Final Exam NURS-106 ALL CONTENT

COMT Inhibitors Common suffix? What is our example drug? Why do we use them for Parkinson's? AEs (p 234 table 15.3)

-capone (COncrete MetaTarsals -memory trick) • Entacapone The enzyme COMT causes the breakdown of catecholamines, including dopamine. We want as much dopamine (and levodopa) as possible, so we want to inhibit that enzyme. • They prolong the duration of action of levodopa and allow us to use a lower dose of levodopa AEs • GI upset (take with food) • urine discoloration (teaching! harmless) • liver failure • orthostatic hypotension, syncope (safety!) • dyskinesia • dizziness (safety!) • fatigue • hallucinations • anxiety • somnolence • dyspnea • rash Monitor liver function labs, look for jaundice, teach patient to report upper left quadrant pain.

Opthalmic quinolones Common suffix? What is it? Used for? AE? Example drug?

-floxacin • antimicrobial Abx Broad spectrum used for microbes that are very difficult to treat. AEs: • Corneal staining • Possible systemic reaction that alters taste and can cause nausea Ciprofloxacin • special AE for cipro: can get white crystalline precipatates inside corneal lesions

What are the suffixes for antifungals?

-fungin -nazole -in ***Except Metronidazole (Flagyl) and Sulfamethoxazole are antibiotics***

MAOIs Common suffix (Parkinson's specific) What are our two example drugs? Why do we use them for Parkinson's? AEs (p 234 table 15.3)

-giline (for Parkinson's ones) • rasagiline (Azilect) • selegiline (Eldepryl) The enzyme MAO causes the breakdown of catecholamines, including dopamine. We want as much dopamine (and levodopa) as possible, so we want to inhibit that enzyme. MAOInhibitors • They help counter dopamine deficiency and increase dopaminergic stimulation in the CNS • They allow us to use a lower dose of levodopa because it's not being broken down as much AEs • headache, confusion • nausea, weight loss, diarrhea • dyskinesia • back pain • rash, stomatitis • dizziness, hypotension (SAFETY!) • insomnia (don't give @ bedtime, may need sleep aid)

SGLT2 Inhibitors Common suffix? How does this work? AEs Contraindications Good things to know

-gliflozin SGLT2 is responsible for glucose reabsorption, so inhibiting this causes increase renal glucose excretion - we expect glycosuria AEs • weight loss • yeast infections (more sugar in urine) • UTI • increased urination • hypotension • hypovolemia • hyperkalemia • increased LDL cholesterol • risk of DKA • acute kidney injury Contraindications: • kidney impairment (d/t increase excretion) • Type 2 only • Low risk for hypoglycemia Black box warning for canagliflozin only: increased risk for leg/foot amputations

Glinides Common suffix? Class? How do they work? When taken? Contraindications? AEs? Good thing to know?

-glinide (Oral antidiabetic) • Help the pancreas to stimulate the release of insulin - pancreas must still be functioning (no type 1) MUST be given with a meal Contraindications: • Hypoglycemia • Don't combine with a sulfonylurea AEs • weight gain • hypoglycemia if not taken with a meal Helpful for those with erratic eating habits because if they skip a meal, you can just skip a dose

Dipeptidyl Peptidase IV Inhibitors (DPP-IV / DPP-4) Common suffix? Class? How do they work? AEs? Fact to remember?

-gliptines (Oral antidiabetic) • Incretin hormones increase insulin synthesis, and these delay the breakdown of incretin hormones, which reduces fasting and postprandial glucose concentrations • Used as adjunct to diet/exercise AEs: • upper respiratory tract infections • headaches • diarrhea • hypoglycemia • pancreatitis (rare) Lowered A1C is less than other oral diabetic drugs

Thiazolidinediones (Glitazones) Common suffix? Class? How do they work? Onset time? Contraindications AEs

-glitazone (Oral antidiabetic) • Decrease insulin resistance, help make insulin receptors more sensitive • Stimulate peripheral glucose uptake & storage • Inhibit triglyceride and glucose production • May preserve beta cell function (slow disease progression) • Slow onset - several weeks to months Contraindications Heart failure - Black Box Warning: may exacerbate heart failure Liver disease Kidney disease AEs • weight gain • reduces bone mineral density (↑ fracture risk) • peripheral edema (watch daily weight)

Sulfonylureas Common suffix? Class? Example drug? How do they work? When taken? Contraindications? AE?

-ide (Oral antidiabetic) • Glipizide (Glucotrol) -this particular one not contraindicated in renal failure • Help the pancreas to stimulate the release of insulin - pancreas must still be functioning (no type 1) • Take daily, 30 min before meals Contraindications • Hypoglycemia • Potential allergy if allergic to sulfonamide antibiotics • People with decreased nutritional intake -NPO patients -Anorexic/loss of appetite -Alcoholism -Advanced age AEs • Weight gain • Hypoglycemia

Loop diuretics Common suffix? How do they work? Used for? AEs? Contraindication? Special consideration to remember?

-ide Extremely potent. Block chloride and sodium resorption in kidneys. Dilates blood vessels. Used in: tx of edema in heart failure, hepatic cirrhosis, renal disease. HTN but not first line for it. Increase excretion of Ca if hypercalcemia AEs: • electrolyte imbalances (especially K, Na, Cl) • hypokalemia (may need K supplementation) • dehydration • severe skin reactions (major sloughing, can be fatal) • agranulocytosis • thrombocytopenia, neutropenia (watch CBC) Contraindications: • severe electrolyte loss • dehydrated • anuria • hypovolemia Considerations: These DO work okay when kidney function is poor • watch labs for elevated liver function, glucose, hyperglycemia, uric acid (gout) - d/t concentated

Amphetamines Common suffix? Schedule? Uses? Method of action? Special considerations?

-amphetamine Schedule II Uses: • Anti-ADHD (Adderall is example drug) • Treat narcolepsy MOA: • Stimulate area of brain associated with mental alertness, similar to SNS • Bronchial dilation, increased respiration • Dilation of pulmonary arteries, ↑ blood to lungs Special considerations: • Strong potential for tolerance - recommend "drug holiday" (weekends/summer break) • Strong abuse potential (sold on streets) • Psychological dependence

Antineoplastic enzymes common suffix AE with these?

-ase (all enzymes) Unique AE: pancreatitis or pancreatic toxicity • left upper quadrant pain • nausea • vomiting • severe hyperglycemia Monitor serum lipase and amylase

Topical anesthetic common suffix? Two example drugs

-caine • lidocaine • bupivacaine

Neuromuscular Blocking Drugs (NMBDs) Common suffix? How do they work? Important things to remember? Interactions?

-ium (not all of them, but many) • succinylcholine is an NMBD Prevent nerve transmission in skeletal and smooth muscle = paralysis Important to remember: • HIGH ALERT drugs • Patient must be ventilated before administration - administration before ventilation can cause death! • Prolonged paralysis and mechanical ventilation can lead to cardiovascular collapse • Used alone, they DO NOT cause sedation, relieve pain or anxiety - all they do is take away ability to talk and move. SCARY for patient - usually combine with a sedative, anxiolytic, analgesic to relieve pain, anxiety, etc Interactions: many interactions that lead to additive effect or oppose the NMBD

Benzodiazepines Common suffix? Schedule? How do they work? What do we use them for? Interactions? Do they cause dependency?

-lam or -pam • Schedule IV • Work by stimulating GABA receptors in the brain. Inhibit stimulation of the brain. • Use for: anxiety, agitation, sleep induction, skeletal muscle relaxation, acute siezure disorder, sedation, alcohol w/d symptoms. Also cause amnesia, so great for painful procedures. • Interacts with other CNS depressants and grapefruit juice • Yes they cause dependency, use short-term if clinically able to and do not discontinue abruptly or can have withdrawal

common suffix for immunosuppressants?

-limus Memory trick: -limus reminds me of Linus from Charlie Brown. Linus always carries a blanket. Think like these are the blankets that are protecting transplanted organs from being rejected by the immune system REMEMBER: they aren't all -limus • cyclosporine • mycophenolate mofetil • muromonab-CD3

Monoclonal antibodies suffix? Used for? Pro/con? Contraindicated/BB warning? AEs? Example drug

-mab (like Monocolonal Anti Body) Used in RA, MS, cancers, organ transplants Pro/con: • minimal AEs on healthy cells - target cancer • expensive ($10k+ per dose!) Contraindicated/BB warning: • Immunosuppressive - NO with active infection • high risk for acquiring serious or fatal infection ----often systemic fungal infections or TB AEs: • flu-like sx • severe allergic inflammatory-type reactions • long half-life (weeks-months) increases risk for interactions and toxicities Examples: • Adalimumab (Humira) • Infliximab (Remicade)

Anti-glaucoma drugs: beta-adrenergic blockers Common suffix? How do they work? What types of glaucoma do we use it for? AEs?

-olol Reduce AH formation (when elevated or normal) Used for open-angle glaucoma and ocular HTN AEs: • burning, pain, lacrimation • blurred vision • photophobia • blepharitis (inflamm of eyelid) • keratitis (inflamm of cornea) • decreased corneal sensitivity Contraindicated in conditions where a beta-blocker could be harmful. (Other chapters say bradycardia, heart failure, pregnancy - but this chapter says few if any systemic effects, so ?)

Beta blockers for tx of angina Common suffix? How do they work for angina? Used for?

-olol Only some are approved for angina • Block beta1 receptors in heart = slows HR, slows conduction through AV node, reduces myocardial contractility, reducing the O2 demand of the heart • Block harmful effects of epi and norepi after an MI, so given to all acute MI patients • Suppress renin (vasoconstrictor), reducing BP Used for: Tx of exercise/exertional angina (not sure if relevant for this test, but she also brought up used for MI, HTN, dysrythmias, essential tremors, migraines and stage fright tachycardia)

Psychotherapeutic drug names/suffixes -pam -lam buspirone lithium -mine -line -pram -odone -azine -apine -idone -azole

-pam: benzodiazepine -lam: bendiazepine buspirone: anxiolytic lithium: mood stabilizer -mine: antidepressants (most tricyclic) -line: antidepressants (most tricyclic) -pram: SSRIs -odone: misc antidepressants -azine: conventional antipsychotics -apine: atypical antipsychotics -idone: antipsychotics -azole: quinolone antipsychotics

Proton pump inhibitors (PPIs) common suffix? What are they? How do they work? AEs

-prazole PPIs are more powerful than H2 blockers • Stop more than 90% of acid secretion over 24hr • H2 blockers and antihistamines do not stop the action of the proton pump • Prevents movement of H+ from the parietal cell into the stomach AEs - generally well tolerated, but long term/high dose: •Achlorhydria - ALL gastric acid secretion temp blocked ----potential for bacterial overgrowth • GI tract infections, C.diff infections • osteoporosis - wrist, hip and spine fractures ---- ↑ bone demineralization • pneumonia • depletion of magnesium • possibly dementia and lupus (theory) THESE ARE OTC! Assessment questions!!

ACE Inhibitors Common suffix? Used for? How do they work to help hypertension? Contraindications? AEs? Interactions?

-pril First line treatment for HTN and heart failure. Commonly combined with a diuretic or a calcium channel blocker, but can be stand alone. ACE = angiotensin converting enzyme. This ezyme inhibits AII (vasoconstrictor) and aldosterone (causes sodium & water retention) and it also prevents the breakdown of bradykinin (vasodilator) to reduce blood pressure. Contraindications: • Pregnant or lactation (cat C&D) • K-sparing diuretic or potassium supp AEs: • hyperkalemia • dry, nonproductive cough (annoying but not harmful) • loss in sense of taste • angioedema (neck/throat swelling- life threat) • possible acute renal failure if have renal impairment Interactions: • NSAIDs (reduce effect of ACE inhibitor and also increases risk of renal failure when combined) • Potassium supp or potassium-sparing diuretic

Anti-glaucoma drugs: Prostaglandin agonists Common suffix? How do they work? AEs? Special thing to remember? Special benefit?

-prost Increase AH drainage, lowering IOP AEs: • feels like foreign body in the eye • may turn blue/hazel/green eyes brown permanently • bloodshot • burning, stinging, itching Remember: If using another drug that contains thimerasol - must give 5 minutes apart Benefit: Work for 20-24 hours, so single-day dosing benefit

Angiotensin II Receptor Blockers (ARBs) Common suffix? How do they work to help hypertension? Contraindications? AEs? Interactions?

-sartan First line treatment for HTN. Blocks binding of angiotensin II and aldosterone secretion, so potent vasodilator and decreased retention of sodium and water. Can be adjunct for heart failure or can be combined with diuretics for HTN and heart failure. Contraindications: • Pregnancy • Caution used in older adult • Caution in renal dysfunction • K-sparing diuretic or potassium supp AEs: • Chest pain • Hypoglycemia • UTI • Diarrhea • Anemia (watch CBC) • Possible hyperkalemia Interactions: • NSAIDS (decrease effect)

Serotonin blockers: antiemetic (5HT blocker) common suffix? How work? Used for? Admin? Example drug?

-setron Block serotonin receptors in the GI tract • used for N/V in patients receiving chemotherapy • used for post-op N/V • used in pregnancy morning sickness (ondansetron) Admin: given 30 min before end of surgery or 30-60 min before chemo Example: ondansetron (Zofran) • used in pregnancy morning sickness -----risk for cleft lip if used in 1st trimester • avoid: alcohol, CNS depressants, skills requiring mental alertness • headache (do not use aspirin) • risk for wide QT interval, cardiac dysrythmias

What is metabolic syndrome? What are the s/sx to identify this? "I don't need you to know the numbers, but I want you to be able to identify these criteria to say a patient has metabolic syndrome"

A person who is on the cusp of developing heart disease or diabetes • Waist circumference • Serum triglycerides • HDL levels • BP • Glucose

What is status epilepticus? What are the first choice drugs to treat this?

A seizure disorder characterized by generalized tonic-clonic seizures that occur repeatedly This is a medical emergency. Hypoxia, brain damage, death possible. Diazepam and lorazepam are first choice treatments.

A fungal infection as a result of taking an antibiotic is _______.

A superinfection

Glucocorticoids Suffix? What do they do? What are some indications? Contraindications?

-sone or -solone • antiinflammatory • immunosuppressant • produce glycogen in the liver (glycogenesis) • stabilize mast cells (helps w/ allergies) Indications: (there are more but she said these) • dermatological issues (topical) • GI diseases • Autoimmune diseases • Organ transplant patients • Asthma and COPD Contraindications: may intensify diseases • fungal and bacterial infections • cataracts, glaucoma, increased IOP • diabetes melliuts - increases BG • serious infections: sepsis, fungal, varicella • PUD, reflux, gastritis - perforation risk • cardiac/heart failure - fluid retention • renal/liver dysfunction - alterations in elim ↑↑↑ contraindications but not always a no, sometimes benefit outweighs the risk

Statins Common suffix? How do they work? What is the result seen in labs? Consideration for dosing? Teaching?

-statin First line drugs for antilipemic tx. Decreases rate of cholesterol production by inhibiting enzyme CoA. This opens up LDL receptors in the liver, which pulls LDL out of the blood to bind to those receptors so the liver can continue to produce cholesterol (including HDL) These can lower LDL and also raise HDL. Dosing: Higher dose and higher potency = greater reduction in LDL % but have more AEs Teaching: • 6-8 weeks for max effect • Elevated liver enzymes are expected from statins • If you begin to have muscle pain or notice a change in the urine, tell us immediately!

Barbituates Common suffix? Uses? AEs? Special considerations?

-tal Uses: • short anesthesia • reduce ICP • control convulsions • prophylaxis in epilepsy (prevent seizures) AEs: • drowsy, lethargy, dizzy, hangover • paradoxical restlessness or excitement (children) • deprive REM sleep = agitation • REM rebound if stopped = nightmares • respiratory depression • vasodilation/hypotension (esp. if given rapidly) • cause anemia Special considerations: • Cut dose in half if need to use in older adult • Causes liver enzymes to metabolize drugs more quickly, shortening efficacy of other drugs

Diuretics used for HTN Common suffix? How do they work to help hypertension?

-thiazide Decreases plasma and extracellular fluid volumes = decreased preload, decreased CO, decreased peripheral resistance = less workload on the heart

Thiazide diuretics Common suffix? What do we use it for? How does it work?

-thiazide Diuretic that is a first line for treatment of HTN. Also used in tx of HF, edema, diabetes insipidus Inhibit resorption of NA, K, Cl = osmotic water loss. Direct relaxation of arterioles = reduced PVR. AEs: • hypokalemia • hypercalcemia • may cause hyperlipidemia • hyperglycemia & hyperuricemia (may be just due to more concentrated fluids and appear elevated) • headache • decreased libido • impotence • agranulocytosis, leukopenia (changes on CBC) Contraindications: • anuria • severe renal failure OD: • hypokalemia Efficacy diminishes with decreased renal function

Incretin Mimetics Common suffix? How do they work? When do we give? Contraindications? Important things to know?

-tide Mimics hormone incretin. Incretin is hormone released in GI tract that stimulates insulin release, reduce after-meal glucagon production, slow gastric emptying, increase satiety • Give 60 minutes before a meal SubQ • Some 1-2x daily, some weekly Contraindication: • DO NOT use with insulin • Thyroid cancer • Endocrine issues AEs • weight loss of 5-10lbs • pancreatitis (rare) Only for Type 2 Black Box Warning - ↑ risk thyroid tumors

Histamine 2 Receptor Antagonists (H2 blockers) common suffix? used for? AEs? Interactions? Admin?

-tidine • cimetidine, nizatidine, famotidine, ranitidine Used for: • reduce acid secretion • peptic ulcer prophylaxis (stress/ICU patients) AEs: • Confusion/disorientation (rare) in older adults • May ↑ secretion of prolactin • Thrombocytopenia - ranitidine and famotidine • impotence and gynecomastia - cimetidine Interactions: • may inhibit metabolism = ↑ drug levels • ↓ absorption of drugs that require acidic environment • smoking decreased effectiveness Admin: • these need acidic environment so take 1-2 hours before antacids

Antimigraines Common suffix? AKA? Uses? AEs? Contraindications?

-triptans AKA: selective serotonin receptor agonists (SSRA) Uses: • Treating acute migranes (not prophylaxis) - "abortive therapy" making headache go away AEs • Overuse can cause rebound headache • Vasoconstrictor effects including effect on coronary circulation Contraindications: • Cardiovascular disease • HTN • Cerebrovascular disease • Glaucoma (vasoconstriction increases pressure) Special things to know: • Enhanced by caffeine • Come in many forms because migraines commonly cause N/V making oral form difficult for pts

Alpha blockers common suffix? How do they work to help HTN?

-zosin Usually used to treat BPH, but can be used for hypertension sometimes d/t ability to dilate arteries and veins

Pain scale types

1-10 scale Faces good for children/older adults Verbal - has descriptors Flacc scale - nonverbal children Alternative for older adults with mental impairment

what should the ph of the stomach be?

1-4

What is the order that you draw up insulin when mixing? Why?

1. Always pull up regular or rapid-acting first 2. Intermediate or NPH second "clear to cloudy" We don't want to contaiminate the rapid-acting insulin with a longer-acting form. More dangerous to lengthen the onset of action in the rapid than the other way around according to Tillemans during lab last semester.

What respiratory rate signals respiratory distress?

10 or less

What is the lifespan of a red blood cell?

120 days

We haven't studied the safety of TB drugs in age _____ and younger

13

What percentage of vaccinated population is considered herd immunity?

95% of the population vaccinated

What is important to remember about the dose for adrenergic drugs?

A low dose and a high dose of the same drug can stimulate different things. IE: low dose of epinephrine effects beta1 more than beta2 and additionally more than alpha1, but a high dose effects all three equally

What is itching?

A mild pain sensation in the body, not quite strong enough to be felt as pain. AKA pruritus

What are the A1C and fasting glucose goals for a diabetic patient?

A1C less than 6.5% Fasting glucose of 70-130

What class of drugs end in -pril? What do they do as it relates to heart failure? Main side effects?

ACE inhibitors They prevent NA and H2O retention - cause diuresis, decrease preload, decrease work of the heart May cause: • hyperkalemia • dry cough • decreased renal function

Antiemetics: AEs and interactions

AEs: • GI upset • drowsy, lethargy, weakness • extrapyramidal reactions (unvoluntary muscle movemt) • orthostatic hypotension • anticholinergic effects w/ anticholinergic and antihistamine meds • prolonged QT interval w/ serotonin blockers Interactions: • additive and increased effects with other meds ---IE increased drowsiness, drying etc

What is salicylate toxicity? What are the s/sx? Interventions? ***know all of this***

AKA aspirin poisoning Example: Pepto Bismal contains salicylate, can OD if taking with aspirin also • Tachycardia • Tinnitis/Hearing loss • Dizziness/Drowsiness/Confusion • Behavior changes in kids • Hyper/Hypoglycemia • Sweating • Hyperventilation 👷Hemodialysis to try and remove aspirin 👷 Managing symptoms / supportive care 🕵️ Monitor labs for bleeding times

Moderate sedation AKA? Example drugs? Benefits of this type of sedation? Requirements? AEs? p 169 & 179 box 11.8

AKA conscious sedation, procedural sedation Medazolam + Fentanyl, Morphine or Propofol Benefits: • Faster recovery than general anesthesia • Better safety profile, lower risk • Patient can respond to verbal commands • Patient can maintain own airway • Reduces anxiety • Possible amnesia Requirements: • Requires ACLS (advanced cardiac life support) certification to administer • Requires one person who can intubate if needed • Requires one person to monitor patient AEs • amnesia (used as a benefit) • headache • hangover feeling • nausea, vomiting

Nitrus Oxide What is it? Strength? Uses? AE? p 168

AKA laughing gas • Only inhaled gas currently used as a gen anesthetic • Weakest of the gen anesthetic drugs but has good analgesic properties • Used primarily for dental procedures • Rarely given as sole anesthetic for major surgery, usually a supplement to more potent drugs AE: in procedures over 1 hour, has increased incidence of post-op nausea/vomiting (PONV)

Retinoic acid AKA? What is it used for? AEs?

AKA: tretinoin, vitamin A acid, Renova, Retin-A Used for: • acne • skin changes associated w/ sun damage (fine wrinkles, mottled hyperpigmentation, rough patches) AEs: • local inflammation • blisters • temp alterations in skin pigment • severe sunburn Waxing procedures are contraindicated (think about that peeling skin and what waxing would do to it)

What is very important for education regarding antibiotics?

ALWAYS complete the entire antibiotic regimen The germ may not be completely eradicated, it can reinfect and it learns how to resist the antibiotic.

What class of drugs end in -sartan? What do they do as it relates to heart failure? Important things to remember about them?

ARBs Potent vasodilators - decreases systemic vascular resistance (afterload) • Less likely to cause hyperkalemia • Less likely to cause cough • May be used with diuretics • Pregnancy category D!

bulk-forming laxatives How do they work? Safety considerations?

