or cheddar cheese, and salami contain tyramine. Patients who are taking MAOIs need to avoid tyramine-containing foods because of a severe hypertensive reaction that may occur. Orange juice, eggs, biscuits, and honey do not contain tyramine.

The nurse reads that the half-life of the medication being administered is 12 hours. What interpretation will guide the nurse's care of this patient? A) The medication will be administered every 6 hours to maintain consistent blood levels. B) The patient will require two doses of the medication before there is an effect. C) This medication will be 50% eliminated in 12 hours, so the dosing will be spread apart. D) The medication will not work for the first 12 hours.

C) This medication will be 50% eliminated in 12 hours, so the dosing will be spread apart.

The nurse is reviewing the medications for a patient recently diagnosed with ADHD and prescribed methylphenidate. Which previous medical condition in the patient's history should the nurse report to the prescriber? A) Peptic ulcer disease B) Hypothyroidism C) Seizure disorder D) Narcolepsy

C) seizure disorder Methylphenidate is a CNS stimulant. It is prescribed to help with narcolepsy, an excessive sleep disorder, as well as ADHD. Symptoms of hyperthyroidism include anxiety and tachycardia, therefore it is a concern when a patient is prescribed a stimulant. Hypothyroid symptoms are the opposite, therefore is not a concern with stimulant use. Antiseizure medications may interact with stimulants, therefore it is important to report this to the prescriber.

Most drugs are metabolized in the A. kidney. B. small intestine. C. liver. D. brain.

C. Liver Drugs can be metabolized in the gastrointestinal tract; however, the liver is the primary site of metabolism. Liver diseases (like cirrhosis and hepatitis) causes a decrease in metabolism rate and causes toxicity

The nurse is caring for an elderly client. The nurse knows that this client is at greater risk for A) Reduced side effects. B) Excess compensatory mechanisms. C) Polypharmacy. D) Increased drug excretion.

C. Polypharmacy

Adverse reactions and drug interactions occur frequently in older adults due to all of the following except A. consumption of numerous drugs owing to multiple chronic illnesses. B. drugs ordered by several health care providers. C. increased incidence of allergic responses. D. self-medication with OTC preparations.

C. increased incidence of allergic responses. The immune system of the older adult decreases ratherthan increases in allergic responses. It is common forolder adults to take many drugs together. Polypharmacyis due to multiple health care providers ordering manymedications for older adults. Older adults are prone toself-medicate with OTC preparations.

The nurse is administering medications to a patient with chronic renal failure. What is the nurse's priority action? A) Administer all medications via IV route. B) Hold medications for low urinary output. C) Assess drug levels daily. D) Assess the patient for toxicity to the medications.

D) Assess the patient for toxicity to the medications.

When assessing older adults and those with renal dysfunction, the nurse knows that creatinine clearance is usually A.substantially increased. B.slightly increased. C.decreased. D.in the normal range.

C.decreased. Creatinine clearance is the most accurate test to determine renal function. Creatinine is a metabolic byproduct of muscle that is excreted by the kidneys. Creatinine clearance varies with age and gender. Lower values are expected in older adult and female patients because of their decreased muscle mass. A decrease in renal GFR (common in older adults) results in a decrease in urine creatinine clearance.

Action of Benzodiazepines

CNS depression- slowing down how brain and spinal cord processes and responds to internal and external stimulus. increase the action of inhibitory neurotransmitter gamma-aminobutyric acid (GABA) to the GABA receptors. Neuron excitability is reduced.

What should the nurse teach the patient to minimize gastrointestinal (GI) side effects of opioid analgesics for chronic pain? A) Take diphenoxylate hydrochloride and atropine sulfate with each dose. B) Eat foods high in lactobacilli. C) Take the medication on an empty stomach. D) Increase fluid and fiber in the diet.

D) Increase fluid and fiber in the diet.

When teaching a patient about taking a newly prescribed antiepileptic drug (AED) at home, the nurse will include which instruction? A) "Driving is allowed after 2 weeks of therapy." B) "If seizures recur, take a double dose of the medication." C) "Antacids can be taken with the AED to reduce gastrointestinal adverse effects." D) "Regular, consistent dosing is important for successful treatment."

D) "Regular, consistent dosing is important for successful treatment." Consistent dosing, taken regularly at the same time of day, at the recommended dose, and with meals to reduce the common gastrointestinal adverse effects, is the key to successful management of seizures when taking AEDs. Noncompliance is the factor most likely to lead to treatment failure.

A patient is taking a hypnotic nightly toenhance sleep. The patient experiences vivid dreams and nightmares. This may be associated with A. hangover. B. tolerance. C. hypersensitivity. D. REM rebound.

D) REM rebound REM rebound, which results in vivid dreams and nightmares, frequently occurs after taking a hypnotic for a prolonged period and then abruptly stopping. A hangover is residual drowsiness resulting in impaired reaction time. Tolerance results when there is a need to increase the dosage over time to obtain the desired effect. Hypersensitivity is the development of skin rashes and urticaria.

Assessment findings for a patent with neuroleptic malignant syndrome (NMS) A) bradycardia B) Hypothemia C) Muscle Weakness D) Rhabdomyolysis

D) Rhabdomyolysis NMS symptoms include muscle rigidity, sudden high fever, altered mental status, blood pressure fluctuations,tachycardia, dysrhythmias, seizures, rhabdomyolysis, acute renal failure, respiratory failure, and coma.

A patient who has been taking a benzodiazepine as a sleep aid for several months wishes to stop taking the medication. The nurse will suggest that the patient taper the dose gradually to avoid which effect? A) Depression B) Hangover C) Hypnotic rebound D) Withdrawal

D) Withdrawal Benzodiazepines cause tolerance, which means that abrupt cessation can result in withdrawal symptoms such as tremors and muscle twitching. A hangover is residual drowsiness that occurs the day after taking a hypnotic.

When assessing older adults' renal function,which laboratory value will the nurse monitor? A. Liver enzymes B. Serum electrolytes C. Complete blood count D. Blood urea nitrogen and creatinine

D. Blood urea nitrogen and creatinine

Which is a physiologic change seen in the older adult that has an effect on drug administration? A. Lower (acidic) gastric secretions B. Increased first-pass effect through the liver C. Increased glomerular filtration rate D. Lower cardiac output

D. Lower cardiac output Lower cardiac output is a physiologic change associated with the older adult. The pH increases, not decreases,causing alkaline gastric secretions. The first-pass effect through the liver is decreased. The glomerular filtrationrate is decreased.

Which nursing actions would be most appropriate for ensuring patient safety with a medication that has a low therapeutic index? A.Monitoring a patient's urine output B.Assessing vital signs hourly C.Maintaining strict isolation precautions D.Monitoring serum peak and trough levels

D. Monitoring serum peak and trough levels Serum peak level is the highest plasma concentration of a drug at a specific time, indicating rate of absorption. Serum trough level is the lowest plasma concentration of a drug. They are drawn immediately before the next dose of the drug is to be administered. Trough levels indicate the rate of elimination of the drug. If either the peak or the trough level is too high, toxicity can occur. If the peak is too low, no therapeutic effect is achieved.

Which nursing intervention would be most appropriate for a patient taking lorazepam? A. Monitor for fever. B. Give drug intravenously only. C. Monitor daily weights. D. Tell patient to ask for help before standing

D. Tell patient to ask for help before standing For safety, the patient should ask for help in getting up (especially an older adult who may have an unsteady gait) when taking a sedative-hypnotic. Temperature is usually not affected with temazepam; however, respiratory depression may occur. Temazepam is only given orally. Monitoring daily weight is not necessary, but renal impairment should be monitored.

What would indicate to the nurse that a patient taking a sedative-hypnotic requires more teaching? A. The patient wants to listen to music on the radio. B. The patient has saved her urine to be measured. C. The patient says she has taken 1800 mL of fluid today. D. The patient requests a cup of kava kava tea to help her get to sleep faster

D. The patient requests a cup of kava kava tea to help her get to sleep faster Kava kava is an herb that may interact with CNS depressants. Listening to music may promote sleep. Renal impairment should be monitored, and an adequate amount of liquid is necessary.

When administering medications to the older adult population, the nurse is aware that the physiologic changes of aging that can affect drug activity include all of the following except A. increased fat-to-water ratio. B. decreased liver enzyme production. C. loss of nephrons. D. increased gastrointestinal blood flow.

D. increased gastrointestinal blood flow. Older adults have decreased gastric acidity, reduced peristalsis, decreased body water, increased fat-to-water ratio, decreased numbers of functioning nephrons, and decreased liver enzyme production and function.

Geriatric considerations: Distribution

Decreased available protein; decline in muscle mass and increase in fat=lipid soluble drugs have a greater volume of distribution, increased drug storage, reduced elimination, and prolonged period of action reduction of total body water-affects water soluble drugs and reduces albumin (results in decreased protein binding of drugs and increased free drug available to exert therapeutic effects, also increase the risk for drug toxicity)

Geriatric Considerations: Excretion

Decreased kidney function changes in kidney function lead to prolonged half-life and elevated drug levels. Doses will need to be adjusted based on kidney function

Geriatric considerations: Metabolism

Decreased liver function hepatic blood flow is decreased, liver size is decreased, and reduction of P450 enzyme activity-responsible for the breakdown of drugs Prolongs drug half-life-increased drug levels and risk for drug toxicity Assess liver functions: AST and ALT

Nursing actions to help adherence in older adults

Develop a schedule/chart of when to take what drug and use of a daily or weekly pill container explain purpose, action, and importance of drug-reinforce and provide time for questions; provide written instructions involve family and friends to assist in compliance of drug regimen ensure patient is wearing their glasses and hearing aids; if they do not have these and are having trouble, suggest eye or ear examination educate on possible side effects/adverse reactions and what is important to report to the doctor. Work with social services and patient assistance programs to provide low cost prescriptions for patient.

Proper disposal of medications

Do not flush down toilet; Label with patient identifiers should be removed and medication should be placed in a container with an undesirable substance. Drugs should be returned to community "drug take-back" program

Drug interaction vs. Drug incompatibility

Drug interactions: altered or modified action/effect of a drug as a result of interaction with one or multiple drugs. -Increased risk in drug interactions: people with chronic health conditions, polypharmacy (taking multiple medications), seeing and evaluated by multiple doctors, filling prescriptions at multiple pharmacies, older adults (due to all the above) Drug incompatibility: Happens outside the body (IM or IV); chemical or physical reaction that occurs when two or more drugs are combined in the same container. -Can cause decreased drug effectiveness, unexpected side effects, and increase the action a particular drug.

Drug absorption (definition and factors affecting)

Drug movement from the GI tract to the bloodstream Factors: blood circulation, pain, stress, exercise, food texture, fat content, temperature, pH, route of administration

Drug toxicity vs drug tolerance

Drug toxicity: drug levels exceed the theraputic range; can occur due to intentional/unintentional overdose, or drug accumulation. -Factors include age, disease processes, and genetics Drug tolerance: decreased response to a drug over the course of therapy; this will lead to a dose increase to achieve theraputic response.

Right drug

Order must be prescribed by licensed health care provider. Drug label must be read three times (two at the medication cart, once in the room), and check dose calculations. Nurse should be familiar with patient's health record, allergies, lab results, and vital signs. Checking start and end date of medication administration. why the patient is receiving medication and if it reflects the patient's diagnosis.

Mechanism of action for Phenobarbital

Enhances GABA activity

Enzyme inducers vs enzyme inhibitors

Enzyme inducers: Increased metabolism promotes drug elimination, decreases plasma concentration of the drug, and decreases drug theraputic action Enzyme inhibitors: decreases metabolism, increased plasma concentration-patient will need a dose reduction in drug.

Drug prototype: SSRIs

Fluoxetine

Right time

Give with drugs that irritate the stomach; Drugs that are affected by food are given 1 hour before or after meals. Check for scheduled procedures Administer medications at even intervals; Use of military time reduces errors ***Hold antihypertensives prior to dialysis; check with dialysis nurse

What fruit alters metabolism of many drugs by inhibiting the CYP450-3A4 drug metabolizing enzyme; can cause serious adverse drug reactions

Grapefruit

what is a drug's half life and why is it important?

Half life is the time it takes for the amount of drug in the body to be reduced by half. It is affected by the amount of drug administered, the amount of drug remaining in the body from previous doses, persons metabolism, and rate of elimination. It is important as this is what determines a dosing interval for a drug. This also helps determine a drugs steady state, which is when the amount of the drug administered is the same amount being eliminated-achieves optimal theraputic benefit.

The nurse knows that Benzodiazepines slow down the CNS. What side effects would the nurse expect to see? (Select all that apply.) -Drowsiness -Lethargy -Hypotension -Increased HR -Agitation

Hypotension Drowsiness Lethargy

Adverse reactions for Benzodiazepines

Hypotension tachycardia respiratory depression Dependency Seizures

With altered renal or hepatic function, there is usually an _______ in free drug concentration.

Increase; essential to closely monitor these patient's for drug toxicity when they take multiple drugs

Anti-inflammatory, NSAID: Celecoxib (Interactions, Side effects, Adverse effects, Monitoring/safety, Teaching)

Interactions: Decreased effect of ACE inhibitors; may increase toxicity with lithium; Ginkgo biloba may increase bleeding risk. Side effects: Dizziness, drowsiness, headache, dyspepsia, GI distress (anorexia, nausea/vomiting/diarrhea, abdominal pain, constipation) Adverse effects: GI bleeding/obstruction/ulcer/perforation, hypertension, dyspnea, tendon rupture, tinnitus or hearing loss, thromboembolism **Life threatening: renal or hepatic failure, anemia, thrombocytopenia, pancytopenia, Stevens-Johnson syndrome. Monitoring and Safety: Evaluate labs (may cause elevation in liver enzymes, and may cause hypophosphatemia, hyperkalemia, and increased BUN) Teaching: Instruct patient to take only as prescribed and to avoid use of more than one NSAID or aspirin at a time-increased risk for GI toxicity; Instruct patient to monitor blood pressure and ensure proper technique, Inform patient to immediately call provider if development of shortness of breath, chest pain, slurred speech, or facial/throat swelling-medication increases risk of blood clots.

Opioid analgesic: Morphine Sulfate (Interactions, side effects, Adverse reactions, Monitoring/Safety, Teaching)

Interactions: Increased effects when combined with alcohol, sedative-hypnotics, antipsychotic drugs, and muscle relaxants; St. John's Wort may decrease effectiveness Side effects: sedation, drowsiness, dizziness, confusion, depression, pupil constriction (miosis), GI distress (abdominal pain, nausea, diarrhea, constipation), Urinary retention, erectile dysfunction, anxiety Adverse effects: Psychological dependence, respiratory depression, hypotension, bradycardia, GI obstruction/ileus Monitoring and Safety: monitor urinary output, continue to monitor vitals at frequent intervals (respiratory rate and blood pressure), Monitor for decreased bowel sounds Teaching: Do not use with alcohol or other CNS depressants, inform on non-pharmacological methods of pain relief, Observe sedation precautions (do not drive)

Antigout, Xanthine Oxidate inhibitor: Allopurinol (Interactions, side effects, Adverse reactions, Monitoring/Safety, Teaching)

Interactions: Use of thiazide diuretics or ACE inhibitors increase risk of hypersensitivity reactions, use with oral hypoglycemic agents and warfarin increase effects of drug Side effects: Dizziness, headache, GI distress (Anorexia, nausea/vomiting/diarrhea) Adverse effects: Liver or kidney damage Monitoring and Safety: Record urine output, monitor lab test for renal and hepatic function Teaching: Instruct patient to increase fluid intake to increase drug and uric acid excretion-kidney stones can form, Medication can be taken with food to limit GI distress, advise patient to have a yearly eye exam as vision changes can result from prolonged use, instruct patient to decrease intake of high uric acid foods ***Organ meats, sardines, salmon, gravy, herring, liver, meat soups, legumes, caffeine, and alcohol (especially beer)

Analgesic: Acetaminophen (Interactions, side effects, Adverse reactions, Monitoring/Safety, Teaching)

Interactions: increase bleeding risk if also on warfarin (INR should not exceed 4), NSAIDs may increase the risk of adverse renal effects (avoid chronic concurrent use), Concurrent use with phenytoin and barbiturates may increase the risk of liver damage and decrease effects of acetaminophen Side effects: headache, anxiety, insomnia, constipation, peripheral edema. -Causes little to no GI distress and does not interfere with platelet aggregation. Adverse effects: Stevens-Johnson syndrome, hepatotoxicity and renal failure if used in excess, neutropenia, pancytopenia, Oliguira Monitoring and Safety: MAXIMUM DOSE IS 4 G/DAILY; Assess health status and alcohol use, Check liver enzyme and kidney function periodically for high dose, prolonged therapy; Increased bilirubin, LDH, ALT/AST, and prothrombin time can indicate liver damage. Teaching: Avoid alcohol ingestion while taking acetaminophen; inform of max dose (4 g/daily), Seek medical attention if no relief with taking acetaminophen for 10 days, take medication with a full glass of water, Medication can be taken with food or on an empty stomach.

Methylphenidate (Interactions, side effects, Adverse reactions, Monitoring/Safety, Teaching, Dietary restrictions)

Interactions: pseudoephedrine and psychostimulants (caffeine) taken concurrently with medication will increase stimulatory effects of irritability, nervousness, tremors, and insomnia; Inhibits the metabolism of some barbiturates (phenobarbital), oral anticoagulants, and anticonvulsants, which can increase blood levels and cause potential toxicity; can reduce antihypertensive effects. Side effects: dry mouth, anorexia, dizziness, insomnia, restlessness, anxiety, tremors, headache Adverse effects: Tachycardia, hypertension, growth suppression, hepatotoxicity, psychosis. Monitoring and Safety: Monitor height, weight, and growth of children. Teaching: taken in the morning and at lunch, 30-45 minutes prior to meals; Should be given 6 or more hours before sleep, will induce insomnia; Encourage use of sugarless gum to relieve dry mouth, teach diet with good calorie intake; Do not stop abruptly. Dietary restrictions: avoid caffeine (coffee, tea, chocolate, soft drinks, and energy drinks)

Benzodiazepines: Midazolam (Uses, assessment, monitoring/safety, nursing interventions/teaching)

Intravenous anesthetic Use: Induction and maintenance of anesthesia or conscious sedation for minor surgery or procedures (patients are sedated and relaxed, but responsive to commands) Assessment: obtain baseline vitals and neurological assessment/mental status, review medication history and medical history (issues with sedation?), assess level of sedation and level of consciousness through and for 2-6 hours following administration Monitoring/safety: Monitor BP, pulse, and respiration continuously during administration, advise on ambulatory assistance for the next 24 hours as medication causes dizziness and drowsiness, supervise ambulation and transfer of patients after administration (2 side rails raise and call bell within reach at all times) Nursing interventions/teaching: inform patient that medication will decrease mental recall of procedure, report immediately for increased agitation, depression, or suicidal ideation

Local Anesthetic: Spinal anesthesia/Epidural (Indication, contraindications, Side effects, adverse effects)

Local anesthetic injected into the spinal or epidural space of the spine, commonly used in Cesarian sections Indication: Surgeries to the lower abdomen and pelvic region, lower extremities, and C-sections; acute post op pain management, and chronic pain relief. Contradiction: Local or systemic infection, malignancy, peripheral neuropathy, hypersensitivity, spinal stenosis, prior spinal surgery (laminectomy), coagulation defects, hypotension Side effects: Headache-can be due to leak of cerebrospinal fluid at the puncture site. Adverse effects: Hypotension-due to ensuing sympathetic blockade and predisposing factors that include sensory block location, history of hypertension, and chronic alcohol intake; respiratory distress or failure due to anesthesia spreading too high and affecting respiratory muscles.

Other types of Benzodiazepines

Lorazepam-substance withdrawal, controlling seizures, acute agitation/psychosis Diazepam (Valium)-seizures, muscle relaxant, status epilepticus.

Pharmacodynamics: Age related changes

Loss of sensitivity in adrenergic receptors: reduced response to beta blockers and beta2 agonists blunting compensatory reflexes: leads to orthostatic hypotension and falls reduction in dopaminergic and cholinergic receptors, neurons, and available neural connections in the brain reduced blood flow to the brain and more permeable blood-brain barrier: more risk for CNS drug side effects (dizziness, seizures, confusion, sedation, and extrapyramidal effects)

Celecoxib

NSAID that is a COX 2 inhibitor only, leaving protection for the stomach lining and delivering relief of pain and inflammation. **Caution used in patients at risk for stroke or heart attack (COX 1 is not blocked, promoting blood clotting)

Analgesic: Acetaminophen (Action, indications, assessment, contraindications)

Nonopioid analgesic used for mild to moderate pain; Acts on the peripheral nervous system at the pain receptor sites. **Antidote is: acetylcysteine Action: Inhibits/weakens prostaglandin synthesis, inhibit hypothalamic heat regulator center ***NO ANTI-INFLAMMATORY ACTION Indications: Decrease pain and fever Assessment: pain assessment, fever assessment (absence of diaphoresis, tachycardia, and malaise) obtain medical history of liver dysfunction and alcohol use, obtain vital signs, assess other medications for inclusion of acetaminophen. Contraindications: hypersensitivity, liver disease or severe hepatic impairment, alcoholism, malnutrition

Issues with adherence and the older population

Patient may not fully understand or correctly follow the drug regimen-causes underdosing or overdosing Polypharmacy-multiple drugs taken at different times Impaired memory decreased mobility and dexterity visual/hearing disturbances side effects/adverse reactions of medications-fear drug coverage=not all people have drug coverage or insurance. ***failing to adhere=more hospitalizations/admissions/death

Components of a drug order/prescription

Patient's name and date of birth Drug name and strength Drug frequency or dose (once daily, BID) Route of administration (PO, Subcutaneous) Duration of medication course (x 7 days) number of refills (0 if none) number of pills to be dispensed special instructions (take if systolic blood pressure greater than 150) Date the order is written provider signature (or written name if an electronic order, telephone order, or verbal order) signature of licensed staff who took the telephone order or verbal order-if applicable ***DEA number is required for writing controlled substances. Page 73-74

Peak and trough lab-differences

Peak: measures rate of drug absorption; administration route affects time lab is drawn -oral administration: peak is 2-3 hours after administration -IV meds: peak is 30-60 minutes once infusion is complete -IM meds: peak is 2-4 hours after injection Trough: measures rate of drug elimination; lab is drawn right before next dose of medication regardless of administration route.

Transdermals

Placed on the skin for extended periods of time and bypasses the GI tract -Alternate sites to avoid skin irritation -clean area throughly prior to placement of new transdermal patch -perform hand hygiene and wear gloves during application to avoid transfer of medication -secure with tape (too tight can alter drug delivery) ***Never cut patch in half Page 85

The nurse is preparing to administer a barbiturate. Which conditions or disorders would be a contraindication to the use of these drugs? (Select all that apply.) - Gout - Pregnancy - Epilepsy - Severe chronic obstructive pulmonary disease - Severe liver disease - Diabetes mellitus

Pregnancy, Severe COPD, and severe liver disease.

Right documentation

Record drug administration immediately after administration (not prior) Record of the drug name, dose, route, time, date, and nurses signature/initials; reason for medication being held or refused should be documented document patient's response to drug (very important for analgesics, sedatives, and antiemetics)

Physiologic changes associated with aging

Reduction in total body water and lean body mass-results in increased body fat-alters the volume of distribution of drugs reduction in kidney mass and lower kidney blood flow-reduced GFR and reduced clearance of drugs excreted by the kidneys reduction in liver size and blood flow-resulting in reduced hepatic clearance of drugs postural hypotension with antihypertensives volume depletion and electrolyte abnormalities due to diuretics excessive bleeding with anticoagulants and anti-platelet drugs altered glycemic response due to anti-diabetic drugs GI irritation due to NSAIDS

Six Rights of medication administration

Right patient Right medication Right dose Right route Right time Right documentation

Anticonvulsant, Hydantoin: Phenytoin (safety precautions, Side effects, adverse effects, monitoring, teaching)

Safety precautions: Seizure precautions, do not drive or operate machinary Side effects: headache, confusion, dizziness, nausea/vomiting, tinnitus, nystagmus, ataxia, hyperreflexia, urine discoloration, gingival hyperplasia Adverse effects: Injection site reaction (purple glove syndrome-swollen, discolored, painful extremities), depression, suicidal ideation, Stevens-Johnson syndrome, V.Fib, thrombocytopenia, leukopenia, hyperglycemia (drug inhibits release of insulin) Monitoring and Safety: Therapeutic range between 10-20 Teaching: do not miss a dose.

Antipsychotic, neuroleptic: Haloperidol (Safety, side effects, adverse effects, monitoring, proper teaching)

Safety: Do not abruptly stop; Seizure and fall precautions. Side effects: drowsiness, headaches, photosensitivity, depression, confusion, euphoria, lethargy, tremor, dry mouth, erectile dysfunction, urinary retention. Adverse effects: Tachycardia, orthostatic hypotension, EPS, seizures, hyponatremia, hepatic failure, kidney failure, rhabdomyolysis. Monitoring: urinary output, blood pressure, and CBC for WBC Teaching: Inform patients that medication may take 6 weeks or longer to achieve full effect, Encourage smoking cessation (high risk for tardive dyskinesia), avoid combining with alcohol and other CNS depressants, Do not drive, Medication should not be abruptly stopped

Benzodiazepines-About the drug class

Sedative-hypnotic Schedule IV drug, initially introduced to relieve anxiety, but also ordered as sedative hypnotics for inducing sleep; Increase the action of inhibitory neurotransmitter gamma-aminobutyric acid (GABA) to the GABA receptors CNS Depressants "-pam's and lam's"

Nonbenzodiazepine: Zolpidem (Use, Theraputic effect, assessment, monitoring/safety, nursing interventions/teaching)

Sedative-hyponotic; Neurotransmitter inhibition; produces CNS depression by binding to GABA receptors Therapeutic effect: induction of sleep Use: Treat short-term insomnia (smaller dose in older adults) Assessment: Baseline vital signs, drug and medical history, Assess mental status, sleep patterns, and potential abuse prior to administration (>7-10 days increases dependence, limit availability to patient), Assess alertness at time of peak effect, Assess for pain or other possible reasons for sleep disturbances(pain decreases sedative effects) Monitoring/safety: use of bed alarm (if in the hospital), Monitor vital signs and observe for respiratory depression Nursing interventions/teaching: Monitor vital signs and compare, level of consciousness, observe for side effects/adverse effects, instruct patient to take only at bedtime, instruct patient to try non-pharmacologic interventions first, do not drive while taking medications, report feelings of hangover or unwanted effects, Use of bed alarm (if in the hospital)

Sumatriptan (side effects, Adverse reactions, Monitoring/Safety, Teaching)

Side effects: Dizziness, drowsiness, flushing, fatigue, GI distress Adverse effects: hypotension or hypertensive crisis, Bradycardia, thromboembolism (clot formation), elevated liver enzymes, suicidal ideation, GI bleed, intracranial hemorrhage. Monitoring and Safety: get up slowly due to side effects of dizziness, drowsiness, and blurred vision, Monitor BP before and 1 hour after, Teaching: Take as soon as symptoms appear and only during a migraine, can be taken orally, subcutaneously, and intranasally; Avoid driving while taking medication, avoid alcohol

Analgesic, Anti-inflammatory: Aspirin (Side effects, adverse effects, monitoring/safety, Teaching)

Side effects: Dizziness, drowsiness, headache, dyspepsia, GI distress (anorexia, nausea, abdominal pain, gastritis, vomiting) Adverse effects: Tinnitus or hearing loss (sign of toxicity), hypokalemia, hypernatremia, elevated liver enzymes, GI bleeding/perforation/ulceration, intracranial bleeding. **Life threatening: Reye syndrome in children (vomiting, lethargy, delirium, and coma), anemia, leukopenia, thrombocytopenia, pancytopenia, respiratory alkalosis, renal or hepatic failure, pulmonary edema, Stevens-Johnson syndrome. Monitoring and safety: Monitor serum salicylate (aspirin) level when patient takes high doses for chronic conditions (therapeutic range is 15-30 mg/dL), observe for bleeding gums, petechiae, bruising, or black stool; Monitor vital signs Teaching: Inform of side effects/adverse effects to immediately report (black tarry stools, gum bleeding, petechiae), Taking medication with food will decrease stomach irritation, Avoid alcohol-will increase gastric irritation, Advise patient to not take aspirin and acetaminophen with NSAIDs due to increased risk of GI bleeding, Instruct patient to discontinue aspirin approximately 7 days before surgery to reduce risk of bleeding, inform patients to take acetaminophen instead of aspirin 2 days before and during the first two days of their menstrual cycle. ***Warn parents to not give aspirin to children with virus or flu symptoms to avoid the risk of Reye syndrome.

Anti-inflammatory (NSAID): Ibuprofen (Side effects, adverse effects, monitoring/safety, Teaching)

Side effects: Dizziness, drowsiness, headaches, dyspepsia, abdominal pain, nausea/vomiting/diarrhea or constipation (GI distress), fluid retention (peripheral edema) Adverse effects: GI bleeding/perforation/ulcer, Tinnitus (ringing in the ears), seizure; -Life threatening: Anaphylaxis, anemia, neutropenia, thrombocytopenia, renal failure/nephrotoxicity, Stevens-Johnsons syndrome Monitoring and safety: observe for bleeding gums, petechiae, bruising, or black stool; Monitor vital signs Teaching: Inform of side effects/adverse effects to immediately report (black tarry stools, gum bleeding, petechiae), Taking medication with food will decrease stomach irritation, Avoid alcohol-will increase gastric irritation, Advise patient to not take aspirin and acetaminophen with NSAIDs due to increased risk of GI bleeding, and warn females to not take NSAIDs 1-2 days before menstruation to avoid heavy menstrual flow.

Benzodiazepines: Midazolam (Side effects, adverse effects, Interactions, and contradictions)

Side effects: Drowsiness, agitation, nausea, headache adverse effects: hypotension, excess sedation, respiratory and cardiac depression Interactions: increased CNS depression when used with alcohol, opiates, antihistamines, or other sedative-hypnotics, use of antihypertensives, Intake of KavaKava or chamomile can increase CNS depression, Grapefruit juice will decrease metabolism and increase risk for toxicity Contraindications: Pregnancy or breast feeding women, patients with pulmonary disease or heart failure, renal disease or severe hepatic impairment, Open-angle glaucoma.

Nonbenzodiazepine: Zolpidem (Side effects, Adverse reactions, interactions, contraindications)

Side effects: drowsiness, lethargy, dizziness, memory impairment Adverse reactions: complex sleep behaviors (sleep driving, sleep walking, other activities while asleep), residual drowsiness/daytime drowsiness, vivid dreams/nightmares, drug dependence, drug tolerance, excessive depression, respiratory depression, hypersensitivity Interactions: use of other CNS depressants, Alcohol, taking with food decreases absorption, KavaKava and chamomile can increase CNS depression, St. John's wort may decrease levels Contraindications: Sleep apnea/respiratory depression, severe renal or liver disease (increases risk for hepatic encephalopathy), caution in those with previous psychiatric impairment, older adults (increased risk in falls-lower dose needed), allergy to benzodiazepines.

Side effects vs. Adverse drug reaction

Side effects: secondary effects of drug therapy that can be predictable, and ranges from mild/inconvenient to severe/life threatening. Effects can be desired -nurse role: educate on common side effects and the importance of reporting symptoms. Side effects can be managed with dose adjustments, changing to a different drug within the same drug class, and implementing other interventions Adverse drug reactions: unintentional, unexpected, and always undesirable reactions to drug therapy that occur with normal drug dosages. Can happen on initial dose of medication or after a couple doses. -important to report and record immediately.

Geriatric Considerations: absorption

Slowing of the GI tract; decrease in small bowel surface area, slowed gastric emptying, reduced gastric blood flow, and 5-10% decrease in gastric acid production ***swallowing difficulties, poor nutrition, dependence on feeding tubes.

Pharmacodynamics

Study of the way drugs affect the body; drugs act within the body to mimic the actions of the body's own chemical messengers Primary effect: desirable response Secondary effect: Desirable or undesirable.

Mechanism of action for Valproic Acid

Suppresses sodium and calcium influx

IV

Systemic effect; most rapid effect Location: accessible peripheral veins are preferred Adults: 20-21 gauge, 1-1.5 inches Infants: 24 gauge, 1 inch Children: 22 gauge, 1 inch **Large bore needles needed for viscous drugs, blood transfusions, or rapid infusions Page. 92

Photoallergic reaction

The body's immune system recognizes changes caused by sun exposure as a foreign threat. The body produces antibodies and attacks, causing a reaction. A photoallergic reaction can leave you with a rash, blisters, red bumps or even oozing lesions one to three days after application and exposure to the sun; does not depend on the dose of the medication and only requires previous exposure or sensitization

Adherence

The extent to which a patient continues an agreed-on mode of treatment without close supervision

drug reconciliation

The process of identifying the most accurate list of all medications a patient is taking ***advise patient to always carry a current, updated list of personal drug information; this includes all prescribed medications and when/reasoning for taking, vitamins, otc medications, herbal supplements, etc.

Pharmacodynamic interaction: additive effect

The sum effects of two drugs; when two or more drugs are administered in combination, and the response is increased beyond what either could produce alone. can be desirable (such as taking a diuretic and betablocker to treat for hypertension) or undesirable (taking hydralazine for hypertension and nitroglycerin for chest pain will cause severe hypotension if taken together)

Topical medications

applied directly to the skin -Apply to clean, dry skin -Remove medication with gloved hand or applicator to avoid drug contamination; gloves and applicators used with prior contact should make contact again with container. If more topical is needed, use a new glove or applicator. -Wear gloves always; can apply with glove, tongue blade, or cotton tip applicator Page 85

Pharmacodynamic interaction: Synergistic effect

Two or more drugs given together, producing a greater effect than that of either drug alone. Examples: Undesired-alcohol and sedative combined causes increased CNS depression. two cytotoxic drugs given in order to reduce the dosing of each drug and potential side effects. antibiotics can include an enzyme inhibitor (Amoxicillin with clavulanate) that potentiates the therapeutic effect; Antibiotics can be given without the inhibitors, however, with the inhibitors, the effect of the drug is enhances and the spectrum of activity is broadened.

Foods to avoid when taking an MAOI (monoamine oxidase inhibitor) antidepressant

Tyramine-rich foods: cheese, wine, organ meats, beer, yogurt, sour cream, or bananas Tyramine is a potent vasoconstrictor and can cause a hypertensive crisis if ingested with an MAOI.

Rectal suppositories

Used for local and systemic absorption; numerous rectal capillaries in the rectal area promote medication absorption -Hand hygiene, wear gloves; some suppositories are refrigerated because they soften at room temperature. -Foil wrapping removed and suppository is lubricated with water-soluble lubricant. Patient should be positioned lying down in the modified left lateral recumbent position. -Instruct patent to breathe slowly through the mouth to relax the anal sphincter. -Place suppository past the internal anal sphincter (otherwise it will be expelled before it can dissolve and absorb into the mucosa) -Patient should remain flat or on one side for at least 30 minutes to prevent expulsion. Page 88

Intradermal injections

Usually administered for local effect-skin testing such as tuberculin screening and allergy testing. Location: chosen so inflammatory reaction can be observed, hairless, and free from lesions; Ventral mid-forearm, clavicular area of the chest, or scapular area of the back. Needle: 25-27 gauge, 1/4/-1/2 inch long Syringe: 1 mL -Hand hygiene, wear gloves, clean area -Skin held taut -insert the needle, bevel up, at 10-15 degree angle. -Injected slowly to form a bleb -Do not massage afterward and mark injection site. Do not place adhesive bandage over site. -reaction should be read in 24-72 hours.

Drug prototype: SNRIs

Venlafaxine

Right dose

Verify the dosage calculation and ensure that the drug is safe for the patient; weigh the patient if dose is dependent upon the weight Validate dose of high risk medications with 2 RN's (Insulin, Heparin, Opiates) ****Cannot use LPNs, must be RN or higher degree

The nurse is assessing a young adult patient with schizophrenia who recently began taking fluphenazine. The patient is exhibiting spasms of facial muscles along with grimacing, and the nurse notes upward eye movements. The nurse suspects which side effect? A) Acute dystonia B) Akathisia C) Pseudo parinsonism D) Tardive dyskinesia

a) Acute dystonia Tardive dyskinesia causes involuntary movements most commonly in areas of the face, eyes, and mouth. Dystonia, on the other hand, leads to involuntary muscular contractions that can affect the head, face, and neck.

What is the most important information for the nurse to include in a teaching plan for the patient receiving allopurinol? A) "Do not take this medication during an acute attack of gout." B) "Include salmon and organ meats in your diet weekly." C) "Take the medication with food to minimize gastrointestinal distress." D) "This medication may cause your urine to turn orange."

a. "Do not take this medication during an acute attack of gout." Allopurinol should not be taken during an acute attack because the initial response to allopurinol is an exacerbation of the symptoms. It is used prophylactically to prevent gout and treat hyperuricemia. It should not be taken with an antacid, will not be affected by the patient's usual diet, and will not result in a change in the color of the urine

A 65 year old man has been diagnosed with chronic gout

allopurinol

Beers Criteria for Potentially Inappropriate Medication Use in Older Adults

addresses drugs that may exacerbate disease or syndrome, drugs to be used with caution in older adults, those with clinically important drug interactions, and drugs that should not be prescribed or have their dose reduced due to kidney dysfucntion

Types of adverse drug events for older adults

adverse drug reactions-more serious, life-threatening effects medication errors therapeutic failures adverse drug withdrawal events overdoses (elderly can overdose more easily)

How NSAIDs work

block COX 1 and COX 2 -loss of stomach lining protection and prevents blood clotting; increases risk for ulcer and GI bleeding -Reduces pain and suppresses inflammation

Local anesthetic

blocks pain at the site where the drug is administered; inhibits transport of ions across the neuronal membranes, thereby preventing initiation and conduction of nerve impulses. Uses: dental procedures, suturing lacerations, minor surgery at localized area, nerve block, below insertion of spinal anesthetic, diagnostic procedures such as a lumbar puncture or thoracentesis, and regional blocks to provide analgesia for surgery (brachial plexus, femoral, axillary, and sciatic)

Disintegration

breakdown of oral drug form into small particles the rate is the time it takes the drug to disintegrate and dissolve to become available for the body to absorb it

Therapeutic drug monitoring

checks serum drug levels, which is important with drugs that have a narrow therapeutic range (example: Digioxin and phenytoin)

COX-1 and COX-2

cyclooxyrgenase 1 & 2 are enzymes that convert arachidonic acid to prostaglandin, resulting in pain and inflammation. COX-1: protects stomach lining, decreases, fever, and promotes platelet aggregation (blood clotting) COX-2: triggers pain and inflammation

Sublingual

dissolved under the tongue *must remain in place until fully absorbed/dissolved. *no intake of food or drink until fully dissolved. Page 85

What should not be taken with medications as this can change the bioavailability of them

do not mix with large amounts of food or beverage-will not get the full dose of the medication (Can administer with a small amount of food if drug causes GI discomfort) Antacids: this will break down the drug and weaken the drug strength Nutritional deficiencies (protein malnutrition) alters pharmacokinetic processes and drug response, causing toxicity Tyramine containing foods when taking a MAOI: Avoid due to risk for a severe hypertensive reaction (Aged cheeses, salami, wine, organ meets, beer, yogurt, sour cream, bananas) St. John's Wort: over-the-counter remedy that helps manage symptoms of depression. -induces metabolism of certain drugs such as warfarin, digoxin, and theophylline, decreasing their effectiveness and requiring a dose increase just to sustain efficacy; Also increases serotonin levels when taking Venlafaxine Citrus foods: contain flavonoids; -potent inhibitors of the metabolism of certain drugs such as cabamazepine, calcium channel blockers, and drugs to treat erectile dysfunction. Patient's that are stabilized on therapeutic doses of these drugs may be subjected to adverse effect from greater-than-expected drug levels -Grapefruit

Phototoxic reaction

drugs and their metabolites absorb light inducing a direct cellular damage, causing sun-burn like presentation to exposed skin areas within 2-6 hours of sunlight exposure; may result from the dose of the drug

Start low and go slow

drugs for older adults should initially be prescribed at low dosages with a gradual increase in dosage based on therapeutic response; reduces the chance of drug toxicity

Ways to reduce polypharamacy

encourage the use of one pharmacy provide a list all drugs, herbs, and OTC medications used.

_____should not be crushed because crushed because crushing alters the place and time of absorption of the drug.

enteric coasted, capsules, and sustained-released.

Reversal agent for Midazolam

flumazenil

What is needed for medications to work properly

high protein

effects medication absorption

hydration

Protein binding complications

important to check patient's protein and albumin levels prior to administration; effects those that are malnourished, older adults, and those with liver and kidney disease -Two high protein-bound drugs administered together: compete for protein-binding sites, leading to an increase in free drug being released into circulation. Leads to possible for drug accumulation and toxicity -Low plasma protein levels: decrease the number of available binding sites and can lead to an increase in the amount of free drug available. Leads to drug accumulation and toxicity

Mechanism of action for Phenytoin

inhibits sodium influx and decreases electrical activity

Characteristics in older adults that increase the risk for problems with drug administration

lack of coordinated care recent discharge from the hospital self treatment multiple diagnoses sensory and physical changes associated with aging multiple healthcare providers cognitive impairment

Drug absorption in the stomach is slower very young and older adults due to

less gastric acidity

Tablets and Capsules

most common drug -Not given to patients who are vomiting, who lack a gag reflex, or who are comatose -do not mix with large amounts of food or beverage-will not get the full dose of the medication (Can administer with a small amount of food if drug causes GI discomfort) -Extended release or enteric coated tablets cannot be crushed-increases rate of absorption and can lead to drug toxicity Page 84-85

Dissolution

process of combining small drug particles with liquid to form a solution

Drug-laboratory interactions

occur when a drug or a substance alters the concentrations of substances in the body caused by cross reaction of antibodies, interference of enzyme reactions, or alteration of chemical reactions Leads to misinterpretation or invalidation of test results, additional healthcare costs for repeat or additional testing, and missed or erroneous clinical diagnosis

Drug prototype: MAOIs

phenelzine sulfate

Buccal

placed between the cheek and gum *must remain in place until fully absorbed/dissolved. *no intake of food or drink until fully dissolved. Page 85

Excipients

placed in tablets; allow the drug to take on a particular size and shape, and enhance drug dissolution

drug metabolism (biotransformation)

process of body chemically changing drug into a form to be excreted

Local Anesthetic: Lidocaine (Uses, contraindications, side effects, adverse effects)

rapid onset and long duration of action, fewer hypersensitivity reactions uses: for nerve block, infiltration, epidural, and spinal anesthesia; also used to treat cardiac dysrhythmias (IV) Contraindications of use: Vicious lidocaine (oral) should not be used for teething pain; should only be used when other alternatives have failed. Side effects: Stinging, burning, erythema, can cause a decrease or absent gag reflex if used in the mouth Adverse effect: paresthesia, contact dermatitis; Increased amount and frequency of use increases the likelihood for systemic absorption and adverse reactions. .

Right patient

requires confirmation/verifying two forms of identification (name and date of birth) and compare with ID band and MAR Verify name with family member if present and be aware of 'name alerts' (patients have the same name)

Benzodiazepines: Alprazolam (side effects, Adverse effects, interactions, and contraindications)

side effects: Lethargy, drowsiness, dizziness, memory impairment, confusion, fatigue, ataxia adverse reactions: depression, hypotension, **Patient's can easily build tolerance and become dependent. Patient's should be slowly titrated off medication. If medication is immediately stopped, patient can have withdrawal symptoms, some as severe as seizures. **Life threatening adverse reactions: Hepatic failure and Stevens-Johnson syndrome. Interactions: alcohol, other CNS depressants, Grapefruit increases alprazolam levels, green tea decreases alprazolam levels Contraindications of use: Respiratory depression, allergy; caution with older adults, patient's with sleep apnea and renal or liver dysfunction, depression or suicidal ideation, and hx of substance or alcohol abuse.

Black box warning

strongest drug safety actions that the US Food and Drug administration can implement; often warns of serious risks.

preventing photosensitive reactions

sunscreen with SPF greater than 15 avoid excessive sunlight exposure-be aware of height of sunlight exposure wear protective clothing **decreasing dose may help decrease this risk of reaction if treatment is required.

non-pharmacologic methods to induce sleep

taking a bath, listening to quiet music, drinking warm fluids, and avoiding drinks 6 hours prior to bedtime

polypharmacy definition and risk factors

use of more medications that is medically necessary; 5 or more drugs increase incidence of adverse drug reactions, geriatric syndromes (cognitive impairment, falls, decreased functional status, urinary incontinence, delirium, weight loss), poor adherence, and increased mortality Risk factors: advanced age, female sex, multiple health care providers, use of herbal therapies and otc medications, multiple chronic diseases, and number of hospitalizations/care transitions

Intramusclar

used for systemic effect; more rapid effect and are used for solutions that are more viscous and irritating Location: chosen for adequate muscle size and minimal major nerves/blood vessels in the area. -Ventrogluteal: near the gluteus medius and away from major nerves. Preferred site for most injections; Z-Track method used; 18-25 gauge needle, measuring 1.5 inches, angled slightly toward the iliac crest during insertion -Deltoid: site used for small medication volumes (0.5-1 mL) or when other sites are inaccessible; Risk for injury due to nerves and arteries lying along the humerus. Not used in infants or children due to underdeveloped muscles. 23-25 gauge needle measuring 5/8-1.5 inches, inserted at a 90 degree angle. -Vastus lateralis: use with caution due to sciatic nerve and femoral structures. Volume of drug 0.5-2 mL max. Used for infants and toddlers receiving immunizations Page 91-92

Drug doses are often adjusted according to older adult's...

weight, laboratory results (liver enzymes and kidney function), and cormorbid health problems. ***because of altered organ function, effects must be closely monitored to prevent adverse reactions and possbile toxicity