NUR 334 PHARMACOLOGY EXAM 1 MOD 1 - 2
Embryonic period.
During the embryonic period, from 3 to 8 weeks postconception, there is rapid development of internal structures. This is the period of maximum sensitivity to teratogens.
Most drugs are category C because
very high doses in laboratory animals often produce teratogenic effects.
Some formulations combine an NSAID with a drug that protects the gastric mucosa, such as
Vimovo (naproxen with esomeprazole) and Duexis (ibuprofen with famotidine).
Neuropathic pain
is caused by direct injury to the nerves.
C fibers a.
Are unmyelinated; thus, they carry nerve impulses more slowly and conduct dull, poorly localized pain
Most of the adverse effects of aspirin and ibuprofen are due to inhibition of
COX-1, the protective form of the enzyme.
Common types of neuropathic pain
-Carpal tunnel syndrome -Central pain syndrome -Degenerative disk disease -Diabetic neuropathy -Intractable cancer pain -Phantom limb pain
Older adults absorption
-Gastric pH less acidic -Gastric emptying slowed -Movement through GI tract slowed because of decreased muscle tone and activity -Blood flow to GI tract reduced -Absorptive surface of GI tract reduced
The nerve impulse signal-ing the pain is sent to the spinal cord along two types of sensory neurons, called
A@ and C fibers.
Methadone (Dolophine)
Abstinence maintenance med. Binds with opiate receptors in CNS to produce analgesic and euphoric effects. Prevents withdrawal symptoms in clients who were addicted to opiate drugs. Precautions/interactions: do not use in clients who have severe asthma, chronic respiratory disease, or history of head injury. Side/adverse effects: sedation, respiratory depression, paradoxical CNS excitation.
Aspirin (Acetylsalicylic Acid, ASA)
Actions and Uses Aspirin inhibits prostaglandin synthesis involved in the pro-cesses of pain and inflammation and produces mild to mod-erate relief of fever. Adverse Effects: At high doses, such as those used to treat severe inflammatory disorders, aspirin may cause gastric discomfort and bleeding because of its antiplatelet effects. Contraindications: Because aspirin increases bleeding time, it should not be given to patients receiving anticoagulant therapy, such as warfarin and heparin. Interactions Drug-Drug: Concurrent use of phenobarbital, antacids, and glucocorticoids may decrease aspirin's effects. When aspirin is taken with alcohol, pyrazolone derivatives, steroids, or other NSAIDs, there is an increased risk for gastric ulcers. Herbal/Food: Feverfew, garlic, ginger, and ginkgo may increase the risk of bleeding. Treatment of Overdose: Treatment may include any of the following: activated charcoal, gastric lavage, laxative, or drug therapy
Nonpharmacological Techniques used for reducing pain are as follows:
Acupuncture Art or music therapy Biofeedback therapy Chiropractic manipulation Guided imagery Heat or cold packs Hypnosis Massage Meditation or prayer Natural agents applied to the skin to produce a warm-ing sensation Physical therapy • Relaxation therapy
Current FDA pregnancy category: Risk category X
Adequate well-controlled or observational studies in animals or preg-nant women have demonstrated positive evidence of fetal abnormalities or risks.The use of the product is contraindicated in women who are or may become pregnant. There is no indication for use in pregnancy. Examples: Clomiphene, fluorouracil, isotretinoin, leuprolide, menotropins, methotrexate, misoprostol, nafarelin, oral contraceptives, raloxi-fene, ribavirin, statins, temazepam, testosterone, thalidomide, and warfarin
Current FDA pregnancy category: Risk category D
Adequate well-controlled or observational studies in pregnant women have demonstrated a risk to the fetus. However, the benefits of therapy may outweigh the potential risk. For example, the drug may be acceptable if needed in a life-threatening situation or serious disease for which safer drugs cannot be used or are ineffective. Examples: Alcohol, angiotensin-converting enzyme (ACE) inhibitors, angio-tensin receptor blockers (ARBs) in the second and third trimesters, gentamicin, carbamazepine, cyclophosphamide, lithium carbonate, methimazole, mitomycin, nicotine, nonsteroidal anti-inflammatory drugs (NSAIDs) in the third trimester, phenytoin, propylthiouracil, streptomycin, tetracyclines, valproic a
Current FDA pregnancy category: Risk category A
Adequate, well-controlled studies in pregnant women have not shown an increased risk of fetal abnormalities in any trimester of pregnancy Examples Prenatal multivitamins, insulin, levothyroxine, folic acid
Common diseases that benefit from anti-inflammatory therapy include
allergic rhinitis, anaphylaxis, ankylosing spondylitis, contact dermatitis, Crohn's disease, glomerulonephritis, Hashimoto's thyroiditis, peptic ulcer disease, RA, SLE, and ulcerative colitis.
Lee Sutter, 45 years old, is on a PCA pump to manage postop-erative pain related to recent cancer surgery. The PCA is set to deliver a basal rate of morphine of 6 mg/h. As his nurse, you discover Lee to be unresponsive with a respiratory rate of 8 breaths per minute and oxygen saturation of 84%. What follow-up is needed after this time
After these initial steps have been completed and the patient is stabilized, you would inform the healthcare provider of this adverse effect of the mor-phine. A change in the basal rate of the PCA may be needed. Mr. Sutter should also be encouraged to continue deep breathing exercises every hour, and to ambulate regularly.
Current FDA pregnancy category: Risk category B
Animal studies have revealed no evidence of harm to the fetus; however, there are no adequate and well-controlled studies in pregnant women. OR Animal studies have shown an adverse effect, but adequate and well-controlled studies in pregnant women have failed to demonstrate risk to the fetus in any trimester. Examples: Penicillins, cephalosporins, azithromycin, acetaminophen, ibuprofen in the first and second trimesters
Current FDA pregnancy category: Risk category C
Animal studies have shown an adverse effect, and there are no ade-quate and well-controlled studies in pregnant women. OR No animal studies have been conducted, and there are no adequate and well-controlled studies in pregnant women. Examples: Most prescription medicines; antimicrobials, such as clarithromycin, fluoroquinolones, and Bactrim; selective serotonin reuptake inhibi-tors (SSRIs); corticosteroids; and most antihypertensives
A 24-year-old patient reports taking acetaminophen (Tylenol) fairly regularly for headaches. The nurse knows that a patient who consumes excessive acetaminophen per day or regularly consumes alcoholic beverages should be observed for what adverse effect? 1. Hepatotoxicity 2. Renal damage 3. Thrombotic effects 4. Pulmonary damage
Answer: 1 Rationale: Excessive doses of acetaminophen or regular consumption of alcohol may increase the risk of hepatotoxicity when acetaminophen is used. Options 2, 3, and 4 are incorrect. Nephrotoxicity or pulmonary toxicity and thrombotic events are not adverse effects associated specifically with acetaminophen.
Which planned teaching needs for a patient who is to be discharged postoperatively with a prescription for oxycodone with acetaminophen (Percocet) should be included? 1. Refer the patient to a drug treatment center if addiction occurs. 2. Encourage increased fluids and fiber in the diet. 3. Monitor for gastrointestinal bleeding. 4. Teach the patient to self-assess blood pressure.
Answer: 2 Rationale: Opioids such as hydrocodone with acetaminophen (Percocet) slow peristalsis, which can lead to constipation. Increasing fluids and fiber in the diet may help prevent this adverse effect. Options 1, 3, and 4 are incorrect. Drug treatment programs are not needed if the drug is taken as ordered for the time pre-scribed. The drugs should not cause GI bleeding and for most patients will not cause a significant drop in blood pressure.
A patient with diabetes reports increasing pain and numbness in his legs. "It feels like pins and needles all the time, especially at night." Which drug would the nurse expect to be prescribed for this patient? 1. Ibuprofen (Motrin) 2. Gabapentin (Neurontin) 3. Naloxone (Narcan) 4. Methadone
Answer: 2 Rationale: The patient is describing neuro-pathic pain, which is most likely to respond to the adju-vant analgesic gabapentin, an antiseizure drug used for neuropathic pain. Options 1, 3, and 4 are incorrect. Nonopioids, such as ibuprofen, or opioids, such as methadone are less effective at relieving pain that is of neurologic origin. Naloxone is an opioid antagonist and will not relieve the patient's pain. Cognitive Level: Applying; Nursing Process: Planning; Client Need: Physiological Integrity.
A patient with a history of hypertension is to start drug therapy for rheumatoid arthritis. Which drug(s) would be contraindicated, or used cautiously, for this patient? (Select all that apply.) 1. Aspirin 2. Ibuprofen (Advil, Motrin) 3. Acetaminophen (Tylenol) 4. Naproxen (Aleve) 5. Methylprednisolone (Medrol)
Answer: 2, 4, 5 Rationale: NSAIDs such as ibuprofen and naproxen have been shown to increase the risk of serious thrombotic events, MI, and stroke which can be fatal. These drugs should be used cautiously or avoided in patients with HTN. Corticosteroids such as methylpred-nisolone may cause fluid retention, which may increase the patient's blood pressure. Cautious and frequent monitoring will be required if the patient takes this drug. Options 1 and 3 are incorrect. Aspirin or acetaminophen will not increase the patient's blood pressure. Acetamin-ophen would only provide pain relief without treat-ing the underlying inflammation associated with RA
A 16-year-old adolescent is 6 weeks pregnant. The pregnancy has exacerbated her acne. She asks the nurse if she can resume taking her isotretinoin pre-scription, a category X drug. What is the most appro-priate response by the nurse? 1. "Since you have a prescription for isotretinoin, it is safe to resume using it." 2. "You should check with your healthcare provider at your next visit." 3. "Isotretinoin is known to cause birth defects and should never be taken during pregnancy." 4. "You should reduce the isotretinoin dosage by half during pregnancy."
Answer: 3 Rationale: As noted in the question, isotreti-noin is FDA pregnancy category X and is contraindi-cated during pregnancy. It should not be used at all during pregnancy. Options 1, 2, and 4 are incorrect. Continuing to take the drug or taking even half of a dose of a category X drug is contraindicated in preg-nancy due to the known association with birth defects.
The patient has been taking aspirin for several days for headache. During the assessment, the nurse discovers that the patient is experiencing ringing in the ears and dizziness. What is the most appropriate action by the nurse? 1. Question the patient about history of sinus infections. 2. Determine whether the patient has mixed the aspirin with other medications. 3. Tell the patient not to take any more aspirin. 4. Tell the patient to take the aspirin with food or milk.
Answer: 3 Rationale: High doses of aspirin can produce side effects of tinnitus, dizziness, headache, and sweat-ing. These symptoms should be reported to the health-care provider. Options 1, 2, and 4 are incorrect. Sinus infections may cause dizziness if the eustachian tubes are blocked but should not cause tinnitus. The nurse should assess whether any of the patient's medications also contain aspirin, but most OTC combination rem-edies include acetaminophen and not aspirin. Taking aspirin with food or milk may decrease the incidence of GI upset but will not prevent tinnitus.
A patient admitted with hepatitis B is prescribed hydro-codone with acetaminophen (Vicodin), 2 tablets, for pain. What is the most appropriate action for the nurse to take? 1. Administer the drug as ordered. 2. Administer 1 tablet only. 3. Recheck the order with the healthcare provider. 4. Hold the drug until the healthcare provider arrives
Answer: 3 Rationale: Hydrocodone with acetamino-phen (Vicodin) contains acetaminophen, which can be hepatotoxic. This patient has hepatitis B, a chronic liver infection with inflammation, which may affect the metabolism of the drug. Options 1, 2, and 4 are incor-rect. The drug should not be given as ordered and the patient may require pain relief before the healthcare provider arrives. It is not within the scope of practice for a nurse to determine the dosage of medication unless the nurse has received advanced specialty practice
An older adult patient has arthritis in her hands and takes several prescription drugs. Which statement by this patient requires further assessment by the nurse? 1. "My pharmacist puts my pills in screw-top bottles to make it easier for me to take them." 2. "I fill my prescriptions once per month." 3. "I care for my 2-year-old grandson twice a week." 4. "My arthritis medicine helps my stiff hands."
Answer: 3 Rationale: Medications should be stored in child-resistant containers and out of reach of children. Patients with arthritic hands may request special easy-to-open medication containers to make self-administration easier. These two situations may be in conflict if older adults and children are present in the same home. Toddlers are at risk for poisoning. Options 1, 2, and 4 are incorrect. Although easy-open bottles or filling a larger quantity of medication prescriptions may assist the older adult with medication routines, they present the risk of poisoning to the young child if the drugs are consumed.
The nurse is preparing to give an oral medication to a 6-month-old infant. How should this drug be administered? 1. By placing the medication in the next bottle of formula 2. By mixing the medication with juice in a bottle 3. By placing the medicine dropper in the inner cheek, allowing time for the infant to swallow 4. By placing the medication toward the back of the mouth to avoid having the infant immediately spit out the medication
Answer: 3 Rationale: The medication should be placed on the side of the mouth in the inner cheek and ade-quate time given for the infant to swallow to prevent aspiration. Options 1, 2, and 4 are incorrect. Medica-tions should not be mixed with formula or foods to avoid the infant's refusing the foods later. Medication should not be placed near the back of the mouth to avoid the risk of aspiration.
The nurse administers morphine 4 mg IV to a patient for treatment of severe pain. Which assessments require immediate nursing interventions? (Select all that apply.) 1. The patient's blood pressure is 110/70 mmHg. 2. The patient is drowsy. 3. The patient's pain is unrelieved in 15 minutes. 4. The patient's respiratory rate is 10 breaths per minute. 5. The patient becomes unresponsive.
Answer: 3, 4, 5 Rationale: Opioids may cause respira-tory depression, particularly with the first dose given. The patient's respiratory rate should remain above 12 breaths per minute. Although the patient may also become drowsy, he or she should not become unre-sponsive after administration of morphine sulfate. Because of the rapid onset of drugs when given IV, if the patient's pain is unrelieved in 15 minutes, the pro-vider should be notified. Options 1 and 2 are incorrect. Drowsiness is a common adverse effect of opioids, and 110/70 mmHg is within normal range for blood pres-sure.
To reduce the chance of duplicate medication orders for the older adult returning home after surgery, what actions should the nurse take? (Select all that apply.) 1. Call in all prescriptions to the patient's phar-macies rather than relying on paper copies of prescriptions. 2. Give all prescriptions to the patient's family member. 3. Take a medication history, including all OTC and prescription medications, and a pharmacy history with each patient visit. 4. Work with the patient's healthcare provider to limit the number of prescriptions. 5. Perform a medication reconciliation before send-ing the patient home.
Answer: 3, 5 Rationale: With each patient visit, the nurse should take a medication history of all OTC and pre-scription medications, noting any new medications not previously mentioned. A pharmacy history will draw attention to the possibility that the patient is obtaining medications from more than one pharmacy, a potential problem in polypharmacy. Performing a medication reconciliation before the patient goes home will com-pare the initial medication history, any new prescrip-tions ordered, and note any duplications, omissions, dosage changes, or questions that need to be clarified. Options 1, 2, and 4 are incorrect. Calling in a medication does not necessarily prevent duplicate doses, especially if more than one pharmacy is used by the patient. A patient's family member may not know what medica-tions the patient is taking or whether additional phar-macies have been used. The number of prescriptions may be appropriate for the patient's condition.
To reduce the effect of a prescribed medication on the infant of a breastfeeding mother, how should the nurse teach the mother to take the medication? 1. At night 2. Immediately before the next feeding 3. In divided doses at regular intervals around the clock 4. Immediately after breastfeeding
Answer: 4 Rationale: Administration immediately after breastfeeding allows as much time as possible for the medication to be excreted from the mother's body prior to the next feeding. Options 1, 2, and 3 are incorrect. These other options do not provide enough time for the medication to be excreted and may result in more drug being secreted in the mother's milk.
The nurse is counseling a mother regarding antipyretic choices for her 8-year-old daughter. When asked why aspirin is not a good drug to use, what should the nurse tell the mother? 1. It is not as good an antipyretic as is acetaminophen. 2. It may increase fever in children under age 10. 3. It may produce nausea and vomiting. 4. It increases the risk of Reye's syndrome in children under 19 with viral infections.
Answer: 4 Rationale: Aspirin and salicylates are asso-ciated with an increased risk of Reye's syndrome in children under 19, especially in the presence of viral infections. Options 1, 2, and 3 are incorrect. Acet-aminophen is not significantly different from aspirin or salicylates for the treatment of fever. Use of aspi-rin or salicylates should not increase fever although it may cause nausea or vomiting related to GI irri-tation; however, it is not contraindicated in children specifically for this reason.
The nurse is caring for several patients who are receiv-ing opioids for pain relief. Which patient is at the highest risk of developing hypotension, respiratory depression, and mental confusion? 1. A 23-year-old female, postoperative ruptured appendix 2. A 16-year-old male, post-motorcycle crash injury with lacerations 3. A 54-year-old female, post-myocardial infarction 4. An 86-year-old male, postoperative femur fracture
Answer: 4 Rationale: Older adult patients are at high-est risk for hypotension, respiratory depression, and increased incidence of adverse CNS effects, such as con-fusion. Options 1, 2, and 3 are incorrect. Most 23-year-old patients can tolerate opioids without adverse effects. Individuals who suffer from traumatic injury may receive narcotic analgesia. However, caution should be taken if the individual has also experienced any type of head injury. Opioids are often used with individuals who suffer MI. No adverse effects such as hypotension or respiratory depression are usually pres-ent if the dose is appropriate for the size of the patient.
While educating the patient about hydrocortisone (Cortef), the nurse would instruct the patient to con-tact the healthcare provider immediately if which of the following occurs? 1. There is a decrease of 1 kg (2 lb) in weight. 2. There is an increase in appetite. 3. There is tearing of the eyes. 4. There is any difficulty breathing.
Answer: 4 Rationale: Side effects that need to be reported immediately include difficulty breathing; heartburn; chest, abdomen, joint, or bone pain; nosebleed; blood in sputum when coughing, vomitus, urine, or stools; fever; chills or signs of infection; increased thirst or urination; fruity breath odor; falls; or mood swings. Options 1, 2, and 3 are incorrect. An increase in weight due to fluid retention may occur but not a decrease in weight. An increase in appetite is a common effect from corticosteroids. An increase in tearing of the eyes is not associated with corticosteroids.
The nurse is admitting a patient with rheumatoid arthritis. The patient has been taking prednisone for an extended time. During the assessment, the nurse observes that the patient has a very round moon-shaped face, bruising, and an abnormal contour of the shoulders. What does the nurse conclude based on these findings? 1. These are normal reactions with the illness. 2. These are probably birth defects. 3. These are symptoms of myasthenia gravis. 4. These are symptoms of adverse drug effects from the prednisone.
Answer: 4 Rationale: Signs and symptoms of bruising and a characteristic pattern of fat deposits in the cheeks (moon face), shoulders, and abdomen are common adverse effects associated with long-term prednisone use. Options 1, 2, and 3 are incorrect. These symptoms are not indicative of the disease process, birth defects, or myasthenia gravis.
The emergency department nurse is caring for a patient with a migraine. Which drug would the nurse anticipate administering to abort the patient's migraine attack? 1. Morphine 2. Propranolol (Inderal) 3. Ibuprofen (Motrin) 4. Sumatriptan (Imitrex)
Answer: 4 Rationale: Triptans such as sumatriptan (Imitrex) are used to abort a migraine attack. Options 1, 2, and 3 are incorrect. Morphine and other narcot-ics are not effective in aborting a migraine. Proprano-lol (Inderal) and ibuprofen (Motrin) may be used as adjunctive therapy in migraine therapy but will not stop a headache from occurring. Cognitive Level: Ana-lyzing. Nursing Process: Planning. Client Need: Physi-ological Integrity
A nurse is administering a liquid medication to a 15-month-old child. What are the most appropri-ate approaches to medication administration by the nurse? (Select all that apply.) 1. Tell the child that the medication tastes just like candy. 2. Mix the medication in 8 oz of orange juice. 3. Ask the child if she would like to take her medica-tion now. 4. Sit the child up, hold the medicine cup to her lips, and kindly instruct her to drink. 5. Offer the child a choice of cup in which to take the medicine.
Answer: 4, 5 Rationale: Toddlers may resist taking med-ications. Short explanations followed by immediate (kind but firm) drug administration are best. Giving small choices, such as which cup to use to take a medi-cation, allows the child some sense of control. Options 1, 2, and 3 are incorrect. For safety reasons, children should not be told that medicine is candy. A toddler is not able to make a decision regarding whether to take a medicine or not. When medication is mixed with liq-uids or other food products, a small amount of liquid should be used; 8 oz may be too much. C
It is important for nurses to recognize drugs that are most likely to cause drug-induced fever, including those in the following list:
Anti-infectives Selective serotonin reuptake inhibitors (SSRIs). Use of SSRIs such as paroxetine (Paxil) Conventional antipsychotic drugs. Drugs such as chlor-promazine (Thorazine). Volatile anesthetics and depolarizing neuromuscular blockers. Immunomodulators Cytotoxic drugs. Drugs that cause neutropenia
A 22-year-old pregnant patient is diagnosed with a kidney infection, and an antibiotic is prescribed. The patient asks the nurse whether the antibiotic is safe to take. What factors are considered when a drug is prescribed for a patient who is pregnant?
Antibiotics and other drugs may be required during pregnancy. The healthcare provider will consider the gestational age of the fetus, the pregnancy category of the drug being considered for use, and other factors, such as allergies that the patient may have that would cause the drug to be contraindicated for use.
Lee Sutter, 45 years old, is on a PCA pump to manage postop-erative pain related to recent cancer surgery. The PCA is set to deliver a basal rate of morphine of 6 mg/h. As his nurse, you discover Lee to be unresponsive with a respiratory rate of 8 breaths per minute and oxygen saturation of 84%. What should be your first response?
As the nurse, you would call for a rapid response and initially manage the patient's airway, breathing, and circulation (ABCs) by opening the airway and pro-viding oxygen support and then stop the PCA pump. Although the nurse's first reaction may be to go directly to the PCA to stop the medication, it is important ini-tially to manage the patient's airway before stopping the PCA because it is unknown how long the patient has been hypoxic.
Although aspirin and ibuprofen have similar efficacy at relieving pain and inflammation and share certain side effects, there are important differences.
Aspirin has a greater effect on blood coagulation than ibuprofen; thus, aspirin is used for the prophylaxis of cardiovascular events but ibu-profen is not. Aspirin poses a greater risk for GI bleeding, especially at high doses. The ibuprofen-like drugs are avail-able in a wider variety of formulations, including parenteral and extended-release forms.
Nonsteroidal Anti-Inflammatory Drugs
Aspirin, ibuprofen, naproxen, indomethacin Used for mild-moderate pain, fever, inflammation Inhibits prostaglandin synthesis and aspirin inhibits platelet aggregration Side effects: GI upset, GI bleeding, renal toxicity, rash, tinnitus (aspirin) Never give aspirin to child with fever Do not give in peptic ulcer disease or bleeding disorders Avoid alcohol Monitor for salicylism: sweating, dizziness, headache, tinnitus, respiratory alkalosis
Centrally acting drugs
are drugs that exert effects directly within the brain and spinal cord. Acetaminophen is a centrally acting nonopioid analgesic.
A@ fibers
are thinly wrapped in myelin, a fatty substance that speeds up nerve transmission. They signal sharp, well-defined pain.
A parent brings a 4-year-old child into the pediatrician's office for symptoms of the flu. The child has a fever of 102°F (38.8°C), rhi-nitis, a nonproductive cough, and reports "feeling sore" (general malaise). The parent tells the nurse that the child has been given "chewable children's Tylenol" for the fever, and an OTC cough and cold remedy for the rhinitis and cough. What additional informa-tion should the nurse gather at this time?
Because many OTC cough and cold remedies contain acet-aminophen, the nurse would want to determine the amount of dosage in the children's chewable Tylenol, as well as the type of OTC remedy given and whether it contains acet-aminophen. This scenario prevents an excellent opportunity to teach the parent that OTC remedies are often combination products and there is a risk of giving additional acetamino-phen when products are combined. Because the parent is concerned about the health of the child, a nonjudgmental attitude is important when teaching the parent about a potential overdose of acetaminophen.
During Pregnancy:: EXCRETION
By the third trimester of pregnancy, blood flow through the mother's kidneys increases by over 50%. This increase has a direct effect on renal plasma flow, glomerular filtration rate, and renal tubular absorption. Thus, drug excretion rates may be increased, and doses of many medications may need to be adjusted
Many drug classifications may be used to reduce inflammation, including the NSAIDs, COX-2 inhibitors, and corticosteroids. Why are corticosteroids not routinely used for reducing inflammation? S
Corticosteroids have a number of serious adverse effects that limit their therapeutic usefulness. These include suppression of the normal functions of the adrenal gland (adrenal insufficiency), hyperglycemia, mood changes, cataracts, peptic ulcers, electrolyte imbalances, and osteoporosis.
Child categories
infancy: 0 to 12 months toddler 1 to 3 years Preschool 3 to 5 years school age 6 to 12 years
NSAIDs block inflammation by
inhibiting cyclooxygenase (COX), the key enzyme in the biosynthesis of prostaglan-dins.
Potential fetal consequences include
intrauterine fetal death, physical malformations, growth impairment, behav-ioral abnormalities, and neonatal toxicity.
Tobacco use has many effects on the mother and baby. These include the following:
Difficulty in getting pregnant Increased incidence of miscarriage • Increased risk of intrauterine growth restriction (IGR) and low birthweight infants. Increased risk of premature delivery. Increased risk for sudden infant death syndrome (SIDS). Increased risk for certain birth defects, such as cleft lip or cleft palate Long-term effects, such as lower levels of focused attention during infancy.
Inflammation
is a nonspecific defense system of the body. Through the process of inflammation, a large number of potentially damaging chemicals and microorganisms may be neutralized.
Prochlorperazine (Compazine) is an antiemetic drug in the pheno-thiazine class that may be prescribed to decrease the nausea and vomiting caused by opioids. what conditions are drugs in the phenothiazine class used to treat? Considering the adverse effects of the phenothiazines, what additive effects are more likely to occur when taking a phenothiazine together with an opioid analgesic?
Drugs in the phenothiazine class are considered first-generation or conventional antipsychotics and are used to treat serious mental disorders, such as schizophrenia. When given with an opioid analgesic, additive effects may include increased sedation, hypotension, and anticholinergic effects, such as urinary retention and constipation.
Pain
is a physiologic and psychologic experience charac-terized by unpleasant feelings, usually associated with trauma or disease.
A teratogen
is a substance, organism, or physical agent to which an embryo or fetus is exposed that produces a per-manent abnormality in structure or function, causes growth retardation, or results in death.
Older adults metabolism
Enzyme production in the liver decreases and the visceral blood flow is diminished, resulting in reduced hepatic drug metabolism. The decline in hepatic function reduces first-pass metabolism.
Preferred IV sites for infants
Feet and scalp veins
Celecoxib (Celebrex)
is the representative COX-2 inhibitor. Other COX-2 inhibitors. Because the COX-2 enzyme is more specific for the synthesis of inflammatory prostaglandins, the selective COX-2 inhibitors provide more specific and peripheral pain relief.
substance P
is thought to be responsible for continuing the pain message,
During Pregnancy: ABSORPTION
Hormonal changes as well as the pressure of the expanding uterus on the blood supply to abdomi-nal organs Increased levels of progesterone can delay gastric emptying, Gastric acidity is also decreased, Progesterone causes changes in the respiratory system during pregnancy—increased tidal volume and pulmonary vasodilation—that may cause inhaled drugs to be absorbed to a greater extent.
Buprenorphine
is used early in opioid abuse therapy to prevent opioid withdrawal symptoms
After a child has walked for about a year, the ventrogluteal site may be used for IM injections because
it causes less pain than the vastus lateralis site.
Health impairments related to cardiovascular disease, hypertension, obesity, arthritis, cancer, hyperlipidemia, digestive disorders, erectile dysfunction, and anxiety begin to sur-face in ---------------age group
late middle age.
Commonly used drugs to blocks the euphoric effect of opioids are
methadone, buprenorphine, and naltrexone
Opioids exert their actions by interacting with at least four major types of receptors:
mu, kappa, delta, and an opioid-like receptor called nociceptin or orphanin FQ peptide.
Medication reconciliation
Is the process of comparing a patient's current medication orders with all of the medications that the patient has been taking to avoid duplications, omissions, dosage differ-ences, or drug interactions.
Triggers for migraines include
nitrates, monosodium glutamate (MSG), red wine, perfumes, food additives, caffeine, chocolate, and aspartame
In general, drugs that are water soluble, ionized, or bound to plasma proteins are --------------likely to cross the placenta. LESS or MORE
LESS
Opioids are narcotic substances, meaning that they can pro-duce
numbness or stupor-like symptoms.
Opioid antagonists are used to reverse the severe symp-toms of opioid intoxication such as
sedation or respiratory distress.
The most common needs for the pharmacotherapy of teens are for
skin problems, headaches, menstrual symp-toms, eating disorders, contraception, alcohol and tobacco use, and sports-related injuries.
older adults excretion
Older adults have reduced renal blood flow, glomerular filtration rate, active tubular secretion, and nephron function. This decreases drug excretion for drugs that are eliminated by the kidneys. When excre-tion is reduced, serum drug levels and the potential for toxicity markedly increase.
Interactions of Morphine
Morphine interacts with several drugs. For exam-ple, concurrent use of CNS depressants, such as alcohol, other opioids, general anesthetics, sedatives, and antidepressants such as monoamine oxidase inhibitors (MAOIs) and tricyclic antidepressants, potentiate the action of opiates, increasing the risk of severe respiratory depression and death. Kava, valerian, and St. John's wort may potenti-ate the effect of morphine. Treatment of Overdose: IV administration of naloxone is the specific treatment. Other treatments include activated charcoal, a laxative, and a counteracting narcotic antagonist. Multiple doses may be needed.
Contraindications of Morphine
Morphine may intensify or mask the pain of gallbladder disease, due to biliary tract spasms. Morphine should also be avoided in cases of acute or severe asthma, GI obstruction, and severe liver or kidney impairment.
Because there are multiple opioid receptors, three general types of drug-receptor interactions are possible:
Opioid agonist. Drugs that activate both mu and kappa receptors; for example, morphine and codeine Opioid antagonist. Drugs that block both mu and kappa receptors; for example, naloxone (Evzio, Narcan) Mixed opioid agonist-antagonist. Drugs that occupy one receptor and block (or have no effect) on the other; for example, pentazocine (Talwin), butorphanol (Stadol), and buprenorphine (Buprenex
As the nurse in the neighborhood, your neighbors turn to you for medication advice. Carlos Alvera, your new next-door neighbor, is requesting advice for medication to take for occasional headache pain. He asks you about acetaminophen (Tylenol) because he knows that the drug is available OTC. What advice will you provide Mr. Alvera about his choice of acetaminophen?
Patients sometimes consider OTC medications to be safer than prescription drugs. You would teach Mr. Alvera to take the recommended dose of acet-aminophen (Tylenol) and not exceed the amount or frequency recommended. You should also caution him about the use of additional cough and cold medica-tions because they often contain acetaminophen and may lead to an overdose. If an additional product is needed, he should read the labels and either choose one without acetaminophen, or stop taking his usual acet-aminophen and take the cough-cold medication alone.
Corticosteroids, however, affect inflammation by multiple mechanisms. They have the abil-ity to
suppress histamine release and can inhibit certain functions of phagocytes and lymphocytes.
types of Opioids
Pure agonist: Morphine, codeine. both mu and kappa receptors Mixed agonist: Buprenorphine; mu activate and kappa blocked Pentazocine Butorphanol; mu blocked and kappa activated. Opioid antagonist: Naloxone; both mu and kappa are blocked.
All category D and X drugs should be avoided during pregnancy due
to their potential for causing serious birth defects.
CHAPTER 18 DRUGS FOR CONTROL OF PAIN
STARTS HERE
CHAPTER 33 DRUGS FOR INFLAMATION AND FEVER
STARTS HERE
Typical Pain Ladder for Pain Management
STEP 1: Adjunctive therapy Nonopioid analgesics NSAIDS STEP 2: Adjunctive therapy Weak opioids STEP 3:Adjunctive therapy Strong opioids STEP 4:Special techniques and procedures Targeted Therapy
A 64-year-old patient has had a long-standing history of migraines as well as coronary artery disease, type 2 diabetes, and hypertension. On review of the medical history, the nurse notes that this patient has recently started on sumatriptan (Imitrex), prescribed by the patient's neurologist. What intervention and teaching is appropriate for this patient?
Sumatriptan (Imitrex) is not recommended for patients with CAD, diabetes, or HTN because of the drug's vasoconstrictive properties. The nurse should refer the patient to the healthcare provider for review of medications and possible adverse reactions related to sumatriptan.
Antimigraine Drugs
TRIPTANS: almotriptan (Axert), eletriptan (Relpax) ERGOT ALKALOIDS: dihydroergotamine (D.H.E. 45, Migranal), ergotamine (Ergostat)
Older adults distribution
The aging liver produces less albumin, resulting in decreased plasma protein-binding ability and increased levels of free drug in the bloodstream. The decline in lean body mass and total body water leads to an increased concentration of water-soluble drugs because the drug is distributed in a smaller volume of water. less body water, making the effects of dehydration more dramatic and increasing the risk for drug toxicity. Increased body fat in the older patient pro-vides a larger storage compartment for lipid-soluble drugs and vitamins. The aging cardiovascular system, moreover, has decreased cardiac output and less efficient blood circulation, both of which slow drug distribution.
Fetal period.
The fetal period is from 9 to 40 weeks post-conception or until birth. During this time, there is continued growth and maturation of the fetus's organ systems. Blood flow to the placenta increases and pla-cental vascular membranes become thinner. Such alter-ations maximize the transfer of substances from the maternal circulation to the fetal blood.
During Pregnancy: DISTRIBUTION & METABOLISM
The increased blood volume in the mother causes dilution of drugs and decreases plasma protein concentrations, affecting drug distribution Blood flow to the uterus, kidneys, and skin is increased whereas flow to the skel-etal muscles is diminished. Fat-soluble drugs are distributed into the lipid-rich breast milk and may be passed to the lactating infant.
An 8-month-old child is prescribed acetaminophen (Tylenol) elixir for management of fever. She is recov-ering from gastroenteritis and is still having several loose stools each day. The child spits some of the elixir on her shirt. Should the nurse repeat the dose? What are the implications of this child's age and physical condition for oral drug administration?
The nurse should consult with the pharmacist regard-ing the need to repeat the dose. Many oral elixirs are absorbed to some degree in the mucous membranes of the oral cavity. Therefore, the nurse may not need to repeat the dose. The nurse should consider using an oral syringe to accurately measure and administer medications to infants. The syringe tip should be placed in the side of the mouth, not forced over the tongue. Conditions affecting the GI tract, such as gastroenteri-tis, can affect drug absorption because of their effect on increasing peristalsis.
The mother of a 7-year-old child calls the health-care provider's office stating that her daughter has a temperature of 38.3°C (101°F). She states that the child is also complaining of being tired and "achy" all over. The mother asks how much aspirin she can give her daughter for her temperature. How should the nurse respond?
The nurse should educate the mother that aspirin and aspirin-containing products should not be given to children younger than age 18. These drugs have been associated with an increased risk of Reye's syndrome, a potentially fatal adverse reaction. Acetaminophen (Tylenol) is the antipyretic of choice for treating most fevers. The nurse should also question the mother regarding the length and severity of symptoms for pos-sible referral to the healthcare provider
A 58-year-old woman with a history of a recent MI is on beta-blocker and anticoagulant therapy. The patient also has a history of arthritis and during a recent flare-up began taking aspirin because it helped control pain in the past. What teaching or recommendation would the nurse have for this patient?
The patient should be taught not to take any medica-tion, including OTC medications, without the approval of the healthcare provider. This patient is taking an anticoagulant, and aspirin increases bleeding time. The patient needs to be taught how to recognize the signs and symptoms of bleeding related to the antico-agulant therapy. The patient should review with the healthcare provider all her medications. Possibly, her anti-inflammatory medication can be changed from aspirin to another drug for treatment of arthritis
A 64-year-old patient with diabetes is on prednisone for rheumatoid arthritis. The patient has recently been admitted to the hospital for stabilization of hypergly-cemia. What are the nurse's primary concerns when caring for this patient?
The primary current concern is the hyperglycemia—an adverse effect of the prednisone that can become serious when the patient has diabetes. Glucose levels should be monitored and a potential change in antidia-betes medication may be required while the patient is taking the prednisone. Blood pressure must be moni-tored for potential HTN, which is related to sodium and fluid retention, and the client is also at high risk for infection while on prednisone because of suppression of the immune system.
An 86-year-old male patient who lives with his son and daughter-in-law at home is confused and anxious, and an antianxiety drug has been ordered. What con-cerns might the nurse have about pharmacotherapy for this patient?
The principal complications of drug therapy in the older adult population are due to degeneration of organ systems, multiple and severe illness, polyphar-macy, and unreliable adherence. All pharmacokinetic processes from absorption through excretion will be altered in this age patient. The nurse would want to assess for the presence of other illnesses and diseases, whether the patient is on other drugs that may interact with the prescribed medication, and whether there is a family member or caregiver who will be able to manage the medications at home.
anaphyaxis
The rapid release of the inflammatory mediators on a large scale throughout the body is responsible for anaphylaxis, a life-threatening allergic response that may result in shock and death. A number of chemicals, insect stings, foods, and some therapeutic drugs can cause this widespread release of histamine from mast cells if the per-son has an allergy to these substances.
The two major classes for terminating acute migraines,
The triptans and the ergot alkaloids, are both serotonin (5-HT) ago-nists.
Advantages of Opioids with Mixed Agonist-Antagonist Activity
Their advantages are that they cause less respiratory depres-sion, have a lower potential for dependence, and have less intense withdrawal symptoms.
Ibuprofen (Advil, Motrin, others)
Therapeutic Class: Analgesic, anti-inflammatory drug, antipyretic. Pharmacologic Class: NSAID. Actions and Uses Ibuprofen is an older drug that is prescribed for the treatment of mild to moderate pain, fever, and inflammation. Adverse Effects When used intermittently at low to moderate doses, the adverse effects of ibuprofen are generally mild and include nausea, heartburn, epigastric pain, and dizziness. Black Box Warning: NSAIDs may cause an increased risk of serious thrombotic events, MI, and stroke, which can be fata. Contraindications: Patients with active peptic ulcers should not take ibuprofen. This drug is also contraindicated in patients with significant CKD or hepatic impairment and in those who have a syndrome of nasal polyps, angioedema, or bronchospasm due to aspirin or other NSAID use. It should be used cautiously in patients who have HF, serious HTN, or a history of stroke or MI. Interactions Drug-Drug: Because ibuprofen can affect platelet function, its use should be avoided when taking anticoagulants and other coagulation modifiers. The antihypertensive action of diuretics, beta blockers, and ACE inhibitors may be reduced if taken with ibuprofen. Herbal/Food: Feverfew, garlic, ginger, or ginkgo may increase the risk of bleeding.
Prednisone
Therapeutic Class: Anti-inflammatory drug Pharmacologic Class: Corticosteroid Actions and Uses: is occasionally used to terminate acute broncho-spasm in patients with asthma and as an antineoplastic drug for patients with certain cancers, such as Hodgkin's disease, acute leukemia, and lymphomas. It is available in tablet and oral solution forms. Onset 1-2hrs. Peak 1-2hrs Duration 24-36hrs Adverse Effects: Long term use may result in Cushing's syndrome, a condition that includes hyperglycemia, fat redistribution to the shoulders and face, muscle weakness, bruising, and bones that easily fracture. Contraindications: Patients with active viral, bacterial, fungal, or protozoan infections should not take prednisone. Interactions Drug-Drug: Azole antifungal drugs increase the effects of pred-nisone, and their concurrent use should be avoided. Prednisone will decrease the effectiveness of statins. Because prednisone can raise blood glucose levels, patients with diabetes may require an adjustment in the doses of insulin or oral hypoglyce-mic drugs. Prednisone decreases the effectiveness of vaccines. Herbal/Food: Herbal supplements, such as aloe, buckthorn, and senna, may increase potassium loss. Licorice may potentiate the effect of corticosteroids. St. John's wort may decrease prednisone levels.
Sumatriptan (Imitrex, Onzetra)
Therapeutic Class: Antimigraine drug Pharmacologic Class: Triptan; 5-HT (serotonin) receptor drug; vasoconstrictor of intracranial arteries. Actions and Uses: The triptans act by causing vasoconstriction of cranial arteries. This vasocon-striction is moderately selective and does not usually affect overall blood pressure. Pregnancy category C. Adverse Effects: Some dizziness, drowsiness, or a warming sensation may be experienced after taking sumatriptan; Contraindications: Sumatriptan is contraindicated in patients with acute kidney injury (AKI) or hepatic impairment. Interactions Drug-Drug: Sumatriptan interacts with several drugs. For example, an increased effect may occur when taken with MAOIs and selective serotonin reuptake inhibitors (SSRIs). Fur-ther vasoconstriction can occur when taken with ergot alkaloids and other triptans. Herbal/Food: Ginkgo, ginseng, echinacea, and St. John's wort may increase triptan toxicity.
Acetaminophen (Tylenol, others)
Therapeutic Class: Antipyretic and analgesic Pharmacologic Class: Centrally acting COX inhibitor. Actions and Uses: Acetaminophen reduces fever by direct action at the level of the hypothalamus and dilation of peripheral blood vessels, which enables sweating and dissipation of heat. has no anti-inflammatory properties; Onset 30-60min Peak 0.5-2hrs Duration 4-6hrs Adverse Effects: Acetaminophen is generally safe, and adverse effects are uncom-mon at therapeutic doses. The risk for adverse effects is dose related and increases with long-term use. Acute acetaminophen poisoning is very serious. Symptoms include anorexia, nausea, Contraindications: Contraindications include hypersensitivity to acetaminophen or phenacetin and chronic alcoholism. Interactions: Drug-Drug: Acetaminophen inhibits warfarin metabolism, causing the anticoagulant to accumulate to toxic levels, resulting in potential bleeding. Ingestion of this drug with alcohol or other hepatotoxic drugs, such as phenytoin or barbiturates, is not recommended because of the possibility of liver failure from hepatic necrosis. Herbal/Food: The patient should avoid taking herbs that have the potential for liver toxicity, including comfrey, coltsfoot, and chaparral. Treatment of Overdose: The specific treatment for overdose is the oral or intravenous (IV) administration of N-acetylcysteine (Acetadote) as soon as possible after the overdose. This drug protects the liver from toxic metabolites of acetaminophen.
Naloxone (Evzio, Narcan)
Therapeutic Class: Drug for treatment of acute opioid overdose and misuse Pharmacologic Class: Opioid receptor antagonist. Actions and Uses: Given IV, it begins to reverse opioid-initiated CNS and respiratory depression within minutes. It is occasionally given as adjunctive therapy to reverse hypotension caused by sep-tic shock. Adverse effects: Naloxone itself has minimal toxicity. However, reversal of the effects of opioids may result in rapid loss of analgesia, increased blood pressure, tremors, hyperventilation, nausea and vomiting, and drowsiness. Contraindications: Naloxone should not be used for respira-tory depression caused by nonopioid medications. Interactions Drug-Drug: Drug interactions include a reversal of the analge-sic effects of opioid agonists and mixed agonist drugs. Herbal/Food: Echinacea may increase the risk of hepatotoxicity. Treatment of Overdose: Naloxone overdose requires the use of oxygen, IV fluids, vasopressors, and other supportive measures as indicated. These treatments may be useful in combination drug overdoses (for example, pentazocine with naloxone [Talwin NX]).
nocicep-tor pain
This is Injury to tissues. This type of pain may be further subdivided into somatic pain, which produces sharp, localized sensations in the body, or visceral pain, which produces generalized dull and internal throbbing or aching pain. The term nociceptor refers to activation of receptor nerve endings that receive and transmit pain signals to the central nervous system (CNS). N
A patient has Tylenol #3 with codeine ordered. When opening the medication dispensing system, the cassette for Tylenol #3 is empty, but Tylenol #2 is available. Consulting a drug guide as needed, why would it be inappropriate for the nurse to give two Tylenol #2 tablets in place of one Tylenol #3?
Tylenol #3 contains 30 mg of codeine with 300 mg of acet-aminophen. Tylenol #2 contains 15 mg of codeine with 300 mg of acetaminophen. While giving two Tylenol #2 tablets will provide the same 30-mg dose of codeine, it doubles the amount of acetaminophen. This deviates from the original order and should not be given without consulting with the prescriber.
Which site is preferred for IM injections for infants
Vastus lateralis
Preimplantation period.
Weeks 1 to 2 of the first trimes-ter are known as the preimplantation period. Before implantation, the developing embryo has not yet estab-lished a physical connection to the mother. This is some-times called the "all-or-none" period because exposure to a teratogen either causes death of the embryo or has no effect. Drugs such as nicotine, however, can create a negative environ-ment for the embryo and potentially cause intrauterine growth retardation.
General recommendations regarding pharmacotherapy during lactation are as follows:
When feasible, pharmacotherapy should be postponed until the baby is weaned. If possible, administer the drug immediately after breastfeeding, or when the infant will be sleeping for an extended period. Drugs with a shorter half-life are preferable. Whenever possible, drugs with high protein-binding ability should be selected because they are not secreted as readily to the milk
patient-controlled analgesia (PCA).
With a PCA pump, patients are able to self-medicate by pressing a limited rate-controlled button. Safe levels of scheduled pain medication are delivered with an infusion pump. Morphine is the opioid usually used for PCA; how-ever, fentanyl or hydromorphone may be used.
Neuropathic pain responds well to
adjuvant analgesics, such as antisei-zure drugs and antidepressants.
As the nurse in the neighborhood, your neighbors turn to you for medication advice. Carlos Alvera, your new next-door neighbor, is requesting advice for medication to take for occasional headache pain. He asks you about acetaminophen (Tylenol) because he knows that the drug is available OTC. What additional information will you gather from Mr. Alvera that will be important to cover when teaching him about acetaminophen?
You would also assess Mr. Alvera for a history of liver conditions such as hepatitis and discuss whether he drinks alcoholic beverages and the amount. Acetamino-phen can be hepatotoxic and a history of liver disease may represent a contraindication to the use of the drug. Drinking more than two alcoholic beverages per day for men, one for women, increases the risk of hepa-totoxicity from the acetaminophen, and another OTC medication may be preferable to the acetaminophen if the patient drinks more than the recommended limit.
Lee Sutter, 45 years old, is on a PCA pump to manage postop-erative pain related to recent cancer surgery. The PCA is set to deliver a basal rate of morphine of 6 mg/h. As his nurse, you discover Lee to be unresponsive with a respiratory rate of 8 breaths per minute and oxygen saturation of 84%. What do you anticipate will be needed after that initial response?
You would anticipate the need to administer IV nalox-one (Evzio, Narcan), which is a narcotic antagonist.
High doses of ASPIRIN may produce salicylism, which is
a syndrome that includes symptoms such as tinnitus (ringing in the ears), dizziness, headache, and excessive sweating.
NSAIDs inhibit
cyclooxygenase (COX), an enzyme responsible for the formation of prostaglandins.
The principal complications of drug therapy in the older adult population are due to
degeneration of organ systems, multiple and severe illness, polypharmacy, and unreliable adherence.
The activity of substance P may be affected by other neurotransmitters released from neurons in the CNS. One group of these neurotransmitters, called endogenous opioids, includes
endorphins, dynorphins, and enkephalins.
The fetal membranes contain ----------------- that detoxify certain substances as they attempt to cross the membrane.
enzymes
Pregnancy registries
help identify medications that are safe to be taken during pregnancy. These registries gather infor-mation from women who took medications during preg-nancy.
Chemical mediators of inflammation include
histamine, leukotrienes, bradykinin, complement, and prostaglandins
Risk factors for aspirin-induced GI bleeding include
history of peptic ulcers, age greater than 60, use of anticoagulants or corticosteroids, Helicobacter pylori infection, smoking, and use of alcohol.
There are some serious conditions, how-ever, that may require pharmacotherapy in patients who are pregnant or lactating. For examples are
if the patient has epilepsy, hypertension, or a psychiatric disorder prior to the pregnancy, infections, UTI, STI
Adverse effects of Opioids
including nausea, vomiting, consti-pation, sedation, and respiratory depression.
Interactions may occur between fish oil supplements and aspirin, other NSAIDs, and anticoagulants. Although rare, such interactions might be manifested by
increased susceptibility to bruis-ing, nosebleeds, hemoptysis, hematuria, and blood in the stool.