Absorb water into intestine to increase bulk • high fiber • distend bowel to ↑ reflex bowel activity Safety consideration: • if powdered, MUST mix with a lot of water until completely dissolved and drink it right away - if taken dry or allowed to sit and thicken the water = choking hazard • these are the only laxatives that can be used long term Interactions: • ↓ absorption digoxin, warfarin, other drugs Example drugs: • psyllium • methylcellulose AEs: • impaction • fluid overload • electrolyte imbalances • esophageal blockage

What do positive dromotropic drugs do? negative dromotropic?

Accelerate conduction through the heart Negative slows the conduction through the heart

Which drug is the #1 cause of poisoning in children? What are the s/sx of poisoning? How do we treat it? ***know all of this***

Acetaminophen (APAP) "Tylenol" 🕵️ S/sx acetaminophen poisoning: rapid & weak pulse, dyspnea, cold/clammy extremities, jaundice, pain in area of liver (due to hepatotoxicity), bleeding, loss of energy, fever, sore throat, easy bruising 😱 Hepatotoxic in high doses 😱 Hepatic Necrosis in overdose 👷 Treat overdose with acetylcysteine within 10 hours 👷 Acetylcysteine smells and tastes really bad, preferred to give IV so patient does not vomit 🎓 Teach to look at labels for hidden acetaminophen because it is in so many things, IE cough medicine

What neurotransmitter is involved with the parasympathetic system? What enzyme breaks this down?

Acetylcholine Acetylcholinesterase breaks it down

What is the difference between aqueous humor and vitreas humor?

Acqueous = liquid Vitreas = jelly

Acute vs chronic diarrhea

Acute: • Sudden onset • lasts less than 2 weeks • causes: bacteria, viral, protozoa, drug induced, nutritional factors Chronic: • lasts more than 3-4 weeks • associated with fever, loss of appetite, N/V, weight loss, chronic weakness (likely d/t dehydration) • causes: tumors, DM, Addison's disease, IBS, Hyperthyroid, AIDS

Lithium Class? AEs? Contraindications Remember? Teaching? ON KAPLAN

Affective / Mood-stabilizing drugs AEs: • cardiac dysrythmias • ataxia (balance, gait, stability issues) • epileptic seizures • drowsy, slurred speech • hypotension Contraindicated: • major renal dysfunction • lots of drug interactions Remember: • Narrow therapeutic range - monitor serum drug levels • dehydration & hypovolemia increases OD risk • hyponatremia increases OD risk THINK: we want to avoid dehydration to avoid that increased toxicity risk, but if we overhydrate then we are risking low sodium and the hyponatremia toxicity risk: find a balance Teach: • take at same time every day to maintain narrow therapeutic levels

AEs of chemotherapy drugs what labs do we monitor?

Affects rapidly dividing cells: • Hair follicles - hair loss • GI tract - nausea/vomiting • Bone marrow - low WBC, RBC, platelets • Stimulates the CTZ (chemoreceptor trigger zone) which causes nausea/vomiting pre-medicate w/ steroids, antihistamines & entiemetics AEs: (lots of detail, each has its own card) • Myelosuppression • Extravasation • Dermatologic affects • GI/oral affects • Reproductive • toxicities • Pain!!! assess! Monitor labs: • electrolytes • uric acid • CBC • renal fx • hepatic fx • cardiac enzymes • tumor markers

What is a wash-out period?

After having a drug interaction, a patient has 2-week window being off of an MAOI before they start another drug

What are host factors to consider with antibiotics?

Age Allergies Kidney function Liver function Pregnancy Site of infection (spinal fluid, mucous membrane, etc) Genetics Host defenses (immune compromised, nutrition, hydration, etc)

Tuberculosis has what kind of precautions?

Airborne Fitted N95 mask

Asthma is treated in a step-wise approach. What is always step 1?

Albuterol - a short-acting inhaled beta agonist (rescue medication)

Causes of hepatitis What are the types and which do we have vaccines for?

Alcohol (type C), meds, viruses, blood/body fluids Types A, B, C We have vaccines for A & B

Spironolactone What is it?

Aldosterone antagonist - Potassium sparing diuretic

Cisplatin Class AEs? Interventions? Interactions?

Alkylating - non-specific chemo drugs Nephrotoxicity • Monitor renal function • IV hydration - we really need to hydrate to protect kidneys and they probably won't be able to drink enough Peripheral neuropathy • monitor changes in sensation - numb/burn/tingle -----safety and risk for injury! Bone marrow suppression Interactions: combined effects with other drugs that have similar effects - IE ↑ nephrotoxicity

Cyclophosphamide class? used for? AE? Intervention?

Alkylating - non-specific chemo drugs ---can also be used for anti-rejection and severe rheumatoid disorders Hemorrhagic cystitis • inflammation and bleeding of bladder lining • watch renal fx labs, blood in urine • maintiain/increase hydration Bone marrow suppression Interactions: combined effects with other drugs that have similar effects - IE ↑ hemorrhagic cystitis

Prednisone vs. Methylprednisone vs. Budesonide vs. Fluticasone What are these and what are the differences?

All are corticosteroids - difference is form • Prednisone - oral 💊 (systemic) • Methylprednisone - IV 💧 (systemic) > Solu-Medrol • Budesonide - inhaled 💨 > Pulmicort • Fluticasone - inhaled 💨 > Flonase (nasal) > Flovent (oral)

_________ asthma patients will have beta adrenergic agonists. _________ COPD patients will have beta adrenergic agonists.

All asthma patients will have beta adrenergic agonists. Most COPD patients will have beta adrenergic agonists.

PSCK9 Inhibitors

All she wanted us to know is that these are antilipemics and can be given SubQ

Dermatological therapeutic drugs: Nursing assessment

Allergies still matter even though topical! Get cultures/sensitivity before applying to wound because we don't want to alter the culture results. Baseline skin assessment: • hydration • irritation • dryness • warmth/redness • intactness • drainage • itching (subjective) • any changes in moles or freckles? (subj) Remember skin is thinnner and more permeable with age, potential for greater absorption. Labs: WBC, pregnancy test - make sure you know pregnancy category of any med before you give if the woman is pregnant

Tamsuolosin Class What does it do? What do we use it for?

Alpha blocker Used to treat BPH (benign prostatic hypertrophy) and urinary retention DO NOT take with erectile dysfunction drugs - can have a very big drop in blood pressure!

Nitrates Used for? Forms? Onset of action? Assess/Implement consider?

Anti-angina drugs. Dilates the blood vessels by making the smooth muscles relax. Mostly effects the veins and coronary arteries and also lowers O2 demand of heart by reducing volume and pressure in left ventricle. Comes in many different forms. • Rapid acting - used for acute attack • Long acting - used for prophylaxis Assessment/Implementation: May want "drug holidays" to help prevent tolerance. Maybe overnight while sleeping. If pt mentions that it doesn't work as well as it used to, it's likely tolerance.

Anxiolytic drugs What are these? Safety considerations?

Anti-anxiety drugs • Can cause orthostasis - measure BP, monitor for oversedation, baseline visual testing, caution with position changes and move slowly • Several are lipid soluable, half-life is increased in obese patients • Be aware of look-alike/sound-alike drugs • Check for "cheeking"

Adsorbents What do they do? Used for? Example drugs? AEs?

Anti-diarrheal: Coat the walls of the GI tract and binds to the bacteria or toxin which is then eliminated through the stool Used for: mild cases of diarrhea Examples: • bismuth subsalicylate (Pepto-Bismol) • activated charcoal • colestipol (anitlipemic) • cholestyramine (antilipemic) AEs: • constipation • dark stools and dark tongue (bismuth - harmless)

Simethicone What is it? What is it used for? How does it work? Admin?

Anti-gas / anti-flatulant Used for: • reduce discomfort of gastric or intestinal gas • expel gas after laproscopic surgery • colic in babies Works by: • Alters elasticity of mucus-coated gas bubbles, breaking them into smaller ones ---Result is decreased gas pain and increased expulsion via mouth or rectum Admin: Taken at meals or bedtime

Dermatological therapeutic category: Antipruritics What are they used for? What are they made with? Considerations?

Anti-itch May contain antihistamines or anesthetic + antipruritic combination If contains antihistamine, we don't use on large areas to prevent systemic absorption.

Benzodiazepines Class? Common suffix? How do they work? Uses? Contraindicated? AEs?

Antianxiolytics -pam -lam Increase the action of GABA. GABA blocks some nerve transmissions, which depresses activity in some areas of the brain Schedule IV controlled substance Uses: • alcohol withdrawal • insomnia • severe muscle spasms • seizure disorders • combine with other meds for anesthesia • adjunct for depression Contraindicated: • pregnancy • narrow angle glaucoma AEs • sedation (CNS depression) • hypotension • big potential for addiction • weight gain • sometimes paradoxical reaction • vision changes - monitor eyes! Not usually lethal on their own if OD, but outcome is poor if combined with other CNS depressants like alcohol. Monitor for oversedation and BP.

Warfarin Class? How does it work? Interactions? AEs? Important to remember? Teaching? Antidote? ON KAPLAN

Anticoagulant Inhibits vitamin K synthesis in the GI tract. Vitamin K necessary for clotting cascade Interactions: • Many! "since I'm nice, I'm not going to ask you what they are" Just know that there are a lot -----usually the interaction causes an increase in the effectiveness of warfarin and they can get too much AEs: • bleeding • lethargy • muscle pain • purple toes / necrosis Important: • Requires INR monitoring • monitor liver function because liver synthesizes clotting factors Teaching: • consistent in eating of foods high in vitamin K • avoid cranberry juice and alcohol Antidote: vitamin K (after giving, can cause warfarin resistance for up to 7 days)

Factor XA (10A) inhibitors Class? Example drug? Benefit? AEs? Black box? Antidode?

Anticoagulant Rivaroxaban Benefit: doesn't need monitoring (no PTT or INR) AEs: • bleeding • hematoma • dizzy • SOB • fever • urticaria (red, itchy welts on skin) Black box warnings: • spinal hematoma with epidural • thrombosis with abrupt stopping Antidote: andexa Memory trick for antidote: Andexa has an XA in it, just like the Factor XA

Dabigatran (Pradaxa) Class? How does it work? Important to know? AEs?

Anticoagulant direct thrombin inhibitor Important: Do not use with other anticoagulants AEs: • bleeding • hematoma • dizzy • rash • GI distress • anemia Teaching: • MUST keep in original bottle at all times, away from moisture, light, heat, etc or can lose potency

Enoxaparin (Lovenox) Class? What is it? AEs? Important to remember? Allergies? maybe ON KAPLAN

Anticoagulant • synthetic heparin - AKA low molecular weight because smaller molecule Memory trick: ends in -aparin just like heparin, so you can remember they are basically the same thing AEs: • bleeding • hematoma • anemia • thrombocytopenia Important: • DO NOT use with an epidural because it can cause a spinal hematoma • NEVER use at same time as heparin - double dose! • okay to use with warfarin • does not require PTT monitoring Allergies: contains sulfites, benzyl alcohol

Heparin Class? Half-life? Used for? Important to remember? Allergies? Antidote? ON KAPLAN

Anticoagulant • short half-life • used for central line flushing because it is really detrimental for patient if this line gets a clot • can be used prophylactic to prevent clots AEs: • bleeding • hematoma • anemia • thrombocytopenia Remember: • Okay to combine with warfarin - often will be on heparin in the hospital and we add in warfarin and discontinue the heparin to send them home (overlap for about a week while waiting for therapeutic dose of warfarin to come up) • must use an IV pump • HIGH ALERT drug - double check with another nurse and always make sure you grabbed the right concentration • this is a large molecule, derived from animal sources (usually pig) AKA high molecular weight • ONLY anticoag approved for pregnancy Allergies: contains benzyl alcohol Antidote: protamine sulfate

What is the difference between anticoagulants and antiplatelets?

Anticoagulants work on the clotting cascade Antiplatelets prevent platelet adhesion at the site of blood vessel injury, before the clotting cascade

Carbamazepime (Tegretol) Class? AEs? Contraindications? Interactions? Special considerations? ON KAPLAN

Antiepileptic AEs: • Rash • Vision changes • Dizziness (safety!) Contraindications: • Myoclonic or absence seizures - WILL MAKE THESE WORSE! • Bone marrow depression, can make it worse Interactions • MAOIs • Oral contraceptives • Acetaminophen • Grapefruit juice Special considerations: • Baseline and monitor CBC d/t bone marrow AE • Autoinduction may happen • Higher risk for liver tox with acetaminophen

Topiramate Class? Two major AEs

Antiepileptic Can cause acute glaucoma - report any vision changes immediately! Can cause increased risk for cleft palate if pregnant mom is taking it (teratogenic)

Valproic Acid (Depakote) Class? Contraindications? AEs? Interactions? Special considerations?

Antiepileptic Contraindications • Do not take with carbonated beverages - memory trick "sodas are acidic, valproic acid" • Liver issues AEs • Hepatotoxicity • Pancreatitis • Weight gain Interactions • Aspirin - increases level of valproic acid in blood Special considerations • Get baseline weight • Get baseline liver function tests • Low protein in blood- risk for easy toxicity • Has a "sprinkle" form for pts that can't swallow pills

Opthalmic anti-allergy drugs

Antihistamines - for itching and tearing Decongestants - vasoconstriction of vessels in/around eye to reduce edema, control redness, burning Lubricants and moisturizers - artificial tears, liquid or ointments • Restasis is an Rx version, use it 15 minutes apart from artificial tears

Are opioid analgesics given PRN or around the clock?

Around the clock We want to give it before the pain reaches its peak

Always assess what before giving antibiotics?

Always assess pt baseline GI function, bowel sounds, bowel patterns.

Dopamine Modulators What is our example drug? Why do we use them for Parkinson's? When does it work best? AEs (p 234 table 15.3)

Amantadine is the only one (also an antiviral) • Causes dopamine to be released from storage and blocks re-uptake of dopamine, increasing the level of dopamine available to the body. • Also has anticholinergic effects Works best in the early stages of Parkinson's while there are still intact neurons, only effective for 6-12 months. AEs • orthostatic hypotension (change position slowly!) • peripheral edema • dizziness (safety!) • insomnia • agitation, anxiety • headache, nausea, dry mouth • hallucinations

Analeptics Example drugs Uses? Method of action? AEs? Contraindications?

Aminophylline, theophylline, caffeine Uses: • Treat respiratory depression • Bring out of anesthesia if struggling • Treat hypercapnia (high CO2 in blood) • Drug abuse (resp. depression) MOA: • CNS stimulant - areas that control respiration • stimulates area of brain that senses CO2 content AEs: • Vagal response (increase GI, diarrhea, tachycardia) • Flushing, redness, sweating • Tachypnea • Muscle tension, tremors Contraindications: • Peptic ulcer disease • serious cardiovascular conditions • Interacts with sildenafil Special consideration: • Caffeine- caution with recent MI, PUD, dysrythmias

Atomoxetine (Strattera) Class? Use? Contraindication? Specific AEs? Special things to know?

Amphetamine Use: Treatment of ADHD Contraindication: • Do not use under 6 years old AEs: (amphetamine AEs plus: ) • May cause suicidal thinking in a small number - watch for mood changes • Erectile dysfunction Special to know: Non-addictive

Methylphenidate (Ritalin) (Concerta) Class? Uses? Special things to know?

Amphetamine Use: • ADHD • Narcolepsy Special to know: • Comes in extended release forms so kids don't have to dose while at school

What are dopaminergic receptors?

An adrenergic receptor (in addition to alpha and beta) which is located in various tissues and activated by dopamine. They dilate vessels (increase blood flow, decrease blood pressure) and increase blood flow to tissues.

What are the different types of immunity?

Artificial active immunity - provided by toxoid or vaccine Artificial passive immunity - provided by an immune globulin, anti-toxin or anti-serum Natural active immunity - patient got sick and their body formed antibodies Natural passive immunity - mother passes immunities to baby through placenta or breastmilk

Nursing Process: Assessment & teaching Parkinsons

Assess baseline and followup: • sensory • sensations • motor abilities • gait, mobility • muscle movements (smooth? tremor?) • change in sensation in extremities? • memory function • muscle tone and strength, rigidity • pupils • psychosocial (mood, emotions?) • urinary patterns • supine/standing BP for orthostatic HTN

Always assess for what during a course of antibiotics?

Assess for superinfections - fever, mouth sores, thrush, perineal itching Assess for allergic reactions Assess for signs of pt feeling and looking better - reduced fever, normal vital signs, negative culture results, normal CBC, increased energy, increased appetite

Things to remember when treating pain

Assess the pain Provide treatment Always follow up for effectiveness and adverse effects

Before any antihistamines, antitussives or expectorants are used, what do we need to do and why?

Assess! We want to be sure we aren't dealing with an acute allergic reaction so patient can get emergency care if needed. Ensure no drug interactions (MAOIs)

Amphetamine nursing implications Assessment Implementation Teaching

Assessment: • Weight, nutrition - it causes loss of appetite, are they eating? • Sleep patterns - insomnia? May need melatonin. Implementation: • Morning dosing Teaching: • Take 30-45 mins before meals • Do not take within 4-6 hours of bedtime

Nursing process: Assessment & education CNS stimulants: amphetamines, antiexorants, antimigraines, analeptics, etc

Assessment: • Pre-existing conditions - cardiac (MI, palpitations, chest pain?) - neuro (stroke, seizure risk?) - diabetes (increased glycogenolysis) • Use of other CNS stimulants? - OTC decongestants - Excedrin (has caffeine) - coffee? • Use of MAOIs? • Substance abuse behaviors • VS: HR, BP, RR, risk for HTN • Height, weight, BMI baseline if appetite suppressant • Sleep pattern history baseline • Nutrition/dietary baseline Education: • AEs the might see: tachycardia, increased BP, palpitations, change in sleep patterns, change in mood, seizures possible • Keep out of reach of children/teens • Avoid stopping abruptly • Avoid alcohol, OTC cold meds/cough syrups that contain alcohol, caffeine, nicotine • Tell provider about new chest pain/palpitations

HTN drugs: assessment and evaluation

Assessment: • VS: BP, HR, O2 sat, RR, orthostatic BP • Weights, breath sounds, heart sounds, I&O, edema • CBC, BMP, sodium level, renal function, hepatic function • Eye exam (changes caused by HTN) every 6 months Evaluation: • Decreased s/sx HTN (edema, crackles, abnormal heart tones, long cap refill, see spots, headaches) • Meeting BP goals? • AEs

What is the aspirin triad?

Asthma, nasal polyps, rhinitis If a patient has these 3 things, they are at a greater risk for an allergic reaction to aspirin 🕵️ Assess for these issues 🕵️ Assess for history of respiratory problems

Which beta blockers can be used for angina?

Atenolol (PO only) Metoprolol (PO & IV) Nadolol Propranolol

What do we give to reverse cholinergic crisis?

Atropine

Clozapine (Clozaril) Class? Used for? AEs?

Atypical antipsychotic Used mostly for parkinson's Can get low WBC

Rispiridone (Risperdal) Class? Used for?

Atypical antipsychotic Used often for schizophrenia AEs • extrapyramidal symptoms • sedation • tachycardia • seizures • insomnia • appetite and weight gain • tardive dyskinesia • akathisia/restlessness

Aripiprazole (Abilify) class? used for?

Atypical antipsychotic Used with children for agitation with autism

Chemo patient teaching

Avoid ASA or NSAIDs - ↑ bleeding risk Hydration - cranberry juice good option to prevent UTI Protect themselves from the sun Contraceptive measures: 3 months-2 years after chemo

What is BNP? When is it released? How does it work? What is the name of the synthetic version?

B-Type Natriuretic Peptides Secreted when the ventricle has increased pressure/stretch. Lab for this goes up as heart failure worsens. Memory trick: It causes you to BNPee Increases vasodilation and diuresis so body is compensating for thinking there is increased pressure by diuresing. Synthetic version: Nesiritide

Patients do much better with Ipratropium when also using what? What kind of drug is Ipratropium (Atrovent)? How often is it dosed?

Better when combined with a beta-2 agonist Ipratropium is an anticholinergic 2x daily

Antiemetics: antidopaminergic drugs

Block dopamine receptors Used for: • nausea • psychotic disorders • intractable hiccups AEs: • anticholinergic & antihistamine effects • calm CNS Example drugs: • prochlorperazine • promethazine

What do anticholinergic drugs do? AKA and AKA?

Block the effects of acetylcholine - compete to bind at muscarinic receptors "anti-rest and digest" They have many of the same effects as the adrenergic agonists do AKA Cholinergic-blockers AKA parasympatholytics

Potassium sparing diuretics Example drug?

Blocks aldosterone receptors - Na & H2O excreted while K is retained. Relatively weak so sometimes used as an adjunct (can help balance K when used with other diuretics) Contraindications: • hyperkalemia • anuria • severe renal failure AEs: • gynecomastia (increase in breast tissue size) • amenorrhea (lack of period or bleeding post-menopause) • hyperkalemia Interactions: • can increase risk of hyperkalemia if used with an ACE inhibitor • potassium supplements - can increase hyperkalemia Often used for heart failure in children. Can be cardio protective. Used in edema r/t heart failure.

What do we ALWAYS assess BEFORE giving a beta blocker?

Blood pressure! Heart rate! Apical pulse for one full minute before administration. If 60 or less, HOLD.

Pentobarbital (Nembutal) Class? Schedule? Short or long acting? Uses?

Barbituate Schedule II • Short-acting Uses: • Insomnia • Pre-op sedation & anxiety • Status epilepticus • Treat withdrawal for pts physiologically dependent on barbituates or nonbarbituate hypnotics

Phenobarbital (Luminal) Class? Schedule? Short or long acting? Uses? AEs? Special consideration?

Barbituate & Antiepileptic Schedule IV • Long-acting Uses: • Prevent tonic-clonic seizures • Fever-induced convulsions • Hyperbilirubinemia in neonates AEs: • Dizzy/Drowsy (safety!) • CNS depressing • Interacts w/ oral contraceptives Monitoring of therapeutic serum drug levels required

Why are anticholinergics useful for Parkinson's?

Because Parkinson's is all about having too much acetylcholine vs level of dopamine • Used as adjunct to block tremors, help with muscle rigidity

Why is aspirin used in acute heart attack?

Because it has antiplatelet effect

Why do we usually use synthetic thyroid hormone? What is another name for natural hormone?

Because it is 100% pure vs the natural kind mya not be as pure. Natural hormone AKA simple hormone

Why do we assess for any past/present neuro disorders like alzheimers, dementia, stroke when giving an opioid agonist?

Because the opioid may alter the symptoms of the disease process and you won't be able to tell if it is the opioids or the disease process causing the symptoms.

When do you assess for pain?

Before Intervention During Intervention After Intervention • At rest • With activity DOCUMENT ALL OF THESE!

HIV/AIDS

Belongs to retrovirus family, frequent mutations, can become resistant to medications and to patient's immune system • Present in blood, semen, vaginal secretions • Vaccines are in trial but frequent mutations making it difficult • Opportunistic infections and cancers are often cause of death • 25% of HIV patients also have HepC because HIV drugs strain the liver

Anticholinergic Drugs Example drug for Parkinsons? Why do we use them for Parkinson's? AEs (p 234 table 15.3) Patient teaching?

Benztropine • Used as adjunct to block tremors, help with muscle rigidity (they don't help with bradykinesia) AEs • tachycardia • confusion, memory impairment • rash • hyperthermia (decrease sweating) • constipation • dry throat, dry mouth • nausea, vomiting • urinary retention (assess!) • constipation • blurred vision (safety!) • fever Teaching • Avoid heat, sauna, etc due to decreased sweating • Take before bed d/t sedating • Take with food • Avoid alcohol d/t CNS effects

Indications/uses for adrengergic drugs?

Beta 1 • Cardiac failure • Shock Beta 2 • Asthma, COPD, Bronchitis - Bronchodilation • Pre-term labor • Vascular smooth muscle relaxation > (decrease blood pressure, increase blood flow to tissues) • Dilate pupils (mydriasis) Beta 3 • Relax detrusor muscle > decrease frequency of bladder contractions, allow greater filling and storage Alpha 1 • Constrict arterioles > Nasal decongestion, decreases nasal blood flow - IE: Phenylephrine > Eye decongestion, lowers intraocular pressure - Useful for glaucoma • Cardiac failure • Shock

What system does beta 1 affect? What system does beta 2 affect?

Beta 1 = cardiac Beta 2 = respiratory

Where are beta 1 receptors located and what does stimulation result in?

Beta 1 are located in the myocardium of the heart. They influence the conduction of the heart. Stimulation results in: (Table 18.1 p290) • Increased force of heart contraction • Increased HR (AV & SA nodes) • Increases heart electrical conduction • Increased renin production in kidney Memory trick: we only have ONE heart (Beta ONE)

Metoprolol (Lopressor) What type? What do we use it for? Safety alert?

Beta 1 beta blocker Most commonly used Shown to increase survival rate after MI HIGH ALERT when given IV, usually given PO

Where are beta 2 receptors located and what does stimulation result in?

Beta 2 are located in bronchioles in the lungs, the visceral organs and arterioles. Stimulation results in: • Relaxation of smooth muscle > GI relaxation (decreased motility) > Uterus relaxation (stop early labor) > Dilate bronchial smooth muscle • Glycogenolysis • Vasodilation Memory trick: we have TWO lungs (Beta TWO)

What class of drugs end in -lol? What do they do as it relates to heart failure? Which two are most commonly used for heart failure?

Beta blockers Prevent effects SNS, cardioprotective, reduce HR, delay conduction through AV node, reduce contractility, decreased automaticity • Metoprolol (most common) • Carvedilol

If someone has a new Rx for a beta blocker vs an old Rx for a beta blocker - thoughts when it comes to HTN?

Beta blockers used to be first line treatment for HTN but no longer are. If you see a newer Rx for a beta blocker, it's likely that it is for something other than HTN. If someone has an old Rx for HTN, it's more possible that it is for HTN. She brought this up in two lectures now, so may be important?

What is glycogenolysis?

Body breaks down glycogen into glucose to help correct hypoglycemia. Stimulated by beta 2 agonists.

What is aminophylline metabolized into?

Body metabolized aminophylline into theophylline and theophylline into caffeine.

NDDRAs Example drug? Why do we use them for Parkinson's? AEs (p 234 table 15.3) Contraindications

Bromocriptine These are not dopamine, but work by stimulating the dopamine receptors. Can be used in early or late stages of Parkinson's. "First line drugs" AEs • ataxia • dizziness (safety!) • headache • depression • drowsiness • GI upset • edema • visual changes Contraindications • Can cause vasoconstriction, so contraindicated in peripheral vascular disease. • Don't combine with adrenergic drugs

Buspirone vs. bupropion

Bupropion = antidepressant and quit smoking Buspirone = antianxiety

Antiepileptics Uses? Method of action? Special considerations?

CNS depressing Uses: • Reduce seizures while minimizing AEs • Also treat migraines, psychiatric disorders, neuropathic pain MOA: Stabilizes cell membranes by movement of Na, K, Ca and Mg. Increases activity threshold, limits spread of seizure, decrease speed of impulse, enhance or increase GABA Special considerations: • Abrupt withdrawal can cause rebound seizures • Typically (but not always) on antiepileptics for life • Low threshold, need to monitor serum levels • Switching from brand name to generic, need increase monitoring • Taking with food or snack can limit GI AEs

Why do we have to monitor diabetes patients with CNS stimulants?

CNS stimulation increase glycogenolysis

Omeprazole is a strong inhibitor of ___________

CYP2C19 which is part of the CYP450 system in the liver - strong drug interactions with drugs that need that enzyme!

Nifedipine ON KAPLAN

Calcium channel blocker She really didn't talk about this and there's no info about it in this chapter, but making a card because FYI it's on Kaplan

Amlodipine Class? Used for? AKA? Form? Teaching?

Calcium channel blocker • used for angina, dysrythmias and HTN If we are going to use a Ca channel blocker for HTN, this one is the most common choice. Brand name: Norvasc • PO only Teaching: • Hold if HR less than 60 • Avoid alcohol and OTC meds, especially cold/flu • Okay with or without food

Why are "wean" or "taper" orders so important for patients to follow with systemic corticosteroids?

Can have severe adrenal effects if stopped cold-turkey

What is serum sickness? S/sx Treatments

Can occur after repeated doses of equine/horse-derived immunizing drugs S/sx: • edema of the face, tongue and throat • rash • urticaria • arthritis • adenopathy (swollen lymph nodes) • fever • flushing • itching • cough • dyspnea • cyanosis • vomiting • cardiovascular collapse Tx: • analgesics • antihistamines • epinephrine • corticosteroids

Hydralazine (Apresoline) Used for? Forms? AEs? Interactions?

Can reduce BP in 10-80 minutes so great for hypertensive emergencies Forms: IV or PO AEs: • Can get symptoms of Lupus (joint pain, rash) - notify provider right away Interactions: • Other antihypertensive drugs = additive hypotension

What can anticoagulants do and not do?

Can: • prevent formation of a clot • prevent extension of an existing clot Cannot: • break down a clot that has already formed

What is the most common fungal infection?

Candidiasis / Candida albicans

S/sx hypothyroidism "you need to know these"

Decrease in metabolism - think "slowing" • cold intolerance • weight gain • decreased appetite • depression • fatigue (present in both hypo and hyper) • hair falling out or breaking • dry, brittle nails • constipation • poor memory/concentration "foggy"

Antimotility drugs: anticholinergics What do they do? AEs? Contraindicated?

Decrease intestinal smooth muscle tone and peristalsis --slows the movement of fecal matter through GI tract Used for: severe cases of diarrhea AEs: • can't pee: urinary retention, impotence • can't see: blurred vision • can't spit: dry mouth • can't shit: constipation • hypotension, bradycardia, flushing • headache, dizzy, confusion, anxiety, drowsy Contraindication: • narrow angle glaucoma • GI obstruction • paralytic ileus • toxic megacolon

What are keratolytics?

Dermatologic drug category used to promote sloughing or peeling of an area. Used for things like: • Plaque psoriasis • Wrinkles

Which non-opioid antitussive is popular drug of abuse?

Dextromethorphan

Diazepam (Valium) Class? Uses? Dosage form?

Diazepam (Valium) is a benzodiazepam Used for: • Anxiety • Procedural sedation & anesthesia adjunct • Anticonvulsant therapy • Skeletal muscle relaxation after injury/surgery Forms: • Oral • Injectable • Rectal

What is important to know about how sedatives/hypnotics work with the sleep cycle?

Different drugs affect different stages of the sleep cycle.

Cardiac glycosides Example drug? What does it do? Important thing to remember? Interactions? Teaching? Implementation?

Digoxin (the only one there is in US) Positive inotropic, increases myocardial contractility. Enhances PSNS and delays conduction, reducing heart rate and increasing filling. Low therapeutic index - easy OD! Increased risk for toxicity if: • low potassium • low magnesium • poor renal function Monitor serum drug levels and s/sx toxicity Interactions: lots of them, including herbals! Interaction can increase the digoxin level by up to 50% and become toxic! Teaching: • large amounts of fiber / bran can decrease absorption • talk to provider before using herbs Implementation: DO NOT give if HR less than 60 or over 100!

Example toxoid vaccines?

Diptheria and tetanus

Anticoagulants Contraindications AEs ODs Interactions Admin?

Contraindications: • Patient with acute bleeding • Pregnancy (except okay with heparin) • Indwelling epidural - spinal hematoma AEs: • bleeding - increases with dose or ASA, antiplatelets • low platelets (heparin specifically) • skin necrosis (warfarin specifically) ODs: • may need to give packed RBC, human plasma or clotting factor concentrate transfusion • heparin antidote: protamine sulfate • warfarin antidote: vitamin K Interactions: there are a lot - all of them interact with ASA and NSAIDS Admin: Never ever give IM, only oral, IV or SQ - tip: if have to inject, grab a SQ length needle so you can't accidentally inject IM (can cause hematoma)

Nitrates Contraindications? AEs? Interactions?

Contraindications: • Severe anemia • Hypotension • Severe head injury • Erectile dysfunction drugs AEs: • Headache ~ 20 mins • Reflex Tachycardia • Orthostatic hypotension • Contact dermatitis - topical form Interactions: • other drugs that cause hypotension - alcohol, beta-blockers, calcium channel blockers, erectile dysfunction drugs •

Beta blockers Contraindications? AEs? Important to remember? Teaching?

Contraindications: • Systolic heart failure • Conduction disturbance • Caution with asthma • Caution in diabetes and PVD AEs: • bradycardia • hypotension • AV block • mask symptoms of hypoglycemia • decreased cardiac output • bronchoconstriction • decreased renin • hypo and hyperglycemia Remember: • check HR before admin, hold if less than 60 • Black box warning - do not abruptly discontinue • take daily weights and report abnormal weight gain Interactions: • drugs that cause hypotension: calcium channel blockers, antihypertensives, diuretics • insulin and DM drugs

Adrenergic drugs (hypertension chapter) Contraindications? AEs? Interactions? Teaching?

Contraindications: • acute heart failure • MAOI use concurrently • Peptic ulcer • Severe kidney or liver disease • Asthma for beta-blockers AEs: • Bradycardia • Sexual dysfunction • Orthostatic hypotension • First dose syncope • Inhibit glycogenolysis (if non-selective) • Bronchoconstriction (if non-selective) Interactions: • alcohol (additive CNS ↓) • opioids (additive CNS ↓) • benzodiazepines (additive CNS ↓) Teaching: • Do not abruptly discontinue - risk for rebound HTN • Report sexual dysfunction so we can change med • Take at bedtime d/t orthostatic hypotension

Barbituates Contraindications? Interactions?

Contraindications: • pregnancy or lactation • respiratory difficulties • severe kidney or liver disease • older adults (increased fall risk) Interactions • Additive CNS effects w/ alcohol, antihistamines, benzo's, opioids, tranquilizers • MAOIs • Anticoagulants - decreased anticoagulation • Oral contraceptives • Glucocorticoids • Tricyclic antidepressants

Statins (HMG-CoA Inhibitors) Contraindications? AEs? Interactions?

Contraindications: • Liver disease • High liver enzymes and we don't know why AEs: • Elevated CPK (creatinin) • Constipation • Myopathy (rhabdo) Interactions: • Other drugs that are metabolized by Cytochrome P450 3A4 (CYP3A4) d/t competing • Grapefruit juice (inactivates CYP3A4) Lovastatin and simvastatin are most potent inhibitors of CYP3A4, so they have the most interactions

Antiplatelets class in general Contraindications? AEs? Teaching?

Contraindications: • thrombocytopenia • active bleeding • leukemia • GI ulcer (bleeding and hard on GI tract) • vitamin K deficiency • recent stroke • traumatic injury • antiplatelets + steroids or NSAIDS can cause ulcers AEs: • thrombocytopenia • leukopenia and neutropenia • hemolytic anemia • bleeding • N/V Teaching: • hold antiplatelet for 5-7 days before surgery

What is CRE?

Carbapenem-resistant Enterobacteriaceae Not as common, but very "nasty germ to have"

What is the differece between: • carcinoma • sarcoma • lymphoma • leukemia

Carcinoma - epithelial tissue (throughout body) Sarcoma - connective tissue (bone, cartilage, muscle) Lymphoma - lymphatic tissue Leukemia - bone marrow, cancers of the blood

How are ACE inhibitors cardiac protective? How are they kidney protective?

Cardiac: they stop heart remodeling process, which is a permanent change in the left ventricle. Kidneys: they reduce the filtration pressure (helpful for diabetic patients)

Atenolol What type? What do we use it for? ON KAPLAN

Cardio selective beta blocker Used for HTN and angina

What is Cushing's syndrome?

Caused by oversecretion of glucocorticoids or long-term use of steroids. • causes redistribution of fat - causes "moon face", belly fat and "buffalo hump" with thinner extremities • bruising • HTN (d/t Na & H2O retention) • low potassium • high sodium • hyperglycemia • muscle atrophy (d/t potassium loss) Memory trick: fat "cushion"

Why does it take so long to treat a fungal infection in the nails?

Cell turnover is slow in the nails, so nail fungal infections are very difficult and take a long time to treat.

How does chemotherapy work? Cell-cycle specific or non-specific

Cell-cycle specific interrupts a certain segment of the cell reproduction cycle Non-specific is more broad Think like a narrow vs broad spectrum antibiotic

Local anesthetics: Types

Central ---large areas d/t spinal, but doesn't put them to sleep • intrathecal - subarachnoid space • epidural - epidural space Peripheral • infiltration - injected into specific tissue area • nerve blocks - block a whole region, large area • topical - surface of skin, eye, mucous membrane • pump - peripheral nerve catheter with PCA pump

Why is it important that a provider knows what type of seizure a patient is having?

Certain drugs treat only certain types of seizures. If you use some seizure medications on the wrong type of seizure, it could make them worse

What are the three ways we classify CNS stimulants?

Chemical structure, site of action or therapeutic category Chemical structure: • amphetamines • serotonin agonists • sympathomimetics • xanthines • misc Site of action: • cerebrovascular system, 5HT receptors • cerebral cortex • hypothalamic and limbic regions • medulla and brainstem Therapeutic category: • Anti-ADHD • Antinarcoleptic • Anorexiant • Antimigraine • Analeptic

What is angina? What can we do to help?

Chest pain d/t lack of oxygen to the heart. When the heart doesn't have enough oxygen, it begins anaerobic metabolism, which generates lactic acid and causes the pain. Increase the blood flow to the heart muscle or decrease the O2 demand of the heart

Who is most at risk for paradoxical reactions?

Children and older adults

Opthalmic: antimicrobials AEs? Good things to remember?

Choice based on causative infectious agent, if severe may use systemic form instead. AEs: • inflammation • burning, stinging • lacrimation • angioedema • drug hypersensitivity • dermatitis Can interfere with normal flora, so possible opportunistic infections If use corticosteroids at the same time, can make antimicrobials less effective d/t immunosuppressive effect

Ezetimibe What is it? What does it do? Interactions? Contraindications? Good things to know?

Cholesterol absorption inhibitor Lower total cholesterol, lower LDL, lower triglycerides, raise HDL Interactions: • Can combine with a statin, enhances the effect • Cannot be combined with a fibrate Contraindicated: liver disease or elevated liver enzymes with unknown reason Good to know: • Okay for patients with moderate to severe kidney disease • Take with or without food

What is COPD?

Chronic Obstructive Pulmonary Disease - nonreversible obstruction of the airway Keyword: non-reversible we cannot fully reverse the obstruction of the airway, it is going to remain to some degree.

When do we put someone with gout on an anti-gout medication?

Chronic gout effects/infections

Antidysrythmic drug classes and the AEs for each Also, what AEs are common for most antidysrythmics?

Class 1: • hypotension • rash • diarrhea Class 2: • bradycardia • AV block • heart failure • glucose changes Class 3: • pulmonary toxicity • thyroid disorders • hypotension • bradycardia Class 4: • heart block • hypotension • constipation Common to most: • GI upset: N/V/D • dizziness, headache • blurred vision • palpitations • new dysrythmias (prolonged QT most concerning)

Antidysrythmic drug classes and what each does

Class 1: • stabilize the excitability • delay repolarization • prolong action potential ----- there is a class 1a, 1b, 1c but she said we don't really need to differentiate those Class 2: • these are beta blockers: all of them ----- blocks response of body to SNS, decreasing HR and BP Class 3: • prolong action potential • block alpha and beta cells Class 4: • these are calcium channel blockers: verapamil and diltiazem

Procainamide Class? What does it do? AEs?

Class 1a antidysrythmic Local anesthetic properties, membrane stabilizing AEs: • Lupus s/sx • GI effects • Prolonged QT interval

Lidocaine (as it relates to antidysrythmias) Class? How does it work? AEs? Important to remember?

Class 1b antidysrythmic • Act preferentially on ischemic heart tissue • Block Na channels but accelerates repolarization Form: IV due to huge first pass effect AEs • respiratory depression/arrest • hypotension • bradycardia • dysrythmias Remember: • Be sure to grab the bottle of CARDIAC lidocaine and not the ANESTHETIC lidocaine - concentrations are different and anesthetic one may have epinephrine in it! • Only stable parenterally for 24 hours

Flecainide Class? How does it work? AEs?

Class 1c antidysrythmic • Slows conduction through AV nodes and ventricles • Strongly suppressess PVCs • First line drug for a-fib (acute) AEs: • dizziness • visual disturbances • dyspnea ​

Propafenone Class? How does it work? AEs? Important to remember?

Class 1c antidysrythmic • Slows conduction through AV nodes and ventricles • Strongly suppressess PVCs • Used for a-fib AEs: • dizziness • metallic taste • headache • N/V/D Use caution with asthma, heart failure, significant hypotension or bradycardia because this has similar effects as a beta blocker!

Which class of antidysrythmic drugs are the "yucky" ones with lots of side effects? What is our example drug?

Class 3 Amiodarone

Dofetilide Class? Used for? Unique to remember? AE?

Class 3 antidysrythmic Patient has to be in hospital and on ECG for 3 days to verify dose is nailed down Provider must be specially trained to use AEs: can produce dysrythmias

Ibutilide Class? Used for? AE?

Class 3 antidysrythmic Use to rapidly correct a-fib and a-flutter AE: can cause dysrythmias

Sotalol Class? AEs? Contraindications? p395

Class 3 antidysrythmic even though it's a beta blocker because it is unique and fits better as a class 3 AEs: • can cause dysrythmias Contraindicated: • asthma • bradycardia

Calcium channel blockers for use in dysrythmias How do they work? Which drugs do we use?

Class 4 Slows conduction of AV node, limited effect in atria and AV node - little effect on ventricles. Controls ventricular response after a-fib and a-flutter Diltiazem & Verapamil

Salmeterol What class of drugs? What type of drug in that class? Short or long acting? 😱 AE 🎓 Teaching

Class: Beta-adrenergic agonist Type: Beta 2 Long-acting (maintenance) • Used in-combo w/ inhaled corticosteroid > cannot be used alone, must be in-combo • Used 2x daily (only!) 😱 HA 😱 Tachycardia 🎓 Not for rescue, use every day

Albuterol What class of drugs? What type of drug in that class? Short or long acting? ON KAPLAN

Class: Beta-adrenergic agonist Type: Beta 2 Short-acting (rescue) 😱Tremors 😱Anxiety 😱Palpitations 😱Tachycardia 😱 Nausea 😱HTN 😱Hyperglycemia 😱Hypokalemia 😱 Risk for rebound or paradoxical effect (with excess use) 🕵️ If using this frequently, means patient doesn't have asthma under control, should let provider know

Anti-glaucoma drugs: cholinergics Class? How do they work? AEs? Special consideration?

Class: Miotics Helps reduce IOP by increasing drainage of AH. Causes pupil constriction, vasodilation. (Think: cholinergics = wet so they won't decrease production but work on drainage instead) AEs: • blurred vision • burning, itching, redness in eye • blurred vision • lacrimation • nearsightedness • decreased nighttime vision • eyelid twitching and spasms Miosis may be less pronounced in those with dark eyes because the pigment absorbs some of the drug.

Anti-glaucoma drugs: sympathomimetics Class? How do they work? AEs?

Class: Mydriatics Helps reduce IOP by enhancing AH drainage and reducing production of AH by ciliary body. (Think: ciliary body produces AH and ciliary muscle contraction dilates pupils, so memory trick could be that when the ciliary muscle is small, the ciliary body can't make as much AH) AEs: • burning • eye pain • lacrimation • conjunctival hyperemia (bloodshot) • melanin deposits in conjunctiva

Tacrolimus class? Used for? AEs? admin considerations? referral consideration?

Class: immunosuppressant Used to: prevent organ rejection or treat ongoing organ rejection AEs: • hepatotoxicity • angioedema • bone marrow suppression • pancreatitis • seizures • a-fib, palpitations • pulmonary hemorrhage (more! see table 48.2 p758) Admin: • Narrow therapeutic index - monitor serum levels • monitor for hepatotox and nephrotox • IV form- use specific container and tubing only! • PO from - empty stomach only • avoid alcohol Referral: nutritional counseling is beneficial to help avoid high-fat foods and because of high cholesterol/triglyceride AEs

Sirolimus Class? Used for? black box? interactions? Monitor for? Consideration for referral?

Class: immunosuppressant Used to: prevent organ rejection or treat ongoing organ rejection Black box: serious infections, lymphoma Interactions: high-fat meals increases drug level Monitor for: liver or kidney toxicity AEs: • hepatotoxicity • angioedema • bone marrow suppression • pancreatitis • seizures • a-fib, palpitations • pulmonary hemorrhage (more! see table 48.2 p758) Referral: nutritional counseling is beneficial to help avoid high-fat foods and because of high cholesterol/triglyceride AEs

Dermatological therapeutic category: Skin prep drugs Used for? Example drugs? Contraindications?

Cleansing before procedures Examples: • isopropyl alcohol • iodine • chlorhexadine (scrub before surgery) Contraindications: • Iodine - shellfish allergy

Docusate salts Example drug? class? used for?

Colace emollient laxatives Used for tx of opioid constipation

Azithromycin (Zithromax)

Commonly used 👍 Dosed once daily, usually 3-5 days 👍 Respiratory infections, skin infections Class: Macrolides 💪

Fungal infections can sometimes take up to ________ to treat.

Fungal infections can sometimes take up to 1 year to treat.

What are lower H&H and RBC count pointing to?

GI bleeding

What types of adverse effect is common/typical/expected with antibiotics? (all antibiotic classes)

GI-related issues • Nausea • Vomiting • Diarrhea Always should be monitored for in a pt getting antibiotic therapy.

How much weight gain in what time frame is concerning/reportable?

Gain of 2lbs or more in 24 hours or 5lbs in a week

Ketamine What is it? Special considerations? p 168

General anesthetic Causes bronchodilation, so good choice for asthmatic If given alone, can cause scary hallucinations - always given with a benzodiazepine

Propofol What is it? Uses? Special consideraion? AEs? p 169

General anesthetic Uses: • used for induction and maintenance of general anesthesia • used for sedation during mechanical ventilation in ICU settings • low doses can be used as sedative-hypnotic White in color: lipid-based - if giving with total parenteral nutrition or for long periods of time, monitor serum lipids Typically well-tolerated with few AEs

Vitamin B12 Form? Treatment for?

Given IM to treat pernicious anemia

Hepatitis B immune globulin Used for? Interaction? Specific contraindications?

Given as post-exposure prophylaxis Interacts with live vaccines (wait 3 months between) Pregnancy is not a contraindication

Rabies immune globulin

Given in conjunction with the rabies vaccine

Tetanus immune globulin

Given when: • someone who hasn't had confirmed recent tetanus vaccine or booster has had a wound that is prone to tetanus • someone with active tetanus • nails, fences, wires wounds risky

Are gram positive or gram negative bacteria are more difficult to treat?

Gram negative due to their cell wall structure.

Dermatologic form: Sprays Characteristics/benefits Examples

Great for areas that are tender (IE burns) Good for covering large areas Examples: • Solarcaine • Desenex • Kenalog

Dermatologic form: Powders Characteristics/benefits Examples

Great to promote drying Absorb moisture Examples: • Tinactin powder • Desenex powder

Somatropin Class? Used for? Contraindications? Important to remember? Assessments? Antagonist?

Growth hormone Promotes linear (skeletal) growth in children. Promotes growth of organs, muscle, connective tissue. Given to children that have a growth delay or some forms of dwarfism. Given to HIV patients with wasting. Contraindications: • children with closed growth plates • tumors (↑ growth) AEs: • headache • injection site reactions • muscle pain • hypoglycemia • hyperglycemia Remember: • Important not to shake the medication! Swirl only. • Only available SQ or IM, bummer for kids Assess: • weight and height, plot on growth charts • watch motor skills and development • monitor BG, electrolytes, thyroid function Antagonist for this: octreotide

Antiemetics: antihistamines How do they work? Used for? AEs? Example drugs?

H1 receptor blockers • inhibit ACh by binding to H1 receptors • have anticholinergic effects Used for: • motion sickness • nonproductive cough • allergy sx • sedation NO for glaucoma AEs: • paradoxical reactions in children • agitation in older adults • hypotension • anticholinergic effects Examples: • dimenhydrinate (dramamine) • diphenhydramine (Benadryl)

AEs: NMBDs

HIGH ALERT drugs • Increase intraocular pressure (glaucoma!) • Increase intracranial pressure (stroke!) • Muscle spasms before paralysis: hands, feet, face - causes more potassium to be released and patient can get hyperkalemia • Release of histamine - bronchospasm, hypotension, excess secretions, excess salivation • Malignant hyperthermia

Antiretroviral drugs always refer to what? What are we looking for when we use these?

HIV We are looking for a decrease in their viral load.

Bidil What is it? Used for?

HTN drug Hydralazine + an antianginal Used to treat heart failure in African American patients, works well with this ethnicity

What is malignant hyperthermia? p 168

Has a genetic component, patient may have had family members experience it • Rise in temperature, tachycardia, muscle rigidity • Can be fatal! Needs to be treated ASAP. Happens during initiation of anesthesia and under anesthesia. Risk goes down post-anesthesia

What do we need to do before and after the use of these drugs?

Document the symptoms before and after the use of the drug. We want to document the effectiveness or non-effectiveness of the medication.

General anesthesia AEs p 167, table 11.4

Dose dependent - AEs range varying on how high the dose is. From lecture: • hypotension • decreased organ perfusion • malignant hyperthermia • post-op nausea/vomiting • increased ICP From book: • impaired oxygenation, depressed airway protection • airway irritation, possible laryngospasm • depressed myocardium, hypotension • tachycardia or bradycardia (if vagal stimulation) • Increased ICP • reduced hepatic blood flow & clearance • decreased gomerular filtration • skeletal muscle relaxation • vasodilation • CNS depression, blurred vision • nystagmus (uncontrolled eye movements) • decreased alertness, senses, LOC

What do we want to do with an antidepressant drug before we decide it's not working?

Dose optimization - essentially upping the dose until we max it out to find a "sweet spot"

Levofloxacin

Dosed 1x daily Class: Quinolones 👑

What is autoinduction?

Drug can stimulate body to produce enzymes that metabolizes the drug, so it can metabolize itself faster over time

What are sympathomimetic?

Drugs that act like the neurotransmitters: epinephrine, norepinephrine and dopamine.

s/sx of hypercalcemia - early and late

Early s/sx • constipation • headache • increased thirst • dry mouth • decreased appetite • irritability • metallic taste in the mouth Late s/sx • confusion • drowsiness • ↑ BP • irregular HR • N/V • ↑ urination

Cancer Early s/sx? Etiology?

Early s/sx: • anorexia • weight loss • fatigue - can't do ADLs • fever • cachexia (malnutrition, general malaise, wasting) Etiology: we don't really know • some gene and race links • immune-compromised at higher risk • increasing age = increasing risk • oncogenic infections (IE HPV) • exposure to carcinogens Treatment: • surgery • radiation (not systemic - local/regional) • chemotherapy (antineoplastic medications)

What is carbamide peroxide? Used for? How does it work? Pregnancy category? Contraindication?

Earwax emulsifier slowly releases hydrogen peroxide which has weak antibiotic effect and emulsifies impacted cerumen. Once emulsified, can be rinsed out gently with warm water. Pregnancy category C Contraindications: ear drainage, tympanic membrane rupture, significant pain or irritation - unless recommended by a provider

Dermatological therapeutic category: Antifungals Common suffix? Where is a fungal infection usually found? What can cause it? Common types of fungal infections?

End in -azole Found in dark, moist areas like feet, oral, groin. Also happens to the nails. Usually happens after someone has broad-spectrum antibiotics or are immune deficient, but not always. Ringworm, jock itch, vaginal yeast infection, athlete's foot, tinea AEs: • burning • itching • scaling

What are the body's natural pain relievers?

Enkephalins and endorphans IE released when eating chocolate

Eszopiclone (Lunesta) Class? Use? Long or short-term? Contraindications? When should pt avoid taking this?

Eszopiclone (Lunesta) is a non-benzodiazepam sedative/hypnotic Use: provide a full 8 hours of sleep • Long-term use • Contraindication: NO if under 18 years old Avoid taking if must awaken in less than 6-8 hours.

What AEs do we worry about for ALL Parkinson's drugs?

Every single one is a safety issue! They can cause dizziness and hypotension, so we are worried about falls and blood pressure.

Cultural factors to consider with pain

Everyone experiences pain, but some cultures are loud/expressive and some cultures are quiet/suffer-in-silence >>>>Just because someone is not expressing it, doesn't mean they aren't experience extreme amounts of pain Different cultures approach treating pain differently

Osmotic diuretics Example drug? Used for? Good things to remember?

Example drug: mannitol Increases osmotic pressure, pulling fluid into the kidneys from the tissues. Reduces cellular edema, increases urine production, may induce vasodilation, increases GFR, increases renal blood flow, reduces ICP, cerebral edema, IOP, help excrete toxic substances Contraindications: • severe renal disease • intracranial bleeding • severe dehydration AEs: • convulsions • thrombophlebitis • pulmonary congestion Good things to know: • Small loss of electrolytes compared to other diuretics • Must have sufficient renal blood flow and GFR • Prevents kidney damage in early acute renal failure • Not for peripheral edema, does not pull enough sodium to make a difference. • May be used to enhance exretion of toxic substances

What causes hemolytic anemia?

Excessive RBC destruction. Often genetic. • Sickle-cell anemia • Antibodies trageting RBCs • DIC (disseminated intravascular coagulation) - can be fatal

What are excitatory neurotransmitters? What is the inhibitory neurotransmitter?

Excitatory: • Dopamine • Norepinephrine • Serotonin Inhibitory: • GABA

What is the difference between exogenous and endogenous compounds?

Exogenous are synthetic. Endogenous are produced in the body naturally.

Do we want an antitussive or an expectorant for a productive cough?

Expectorant We want the secretions out in order to help prevent infections

Expectorants How do they work? Well known type? 😱 AEs 🎓Teaching

Expectorants thin secretions to make them easier to cough up. ***Can also thin secretions by drinking more water to almost the same level of effect Guaifenesin (Mucinex) 😱 N/V 😱 GI irritation 🎓Teach to increase hydration - take pill with a full glass of water 🎓Won't get optimal benefit if taking it without hydration

What is ESBL?

Extended Spectrum Beta-Lactamase Organisms that produce beta-lactamase enzyme and become resistant to beta-lactam antibiotics

Considerations for topical local anesthetic Eyes? Oral?

Eyes - make sure solution is clear, not cloudy or sediment Oral - make sure patient does not swallow! possible to anesthesize gag reflex and increase risk for aspiration

Fasting plasma glucose to diagnose diabetes? A1C to diagnose diabetes?

Fasting plasma glucose of 126 or higher A1C higher than 6.5%

Patho behind how fats from the diet interact with the liver

Fats from the diet are broken down into triglycerides, which are absorbed into the lymphatic system. Liver is the site of lipid metabolism/manufacture of cholesterol and had LDL receptors for reabsorption from blood. Enzyme CoA is required for the manufacture of cholesterol. Inhibition of this enzymer results in decreased cholesterol production

Why might someone use ferrous fumarate instead of ferrous sulfate? Nursing consideration r/t this?

Ferrous fumarate has more elemental iron (what the body needs) so a patient can take a lower dose for same result. Different forms are not interchangeable because they are different concentrations of elemental iron

Zidovudine (AZT) ***know AEs, administration*** ON KAPLAN

First drug we found to treat HIV 👍 Give to pregnant women and newborn babies as prophylactic to prevent transmission 😱 Bone marrow suppression 😱 Rash 🕵️ Watch CBC and blood counts 🕵️ If any fever, blisters, edema, conjunctivitis notify provider 🎓 Teach to keep head of bed upright for at least 30 min after taking to prevent reflux 🎓 Okay to take with food or milk 🌟 Must be given around the clock at evenly spaced intervals

Diuretics Used for? How do they work? Benefits? Don't work as well when? Classified how?

First line drug for treatment of HTN. Also used for heart failure. Dilate arterioles, decrease PVR, reduce extracellular fluid volume, reduce plasma volume, reducing CO. Benefit: Cheap and good safety profile. Don't work as well with poor blood flow to kidneys or decreased GFR. Classified by site of action in the kidney, potency and chemical structure. Loop diuretics are the most potent.

What is HAART therapy?

Highly active anti retroviral therapy • Cocktail of antiretroviral drugs combined into a single drug dose form • At least 3 medications, may need to modify based on mutations • Redu 😱 Abnormal lipid distribution - typically just cosmetic issue 😱 S/sx of diabetes 😱 Bone demineralization, osteoporosis 💥 Lots of drug interactions, look them up if administering

Which type of histamine are we usually using antihistamines against? Why?

Histamine 1 (H1) Type 1 because it controls smooth muscle contraction and it can dilate capillaries. Dilating vessels increases fluid to that area and seeping of fluid into tissues, causing edema and congestions. Histamine Type 1 cannot work when antihistamines are in the body because they are competing for receptor sites, so we get symptom relief.

Anorexiants How do they work? Uses?

How do they work? • CNS stimulant • Suppress appetite center in the brain • May increase BMR • Release adipose tissue from storage • Enhance glucose uptake into cells • Reduce dietary fat absorption in gut Uses: • Used to promote weight loss in obesity Special considerations: • Effects are minimal without diet/exercise • Can be used up to 1 year • Abuse potential

What is doubling time?

How fast a cancer is going to grow Different for each type of cancer - shorter doubling time = harder to treat, faster to grow

How do you choose which laxative you want to use?

How quickly you need it to work Saline laxative = likely choice if need quickly to remove poison or prep for surgery (3-6 hours) Senna 6-12 hours bulk-forming = longest time

With any respiratory issues, what is something that can be helpful for treating or as a prophylactic?

Humidifier! Mucus membranes and respiratory tract in general needs to be moist, can help to clear pathogens and secretions. May help decrease colds.

Which drug is specifically approved for African Americans with heart failure? What is the important teaching point about it?

Hydralazine / Isosorbide Dinitrate (Bidil) It can cause syncope - not just lightheadedness but full on passing out, if they get this AE will likely need the drug changed

What is the guideline for hypertension?

If 60+ years: • Systolic greater than 150 • Diastolic greater than 90 If under 60, if have chronic kidney disease or diabetes: • Systolic greater than 140 • Diastolic greater than 90

What do we use oral anti-diabetes drugs for vs injectable ones?

If a person is taking oral anti-diabetic drugs, their diabetes is easier to manage. By the time a person gets to the point of having to use injectables, their diabetes is more difficult to manage/further progressed.

Why do we always test blood glucose before giving insulin?

If they were already hypoglycemic, administering insulin could result in brain damage, shock, death. ALWAYS test BG before admin insulin!

What causes Parkinson's disease?

Imbalance between dopamine and acetylcholine in the brain. • Nerve terminals in the brain fail to make enough dopamine and/or are destroyed, causing excessive unopposed acetylcholine. This leads to cholinergic / parasympathetic activity.

What are reticulcytes?

Immature red blood cells

Who is at risk for systemic fungal infections?

Immune compromised Organ transplant recipients Long term steroids Long term biologic modifiers Chemotherapy HIV/AIDS Diabetics - because yeast loves sugar Those on oral contraceptives

Cyclosporine (Sandimmune) Class? Used for? Important to remember? Black box? AEs? Admin/teaching?

Immunosuppressant Tx of some immunologic disorders like psoriasis, rheumatoid arthritis, IBD NOT interchangeable between brand names! Remember: • Narrow therapeutic range - monitor serum drug level • increased risk of skin cancer • increased risk of fatal infection Black box warnings: • renal impairment / nephrotox • liver impairment / hepatotox AEs: • gingival hyperplasia (bleeding gums -dental teaching!) • HTN • neurotoxicity (tremors) • hyperbilirubinemia, dark urine, jaundice Admin/teaching: • NO grapefruit juice! • food high in potassium = ↑ risk nephrotoxicity • do not refrigerate oral suspensions, drink immediately • do not give in styrofoam cup - med sticks and ↓ dose

First line therapy for anti-gout is _________. What else is important to these patients?

NSAIDs are first line therapy. Hydration is important to these patients.

Nitroglycerin Abbreviations to know? Forms? Used for? Teaching? ON KAPLAN

NTG & TNG. Has many different brand names Large first pass effect - so usually use routes other than PO. Spray, buccal, sublingual preferred so can use smaller dose. • Used for onset of acute angina. • Can be taken before stressful activity that patient knows is a trigger for them as prophylaxis. Teaching: Cannot expose to air, moisture, light, plastic because can inactivate drug. Must store in original container.

Antiepileptics - nursing process Implementation Teaching

Implementation • Seizure precautions, safety • ABCs - O2 and suction nearby - use same BLS technique to open airway • Keep patient in bed w/ siderails up - side-lying in case of vomiting, secretions • If mouth is clenched down, leave it that way • Padded bed rails? • Monitor dose and serum levels - small window • Meds on time VERY IMPORTANT • Admin with full glass of fluids, food Teaching • Take meds at same time every day is very important due to small therapeutic window • Move slowly (dizziness) • Daily oral care • No grapefruit w/ carbamezepine • Never abruptly withdraw • No driving or major decisions until used to the drug • Avoid alcohol, caffeine, smoking • Report any suicidal thoughts, changes in behavior • In-home safety (seperate flashcard)

Transfusion reactions Important nursing considerations during transfusion? S/sx? If a reaction occurs? Teaching? ON KAPLAN

Important nursing considerations: • MUST stay with patient for first 30-60 minutes of a transfusion • Document frequent VS in first part of transfusion (5-15 mins) to monitor for a transfusion reaction S/Sx: • fever HUGE RED FLAG • flushing • urticaria (hives) • possible hypotension • possible respiratory distress If reaction occurs: • STOP infusion • Delegate someone to notify blood bank and send EVERYTHING back to them (tubing and all) • Delegate someone to notify provider • Monitor VS • Begin normal saline in new IV line Teach patient: If you start feeling anything unusual report immediately

Are most vaccines live or inactivated? Which one offers lifelong immunity and which needs a booster?

Inactivated Live vaccines offer lifelong immunity, inactivated need boosters

Which antiglaucoma drug classes work by increasing drainage? Which work by decreasing production? Which do both?

Increase drainage: • Cholinergics • Osmotic diuretics • Prostaglandin agonists Decrease production: • Carbonic anhydrase inhibitors Both: • Sympathomimetics (decrease prod. most) • Beta blockers (decrease prod. most)

Teaching for decongestants and expectorants?

Increase fluids!!

S/sx hyperthyroid

Increase in metabolism - think faster • diarrhea • flushing of skin • increased appetite • muscle weakness • fatigue (present in both hypo and hyper) • palpitations • irritability • nervousness • insomnia • heat intolerant • altered (heavier) menstrual flow • bulging of eyes over time

Hyperthyroid What is it? Causes?

Increase in thyroid functioning - increased metabolism Most common cause is Grave's disease - autoimmune disorder Plummer's disease can cause - uncommon nodular disorder

Saline laxatives

Increase osmotic pressure within small intestine, inhibits water absorption, causes more water to enter intestines • Results in watery stool within 3-6 hours - bowel distention, ↑ peristalsis Used for: rapid bowel prep or poison removal AEs: • magnesium toxicity (w/ renal insufficiency) • hypermagnesemia • cramping • electrolyte imbalances • diarrhea • increased thirst Example drugs: • magnesium hydroxide (milk of magnesia) • magnesium citrate (citroma) Taste unpleasant - serving cold can help USE W/ CAUTION IN OLDER ADULTS and NO in renal dysfunction

What do positive inotropic drugs do? negative inotropic?

Increase the force of myocardial contraction Negative decreases the force of myocardial contraction

What do positive chronotropic drugs do? negative chronotropic?

Increase the heart rate Negative decreases the heart rate

Antacids: drug interactions why do we have so many interactions? need to know?

Increased stomach pH • increased absorption of basic drugs • decreased absorption of acidic drugs Increased urinary pH • increased excretion of acidic drugs • decreased excretion of basic drugs Adsorption of other drugs to antacids • reduces ability of the other drug to be absorbed into the body (Quinolone abx up to 50%) Chelation • chemical binding or inactivation of another drug Patients who take antacids should take their antacid at least 2 hours before or 2 hours after any other medications!! **NEED TO KNOW**

What does inflammation have to do with the respiratory system?

Inflammation causes us to have more secretions, secretions include mucus... a lot of discomforting symptoms come from increased mucus production.

Which otic drug is contraindicated for perforated eardrum? Which are indicated for perforated eardrum?

Neomycin + polymyxin B + hydrocortisone is contraindicated in patients with perforated eardrum. Ciprofloxacin and ofloxacin can be used with perforated eardum.

What is Type 2 Diabetes?

Insulin resistance The pancreas may or may not be secreting insulin, but the cells are not responding to it and taking the glucose in from the bloodstream

What is thyroid storm? AKA thyroid crisis

Intense, severe symptoms of hyperthyroidism at once Can be life threatening due to palpitations Usually experienced after stress and triggered by stress - common life stress, infection, when body gets "worn down"

Proton pump inhibitors (PPIs) Interactions and indications

Interaction: Food may decrease absorption of PPIs Indications: • GERD • erosive esophagitis • short-term tx of active duodenal and benign gastric ulcers • Zollinger-Ellison syndrome (hypersecretory) • NSAID induced ulcers • stress ulcer prophylaxis • tx of H.pylori induced ulcers (given w/ abx) Omeprazole is a strong inhibitor of CYP2C19 which is part of the CYP450 system in the liver - strong drug interactions with drugs that need that enzyme!

Artificial passive immunity General interactions? Consideration with creation? Indications?

Interactions: • Immuneglobulin + immunesuppressant cancel out • Not really any drug interactions since single/few doses Needs at least 1000 human donors to create - has been a shortage and reimbursement from insurance is restricted - used for FDA indicated conditions ONLY Indicated for: • Pediatric HIV infections • B-cell chronic lymphocytic leukemia • bone marrow transplants • hepatitis A • idiopathic thrombocytopenic purpura • kawasaki disease • immunoglobulin deficiencies • measles • primary immunodeficiency diseases • varicella

What to remember before taking an oral antibiotic?

Is it supposed to be on an empty stomach or within certain times of meals?

What happens if we give a really high dose of MAO-B inhibitors?

It can cause them to affect the MAO-As as well, so we will then need to watch out for the "cheese effect" and pay attention to tyramine-containing foods.

What is neuroleptic malignant syndrome?

It is a life-threatening condition that can be caused by antipsychotic agents. It is characterized by severe fever, muscle rigidity, altered mental status, cardiovascular instability

Minoxidil (Rogaine) used for?

It is a vasodilator. Topically used for hair growth Systemically used to decrease BP

What is something to remember about opioid-induced constipation?

It is different than normal constipation and it won't always respond to fiber, fluids, increased exercise This is because the opioid is directly affecting the cells in the bowel Often treated different with different types of laxatives

What does it mean if a drug is a "pro" drug?

It is inactive until it is metabolized by the liver and that activates it. Downside, your liver needs to be functioning in order for it to work

SA Node Modulators Example drug? How do they work? AEs Contraindications p371

Ivabradine (only one there is right now) • Inhibits part of the SA node and results in a reduced heart rate Memory trick: Ivabradine practically has the word "brady" in the middle and it slows down conduction AEs: • dysrythmias/conduction abnormalities • bradycardia • a-fib • HTN • heart block • visual disturbances Contraindications: • grapefruit juice • pregnancy

Signs of hepatotoxicity

Jaundice, itching, rash, liver enlargement, BUN changes, creatinine level changes, proteinuria

What is important to remember for a patient taking a nephrotoxic drug?

Keep them hydrated (as long as not on fluid restriction) Monitor kidney function (BUN, creatinine, proteinuria)

Antiepileptic in-home safety teaching Kitchen Bathroom Activites

Kitchen • Use electric stove, not open flame • Use back stove burners • Wear oven mitts when cooking • Microwave cooking is safest • Install heat-control devices on faucets • Carpet floors (cushion falls) • Use plastic dishes instead of glass Bathroom • Heat-control devices on faucets • Carpet floors (cushion falls) • No lock on bathroom door in case need help • Bathe only with a few inches of water • Bathe with another present if seizures not well controlled Activities: • No sports alone • Person with you should know management of airway and seizures • Bike ridking with a helmet, swimming and water sports are okay if person with you knows how to manage seizures and their consequences

What is a huge part of teaching for asthma patients?

Knowing and teaching patients common asthma triggers

Which is good cholesterol and which is bad? Why?

LDL = bad (L for lousy) • Needed for some body functions, but too much is bad • Higher fat content, lower protein content • Responsible for atherosclerosis HDL = good (H for happy) • Responsible for recycling cholesterol • Cardio-protective

Leukotriene Receptor Antagonists Name one How do they work? What do we use them for? How often dosed? 🙅‍♀️Contraindications 🎓Teaching

LTRAs Montelukast (Singulair) • Leukotrienes are an immune substance that trigger inflammation, bronchoconstriction and mucus production, so antagonizing them does the opposite. • Limited to the lungs. Reduce inflammation, prevents smooth muscle contraction, decreases mucus secretion and reduces vascular permeability (edema) in the lungs • Prophylaxis - long term treatment and prevention of asthma 1x daily (PM is best) 👍 Can be used in children under 1 year 🙅‍♀️ Patients with PKU because it contains phenylamine 🎓 PM is best time for dose 🎓 Increase fluids

Nursing process: assessment r/t diabetic drugs

Lab results • A1C • fasting glucose (bedside before insulin) • baseline glucose • 3 checks - high alert drugs! Second nurse • Know how to mix insulin - "clear to cloudy" • Medication and pt history for contraindications, drug interactions, cautions - what type of diabetes do they have? • s/sx hypoglycemia and hyperglycemia • neuro status

psychotherapeutic nursing assessments

Neuro: • PERRLA, LOC, gait • mental alertness • cognitive function • eye contact? • personality changes • MMSE (mini mental status exam) • Baseline reflexes, tremors • suicidal ideation? • weight loss or gain? • sleep habits? • nutrition? • BP, HR, orthostatus • serum drug levels • AEs, sx of serotonin syndrome • older adults - tend to have more body fat, consider for lipid-loving drugs. AEs affect them more • children - don't use unless we have to - ADD, severe enuresis, autism • cultural implications - lower doses for patients of asian decent

What level of pain is considered "adequate" pain relief?

Less than 4

Erythromycin

Lesser used 👍 Best taken on empty stomach if tolerated 👍 All newborn babies get erythromycin in eyes Topical, often used in dermatology and eyes Class: Macrolides 💪

CBC numbers to know

Leukocytes • Normal 5000-10000 • Anything under 2000 notify provider Neutrophils • Normal 1500 • Anything under 500 notify provider Band neutrophils - immature form of neutrophils • increased number means pt is struggling immune-wise • may mean infection if elevated NADIR • lowest level of bone marrow suppression • usually 10-28 days after chemo • watch to help prevent infection RBC • Normal males: 4.6-6.2 million • Normal females: 4.2-5.4 million • Low = anemia, will see low hematocrit & hemoglobin Platelets • Normal 150,000 • Anything under 100,000 notify provider, bleed risk

Easy way to know if a vaccine is live or not?

Live vaccines must be refrigerated and administered quickly after removing from refrigeration

What is digitalizing?

Loading dose of digoxin that may be given if levels need to be risen quickly Watch and use extreme caution Not very common anymore

Lidocaine Class? Forms and uses for each? Caution for dosing? p 172

Local anesthetic Comes alone or with epinephrine Injection • Infiltration anesthesia • Nerve block anesthesia EMLA cream • Applied 30-60 min prior to starting an IV, accessing a central line or port to reduce pain of needlestick Lidocaine patch • Relief of postherpetic neuralgia (per book) Parenteral • Used to treat cardiac dysrythmias • Post-op for pain to decrease use of systemic opiods Caution: too much lidocaine can go systemic and affect heart rythm

Local anesthetics Method of action?

Local anesthetics block the action of epi and nor-epi to produce "sympathetic blockade" AEs • spinal headache • allergy (rare but can switch types to avoid) • bradycardia • hypotension • dysrythmias • infection at the site To limit systemic absorption may be admin with epi for vasoconstriction

Which type of beta-adrenergic agonists are never used for an acute treatment?

Long-acting (LABA) Not meant to relieve airway constriction quickly in someone in serious distress. We use SABA for rescue.

Furosemide (Lasix) Class? Used for? Black box warning? Contraindicated?

Loop diuretic Use in pulmonary edema, heart failure, ascites (fluid in abd cavity), HTN. Black Box Warning: severe electrolyte imbalances, fluid loss, dehydration, hypovolemia, Contraindicated: • hypovolemia • electrolyte depletion

Anemia What is it? Watch for? Interventions?

Low RBC count, low H&H • watch for s/sx anemia (hypoxia, fatigue) • conserve energy, cluster activity and rest • blood transfusions • epoetin alpha • iron supplements

Dosing considerations with anticholinergics

Low dose: • Decrease HR • Decrease muscle rigidity • Decrease tremors High dose: • Increase HR • Drowsiness • Disorientation, hallucinations

Dosing consideration for benzodiazepines with older adults and why?

Lowest effective dose must be used with older adults due to significant fall risk Sometimes we will use half of normal dose.

Hypothyroid drugs method of action? example drugs? contraindications? AEs? Interactions?

MOA: change metabolism - rate of protein, carb, fat metabolism. Increase O2 consumption, body temp, blood volume, cellular growth. Stimulate cardiac system (increased CO and HR). Increase renal blood flow and GFR = diuresis Contraindications: • recent MI (don't stimulate cardiac system)

What is one of the most common healthcare-associated infections?

MRSA

Major and minor adverse reactions to antibiotics

Major Rash Itching Hives Fever Chills Joint pain Difficulty breathing Wheezing Minor Nausea/vomiting Diarrhea (Unless C.diff superinfection!)

What are the two parts of the adrenal glands? What hormones does each secrete?

Medulla and cortex Medulla: • epinephrine • norepinephrine Cortex: • corticosteroids AKA cortisol • glucocorticoids • mineralcorticoids

Antimetabolites - folate antagonists Example drug Used for? How do they work? pros/cons? AEs? Teaching?

Methotrexate cell-cycle specific chemo drugs ----also used for RA, psoriasis due to antiinflammatory and immunosuppressive properties Works by: inhibiting the body's conversion of folic acid to folate, inhibiting the synthesis of DNA in cancer cells ----if cell can't produce DNA, cell dies pro/con • less severe vomiting but ↑ ulcerogenic and ↑ stomatitis AEs: • nephrotoxic • severe bone marrow suppression with high doses • ulcers and stomatitis • folic acid deficiency Teaching: • eat foods high in folic acid to enhance nutrition

Midazolam (Versed) Class? Uses? Dosage form?

Midazolam (Versed) is a benzodiazepam Used for: • Pre-op and for moderate sedation - because it causes amnesia and anxiolysis Forms: • Injection for adults • Liquid oral for children

Phosphodiesterase inhibitors Example drug? What does it do? AEs? Interactions?

Milrinone (it's the only one there is) Positive inotropic and vasodilator. Increases availability of calcium for myocardial contraction and enhanced relaxation, compliance of muscle. May increase HR. AEs • dysrythmias • hypotension • angina • hypokalemia • tremor • thrombocytopenia • elevated liver enzymes Important interaction: Milrinone and Furosemide/Lasix precipitate if they come in contact. Must use separate IV line or flush between drugs if both are IV form

What do cholinergic drugs do? What's another name for them?

Mimic the effects of acetylcholine - they cause us to do the "rest and digest" sort of functions • Increased gastric secretions • Increased GI motility • Increased urinary frequency • Increased salivation • Constriction of pupil (miosis) > helps decrease intraocular pressure • Increased sweating • Reduced HR • Vasodilation • Bronchoconstriction > possible bronchospasm • Conduction abnormalities

How does an insulin pump work? What are the benefits? p 505 -blue box bottom left

Mimics pancreas function with continuous subcutaneous infusion of basal dose of insulin over 24 hours and bolus injections based on food intake Benefits: • More rapid and consistent absorption of insulin • Reduction in occurrence and risk of hypoglycemia • Decreased occurrence of elevated pre-breakfast serum glucose levels (dawn phenomenon) • A1C levels remain somewhat lower (average glucose levels over 3 months)

Aldosterone Class? What does it do? AEs?

Mineralcorticoid • causes sodium to be reabsorbed from urine • results in reabsorbing water as well In order to resorb sodium, something must be exchanged - which is potassium and hydrogen ions, so more of them are excreted. This means possible AEs: • hypokalemia • hypernatremia • alkalosis (d/t hydrogen ions acidic)

What are the mineralcorticoids responsible for? Example drugs?

Mineralcorticoids regulate mineral salts (AKA electrolytes) in the body • blood pressure control • maintain serum potassium levels • maintain pH • sodium and water resorption Aldosterone is the only physiologically important one Fludrocortisone is the only synthetic one ​

What is miosis? What CNS system do miotic drugs influence? What is mydriasis? What CNS system do mydriatic drugs influence?

Miosis = pupil constrict Parasympathetic influence Mydriasis = pupil dilate Sympathetic influence

What conditions do we usually use antihistamines for?

Most commonly used for: • Allergies • Common cold Can also be used for: • Vertigo • Motion sickness • Insomnia • Cough (due to clearing post-nasal drip) • Itching > More benefit from antihistamines if taken early in symptoms. > Can be taken as prophylactic.

Isoniazid ***know AEs, what we monitor for, patient education*** ADR, Black box warning, Interactions, Assessments?

Most widely used anti-TB drug 😱 Liver toxicity >>> Monitor liver function during treatment 😱 Pyrodixine (B6) deficiency >>> Peripheral neuropathy - pain in upper/lower extremities. Pins & needles, burning, tingling symptoms. >>> We supplement with B6 during treatment to avoid this 😱 Optic neuritis 😱 Hyperglycemia 🗃️ Black box warning - possible hepatitis 💥 Antacids will reduce absorption, do not give together 🕵️ Assess baseline vision because can cause blindness and visual disturbances 🕵️ False positive urine test for glucose in urine due to hyperglycemia 🕵️ Watch liver labs

Sucralfate (carafate) What is it? What does it do? What is it used for? AEs? Admin considerations?

Mucosal protectant Coats the stomach lining Used for active stress ulcers - covers surface of ulcer AEs • constipation • nausea • dry mouth Admin: • May impair absorption of other drugs - give other drugs at least 2 hours before sucralfate (not after!) • 1 hour before meals and bedtime • Avoid antacids 30 min before and after

Carisoprodol (Soma)

Muscle relaxant "Soma means coma" • Lots of side effects when used for sleep: nightmares, sleepwalking • Popular drug of abuse (sold on the street) - soma + opiod + benzo = heroin effect called "holy trinity" - watch for pt having Rx for opioids or benzos

Cyclobenzaprine (Flexeril)

Muscle relaxant • Closely related to tricyclic antidepressants • Used after musculoskeletal injuries • Causes marked sedation

Baclofen (Lioresal)

Muscle relaxant • May be used with implantable pump device for chronic spasticity

Opthalmic diagnostic drugs What types and what is each used for?

Mydriatic & Cycloplegic drugs: dilation of pupils and paralysis of ciliary muscle Dyes: locate defects and foreign objects

What is important to remember about fungal or bacterial infections with steroids?

NO They can make the infections grow like crazy and they also suppress the immune system This is a hard NO contraindication

Intermediate acting insulin Example drug? Onset of action? Duration of action? Other important things to know?

NPH insulin = the only intermediate-acting • Onset 1-2 hours • Duration 10-18 hours Cloudy coloration

Naproxen ON KAPLAN

NSAID - Aleve Better adverse effect profile than ibuprofen Twice daily dosing

Ketorolac (Toradol) ***know all of this***

NSAID - Almost as good as an opioid Good option for opioid addicted pts Short term, 5 days only!

Opthalmic anti-inflammatories Classes used? Used for? Which type do we try first? AEs? consideration to remember?

NSAIDS & corticosteroids • Used for tx after acute injuries to reduce inflammation and prevent scarring, irritation • Used before surgery to reduce miosis • Used post-op to prevent inflammation and scarring Start with NSAIDS first since they don't suppress immune system as much as the corticosteroids first. Also use NSAIDS for seasonal allergic conjunctivitis AEs: • burning, stinging AEs with extended use: • cataracts • increased IOP • optic nerve damage Remember: Don't use for minor injuries to avoid immunosuppressing effect

Bile Acid Sequestrants Common name? Used for? How do they work? Dosing/patient considerations?

Not all spelled the same, but all begin with a sound like "cole" or "chol" - think "cholesterol" Used to: Lower LDL, raise HDL a little but also raise triglycerides. How it works: Causes bile acids to be secreted in the feces, causing liver to convert cholesterol into bile acids, which opens more LDL receptors to pull LDL out of the blood. Considerations: • Second line drugs, used for patients who are not candidates or cannot tolerate statins. • Can be combined with statins if patient can only tolerate a low potency statin but needs more lipid reduction. • Better tolerated by patients with liver or kidney disease. • Powder forms can be choking hazards, dilute very well

What are non-catecholemine adrenergic drugs?

Not catecholemines, but do stimulate the sympathetic nervous system. • Albuterol

Are blood clots made out of platelets?

Not really, platelets make temporary plugs before a more permanent fibrin plug forms. The fibrin plug is a true blood clot. The platelet plug is unstable and easily dislodged.

loperamide (immodium)

OTC antidiarrheal with small amount of opioid ----physical dependence not reported Contraindicated: • severe ulcerative colitis • pseudomembranous colitis • acute diarrhea d/t E.coli

Dermatological therapeutic category: Antiinflammatories AEs? Teaching?

Often corticosteroid creams AEs: • acne • burning, itching, dryness • hypopigmentation • hirsutism (growth of hair in hairless areas) • alopecia (loss of hair on scalp) • opportunistic infections • tachyphylaxis (weaking of drug w/long term use) • fragile skin (they thin the skin) • purpura (purple spots) • round/swollen face • folliculitis Teaching: • Come in different potencies - if prescribed for a certain part of the body, do not use in a different area. For example a high potency Rx for hands should never be used on the face. It can thin the skin. • Children never get moderate or high potency, low only. • Do not use two different forms at the same time: IE topical and systemic

Otic antibacterials These are usually blends of what? Administration?

Often use a combination of antibacterial agents and corticosteroids. Administered as drops or can be used with a retrievable cotton wick that is soaked in the drug and placed in the ear canal.

Beta blockers for antidysrythmia Class? How do they work for dysrythmias? Special benefit? Which ones do we use for dysrythmias?

Often used for antiangina and antihypertensive but also a Class 2 antidysrythmic • Block SNS stimulation = blocks transmission of impulses in the heart's conduction system • Reduce HR, delay AV node conduction, decrease myocardial automaticity, reduce myocardial contractility Special benefit: cardioprotective after an MI Used for dysrythmias: • Atenolol - beta 1 selective, less effect on beta 2 -----no for bradycardia, heart block • Esmolol - ultra short acting, used for acute treatment and used after an MI ------ no for asthma, bradycardia, heart block • Metoprolol - used after MI to reduce risk of sudden cardiac death ------ no for asthma, bradycardia, heart block

Trazodone Used for? AE?

Often used for insomnia Bad side effect of priapism - erection that doesn't go away, EMERGENCY - get help if this happens

Affective / Mood-stabilizing drugs Used for?

Often used to treat bipolar, mania, depression Historically used lithium but recently anti-epileptics being used more often

Dermatologic form: Ointments Characteristics/benefits Examples

Oil-based, stickier (similar to vaseline texture) Used in smaller areas Use on dry lesions because they tend to moisturize Examples: • Petrolatum (vaseline) • Zinc oxide ointment • A&D ointment

Consideration for older adults AE from anticholinergics?

Older adults are more sensitive to the CNS effects and can develop delirium

Why do we want to use adjuncts for lower doses of levodopa and/or delay using levodopa as long as possible?

Once we start using levodopa, it only controls the disease for 5-10 years and then the patients decline rapidly. Also lower amounts of levodopa = less adverse effects.

Analapril

Only ACE inhibitor that can be given parenterally.

Fludrocortisone (Florinef) Class? Used for? AEs? Benefit of this? Teaching?

Only mineralocorticoid - remember these have increased retention of sodium/water and increased excretion of potassium/hydrogen Used to treat Addison's disease AE: • fluid retention effects on HF, HTN, ICP • PUD • hyperglycemia • osteoporosis • skin rash • menstrual irregularities • hypokalemia • glaucoma • muscle pain, weakness Benefit: Small doses so this limits AEs and interactions - also makes it so this one doesn't need to be tapered Teach: Give with food to minimize GI upset

Which type of glaucoma is chronic and slow, and which is an acute emergency?

Open-angle glaucoma is chronic, slow progressing - more common Angle-closure glaucoma is an acute emergency

Why do opioids cause constipation and what can you do to counteract it?

Opiods depress the CNS, which decreases GI peristalsis. Preventative measures • Increasing intake of fluids • Possible use of stool softeners • Use of stimulants 👍 Sometimes we use this to our benefit and give opioids to patients with severe diarrhea

Opioid based anti-tussives How do they work? Schedule? 🙅‍♀️ Contraindications 😱 AEs

Opioid based - work by suppressing cough center in CNS, provide analgesia, dry the mucosa > Codeine > Hydrocodone • Rx needed • Schedule 5 drug when combined with cough suppressant 🙅‍♀️ Codeine - NO for children 🙅‍♀️ Alcohol use 🙅‍♀️ Opioid dependency 🙅‍♀️ Respiratory depression 🙅‍♀️ CNS depression 🙅‍♀️ Increased ICP 🙅‍♀️ BPH (benign prostatic hyperplasia) 🙅‍♀️ COPD 🙅‍♀️ NO pregnancy 😱 Sedation, lightheadedness 😱 Constipation

Why do opioids cause nausea and vomiting? What can we do about it?

Opioids slow down GI peristalsis and stimulates vomiting center in CNS. The only thing we can do is give the pt and anti-emetic

Fluorescein

Opthalmic dye Colors the eye yellow which causes abrasions, injuries, foreign objects to become more visible

Which drugs have lots of interactions and we should just be thinking that right off the bat?

Oral contraceptives Warfarin Lithium MAOIs

Suvorexant (Belsomra) This is the only drug in what class right now? Schedule? AEs? Special considerations?

Orexin Receptor Antagonists Schedule IV AEs: • drowsiness • headache • dizziness • diarrhea • dry mouth • increased serum cholesterol • cough Special considerations: • AEs are more common in females • 12 hour half-life so more occurance of daytime somnolence and safety concerns for that • Unconscious nighttime behaviors

Mannitol Class Used for? Benefit? AES? Special things to remember?

Osmotic diuretic Use for glaucoma when in "dire straits" and we really need an acute decrease in IOP GIven IV - won't penetrate the eye so can use in times where the eye is irritated and topical drugs are contraindicated AEs: • convulsions • thrombophlebitis • pulmonary congestion Special to remember: use a filter, it may crystallize in low temperatures, inspect for sediment. May be stored in a warmer.

What is cortisporin? Used for?

Otic antibacterial combination of neomycin + polymyxin B + hydrocortisone Used for otitis externa and otitis media

What is Ofloxacin? Used for?

Otic antibacterial single drug fluoroquinolone in otic preparation Used for otitis externa and otitis media

What are Ciprodex and Cipro HC? What is the difference between them? Used for?

Otic antibacterials Ciprodex = combination of ciprofloxacin + dexamethasone Cipro HC = combination of ciprofloxacin + hydrocortisone Used for otitis externa and otitis media

What are Cortic and Acetasol HC? Used for?

Otic antifungals Otitis externa

Antifungal otic drugs are primarily used for otitis _______.

Otitis externa

What is NSAID toxicity? What are the s/sx? Interventions?

Overdose of ibuprofen, naproxin, etc • Drowsiness • Confusion • Lethargy • Paresthesias • Aggression • Seizures • Intense headaches • GI bleeding 👷 Treat with activated charcoal - not an antidote, but helps "mop it up"

Truvada

PREP - pre exposure prophylaxis Used in prevention of HIV for high risk patients, such as those with partners who are HIV+

Which lab monitors heparin and which monitors warfarin?

PT or PTT for heparin INR for warfarin

What is one of the most common reasons for someone to see a doctor?

Pain

What are the s/sx of peripheral neuropathies? What can we give a patient to help with this during TB treatment?

Pain in upper/lower extremities. >>>Pins & needles >>>Burning >>>Tingling symptoms. We supplement with B6 during treatment to avoid this

What are analgesics?

Pain relief without causing loss of consciousness

What is scabies?

Parasite that tunnels in the skin. Found in fold of elbow, behind the knee often. Contagious. Itching intense at night due to parasite being active at night.

Cholinergic and anti-cholinergics affect which part of the nervous system?

Parasympathetic "rest and digest"

What's another name for cholinergics?

Parasympathomimetics

what do parietal cells secrete? chief cells?

Parietal - secrete hydrochloric acid Chief - secrete pepsinogen

Why is patient compliance difficult with TB?

Patient compliance is extremely difficult because treatment takes 6-12 months. The longer a treatment takes, the less likely a patient is to follow through as prescribed.

What is very important for a nurse to do regarding discharge?

Patient teaching is really the nurse's job! The provider or pharmacist likely will not!

Consideration for long term use of laxatives? What is the only type that is okay to use long term?

Patients can become dependent and it can lead to damage to the bowel teach non-pharm ways to help with constipation: fiber intake, increase activity, increase fluid intake, reduce stress Bulk-forming agents are the only ones okay for long term use

Pediatric insulin considerations Pregnancy insulin considerations

Pediatric: • Weight-based dosing • Certain combinations are not approved for use under 18 years, always look up Pregnancy: • Hopefully we can manage with diet alone, but if not, insulin is the ONLY recommended drug therapy

What is the medical term for lice?

Pediculosis

What is used to treat syphilis?

Penicillin - 💉 one IM injection

Antacids what do they do? What is usually in them? Why combinations? How do they work? Used for? Contraindications?

Neutralize stomach acids Contain: • aluminum, magnesium, calcium, sodium salts used alone or in combo • many contain antiflatulant called simethicone Why combinations? • many aluminum and calcium based formulations also contain magnesium because aluminum and calcium can cause constipation and magnesium counteracts it How? • Stimulate cells in stomach to secrete mucus and prostaglandins (protectitve to stomach) plus help to neutralize acid Used for? • Acute relief, not a long term cure for peptic ulcer, gastritis, gastric hyperacidity, heartburn Contraindications: • severe renal failure • electrolyte disturbances (poss toxic ↑ of electrolytes) • GI obstruction (mostly with mag - may stim motility)

Considerations with influenza nasal spray vaccine?

Nice for kids because no injection Hard to admin to kids though because have to coordinate inhalation with the spray Need open passageways May not get all of the vaccine like you would with IM

What are the two types of cholinergic receptors?

Nicotinic Muscarinic > Located in smooth muscles, cardiac muscles, glands

Isosorbide dinitrate (Isordil)

Nitrate - vasodilator indicated for chest pain (she said this is all she wanted us to know about it)

Which type of beta-adrenergic agonist has the most adverse effect and why?

Non-selective because it touches on alpha and both types of beta receptors.

Propanolol (Inderal) What type? Contraindication?

Nonselective beta blocker One of the oldest, so we know of many uses Contraindicated - patients with bronchial asthma

Which drug is metabolized into dopamine in the body?

Norepinephrine

difference btw normoactive, hypoactive and hyperactive bowel sounds

Normoactive: 6-32 bowel sounds per minue Hypoactive: less than 6 per minute Hyperactive: over 32 per minute

Tumor lysis syndrome What is it? treatment?

Post-chemo condition. When a tumor cell is lysed or destroyed, it releases uric acid ---uric acid is toxic and hard on kidneys, can lead to nephropathy and gout • treat with anti-gout medication (allopurinol) • keep patient very hydrated to dilute the uric acid Can cause ↑potassium, ↑phosphate, ↓calcium -electrolyte disturbances often tx with diuretics, oral supplementation

Antidiuretic hormone (ADH) Anterior or posterior pituitary? What does it do? What do we use it for?

Posterior Increase water resorption in kidneys, concentrate urine (reduce water excretion up to 90%), potent vasoconstrictor Used for: • patients experiencing symptoms of diabetes insipidus (polyuria, polydispia and dehydration) • various types of bleeding

Spironolactone (aldactone) Class? Used for? Forms?

Potassium sparing diuretic Can have cardio protective benefit after a heart attack. Can be anti-hypertensive. PO form only Can be combined with other diuretics as an adjunct.

Antifibrinolytics in general Used for? Form? Contraindication? AEs? Interactions?

Promote blood coagulation, prevent lysis of fibrin clots and increase platelet aggregation, promotes clot formation. Shortens duration of bleeding post-op. Used for: • hyperfibrinolysis • surgical complications (reduced blood loss) • hemophilia Has a topical form that is sometimes used in surgery Contraindication: • DIC (disseminated intravascular coagulation) - they are forming little clots all over their body and this would enhance it, life-threatening. AEs: • mild and rare usually • rarely thrombotic event Interactions: • anything that increases coagulability • estrogen & oral contraceptives

Misoprostol (cytotec) What is it? What does it do? Pregnancy considerations? AEs? Interactions?

Prostaglandin E analog Inhibits gastric acid secretion Prostaglandins have cytoprotective activity --protect gastric mucosa from injury ↑ mucus or bicarb --promote local cell regeneration --help maintain mucosal blood flow Pregnancy considerations: • can be used to induce labor • aside from inducing labor, pregnancy cat X! AEs: • headache • vaginal bleeding Interactions: • antacids may reduce absorption

What are extrapyramidal symptoms?

Pseudoparkinsonism - shuffling, propulsive gait, masklike face, drooling Akathisia - continuous restlessness and fidgeting Dystonia - head rotated to one side in a stiffly fixed position; drooling and tongue hanging out possible Oculogyric crisis - uncontrolled rolling back of the eyes; may occur with dystonia

Tetrahydrocannabinoids (THC) What is it? Used for? Example drug?

Psychoactive substance in marijuana Alter mood and body's perception of surroundings, which may help relieve N/V Used for: • N/V associated with chemo • anorexia associated with AIDS Dronabinol (Marinol) • non-intoxicating doses, may stim appetite • given 1-3 hours before chemo • can help control glaucoma

Miscellaneous antineoplastics How do some of these work?

Pull patients monocytes out and then reinfuse them into patient Affect development of blood vessels that supply O2/nutrients to new tissue (tumor)

Anti-glaucoma drugs: Osmotic diuretics How do they work? AEs? Contraindication?

Pulls water out of AH and back to bloodstream, decreasing IOP • IV, oral or topical drops AEs: • N/V • headache • fluid and electrolyte imbalances • blurred vision • rebound incresed ICP • "these are rough on the system and we will get into it more in another chapter" Contraindication: if diuretic can make condition worse, like dehydration, cardiac problems, low urine output

What is a PPD?

Purified Protein Derivative - this is the tuberculosis skin test Positive is called a "Mantoux reaction"

Glucose-Elevating Drugs What do we use for? AEs

Rapidly increase glucose for pt in hypoglycemic crisis Forms • IV • buccal • gel • glucagon SubQ (good if IV not avail) Risk for glucagon - can cause vomiting so increase risk for aspiration

What is asthma?

Recurrent reversible shortness of breath Keyword: reversible - we can improve the airway exchange with treatment. Issue typically due to inflammatory processes or edema. Sometimes there is an immune factor with antibody IGE.

🎓Education point for topical decongestant?

Potential for rebound congestion. Rebound symptoms typically worse than original symptoms. Patients tend to use again and again, almost addicted to topical intranasal decongestants. Educate to not use any more than recommended on the bottle. Warn about rebound congestion and vicious cycle.

What is anxiolysis?

Reduced anxiety

Short acting insulin Example drugs? Onset of action? Duration of action? Other important things to know?

Regular insulin AKA short-acting insulin • Humulin R • Novolin R • Onset 30-60 minutes • Duration 6-10 hours Can be given SubQ, IM, IV - this is the ONLY form that can be given IV (emergencies)

Probiotics How do they work? Example drug? AEs? benefit?

Replenish intestinal flora Works by supplying missing bacteria to the GI tract and suppressing the growth of diarrhea-causing bacteria Example: lactobacillus acidophilus No AEs Helps increase function of the immune system

Antiepileptics Teaching

Report any changes in mood, thoughts of suicide

What should you do if patient is showing s/sx of ototoxicity?

Report to doctor so they can consider changing the prescription.

Amylin agonists Drug example? How do they work? When do we give? Important things to know? Contraindications?

Pramlintide is the only one - (memory trick: amylin/pramlin) These mimic the hormone amylin. Amylin is a hormone secreted with insulin by the pancreas. It lowers post-meal glucose, slows gastric emptying, suppresses glucagon secretion, suppresses production of glucose by the liver and makes us feel full. • Give 1 hour before other medications (delayed gastric emptying can slow the absorption of other drugs) • Approved for type 1 and type 2 • Given only SubQ • Insulin dosing reduced by 50%! Contraindication: • Pts with GI motility issues • Pts taking drugs that alter GI motility

Restasis

Prescription cyclosporine ophthalmic drug Helps increase moisture/tearing in the eye Used often if patient is on anticholinergics (d/t drying effects) • Use 15 minutes apart from Restasis use

What is cardiac tamponade?

Pressure around the heart pressess on the heart and doesn't allow expansion for filling memory trick: heart is "tamped down"

What is prophalactic treatment?

Preventative treatment, such as an antibiotic before surgery since we know we are putting the patient at high risk.

Why is preventing nausea important?

Preventing F&E disturbances Minimize nutritional deterioration

Allopurinol (Zyloprim)

Prevents production of uric acid 😱 Severe skin adverse effects - dermis can exfoliate - Steven's Johnson syndrome 🕵️ Watch for any skin changes! 🎓 Educate pt to let us know about any rashes or skin changes 🎓 Educate alcohol and caffeine can cause uric acid production

What is the difference between first line and secondary line treatment for TB?

Primary/First Line goes to everyone who has been "cleared" to have them Secondary/Second Line goes to anyone contraindicated to first line

What is the difference between primary/essential hypertension and secondary hypertension?

Primary/essential hypertension: we don't know what causes it for that patient Secondary: we know exactly what causes it for that patient (Think: "secondary to" something else)

When death occurs from opioids, it is almost always due to what? What preexisting conditions increase risk?

Respiratory depression Preexisting condition causing respiratory compromise, such as asthma, COPD, sleep apnea

What is the goal of diabetes drugs?

Producing a normoglycemic state

What is discontinuation syndrome? S/sx? How do we avoid this?

Resulting symptoms from discontinuing a drug (specifically talked about with antidepressants) too quickly without tapering down enough. • flu-like symptoms • achy • headaches • GI symptoms • dizzy • lack of concentration Taper and do not stop the drug abruptly

Don't forget about nonpharmacologic methods

Such as CAM Just a reminder

Acute vs chronic pain

Sudden onset and limited duration = acute Slow onset and persistent duration = chronic

Glucocorticoids AEs p517 "you will need to know this"

Suffix -sone or -solone AEs: • hyperglycemia even if not diabetic • osteoporosis if long-term use • growth suppression in children (long-term) • exacerbate muscle weakness/fatigue in elderly • edema • moon face, buffalo hump - long term • psychosis • anger, agitation, irritable, mood swings • adrenal suppression • weight gain • HTN • hypernatremia, hypokalemia • ulcers • poor wound healing • fragile skin • immunosupression • increased IOP, glaucoma, cateracts • heart failure Systemic is worse than topical or inhaled

Anti-glaucoma drugs: carbonic anhydrase inhibitors What class? Common suffix? How do they work? AEs? Contraindication?

Sulfonamides "-zolamide" Reduces AH formation AEs: "same as with sulfa Abx" - I'm guessing biggest one since eyes may be photosensitivity Use with caution if allergic to sulfonamides - not 100% contraindicated

Carbonic Anhydrase Inhibitors (diuretics chapter) Common suffix? Example drug? How do they work as a diuretic? AEs?

Sulfonamides "-zolamide" • Acetazolamide (diamox) Used for edema r/t heart failure, used for high-altitude sickness, used for glaucoma Reduces the formation of hydrogen ions in the body. In order for sodium and water to be reabsorbed, need to exchange a hydrogen ion, so if there's not enough ions, then they cannot be reabsorbed and they are excreted. AE: • Can induce both respiratory and metabolic acidosis • Elevated glucose level, glucosuria in diabetic pts • Hypokalemia • electrolyte imbalances Contraindications • Renal dysfunction • Low sodium or potassium - will make it even lower • Acidosis

Adrenergic and anti-adrenergics affect which part of the nervous system?

Sympathetic "fight or flight"

What are catecolamines?

Sympathetic nervous system neurotransmitters. • Epinephrine • Norepinephrine • Dopamine

Desmopressin Class? What does it do? Used for? AEs?

Synthetic vasopressin - antidiuretic hormone Increase clotting factors and tissue plasminogen Used for: • treating hemophilia type A • manage nocturnal enuresis (bedwetting) AEs: • increased blood pressure

Which cells are involved in cellular immunity?

T-cells AKA T-lymphocytes

Difference between T3 and T4?

T3 has 3 iodine molecules T4 has 4 iodine molecules We have more T4 in our body, but T3 is more potent

Levothyroxine Class? Used for? Dosing consideration? Teaching? AEs? ON KAPLAN

T4 thyroid replacement drug Used for: • Hypothyroid - primary, radiated, surgical, etc • Treatment of goiter • pregnancy with hypothyroid (prevent fetal ↑ growth) Important things to remember: • *******dosed in micrograms - NEED TO KNOW • Protein-bound, so has longer half-life - 1x daily • older adults sensitive, may need to ↓ dose by 25% Teaching: • must be protected from light • important to keep appointments and lab draws -- we need to monitor serum levels to determine dose • Take in morning (insomnia) and completely alone with water only, no food, no drugs, no anything else! • cannot switch between brands, be consistent Contraindicated: • recent MI (don't want to stimulate) • adrenal insufficiency • hyperthyroid AEs: (usually due to OD) • tachycardia, HTN • palpitations, angina, dysrythmias (poss lethal) • insomnia, tremors, anxiety • weight loss, sweating, heat intolerance (↑↑↑ symptoms of hyperthyroid essentially) Interactions: oral anticoagulants, oral hypoglycemics, antacids

Thrombocytopenia Watch for? Interventions

S/sx bleeding • obvious bleeding • swelling or pain in joints (bleed into joint space) • tarry or black stools • blood in urine • heavy menstruation • avoid injections - if we have to, smallest needle possible and put prolonged pressure on site • avoid ASA and NSAIDS

Duloxetine (Cymbalta) Class? Used for Contraindication

SNRI Good choice for peripheral neuropathy or fibromyalgia + depression Contraindication • Closed angle glaucoma AEs • Hepatotoxicity (avoid alcohol)

Citalopram (Celexa)

SSRI

Fluoxetine (Prozac)

SSRI

Silver sulfadiazine What is it used for? Contraindication?

Safe and effecive for burn patients to prevent and treat infections. Contraindicated if allergic to sulfa drugs

What is the function of the thyroid gland? What does it secrete? What does it do? What does it need?

Secretes: • thyroxine (T4) • triiodothyryronine (T3) • calcitonin Essential for normal growth and development. Regulates BMR, lipid and carb metabolism, control heat-regulating system in the brain. Communicates with the parathyroid glands to maintain calcium levels. Effects almost every body system in some way. • Body needs iodine to make T3 and T4 (T4 has 4 iodine molecules, T3 has 3 iodine molecules) Thyroid stimulating hormone is released from anterior pituitary in response to low T3 and T4

Difference between sedatives and hypnotics?

Sedatives reduce nervousness, excitability, irritability WITHOUT causing sleep. Hypnotics cause sleep and have a more potent effect on the CNS. However: when used at high doses, sedatives CAN become a hypnotic and induce slee.

What is the difference between selective and non-selective adrenergic drugs?

Selective hones in on a specific receptor • IE: Beta 2 receptors only Non-selective affects multiple or sometimes all adrenergic receptors • Problem is that they have more adverse effects since they influence multiple systems.

Symptoms of Parkinson's p232 - table 15.1

TRAP + B (memory trick: Bear TRAP?) Bradykinesia - slow movements Tremor - shaky extremities, "pill rolling" (usually worse at rest) Rigidity - "cogwheel" and resist passive movement Akinesia - mask-like facial expression Postural instability - Unsteady, leaning, fall risk

Teaching for how to use nitrates: NEED TO KNOW

Take at very first sign of chest pain If not relieved in 5 minutes, call 911 and then take a 2nd and 3rd dose 5 minutes apart No more than 3 tablets

Why is taking an antibiotic as prescribed important?

Taking consistently as prescribed is important for keeping blood levels at an effective dose Finishing the course is important for preventing antibiotic resistance and avoiding reinfection

What is tardive dyskinesia?

Tardive dyskinesia is characterized by repetitive involuntary purposeless movements. grimacing tongue protrusion lip smacking, puckering, pursing rapid eye blinking Involuntary movements of the fingers may appear as though the individual is playing an invisible guitar or piano.

Nursing Process: Teaching Parkinsons

Teaching: • These drugs can take several weeks to start working • Report anything that could indicate OD (twitching, drooling, eye spasms) • Take exactly as ordered and at exactly the right time - even 30 minutes overdue can make a big difference and take a while to get back to baseline. • Avoid alcohol • Change positions slowly • Increase fluids • Compression socks can help offset orthostatic hypotension • Wearing off phenomenon • Stick with the drug that was ordered. NO switching to generic if a brand name was ordered and vice-versa because response can be different and many AEs • Fall prevention (rugs, shower bars, etc)

Chemo drugs often become dose-limiting. What does this mean?

The AEs are so bad that we cannot increase the dose or maximize the chemo because the patient cannot tolerate it

Anytime you mess with the endocrine system, there's a good chance that an AE will effect what?

The blood glucose levels. Either increase or decrease. Monitor blood glucose!

Why do we see decreased urine output with heart failure?

The body deems the kidneys as capable of getting by with less blood and also because it can activate the RAAS to try and compensate and increase cardiac output

S/sx of myopathy Why is it so important that patient alerts us to these symptoms and we stop the statin if they are on one? Who is at higher risk?

Severe form of myopathy = rhabdomyolysis • muscle pain • muscle soreness/aching • myoglobinuria (changes the color of urine) Rhabdomyolysis puts a lot of strain on the kidneys and can lead to renal failure and death. At risk patients: • age over 65 • hypothyroid • renal insufficiency

Hormonal antineoplastics

Sex hormones accellerate the growth of certain cancers ---estrogen (breast cancer) ---androgens (prostate cancer) So we will give hormones that are opposing to those hormones Used often for palliative treatment or as adjunct therapy, not usually alone AEs: • cause menopausal sx if using female hormones • cause puberty sx if using male hormones • menstrual irregularities

What is something that is very important for patient teaching with antihypertensives to help ensure compliance?

Sexual dysfunction is a very common AE with most antihypertensive drugs. Many patients won't be forthcoming that they are having this problem and instead will stop taking the medication. We really need to educate that this is a common AE and it's very important that they tell us if it happens because there are other things we can try to get HTN under control without having this AE. We need to be the ones that breach this topic and make it okay to talk about so they feel comfortable calling us if it happens.

Colchicine (Colcrys or Mitigare)

Short term use for acute attacks of gout or for prophylaxis 😱 Can cause leukopenia 😱 GI/GU bleeding 💥 Must wait 3 days between courses 🕵️ Monitor CBC 🎓 Educate alcohol and caffeine can cause uric acid production

What are the two types of beta-adrenergic agonists?

Short-acting (SABA) Long-acting (LABA)

Similarities between ACE Inhibitors and ARBs? Difference that affects compliance? Difference for diabetics?

Similarities: • Both have result of angiotensin II blocking/inhibiting, which results in decreased aldosterone production as well. ---Angiotensin II is a vasoconstrictor. Aldosterone causes sodium and water retention. -- so these drugs are essentially like vasodilators and diuretics which result in decreased BP. • Both have interactions with NSAIDS that decreases effect Differences: • ACE Inhibitors have an AE of chronic, dry, non-productive cough that is annoying and can cause non-compliance. ARBs do not have this AE. • ARBs have an AE of hypoglycemia so might not be best choice for diabetics. • ACE Inhibitors can be kidney protective, may be helpful for diabetics

Otic drugs in general - AEs and contraindications?

Since most are applied topically, generally they are not involved in drug interactions AEs are uncommmon and usually do not extend beyond irritation. Contraindications usually only for known drug allergy.

Where do anticholinergics work? What are the effects of these drugs?

Sites of action: heart, respiratory tract, GI tract, urinary bladder, eye, exocrine glands Effects: • Increased HR • Dry mucous membranes • Bronchial dilation • Decrease GI motility, secretions & salivation • Decrease bladder contraction > increases urinary retention • Decrease sweating • Dilate pupils (mydriasis) • Increase intraocular pressure

What is somnambulation?

Sleep walking

Basal-Bolus vs Sliding-Scale dosing for insulin Who are not good candidates for basal-bolus?

Sliding Scale: BG done several times daily with the amount of insulin given based on glucose result • Con: we wait until someone is hyperglycemic and then we give insulin = large swings in glucose levels Basal-Bolus: mimics a healthy pancreas. Delivers long-acting insulin contstantly as a basal and then gives short-acting as a bolus when glucose levels rise above a predetermined range • Meal bolus - given to reduce BG with intake of carbs • Correction bolus - given to bring BG back to normal NPO patients are not good candidates for basal-bolus d/t risk for hypoglycemia

Why do patients need to know what adverse effects are possible?

So they know to let us know if they experience them so we can tell provider

Why is it so important to know the adverse effects of drugs?

So you can monitor and respond to them

Sodium, Calcium, Potassium Which are normally outside a cardiac cell, and which are normally inside a cell?

Sodium and Calcium outside the cell Potassium inside the cell Sodium and Calcium come into the cell through channels during depolarization - this is called the action potential

What is difference between solid and circulating cancer?

Solid = massess, tumors, growths Circulating = in blood or lymph

What is the ATPase pump?

The mechanism that keeps the ion balance in cells

Oncologic Emergencies

Something serious enough that warrants us pausing treatment and resolving the issue • fever/chills with a temp over 100.5F • new sores or white patches in mouth/throat • swollen tongue with or w/o cracks and bleeding • bleeding gums • dry, burning, scratchy, swollen throat • cough that is new and persistant • changes in bladder fx or patterns • blood in the urine • blood in the stool • changes in GI or bowel patterns (heartburn, N/V, constipation or diarrhea longer than 2-3 days) • stomatitis w/severe ulceration-limits hydration & nutrition • acidosis/alkalosis • renal failure • liver failure • cardio toxicity: MI, HF, severe dysrythmias

Cholestyramine (Questran)

Sometimes used intentionally for its constipating effect in patients with diarrhea/loose stools

What are the different types of angina?

Stable - primary cause is athlerosclerosis. Triggered by exercise or other stress like cold temperature, emotion, large meals, caffeine, alcohol. Relieved by rest, time. Unstable - usually the early stage of progressive coronary artery disease. Eventually results in a heart attack. Increases in severity and frequency. Can occur when at rest. Vasospastic AKA "Prinzmetal" - occurs due to spasms in the smooth muscle surrounding coronary arteries. Can occur at rest. Somewhat predictable and can happen at the same time each day.

What is the analgesic ladder? (WHO ladder)

Step 1. Non-opioids Step 2. Mild opioids (mild agonist) Step 3. Stronger opioids (strong agonist)

Interleukins (lymphokines AKA cytokines) What do they do? Example drug? AE?

Stimualate release of natural killer cells - have antitumor action, target cancer specifically --- ↑ production of B-cells which are for antibodies --- can be used off-label for HIV and non-hodgkins lymphoma, severe RA, plaque psoriasis Example: Aldesleukin AE: capillary leak syndrome • albumin, proteins, etc leave the blood to surrounding tissue which changes osmolality of blood • rapid weight gain of 20-30lbs • respiratory distress, HR, severe hypotension, MI ---early s/sx runny nose, nasal congestion, cough ---can be managed by stopping the interleukins

Epinephrine (adrenaline) What does it do and what do we need to remember about the dose?

Stimulates Alpha1 and Beta receptors • Vasoactive, used in the ER • Non-selective • Low dose: increase force of contraction in heart rate, used for acute asthma attacks and anaphylaxis • High dose: vasoconstriction and elevating blood pressure (used for shock)

Norepinephrine (Levophed) What do we use it for and how is it administered?

Stimulates alpha receptors, some effects on Beta1 • Causes vasoconstriction • Used for treating hypotension and shock Continuous IV infusion

What is required for active artificial immunity to work?

The patient has to have a functioning immune system for them to work

What is the relationship between the parathyroid gland and calcium levels?

The parathyroid gland can pull calcium out of the bones if we have low calcium in the bloodstream Abnormal calcium levels on labs might indicate issue with parathyroid glands

Nursing process: implementation thyroid drugs

Thyroid replacement: • take at same time daily, in the morning - with no food, no other meds, no anything else except water (especially antacids, iron calcium!) Drink 6-8oz water with it • avoid iodized salt/iodine rich foods (tofu/soy, seafood) • do not switch between brands • crush tablets is okay • do not abruptly stop... lifelong therapy • protect from light • a few weeks to see effects Anti thyroid: • take at same time daily, with meals • do not abruptly stop • avoid iodized salt, shellfish, seafood, tofu/soy • monitor liver function and CBC (hepatitis and bone marrow toxicity AEs) • a few weeks to see effects ​

What leads to increased IOP and glaucoma?

Too much acqueous humor - either too much produced or it is not draining properly

What are adrenergic drugs usually classified by?

Their specific receptor activities and/or what they do. IE: a Beta 2 agonists can be classified as "beta2 agonists" and "bronchodilators"

What do we evaluate for in analgesic therapy?

Therapeutic response >>> pain relief, improved ADLs, improved ambulation, appetite increase Adverse reactions >>> presence or absence

What is monotherapy?

Therapy that uses one type of treatment only

Why are labs so important in choosing which cholesterol drug to put a patient on ?

There are low, moderate and high intensity drugs. They lower the LDL by percentage points. We need to know how high the LDL is so we can choose a drug accordingly. If someone is only slightly elevated, we don't want to give them a high intensity drug and lower it by 50%

Toxicities AEs from chemo Table 45.6 p 704

There are many more, but ones she pulled out: • weakness • headache • hallucinations • loss of taste • paresthesia • seizures • dysrythmias • heart failure • cardiac arrest, MI • pulmonary embolism, fibrosis • anyeurism • bronchitis, laryngitis • epistaxis (nosebleed) • respiratory distress • pneumothorax • stomatitis • Stevens-Johnsons syndrome • pancreatitis (LEQ pain) • severe hyperglycemia (d/t pancreatitis) • hepatotoxicity • blood in urine • renal failure • photophobia • vision changes • hearing loss, ototoxicity • weight loss • electrolyte imbalances • inappropriate secretion of hormones • joint, bone, muscle pain

What are glucocorticoids categorized by?

There are many of these drugs! • natural vs synthetic • method of administration • salt/water retention potential • duration of action

Contraindications to chemo drugs?

There are no contraindications because if they need chemo, they need chemo regardless • we may pause/delay but NOT HOLD completely if: severe low WBC, infection, severe hydration or nutrition compromise, poor function of liver/kidneys

Why is hypertension known as the silent killer?

There are often no symptoms and it may not be diagnosed until there is already damage to the end organs: kidneys, eyes, heart, brain

What is the "cheese effect" with MAOIs?

There are two types of MAO enzymes. MAO-A and MAO-B. Non-selective and MAO-A selective drugs interact with tyramine-containing foods, such as cheese, red wine, beer, yogurt, sausages. This interaction can cause severe hypertension. Selective MAO-B inhibitors are much less likely to have this adverse effect. These include rasagiline and selegiline.

What is Type 1 Diabetes?

There is an absolute deficiency of insulin. The pancreas is not making insulin. Only treatment is giving insulin.

What does an elevated reticulocyte count indicate on a CBC?

There is something going on with the patient, such as some kind of illness or blood loss because this means that they have been creating a lot of new RBCs

AE for adrenergic drugs - Alpha?

These are vasoconstrictors and stimulate the CNS, so we see cardiac and CNS effects. • Headache • Insomnia • Restlessness • Hypertension • Dysrythmias • Bradycardia (reflexive) • Loss of appetite • Dry mouth • N/V

Considerations for older adults with adrenergic drugs?

These drugs have a greater impact to the older adult. • Monitor VS - especially BP and HR • Higher chance for drug-drug interactions

AE for adrenergic drugs - Beta?

These influence the heart (Beta1) and CNS, so we see effects in those areas. • Tremor • Headache • Nervousness • Dizziness • Increased HR • Palpitations • Fluctuations in BP • Sweating • Muscle cramps • N/V

What is the difference between prednisone, prednisolone, methylprednisolone and triamcinolone?

They are all the same drug, the difference is only the form. • Prednisone - oral solid • Prednisolone - liquid • Methylprednisolone - injectable • Triamcinolone - topical

What chemicals in the body typically end in "esterase" and what do they do?

They are enzymes and they typically break down something Memory trick: They "erase" the things they break down

Why are anesthetics given continuously during surgery/general anesthesia?

They are metabolized quickly

Why is it important to establish a trusting relationship with antipsychotic drug patients?

They are often not trusting, paranoid, not full grasp of reality We increase adherence and compliance if they trust us Make sure you are always updating contact information - "they fall off the grid easily" and become difficult to keep in contact with

Why are benzodiazepines good for painful/awkward/uncomfortable procedures?

They can cause amnesia

Consideration with children/teens on aspirin and the flu?

They could develop Reye's syndrome if they get the flu (or another virus) while using aspirin

What are the common black box warnings for immunosuppressants?

They have many black box warnings! The most common one is bone marrow suppression which includes many AEs on its own: • suppress RBCs, prone to anemia • suppress WBC, prone to infection • decrease platelets, prone to bleeding Immediately associate bone marrow suppression with immunosuppressants! • increased risk for cancer, especially skin cancer ---teaching: avoid UV light, wear hats, sunscreen, protective clothing, have frequent skin inspections • new onset diabetes risk ----teaching s/sx diabetes, BG screening • hepatic impairment ---assess jaundice, ascites, platelet count, discolored urine, labs • renal impairment ---monitor urinalysis, bedside urine dipsticks, output • fatal infections

What is the problem with antivirals?

They have to enter human cells to interrupt the virus, so it messes with the human cells in addition to the virus. May kill healthy cells while killing viruses. Requires synergy with the immune system.

What is something that we always need to remember about MAOIs?

They interact with LOTS of other drugs. If a patient is on an MAOI, always look up the interactions.

What is the problem with topical glucocorticosteroids?

They will thin the skin You don't want to use a high potency one on an area that already has thin skin like the face.

Antithyroid hyperthyroid treatment options

Thioamide derivative (Propylthiouracil PTU) Radioactive iodine = ablation of thyroid Treat symptoms with beta blockers. Don't fix the issue just a bandaid.

Propylthiouracil (PTU)

Thioamide derivative - anti hyperthyroid Prevents formation of thyroid hormone. Won't rid body of what's already been created, just prevents new from being created. Contraindications: NO for pregnancy AEs: • liver toxicity (hepatitis-like state) • bone marrow toxicity (really bad - ↓ WBC, ↓ platelets) • increase in renal labs - BUN and creatinine • smoky urine Interactions: oral anticoagulants Teaching: • 2 weeks before seeing symptom reduction • take with food to tolerate better • take at same time every day • do not abruptly stop taking

What is the pain threshold? What is pain tolerance?

Threshold - the level of stimulus needed to produce a painful sensation Tolerance - the part of experiencing pain that is the psychological element and varies from person to person

Thrombolytics in general What do we use them for? AEs? OD? Interactions?

Thrombo"lytics" - they break down clots that have already formed. We prefer to use physical interventions (cath lab) before these when the facility is capable Used for: • Acute stroke • Pulmonary embolism • Severe DVT • Arterial thrombus • Acute MI AEs: • bleeding (internal, intracranial bleed very high risk after a stroke) • induce dysrythmias OD: • no antidote, supportive care only - short half-life Interactions: • anticoagulants - increased bleeding • question giving with heparin, warfarin, ASA, NSAIDS

Why are thyroid issues such a big deal?

Thyroid hormones effect almost every body system in some way

Do traditional or non-traditional antihistamines get anticholinergic effects? What is this effect?

Traditional Drying - dry mouth, dry eyes. > Patients get very uncomfortable > Can cause fissures in lips/tongue > Can cause bad breath

Difference between traditional antihistamines and new antihistamines?

Traditional antihistamines make you tired! (diphenhydramine & benadryl) We don't want to use traditional in elderly due to drowsiness increasing fall risk and paradoxical reactions (irritability, confusion, dizziness)

Dermatological therapeutic category: Antineoplastics What do we use them for? AEs? Patient education?

Treat skin cancer - various precancerous lesions and basal cell carcinoma AEs: • local inflammation • hyperpigmentation • suppuration (pus generation) Education: Wash fingers immediately after application to prevent systemic. Applicator or gloves good idea.

Donepezil (Aricept) What do we use it for? Teaching?

Treatment of Alzheimer's > increasing acetylcholine can help decrease symptoms but is temporary improvement > Many people don't get a therapeutic response (30% effective) Teaching: • Take with food • Dose EXACTLY very consistently • Do not stop taking abruptly • 1x daily • Dissolvable form available • NO NSAIDS - interaction • Up to 6 weeks before seeing improvement

Indications for use of anticholinergics

Treatment of extrapyramidal symptoms - decrease muscle rigidity, diminish tremor > These come from conditions that invoke dysfunction of the extrapyramidal parts of the brain or motor dysfunction. IE Parkinson's, AE from antipsychotics • Pre-op to decrease secretions for intubation or GI surgery • Treat IBS or other conditions with hyper GI tract • Neurogenic bladder • Incontinence • Decrease secretions from common colds

Midodrine What does it do and administration considerations? Safety concern?

Treatment of orthostatic hypotension • Do not give later than 6pm / 4 hours before bedtime > Can cause insomnia > Can cause hypertension while lying flat • Only works if you increase fluids With orthostatic hypotension, can faint/lightheaded upon standing. Stand up slowly, be careful.

Dermatological therapeutic category: Anesthetics What are they used for? Forms?

Treatment of pain or pruritis, used to numb areas before a procedure Sprays, EMLA cream EMLA cream used to numb areas about 30 mins before a procedure

What do we use beta blockers to treat?

Treatment of: Angina • decrease myocardial energy • decrease O2 demand of cardiac muscle MI (Heart attack) • Catecholamines are released in MI, damaging and continuing to stimulate already stressed heart - Beta blocker can prevent this stimulation. Dysrythmias • Slows conduction at AV and SA node, lowering HR > Contraindicated in bradycardia > Contraindicated in heart block > HR and EKG should be done before dosing Hypertension • Reduces HR • Reduces force of contraction

Amitriptyline Contraindications? Used for? AE? Report to provider if experience?

Tricyclic antidepressant Contraindications: • Pregnancy - category D • Not for use in recent MI Used for: • insomnia • neuropathic pain AE: • discoloring urine Report to provider if experiences: • blurred vision • agitation • urinary retention • ataxia

What are the two types of lipids?

Triglycerides - what we use for energy and what is stored in adipose tissue Cholesterol - used to make steroid hormones in the body, cell membranes and bile acids

Most antifungals are safe during pregnancy. True/False?

True

Anticholinergics DRY T/F?

True Anticholinergics are drying

It is very important that patient takes TB drugs at the *exact* same time every single day. True/False

True Very important to take every day at exact same time!!

Why do we need to learn about antituberculars even though it is rare in the US?

Tuberculosis is still a big issue across the globe. 1/3 of the world's population has had it. We get a lot of travelers and refugees in the US.

What do we need to remember about OTC hypnotics?

Typically contain antihistamines - Unisom = doxylamine - Sominex = diphenhydramine - Extra-strength Tylenol PM = acetaminophen + diphenhydramine Concurrent use of alcohol can cause additive CNS depression

Dermatological therapeutic category: Sunscreens What are they for? What SPF is recommended by FDA? Education?

UV protection and moisturization. SPF rating range 2-50. FDA recommends 15+ SPF. Education: • Do not use on infants under 6 months old. Hats, protective clothing, shade only! • Barrier creams like zinc are better than the common sunscreens. There's a clear form out now that might have better compliance

Adenosine Class?

Unclassified antidysrythmic Slows conduction through AV node, used to treat SVT that isn't responding to other efforts Administration: 10 second half-life, give IV push - fastest IV push med that there is. Give in a port closest to the patient and closest to the heart because the half-life is so short Remember: causes a period of asystole before it kicks back into normal sinus rythm

What is Addison's disease?

Undersecretion of corticosteroids • decreased sodium • hypoglycemia • increased potassium • dehydration & hypotension • weight loss • fatigue • N/V

Never give your antibiotic until AFTER what?

Until after you have drawn your culture You will skew the results if you start antibiotics first!

What needs to be done every time we give an antifungal medication parenterally?

Use an IV filter

What is balanced anesthesia and why do we do it?

Use of general anesthetics with adjuncts. Can use smaller dosing of each drug and we have better control of patient's anesthesia. General anesthetics plus one or more: • sedative hypnotics • anxiolytics • benzodiazepines • opioids • barbituates • antiemetics (lower nausea) • anticholinergics (decrease secretions)

Aspirin ***know contraindications***

Used as prophylactic. Used for pain, fever. Antirheumatic effects, used for RA 💊 - PO, regular and enteric coated options Topical cream - aspercream 🙅‍♀️ Do not give to children, PERIOD. 🎓Teach don't take with other ulcerogenics - alcohol, other NSAIDs

Antipsychotics Used for? Subclasses? AEs? Black box? Teaching?

Used for drug induced psychosis, schizo, autism, extreme mania, Tourette's, agitation in dementia • doesn't cure, treats symptoms only --Conventional (old drugs) and Atypical (new drugs) AEs: • severe hematologic effects • tardive dyskinesia (facial movements) • neuroleptic malignant syndrome (life-threat) • extrapyramidal symptoms • insulin resistance & metabolic syndrome • lipid level disturbance • cardiac function • CNS depression, drowsiness • hypotension (postural and high temperature) • cholinergic sx (drying) • weight gain • appetite stimulating Black box warning: • older adults w/ demential have increased risk for death • increase suicidal thinking in children Teach: • don't stop abruptly Can come as an injection that lasts up to a month

Vasoactive adrenergics What are they used for? Quick or slow acting? What are some examples?

Used for heart failure, to treat shock or orthostatic hypotension. Potent, quick acting, injectable, effects cease when administration stops • Dobutamine • Dopamine • Midodrine • Epinephrine • Norepinephrine • Phenylephrine

Oseltamivir (Tamiflu) ***know patient education and administration*** Zanamivir (Relenza)

Used for influenza 👍 Reduce duration of acute influenza by 1-2 days 😱 Mild side effects - GI upset 🌟 Can be used as a prophylactic 👷 Must begin within 2 days of symptoms or else no benefit

Dermatological therapeutic category: Ectoparasiticidal Used for? Common form? Other consideration? Contraindication? Example drug?

Used for lice (pediculosis) and scabies Often comes in shampoo form Personal items and clothing must be decontaminated Permethrin: Lice drug, only kills live lice. Have to use nit comb to comb the eggs out of the hair and retreat to kill eggs missed/hatched.

Corticosteroids Used for? Forms 🙅‍♀️ Contraindications 💥 Interactions 😱 AEs 🎓 Teaching

Used for persistent asthma or acute exacerbations - Reduce inflammation and help beta-agonists work better 💊 PO form (systemic) 💧 IV form (systemic) 💨 Inhaled form 💥Lots of interactions and AE- but most are with systemic forms and not inhaled forms 🙅‍♀️ Do not use if fungal infection in the mouth 😱 Coughing 😱 Dry mouth 😱 Thrush/fungal infection 😱 Mucosal irritation 😱 Many more with systemic forms (immune suppression, F/E imbalance, osteoporosis, seizures, hyperglycemia, adrenal suppression) 🎓 Can take several weeks to see best effects 🎓 Rinse mouth after use, good oral hygeine - to prevent thrush 🎓 Use bronchodilator 2-5 minutes prior! 🎓 Patients need to follow "wean" or "taper" orders

Isotretinoin What is it used for? Important AEs to remember? Benefit?

Used for severe acne that has large boils and scarring that nothing else is able to treat. AEs: • Only Rx by certain doctors with special training through FDA because this is teratogenic and pregnancy category X. Patient has to sign that they will use 2 forms of contraceptives and continue for a month after ending this medication. • Can potentially cause increased suicidal ideation - teach to report any signs of depression • Causes severe dryness. Lips can crack and peel. Benefit: Once the course is over, acne is permanently resolved

Saw Palmetto

Used for: BPH (symptoms, not a cure) hair loss test levels inflammation AE: dizzy, HA, N/V, constipation, rash Contraindications: pregnant/lactating lack of studies in women Interactions: oral contraceptives and hormone-based drugs anticoags antiplatelets Do not take before surgery Take with food

Ginger

Used for: N/V before anesthesia for nausea before chemo for nausea AE: palpitations bruising bleeding Contraindications: pregnant & lactating pt with increased bleeding risk gallstones No data on kids

Milk thistle

Used for: cirrhosis jaundice hepatitis gall bladder disease detox inflammation weight loss insulin resistance alzheimers immune boost NO FOR KIDS AE: N/V/D/bloating, headache Interactions: diazepam & warfarin Contraindications: diabetes and estrogen-related cancers (IE uteran, breast) Avoid alcohol

Ginseng

Used for: inflammation mood boost erectile dysfunction immune boost antioxidant enhance glucose uptake Children - not recommended but if used, 3 days max Interactions: MAOIs stimulants immunosuppressants warfarin anticoags Contraindicated: pregnant/lactation oral antidiabetic drugs anticoagulants Avoid alcohol, caffeine, bitter orange, other herbs

Interferons Used for? Groups? Contraindications? AEs? Example drug?

Used for: • tx of certain viral infections • some types of cancer (anti-tumor) • immunomodulating 3 groups: • alfa - used most often • beta - • gamma - Contra: • not to be used concurrently with immunosuppressants • NO with hepatitis, severe liver disease AEs: • flu-like sx • severe fatigue, sometimes can't even get out of bed ------bad enough fatigue may be dose-limiting Interferon alfa • BB warning: can cause autoimmune disorders • BB warning: neuropsych symptoms • neutropenia • thrombocytopenia

Vasodilators

Used in a hypertensive emergency in order to decrease BP significantly and quickly. Contraindications: Hypotension Cerebral edema Head injury Acute MI AEs: each drug has a unique list, she said she wouldn't be specific.

Niacin (Vitamin B3) Used for? Dosing consideration? Who is this for? AEs? Contraindications? Teaching?

Used to: Reduce triglycerides, reduce LDL, increase HDL Dosing consideration: Much larger dose needed to lower lipids than you would take as a vitamin supplement Who: Used for people that cannot tolerate statins AEs: • Flushing skin • Pruritus • GI distress (take with meals) • Hepatotoxicity • Can cause breakdown of fibrin clots Contraindications: • Liver disease • Peptic ulcer disease (remember breakdown clots) • Active hemorrhagic process (breakdown clots) • Gout Interaction: Niacin + statin can increase risk of myopathy/rhabdo Teach: • Can start to see change in a few days but 3-5 weeks for max effect • Take with meals

Ciprofloxacin

Used with anthrax Class: Quinolones 👑

Desmopressin Used for?

Usually used as an antidiuretic, but it also increases "von Willebrand factor" which promotes platelet aggregation and clot formation, so we also use it as an antifibrinolytic

Dermatological therapeutic category: Wound care drugs Used for? Supplement consideration?

Usually used for debridement Vitamin C and zinc can help improve wound healing

Lidocaine

Usually used for local pain relief Topical ointments Patches (worn up to 12 hours)

Dobutamine What class is it and what does it do?

Vasoactive adrenergic. • Similar to dopamine • Increases cardiac output and stroke volume by increasing contractility

Dermatological therapeutic category: Hair growth drugs How do they work? Education? Example drugs?

Vasodilating effect may stimulate hair follicle growth directly. Education: • Heat reduces effect, so do not use hair dryers. • Do not apply to irritated skin. • Takes at least 4 months to see benefit, if at all Minoxidil (Rogaine) = topical Propecia = systemic

What is really important for patients to remember who are taking Xanthine Derivatives?

Very important to have blood levels drawn, should not blow off! Can easily get into a toxic state.

Extravasation What is it? s/sx? What do we do? She brought this up multiple times!

Very serious complication with chemotherapy - we do not want them to infiltrate! We use central lines or ports - NOT peripheral IV for chemo • we aspirate before giving because we want to be certain we are in the bloodstream Monitor for s/sx of extravasation: • burning • stinging • tingling, numbness • pain • heat or redness at site (or coolness) • any sensation changes • blanching • infusion has slowed/stopped If signs of extravasation: • STOP INFUSION and leave catheter in place • mark area so we can watch for spread • contact provider • aspirate residual drug out of IV line • use of antidotes, hot/cold packs • elevate/rest limb • pay attention to site where catheter ENDS (may be in neck/chest if central line) • specific antidotes for specific drugs

Mitotic inhibitors Example drug? How does it work? Risks? Pro/benefit of this kind? Administration?

Vincristine Usually work during mitotis phase of cell-cycle, affecting cell division, leading to cell death Risks: • extravasation risky- more likely to cause tissue necrosis ----watch near end of central line in chest/neck for signs of infiltration • significant neurotoxin Pro: less bone marrow suppression IV USE ONLY - COULD BE FATAL in any other route!

If a patient has been given an immunoglobulin and needs a vaccine, what do we do?

Wait 3 months after they got the immunoglobulin (antibody passive immunity) because we want their immune system to have to mount a response to get immunity, not just fend it off with the circulating antibodies from the passive immunity

What is one drug / type of drug that most antibiotics interfere with? Why?

Warfarin / anticoagulants Vitamin K is synthesized in the intestines. Vitamin K is a coagulant. Disturbing flora in the gut can decrease Vitamin K and thin the blood further.

Considerations with IV admin of anticoagulants?

Watch IV site closely for infiltration, high risk for hematomas! Always use an infusion pump

Folic acid What is it? Deficiency due to? Form? Contraindication?

Water soluble B vitamin - Necessary for erythropoiesis & synthesis of DNA, RNA (deficiency can cause anemia) Deficiency most often due to malabsorption in GI Must be taken in via ingestion Some drugs can cause false sign of folic acid deficiency Available OTC, multivitamins, prenatal vitamins. Contraindicated: • Pernicious anemia (this is B12 deficiency, not folic acid deficiency)

Dermatologic form: Creams Characteristics/benefits Examples

Water-based, thick and dense Won't oil stain clothing Works well for a large area of the body Use on moist areas Not good for hairy areas Examples: • Hydrocortisone cream • Benadryl cream

What causes migraines?

We aren't really certain, but may be due to decreased seratonin (5-HT) and/or possibly due to abnormal dilation of vessels in the brain

Dermatological therapeutic category: Antivirals Why don't we use them much? When should they be started? Consideration and patient education for application?

We don't use topical antivirals much anymore because they aren't as effective as systemic ones. The earlier you catch it and get on treatment, the better the response. Want to start asap. AEs: • stinging • rash • itching Teaching: If putting a cream on a viral outbreak (IE herpes lesion on the lip), use a gloved hand because you could spread that infection

Amphotericin B ***know AEs, infusion time, assessments, implementation***

We give this to really, really sick patients when we have no choice due to serious adverse effects. 😱 Many adverse effects, they are very serious! 🙅‍♀️ Renal and hepato toxicity 🙅‍♀️ Do not use in bone marrow suppression 💧 Infuse slowly over 2-6 hours 💥 Look for pre-medication orders, we often have to give antipyretics and antiemesis drugs to help pt tolerate this drug 💥 Do not give cloudy solution 🕵️Hyperviligence watching for s/sx 🕵️ Culture and sentivity tests first 🕵️ Baseline renal function tests 🕵️ Baseline hepatic function tests 🕵️ Monitor CBC, platelet counts, WBC 👷 Take vital signs every 15 minutes because can cause cardiac dysrythmias, respiratory difficulties

Nursing Process: Implementation -benzodiazepines, non-benzodiazepines and barbituates

We try non-pharm interventions first: • Avoid alcohol and tobacco at bedtime • Chamomile tea • Don't exercise late in evening • Stretching before bed • Don't use bed for watching TV, etc • Avoid caffeine within 6 hours of bedtime Safety! • Increases in fall risk - side rails, bed alarms • Avoid driving • Orthostatic hypotension • Reduce or half dose with older patients • Renal or hepatic patients monitor Tolerance • Gradual wean-off periods to prevent tolerance Document patient response! • To evaluate effectiveness • Track AEs Teaching • Caffeine no later than 6 hours before bed • Ask for help ambulating • Take sleep meds before midnight to prevent hangover • Do not abruptly stop

Second generation antidepressants Used for? Subclasses? AEs? Interactions? Teaching?

We use these all the time - first line tx for depression • use often because less AEs and tolerated better --also used for bipolar, eating disorders, obesity, OCD, panic, PTSD, substance abuse Subclasses: • SSRI - inhibits reuptake or serotonin • SNRI - inhibits reuptake of serotonin and norepi AEs: • insomnia • weight gain • sexual dysfunction • sedation • serotonin syndrome (this can be very bad) • discontinuation syndrome Interactions: • anything else that works on serotonin could cause serotonin syndrome (MAOIs) • tryptophan • st johns wort Teaching: • 2 hour window from taking fiber • encourage that they will get used to the AEs and they won't be so bad to improve adherence

We do not want to use anti-diarrheal drugs for someone who has a bacterial or protozoan cause of diarrhea, why?

We want them to excrete the microorganism. We don't want to use a medication that will keep it in the GI tract longer. Example: giardia

Parkinsons: What is the "wearing-off" phenomenon? What is the "on-off" phenonmenon?

Wearing-off phenom: • Parkinson's medications begin to lose their effectiveness (despite maximal dosing) as the disease progresses On-off phenom: • Rapid swings in response to administered levodopa. - Disease worse when too little dopamine is present - Dyskinesias when too much dopamine is present • Switches between mobility and immobility near the end of a dose when the next dose is almost due • Uncommonly can present as sudden and unpredictable motor fluctuations

Artificial passive immunity What is it? How does it work? Where do we get it from? What is it good for? Types?

What is it? • administration of serum or concentrated immunoglobulins, anti-toxins, anti-venoms How does it work? • Bypassess host's immune system - actual antibodies are already prepared for the host that kill or inactivate the pathogen • temporary immune state • Obtained from other humans or animals (horses often) What is it good for? • good when rapid prevention or treatment of disease is needed - disease/toxin/venom will kill them before they can mount an effective immune response • good for people rendered immunodeficient and cannot mount an immune response Types: • Antitoxins (usually from horses) • Antivenoms (usually from horses) • Immune globulins (IGG - usually from a large pool of donors. used in very specific situations, supply issue)

Theophylline & Aminophylline What type of drugs? 😱 AE What do they turn into inside the body?

Xanthine Derivatives 😱 Stimulate cardiac system - increased HR, CO, GFR in kidneys • aminophylline turns to theophylline in the body and then theophylline turns to caffeine

What are the only two hypnotics currently approved by the FDA for long term use?

Zolpidem (Ambien) - in the CR form only Eszopiclone (Lunesta)

Zolpidem (Ambien) Class? Use? Long or short-term? Dosing considerations? Contraindications? Special considerations?

Zolpidem (Ambien) is a non-benzodiazepam sedative/hypnotic Use: sleep • Regular = short-term use • CR form = long-term use Dosing: Lower dose for women (5mg vs 5-10 for men) - d/t some imparment the following morning Contraindication: risk for allergy if allergic to aspirin Special considerations: • Somnambulation (sleepwalking) • Temporary memory loss • Nocturnal eating

What is a thrombus?

a blood clot

What is hemophilia?

a genetic disorder that results in a deficiency of a clotting factor so person clots slowly or not at all

sodium bicarb

buffers the acidic properties of HCl quick onset but short duration may cause metabolic alkalosis & electrolyte imbalances sodium content may cause problems in patients with heart failure, HTN, renal insufficiency

Which antacids should not be used in patients with renal issues?

calcium and magnesium based due to being more likely to accumulate to toxic levels

which antacids can cause kidney stones?

calcium containing

Considerations for giving vitamin K via IV?

can cause anaphylaxis when given IV - dilute and give over 30 mins to dilute risk

What can happen if a pregnant woman is hypothyroid?

can cause retarded fetal growth

Which two ACE inhibitors are NOT prodrugs? Why is this important?

captopril and lisinopril They do not need the liver to be functioning in order for them to work.

What does teratogenic mean?

causes birth defects

bismuth subsalicylate (pepto-bismol) What is something important to remember about this? AEs?

chemically related to aspirin - Salicylate This means NO for kids/teens with s/sx of illness = Reye's syndrome AEs: • has all same side effects as aspirin (think bleeding) • harmless darkening of tongue • harmless darkening of stool • constipation

Myelosuppression What is it? What are the effects? Teaching?

chemo affects rapidly dividing cells in bone marrow: • RBC - anemia • WBC - leukopenia • platelets - thrombocytopenia ↑ risk for infection, immunocompromised - increases risk for other types of cancers • NADIR - we can give prophylactic abx and colony stimulating factors Teaching: • low microbe diet - food cooked well, wash produce • avoid ill people, crowds, recently vaccinated persons • very good oral care • turn, cough, deep breathe to avoid pneumonia • hydration to prevent UTI, renal infections, keep respiratory secretions thin

What is the point of combination vaccines?

combine into one shot to decrease number of injections needed and increase compliance

Magnesium salt antacids

common cause diarrhea - usually combo to counteract. when used alone often not tolerated dangerous when used w/ renal failure - failing kidney cannot excrete extra mag, results in accumulation

Why assess how often someone takes OTC antacids?

could be masking sx of a more serious disease rebound hyperacidity milk-alkali syndrome

Rheumatoid arthritis What is it? First line treatment? AEs? Contraindicated? Example drug

degeneration and inflammation of connective tissue • affects joints badly, causing deformation/swelling • chronic, auto-immune disorder • painful first-line therapy using DMARDS (NSAIDS and corticosteroids for pain but not cure) Takes several weeks to begin working AEs: • bone marrow suppression --- warning of serious infection or malignancies Contraindicated: • active bacterial infection • herpes zoster • hepatitis • tuberculosis • avoid live vaccines (but be up to date on vaccines) Methotrexate (MTX) • prevents conversion of folic acid to active form • NO for pregnancy or lactation • given weekly - inject/oral, lower dose than for cancer • take a folic acid supplement

What is gestational diabetes?

diabetes during pregnancy

emollient laxatives how do they work? AEs? Example drugs?

directly lubricate the intestines and soften stool • promote more water and fat in the stools/intestines • lubricate fecal material and intestinal walls • prevents absorption of water from intestines AEs: • skin rashes • decreased absorption of vitamins • electrolyte imbalances • lipid pneumonia • oily stools Example drugs: • docusate salts (Colace - tx opioid constipation) • mineral oils (decrease vitamin absorption)

What is the difference between dysrythmia and arrythmia?

dysrythmia = any deviation from a normal rythm arrythmia = no rythm AKA asystole

What is cerumen?

earwax

What do we use to gauge heart failure in a patient?

ejection fraction the amount of blood pushed out with each contraction normal is about 65% (50-75%)

what is goiter? why is it more common in 3rd world countries? how does it happen?

enlarged thyroid - huge visible lump on neck 3rd world countries don't have iodine prevalent in their diet like is available in developed countries It happens because the thyroid isn't working d/t low iodine, so the body makes more and more thyroid stimulating hormone to try and get it to work, which causes it to enlarge

What is pepsin?

enzyme that digests proteins

What is pain defined as?

Whatever a patient says it is, whenever a patient says it is

What is a paradoxical reaction?

When a drug causes an opposite reaction to what is expected >>>IE instead of sedation, might be overstimulated

Why is it important to know that the body does not store steroids and instead makes them on demand?

When a patient is taking steroids long-term, their adrenal glands "go to sleep" because they do not need to make any steroids. This results in adrenal suppression. This is really bad for a patient that stops taking steroids because they are not making any of their own anymore Teach: must be tapered off! Can get Addisonian crisis if stopped abruptly.

What is colonization?

When a person carries an organism, but it is not causing an active infection. We typically don't treat someone who is colonized, but we do sometimes if they are high risk.

What is a superinfection?

When an antibiotic wipes out our normal flora and an organism that is not susceptible has overgrowth • Yeast is common • C.diff is common

What is the pathway for the adrenal glands to release corticosteroids? What is it called?

When low levels of a particular corticosteroid, the hypothalamus excretes cortioctropin-releasing hormone which travels to the anterior pituitary gland, which triggers the release of ACTH, which goes to the adrenal cortex and stimulates production of that corticosteroid. Once peak levels are reached, a negative feedback signal is sent to the hypothalamus to inhibit this process until the levels are low again. This is called the hypothalamus-pituitary-adrenal (HPA) axis

What is "first dose phenomenon"?

When someone takes their first dose of an alpha-blocker and they can have a big drop in blood pressure, causing them to fall or pass out ***Teaching to take first dose before bed for safety***

What is the hormone that stimulates the production of RBCs? What stimulates release of that hormone?

When the body senses a lower RBC count, the kidneys produce the hormone erythropoietin. Erythropoietin stimulates the production of RBCs.

Dermatological therapeutic category: Antipsoriatics When do we use these? Example?

When topical corticosteroids are not successful, they get a medication like this that is specific for psoriasis plaques. They are antiseborrheic (anti-sebum) These are keratolytics Example: Coal tar - used to soften the crusts on the skin

What is empiric treatment?

When we begin treating based on what we think the most likely bacterium is.

What is definitive treatment?

When we know exactly what organism is causing the issue and we specifically target it with treatment.

What is a therapeutic response?

When we see a decrease in s/sx of infections. IE fever resolving, white count coming back to normal, redness and drainage clearing, pain decreasing

What is mydriasis? What is miosis?

mydriasis - dilation of the pupil miosis - constriction of the pupil

What is tissue plasminogen activator?

natural substance that dissolves already formed clots

Alkylating drugs

non-specific chemo drugs Cisplatin Cycolphosphamide Prevent cancer cells from reproducing by altering the chemical structure of the cell's DNA Effective against wide spectrum: • solid tumors • circulating tumors AEs: • nephrotoxicity-monitor renal fx We can prevent AEs with prophylactic antiemetics, antihistamines, corticosteroids, acetaminophen •

Which drugs are often used as adjunct therapies with levodopa? Why?

rasagiline and selegiline - MAO-B inhibitors When we use these with levodopa, we don't have to use as high of a dose of levodopa or may be able to postpone use of levodopa for a while.

non-pharm options to help with morning sickness?

saltine crackers ginger peppermint oil

What is the role of insulin?

secreted in response to high glucose helps transport glucose OUT of the bloodstream and INTO the cells

What is the role of glucagon?

secreted in response to low glucose causes liver to convert glucose stored in liver to be released into the bloodstream. stimulates glycogenolysis

Bisacodyl (Dulcolax)

stimulant laxative AE: nutrient deficiency Take on empty stomach, interacts w/ milk, antacids, juice

Colony stimulating factors used for?

stimulating growth/differentiation of white blood cells

What are hormones?

substances released by endocrine glands that create very specific responses in target tissues

What is automaticity?

the ability to spontaenously trigger electrical excitability

What controls the pituitary gland? what is another name for this relationship?

the hypothalamus in the CNS/brain "the neuroendocrine system" because it's very similar to the CNS, each is a system for signaling and each operates on a stimulus-response manner

What is emetic potential?

the likelihood that a drug will produce vomiting

what is fibrinolysis?

the reverse of the clotting process, causes breakdown of clots

How do antiemetics work?

there are different neurotransmitters that induce vomiting, so most of them work by blocking those neurotranmitter stimuli: • acetylcholine = anticholinergics • histamine = antihistamines • dopamine = antidopamines • neurokinin = neurokinin antagonists etc

How do cellular immunosuppressants work?

they inhibit T-cells remember that corticosteroids do this too and are considered immunosuppressants as well

Why do we give critically ill or major surgery patients receive acid-controlling medications?

to prevent the development of ulcers due to increased stress they can develop problems even within the first 24 hours

Dermatological therapeutic category: Antiacne drugs

treat bacterial causes of acne Examples: • benzoyl peroxide • retinoic acid (retinoids) AEs: • drying • peeling • red skin • rebound oiliness • sunburn

Dermatological therapeutic category: Antimicrobials What do we use it for? Examples? AEs?

treat bacterial, fungal and viral infections Examples: • Bacitracin • Polymyxin • Neomycin • Silver sulfadiazine AEs: • skin rash • anaphylaxis • itching • burning • inflammation (For AEs, think about where we are applying, topical drug = skin reactions)

Pyrazinamide Contraindications, ADR, Assessments?

used for treating TB 🙅‍♀️ Contraindicated in severe hepatic disease 🙅‍♀️ Contraindicated in acute gout 🙅‍♀️ Do not use in pregnancy 😱 Hyperuricemia (like what causes gout) 🕵️ Assess baseline uric acid levels, any symptoms of gout?

Streptomycin

used for treating TB (can be exchanged with ethambutol) 🍭 Aminoglycoside class - ototoxic & nephrotoxic 🌟 Usually use ethambutol unless patient's TB is MDR 🙅‍♀️ Do not use in pregnancy 🕵️ Assess hearing status and baseline kidney function 🕵️ s/sx ototoxicity and nephrotoxicity

Ethambutol ***know AEs*** Contraindications, ADR, Assessments?

used for treating TB (can be exchanged with streptomycin) 🌟Usually use ethambutol unless patient's TB is MDR 🙅‍♀️ Contraindicated in children under 13 😱 Optic neuritis 🕵️ Assess baseline vision because can cause blindness and visual disturbances "think ethambutol and think eyes"

Aspirin that smells like _______ means it is old/expired.

vinegar

What are common drug interactions with antidysrythmics? see box 25.2 p391

warfarin - antidysrythmics makes warfarin thin the blood even more, watch INR closely grapefruit juice - inhibits metabolism Other drugs that prolong QT Interval: • antibiotics (-mycin and -floxacin common) • anticancer (tamoxifen, sunitinib) • antidepressants (many) • antifungals (-azole) • antinauseants (-etron and droperidol) • antipsychotics (many) • bronchodilators (albuterol, salmeterol, others) • protease inhibitors (-avir)

Nursing implications: antacids

• 2 hour window before/after other meds • give with at least 8 ounces of water (except rapid-dissolve forms)

Nursing process: Assessment for anesthetics p175-177

• ABCs and VS! Baseline, during, after • Use of alcohol - may need a higher dose • Use of nicotine - can put lungs at higher risk of atelectasis or pneumonia afterwards • Lots of labs (don't need detail for this class she said) • Neuro baseline -strength -grip -reflexes -move on command -sensory -LOC, A&O -swallow, gag reflex • Family history of malignant hyperthermia • Baseline respiratory assessment - will it be hard to get them off the ventilator d/t respiratory condition? • Potassium and magnesium electrolyte levels d/t possible imbalance with NMBDs

Why would we want to combine a vasoconstrictor with a topical anesthetic? What is a caution with this?

• Decrease the chance that the topical anesthetic is going to go systemic • Reduce blood loss - IE bleeding from a laceration makes it hard to see where you're stitching up the wound • Area will turn white due to the vasoconstriction, allows you to SEE the exact area that has been anesthesized Cautions: • Caution in small areas like ears, tip of nose, tips of fingers. Don't want to vasoconstrict an area that doesn't have an adequate way to get blood • Comes in different strengths, make sure you know which strength provider wants

Anticholinergic OD s/sx

• Delirium • Hallucinations • Cardiac dysrythmias ***Older adults are more sensitive to the CNS effects and can develop delirium***

Dopamine (Inotropin) What does it do and what do we need to remember about the dose? How do we administer?

• Dilates vessels to increase blood flow • Other effects are dose dependent: > Low/moderate does effects Beta1 > High dose effects Alpha1 • IV and given by continuous infusion with a pump only

Nursing process: implementation r/t diabetic drugs

• Do not shake NPH or premixed insulin - roll only. Bubbles could mean inaccurate dose • Check blood glucose prior to giving • Admin insulin at room temperature • Only use insulin syringes (orange caps) • Clear to cloudy for mixing - regular or rapid first, intermediate or NPH second • Know when to give insulin based on OOA and DOA, be sure meal trays are ready • Oral antidiabetics are usually 30 mins before meals • If giving oral antidiabetics, make sure patient will be able to tolerate a meal • If pt cannot take their oral drug, contact provider

Oral considerations for anticholinergic effects?

• Dry mouth • Can cause fissures in lips/tongue • Can cause bad breath 🎓 Teach Hard candies, lozenges, chewing gum can help 🎓 Teach increased risk of cavities with dry mouth, frequent oral care 👷 Implement frequent oral care

Remember AEs for anticholinergics (specific ones she brought up seperately again at end of lecture)

• Dryness • Urinary retention • Increased intraocular pressure

diuretics: patient education

• Eat K rich foods or take a supplement (except for those on potassium sparing drugs) • take diuretics at same time every day, morning best • change positions slowly, teach fall precautions • caution in hot climates, sun, hot tubs, saunas - d/t dehydration and also dizziness d/t vasodilation • s/sx of hypo and hyperkalemia • keep intaking fluids unless restricted by provider

What two conditions are included under the umbrella term COPD?

• Emphysema • Bronchitis

If epinephrine IV site is infiltrated, what is the issue and what do we do?

• Epinephrine infiltration will vasoconstrict and the tissue in the are could die. • We treat with phentolamine

diuretics: implementations

• Fall precautions! Orthostasis, dizziness • Monitor HR/rythm, palpitations may occur • Prevent constipation from fluid loss • Usually morning dosing - don't want patients to lose sleep d/t having to urinate and/or fall in the dark • Monitor s/sx hypo or hyperkalemia • Measure and record weight at the same time each day • Avoid sun or heat for too long d/t risk for dehydration already from the diuretic

What are the s/sx of liver disfunction?

• Fatigue • Jaundice • Nausea • Vomiting • Dark urine • Anorexia • Itching • Abdominal pain (right upper) • Easy bruising

Insulin When do we use these? What are the differences between different preparations? Uses?

• First and only line of treatment for type 1. • Only for type 2 when other oral anti-diabetic medications have failed or if acutely ill (last resort for type 2) Made in a lab, allergies are rare nowadays Differences • Onset of action • Duration of action • Peak effect • Combinations of different types Uses: • Restores ability to metabolize carbs, fats, proteins • Makes it possible to store glycogen in the liver • Makes it possible to convert glycogen to fat stores

Adult vaccine types

• Flu - recommended every year • Herpes Zoster - for shingles, must be 50+ years old. Allergy to neomycin or gelatin cannot get HZ • Tdap - booster for tetanus, diptheria, pertussis • Pneumococcal - pneumonia for over 65 years • Hepatitis B - if they haven't had it yet because it's newer and wasn't around when many adults were kids

Contraindications for cholinergics

• GI or GU obstruction > increasing secretions and motility can cause perforation • Bradycardia • Hyperthyroidism > aggravates hyperthyroid • Epilepsy • Hypotension • COPD • Asthma Essentially if pt is already experiencing symptom that cholinergics cause, we don't want to make it worse

What is important to remember with patient teaching during antibiotics?

• Give list of foods/beverages to avoid during antibiotics • Advise which adverse effects to report • Teach about foods to help prevent super infections, IE yogurt and probiotics • If on oral probiotics, use another form of birth control • Wear a medical alert bracelet if they have a history of anaphylaxis with medications • Drink lots of fluids • Understand s/sx of superinfections 🚲 Tetracyclines - avoid the sun, severe sunburn! 🐙 Cephalosporins - avoid alcohol

Long acting insulin Example drug? Onset of action? Duration of action? Other important things to know?

• Glargine (Lantus) - 1x daily but can be 2x • Detemir (Levemir) - 1-2x daily, DOA depends on dose These are NOT interchangeable or mixable! • Onset 1-2 hours • Duration 24 hours • AKA "basal insulin" • Provides a constant level in the body, safer since glucose levels do not rise/fall

Contraindications for anti-histamines

• Glaucoma • Cardiac diease • Kidney disease • Hypertension • COPD • Peptic ulcer disease (PUD) • Seizures • Benign prostate hyperplasia (BPH) • Liver impairment (use caution)

Anticholinergic patient teaching

• Good, consistent oral hygeine due to higher risk for cavities, fluids to keep mouth moist • Can't sweat, so pay attention to body temperature > exercise, hot outside, sauna, etc ***Older adults at increased risk for heat stroke, hyperthermia*** • Avoid driving or other activities that require alertness due to potential sedation (improves over time) • Sunglasses due to increased light sensitivity • Increase fluids and fiber to prevent constipation

Remember AEs for anti-leukotriene (specific ones she brought up seperately again at end of lecture)

• Headache • Nausea

Teaching for immunosuppressants

• MUST be taken exactly as ordered • EXACT time each day with exact foods as ordered • NEVER stop immunosuppressants • NURSE: never be late on these with med admin! • usually a complex regimen with multiple medications that may be taken at different times each day, lots of planning • do not interchange brand names or dosage forms

What is the similarity in the drug names in these classes?

• Macrolides - end in "thromicin" except "spiramicin" (like 💪 throws a spear) and "fidaxomicin" (like 💪 throws an ax) • Sulfonamides - start with "sulfa" • Tetracyclines - end in "cycline" • Quinolones - end in "floxacin" • Aminoglycosides - end in "mycin" or "micin" or "kacin" • Monobactams - "azactam" is it • Cephalosporins - start with "cef" or "ceph" • Penicillins - end in "cillin" • Carbapenems - end in "penem"

What are the types of anemia?

• Maturation defects • Hemolytic • Anemia of chronic disease ----this one doesn't fit in the previous categories, but can have anemia, such as with long-term kidney failure

Acetaminophen ***understand this***

• AKA "APAP", "Tylenol" • Non-opioid 💊 PO 💧 IV 🍑 Rectal 👍 Drug of choice for children with mild/moderate pain and fever 👍 Drug of choice for older adults • Not an antiinflammatory, mainly for pain and fever 🙅‍♀️ Do not use for those with liver disease 🙅‍♀️ Do note use for those with cirrhosis or hepatitis 😱 Hepatotoxic - jaundice, pain in area of liver 😱 Hepatic Necrosis in overdose 🕵️ Assess for liver function before giving 🕵️ S/sx acetaminophen poisoning: rapid & weak pulse, dyspnea, cold/clammy extremities, jaundice, pain in area of liver 🎓 Teach not drug of choice for those who consume more than 3 drinks of alcohol per day due to liver effects

Important points to remember with pediatrics and analgesics

• Acetaminophen is drug of choice before getting into more • Assessment of pain may be challenging >>>May be scared to verbalize or unable to verbalize >>>Use verbal and nonverbal cues • May need to use alternative sale (FACES, OUCH, NIPS) • Med doses based on weight/age!!! • Can use EMLA cream to numb before injection • Hold opioid if RR less than 12 • Do not split or halve an adult suppository

What are the types of decongestants? Pros/Cons of PO vs topical?

• Adrenergics • Anticholinergics • Topical corticosteroids (typically inhaled for intra-nasal) PO - longer duration, delayed onset, less potent effect Topical corticosteroids - more potent, quick onset, potential rebound (but not oral inhaled, just nasal spray)

What are the mechanisms of action for opioids? ***know all of this***

• Agonist - bind to opioid receptors in body and produce analgesia >>>No ceiling effect, can raise dose as tolerance increases • Agonist-antagonist - bind to opioid receptor but has weaker pain relief >>>Has a ceiling effect 🙅‍♀️ Not for use under 18 years old 😱 If used with an agonist, can reverse analgesia and cause withdrawal symptoms • Antagonist - bind to opioid receptor sites to reverse opiod effects >>>We use these when someone is experiencing too much sedation, respiratory depression, overdose >>>"Naloxone" and "Naltrexone"

What are the drug therapies for Parkinson's disease aimed at? Does treatment cure the disease?

• Aimed at increasing the levels of dopamine and/or antagonizing the effects of acetylcholine • Drug therapy does not slow the progression of the disease or cure it. Drug therapy is used to slow the progression of symptoms.

What labs are included on a liver function test? Source: Mayo clinic

• Alanine transaminase (ALT) • Aspartate transaminase (AST) • Alkaline phosphatase (ALP) • Albumin and total protein • Bilirubin • Gamma-glutamyltransferase (GGT) • L-lactate dehydrogenase (LD) • Prothrombin time (PT)

Things to assess for in general with antibiotics

• Allergy, hypersensitivity • Liver, renal function, CBC • ECG changes • