Pharm Exam 2

Protein bound drug principles

- drug protein complexes are large molecules - most drug guides give the percentage of the drug bound to protein - more protein bound= increased half life - If pt is taking multiple highly protein bounds meds, monitor for adverse reactions

Antipsychotic prototypes

- haloperidol (Haldol) - risperidone (Risperdal)

CYP450

- hepatic microsomal enzyme family - located in the liver, performs most drug metabolism - explains why individuals may respond differently than expected to a drug

grapefruit juice effect

- inhibits drug metabolism - CYP3A4 - effect can last 3 days - no effect on IV

Anticonvulsant prototypes

- levetriacetam (Keppra) - gabapentin (Neurontin)

Disadvantages of IM and SQ administration

- painful - inconvenient - irreversible - possible injury or hematoma

elderly metabolism considerations

-Aging liver produces fewer microsomal enzymes, affecting drug metabolism -Reduced blood flow to the liver -Decreased liver mass -All of these factors lead to longer half-life of many medications, creating drug accumulation

Lorazepam (Ativan) MOA

-Enhances the inhibitory effect of GABA -CNS depressant

Levodopa/carbidopa (Sinemet) MOA

-Levodopa: converts to dopamine in the brain & activates dopamine receptors -Carbidopa: blocks destruction of Levodopa

Fluoxetine (Prozac) MOA

-blocks uptake of serotonin at neuronal presynaptic membrane enhancing the action of serotonin

Drug distribution factors

-blood flow -protein binding -blood-brain barrier (lipid soluble) -placental barrier: nonselective - sites of preferential accumulation

Enterohepatic Recirculation of Drugs

-drugs excreted in bile -bile recirculates to liver -percentage of drug may be recirculated numerous times -prolongs activity of drug

Lidocaine (Xylocaine) MOA

-sodium channel blocker -blocks pain transmission in peripheral nerves

Therapeutic range of lithium

0.8-1.2

Commonly used for antiplatelet property rather than for pain

Aspirin

Drug antagonist

drugs that oppose or block the action of a particular neurotransmitter; antidote

Anticholinergic effects

dry mouth, blurred vision, constipation, urinary retention

Contraindications

factors that prevent the use of a drug or treatment

Anticonvulsant commonly given for neuropathy pain

gabapentin

Pharmacokinetics

how drugs move through the body

Disadvantages of IV administration

- Irreversible - Expensive - Inconvenient - Can't self-administer - Risk of infection or embolism

Drug excretion sites

- Kidneys - Liver - Lungs - Saliva - Breast milk

What kind of drugs cross the BBB?

- Lipid soluble - Involves neurotransmitters

Drug metabolism sites

- Liver - Kidney - Lung - Plasma - GI tract - Brain - Skin

Acetaminophen Contraindications

- Liver disease

SQ or IM drug absorption factors

- Local pH, solubility, blood flow - Usually absorbed faster compared to oral meds - Cold or heat applied to the site

Ketorolac contraindications

- NSAID allergy - recent GI bleed - Renal failure - Pregnancy

Advantages of IV administration

- Rapid onset - Precise control - Permits use of large fluid volumes - Permits use of irritant drugs

morphine sulfate contraindication

- Respiratory depression - Hypotension

Oral drug absorption factors

- Solubility - Food/liquid given with med - Vascularity - Stomach pH - GI motility - Amount of surface area - First pass liver effects

Topical drug absorption factors

- Surface area - Blood flow - Skin integrity - Skin thickness

Disadvantages of oral administration

- Variable from patient to patient - Potential for N/V - Patient must be conscious - Some drugs inactivated by GI acids - First pass effect

Non-steroidal anti inflammatory prototypes

- acetylsalicylic acid (Aspirin) - ibuprofen (Motrin) - ketorolac (Toradol)

CNS drug classes

- anti-inflammatory - analgesics - narcotic antagonists - skeletal muscle relaxants - anesthetics - CNS depressants - antimania agents - antipsychotics - antiparkinsonians - anticonvulsants - herbals

Fluoxetine nursing considerations

- avoid abrupt discontinuation, look for serotonin toxicity/syndrome signs - watch for drug interactions w/ anti-platelet agents -suicide ideation

Advantages of IM and SQ administration

- Administration of poorly soluble drugs - Administration of depot preparations which absorb slowly

Ibuprofen contraindications

- Allergy to NSAIDs - History of GI bleeding - Renal insufficiency

Aspirin Contraindications

- Children under 12 - Within 7 days of surgery

factors that affect drug excretion:

- Decreased kidney function - Decreased liver function - Lung disease - Age

Advantages of oral administration

- Easy - Convenient - Inexpensive - Self- medicate - Reversible

What affects metabolism?

- Genetics - Extent of protein binding - Age - Disease processes - Social habits - P450 System (helps with metabolism)

neonate/pediatric metabolism differences

- Immature stomach acid producing cells, reduces first pass effects - Protein binding capacity is decreased - Blood brain barrier poorly developed

Pharmacokinetic phases

1. Absorption 2. Distribution 3. Metabolism 4. Excretion

synergistic interaction

2 or more "unlike" drugs that have similar action when given together

additive interaction

2 or more drugs taken together increase the desired effect in a positive way

A client is prescribed oral lorazepam 1.5 mg stat for a panic attack. Lorazepam is available in 0.5 mg tablets. How many tablets would the nurse administer?

3

Oral phenobarbital 30 mg every 6 hours is prescribed for a toddler who has had a seizure. A bottle of phenobarbital liquid labeled "20 mg/4 mL" is available. How much solution should the nurse administer? Record your answer using a whole number. __________

6

A client receiving high doses of haloperidol tells the nurse "I just can't sit still, and I feel jittery." Which side effect would the nurse suspect the client is experiencing? A. Akathisia B. Torticollis C. Tardive dyskinesia D. Parkinsonian syndrome

A Akathisia, a side effect of haloperidol, develops early and is characterized by restlessness and agitation.

The nurse is teaching a client about tricyclic antidepressants. Which potential side effects would the nurse include? Select all that apply. A. Dry mouth B. Drowsiness C. Constipation D. Severe hypertension E. Orthostatic hypotension

A, B, C, and E Dry mouth is a common anticholinergic side effect of tricyclic antidepressants. Drowsiness can be a common side effect but usually decreases with continued treatment. Constipation is a common side effect that usually can be managed with stool softeners and a high fiber diet. Orthostatic hypotension is a common side effect of tricyclic antidepressants. Hypertension is not a side effect of tricyclic antidepressants

Which information would the nurse include when teaching a client with coronary artery disease about aspirin therapy? Select all that apply. A. Take aspirin with food B. Report ringing in the ears C. Monitor and report excessive bleeding and bruising D. Do not mix aspirin with medications for erectile dysfunction E. Avoid OTC pain meds that contain aspirin

A,B,C, and E Take with food to avoid GI upset Tinnitus is a sign of aspirin toxicity Excessive bleeding and bruising can be caused by decreased platelet aggregation OTC meds should be checked for aspirin to prevent OD

Methylphenidate has been prescribed with meals for a child with ADHD. Which rationale would the nurse provide for the parents about the timing of the medication administration? A. Ritalin depresses the appetite B. This will ensure proper absorption C. It is an oral mucous membrane irritant D. Children tend to forget to take it before meals

A. Ritalin depresses the appetite A side effect of methylphenidate is anorexia; it should be given during or immediately after breakfast.

4000 mg per day max

Acetaminophen

Trycyclic antidepressant

Amitriptyline

Ibuprofen is similar to acetaminophen except it has this additional property:

Antiinflammatory

Gabapentin (Neurontin) MOA

Appears to potentiate GABA and also affects N-type calcium channels.

Which life threatening complication may occur in clients taking high dose or long term ibuprofen? A. Anaphylaxis B. Gastrointestinal bleeding C. Cardiac dysrhythmia D. Disulfiram reaction

B Ibuprofen irritates the GI mucosal erosion while decreasing platelet activity, which can result in GI hemorrhage.

A client is prescribed a monoamine oxidase inhibitor (MAOI) for depression. The nurse includes teaching on foods and medications known to cause serious adverse effects when used in combination with MAOIs. Which adverse effect would the nurse include in the teaching? A. A serious drop in BP B. A serious increase in BP C. A significant increase in liver enzymes D. A significant increase in cholesterol levels

B MAOIs, when taken with foods high in tyramine (pickled food, beer, wine, cheese), medications such as antidepressants, certain pain meds, and decongestants can cause a life-threatening increase (not decrease) in BP and hypertensive crisis.

The serum lithium blood level of a client with a mood disorder, manic episode, is 2.3 mEq/L. What should the nurse expect when assessing this client? Select all that apply. A. Elevation in mood B. Decreased coordination C. Decreased mania D. Vomiting E. Diarrhea

B, D, and E Vomiting, diarrhea, and decreased coordination are reflective of lithium toxicity.

CNS depressant prototypes

Barbiturates: phenobarbital (Luminol) Benzodiazepine: lorazepam (Ativan)

lorazepam is the prototype for this class prescribed for anxiety

Benzodiazepine

Flumazenil

Benzodiazepine antagonist, antidote

Antianxiety subclasses

Benzodiazepines Barbiturates

Morphine Sulfate MOA

Binds to receptors in the brain causing CNS depression and alter the pain response

Which would the nurse include when teaching a client with Parkinson disease about carbidopa-levodopa? A. Multivitamins should be taken daily B. A high protein diet should be followed C. The medication should be taken with meals D. Alcohol consumption should be in moderation

C Carbidopa-levodopa should be taken with meals to reduce the nausea and vomiting that are commonly caused by this medication.

Fluoxetine is prescribed for a client with depression. Which precaution will the nurse consider when initiating treatment with this medication? A. It must be given with milk and crackers to prevent hyperacidity and discomfort B. Eating cheese or pickled herring or drinking wine may cause a hypertensive crisis C. The blood levels may not be sufficient to cause noticeable improvement for 2-4 weeks D. The blood level should be checked weekly for 3 months to make sure it is appropriate.

C Fluoxetine does not produce an immediate effect; nursing measures must be continued to reduce the risk for suicide.

The nurse is teaching the parents of a child with attention deficit/hyperactivity disorder. Which medication would the nurse include as the frequently prescribed medication for this disorder? A. Lorazepam B. Haloperidol C. Methylphenidate D. Methocarbamol

C Methylphenidate appears to act by stimulating the release of norepinephrine from nerve endings in the brainstem.

Before beginning administration of morphine via patient controlled analgesia (PCA) pump, which assessment would the nurse perform first? A. Temp B. BP C. Respirations D. Urinary Output

C The nurse must be especially alert to any changes in respirations because morphine decreases the respiratory center function in the brain. A prescription for morphine should be questioned if the baseline respirations are fewer than 12 per minute

A client's serum lithium level is 0.2 mEq/L (0.2 mmol/L). What is the nurse's interpretation of this finding? A. Toxic level B. Borderline toxic level C. Subtherapeutic level D. Borderline therapeutic level

C The therapeutic range of serum lithium levels is 0.5-1.5 mEq/L. A serum lithium level of 0.2 mEq/L is below the therapeutic range (subtherapeutic)

Phenobarbital side effects

CNS depression Suicidal thoughts or behavior N/V

Methylphenidate side effects

Common: headache, insomnia, upper abdominal pain, decreased appetite, and anorexia Immediately report signs of abuse, cardiac or peripheral vascular complication and priapism (prolonged, painful erection). Report mania or psychotic episodes Gynecomastia (swollen male breast tissue)

Acetaminophen MOA

Inhibits prostaglandin synthesis in CNS

Prescribed for muscle spasms

Cyclobenzaprine

A PCP prescribes venlafaxine for a client with a diagnosis of major depressive disorder who has been taking herbal medications. Ehen discussing this medication with the client, the nurse should determine whether the client is taking which herbal supplement? A. Ginseng B. Valerian C. Kava-kava D. St John's Wort

D A client who takes venlafaxine, a selective serotonin reuptake inhibitor, and St John's Wort concurrently is at risk for serotonin syndrome.

A child with ADHD is prescribed methylphenidate. The mother asks about it's action and side effects. Which by the nurse is most appropriate? A. This medication increases appetite B. This medication must be continued until adulthood C. It is a short acting medicine that must be given with each meal D. It is a stimulant that has a calming effect on children with ADHD

D Although the exact mechanism is unknown, clinical improvements have been reported with sympathomimetic amines such as methylphenidate.

A client taking ibuprofen for rheumatoid arthritis asks the nurse if acetaminophen can be substituted. Which response by the nurse is appropriate? A. Yes, both are antipyretics and have the same effect B. Acetaminophen irritates the stomach more than ibuprofen does C. Acetaminophen is the preferred treatment for rheumatoid arthritis D. Ibuprofen has anti-inflammatory properties, and acetaminophen does not

D Ibuprofen has an anti-inflammatory action that relieves the inflammation and pain associated with arthritis, Acetaminophen is not a nonsteroidal anti-inflammatory drug (NSAID). NSAIDs are preferred for the treatment of rheumatoid arthritis

Which client statement indicates the teaching about acetaminophen is effective? A. I can drink beer with this but not wine B. I need to limit my intake of acetaminophen to 650 mg a day C. I should take an emetic if I accidentally OD on acetaminophen D. I have to be careful about which OTC cold preparations I take

D Many OTC contain acetaminophen; the amount of acetaminophen in cold preparations must be taken into consideration when the total amount of acetaminophen taken daily is calculated. A typical single dose is 650mg a day for adults, and should not exceed 4000mg a day

Which inpatient admission orders for a child with viral pneumonia would the nurse question? A. Encourage oral fluids B. Chest physiotherapy twice a day C. Start IV fluids D 5% 0.45% NS at 80mL/hr D. Aspirin 325mg every 4 hrs prn for fever higher than 101.4F

D. Salicylates, such as aspirin, should not be given to children under 16 with viral infections because of the risk of Reye's syndrome.

St John's Wort MOA

Inhibits reuptake of serotonin, dopamine, and norepinephrine

St John's Wort side effects

Dizziness Confusion Tiredness/sedation Dry mouth Photosensitivity GI problems Urinary frequency

Lidocaine side effects

Dizziness Restlessness Euphoria Drowsiness Feeling hot and cold

The neurotransmitter that is associated with Parkinson's disease

Dopamine

Ketorolac side effects

Drowsiness Headache GI bleed Abnormal taste Dyspepsia Nausea Steven Johnson syndrome Edema Renal failure

Protein bound drugs

Drug binds to protein, only free part of the drug is active. so, a drug that is 98% protein bound will have 2% available for distribution in the body those with low protein can experience toxicity

Side effect

Expected, undesirable, but tolerable effect of medication, not an allergy

SQ absorption pattern

Intermediate: 30-60 minutes

Unbound drug

Free active drug causing a pharmacologic response

acetylsalicylic acid side effects

GI upset GI bleeding Tinnitus

Higher chance of having extrapyramidal side effects with:

Haloperidol

Levetiracetam side effects

Headache Somnolence Dizziness Emotional lability Confusion Sedation Pharyngitis Anorexia

Ibuprofen side effects

Headache tinnitus N/V Dyspepsia constipation GI bleeding Steven Johnson syndrome Renal failure

Morphine sulfate side effects

Hypotension CNS depression Tachycardia Respiratory depression Confusion Dizziness Sedation Constipation N/V Sweating

amitriptyline side effects

Hypotension Prolonged QT interval- risk for arrhythmias Sedation Sexual dysfunction Seizures Anticholinergic effects (blurry vision, dry mouth, constipation) Immediately report s/s of suicide

IV absorption pattern

Immediate: enters directly into the blood Complete: reaches the blood in its entirety

Barbituates MOA

Increase GABA, nonselective depression of CNS

Gabapentin side effects

Increased suicidality Dizziness Somnolence Ataxia (poor muscle control) Immediately report rash, fever, or lymphadenopathy

Tranylcypromine side effects

Increased suicidality Hypertensive crisis Serotonin syndrome Mania Orthostatic hypotension Hepatoxicity Seizures Hypoglycemia in diabetics Decreased appetite/weight Dizziness Drowsiness Restlessness

Venlafaxine side effects

Increased suicidality Serotonin syndrome Elevated BP Anxiety Insomnia Decreased appetite/weight Mania Hyponatremia (low sodium) Increased bleeding Elevated cholesterol Somnolence (strong desire for sleep) Nausea Constipation

Methylphenidate (Ritalin) MOA

Increases activity of CNS neurons Promotes NE and dopamine release Inhibits NE and dopamine reuptake

if given this in surgery, teach client to wait 6-8 hours before taking ibuprofen:

Ketorolac

Anticonvulsant prototype

Levetiracetam

Why is levodopa combined with carbidopa?

Levodopa can't cross the BBB, so you need Carbidopa to be the "taxi driver"

Haloperidol and Risperidone side effects

Life threatening cardiovascular events/infections Tardive dyskinesia (repetitive, involuntary movements) Neuroleptic Malignant syndrome Extrapyramidal symptoms Hypersensitivity Falls r/t sedation, motor instability, and postural hypotension

Antimania prototype

Lithium (Lithobid)

Lithium side effects

Lithium toxicity Hyponatremia Tremor Cardiac arrythmia Polyuria Thirst

What can affect albumin levels:

Liver disease Kidney disease Malnutrition Burns

Depresses appetite and requires growth monitoring in kids

Methylphenidate

Narcotic antagonist prototype

Naloxone (Narcan)

This will reverse effects of opioids

Narcan

Naloxone Contraindications

Not be used if patient has adequate respiratory status

Analgesic prototypes

Opioid Agonist: morphine sulfate Non-opioid: acetaminophen (Tylenol)

Lorazepam side effects

Oversedation and drowsiness Respiratory depression Unsteadiness and risk of falls Overdose= coma or death

Methylphenidate MOA

Promotion of NE and DA release and inhibition of NE and DA reuptake

IM absorption pattern

Rapid: 30 minutes

Fluoxetine side effects

Rash Mania Seizures Decreased appetite/weight Increased bleeding Hyponatremia (low sodium) Anxiety Insomnia Immediately report s/s of suicide or serotonin syndrome

2nd generation antipsychotics

Risperidone

St John's Wort can't be taken with fluoxetine due to risk of:

Serotonin Syndrome

Cyclobenzaprine contraindications

Severe cardiovascular disease Hyperthyroidism

Acetaminophen side effects

Skin reddening blisters/rash Hepatic failure/liver damage

Levodopa/Carbidopa side effects

Somnolence/fatigue NMS symptoms with reduced or discontinued dose Dyskinesia Discolored body fluids Hypomobility with long term use Depression, suicidal ideation, hallucinations, intense urges and inability to control them

Herbal prototype

St John's Wort

Therapeutic Index (TI)

The ratio between the toxic and therapeutic concentrations of a drug: large TI = safer drug, small TI = riskier drug

Pharmacogenetics

The study of how genetic variation enhances or decreases an individual's response to drugs. - DNA testing - Clinical trials are ongoing - Genetic testing is expensive

Pharmaceutics

The study of how various drug forms influence the way in which the drug affects the body

Drug peak

The time it takes for a drug to reach its maximum therapeutic response

Why do nurses need to know the half-life of a drug?

To maintain a therapeutic drug level for the desired period of time

Patient needs to avoid tyramine when taking this medication

Tranylcypromine

MAOI Prototype

Tranylcypromine (Parnate)

Antidepressant prototypes

Tricyclic: amitriptyline (Elavil) SSRI: fluoxetine (Prozac) SNRI: venlafaxine (Effexor ER) MAOI: tranylcypromine (Parnate)

Levetiracetam (Keppra) MOA

Unknown; may interfere with sodium, potassium or GABA transmission

SNRI prototype

Venlafaxine

Drug agonist

a drug that will bind to a receptor on a cell and trigger a response by the cell, generally mimicking the response or action of a naturally occurring substance Ex: Albuterol (Ventolin)

Blood Brain Barrier (BBB)

a selective mechanism that protects the brain from toxins and infections

Untoward effect

an effect of a medication in addition to its desired effect that may be potentially harmful to the patient.

Risperidone (Risperdal) MOA

antagonizes or inhibits dopamine and serotonin receptors

amitriptyline side effects

anticholinergic effects tachycardia cardiac arrythmias

adverse drug reaction

any unexpected, unintended, undesired, or excessive response to a medication given at therapeutic dosages, needs to be added to drug allergy list

Haloperidol (Haldol) MOA

blocks dopamine receptors in brain responsible for mood and behavior

Amitriptyline (Elavil) MOA

blocks presynaptic reuptake of serotonin and norepinephrine

GABA function

calming, relaxation

Phenobarbital (Luminal) MOA

changing the action of GABA

Skeletal muscle relaxant prototype

cyclobenzaprine (Flexeril)

Venlafaxine (Effexor ER) MOA

increasing serotonin levels, norepinephrine, and dopamine in the brain

Dopamine function

influences movement, learning, attention, and emotion

Lithium (Lithobid) MOA

inhibits adenylate cyclase

Ibuprofen MOA

inhibits prostaglandin synthesis

Ketorolac MOA

inhibits prostaglandin synthesis

Drug duration

length of time the drug produces a therapeutic effect

Antiparkinsonian prototype

levodopa/carbidopa (Sinemet)

Anesthetic prototype

lidocaine (Xylocaine)

Obstetric Drug Metabolism

liver is stimulated by progesterone to increase metabolism -drug half-life is shorter

CNS stimulant prototype

methylphenidate (Ritalin)

Albumin

most common protein in blood; maintains the proper amount of water in the blood

Tranylcypromine (Parnate) MOA

non-hydrazine irreversible inhibitor of MAOA and is also an irreversible inhibitor of MAO-B

Naloxone (Narcan) MOA

opioid receptor antagonist

Aspirin MOA

prevents platelet activation/aggregation (by inhibiting cyclooxygenase)

indication of drug

reason for using the drug

Cyclobenzaprine (Flexeril) MOA

relieves muscle spasms through central action at brainstem level

Obstetrics Drug Excretion

renal blood flow rate is doubled -monitor closely to assure an effective level of drug is maintained

Oral absorption pattern

slow and variable

Electrolyte to monitor if client is on lithium

sodium

Maintenance dose

the dose of drug that maintains or keeps the drug in the therapeutic range

First pass effect

the initial metabolism in the liver of a drug absorbed from the GI tract before the drug reaches systemic circulation through the bloodstream

Drug onset

the time it takes for the drug to elicit a therapeutic response

Drug Half Life

the time required for the amount of drug in the body to decrease by 50%

Drugs Contraindicated with MAOIs

tricyclic antidepressants SSRIs General anesthesia Diuretic/Antihypertensives Insulin Meperidine Anticholinergics Mehyldopa Sympathomimetics

Loading dose

use of a higher dose than what is usually used for treatment to allow the drug to reach the critical concentration sooner

Pharmacodynamics

what the drug does to the body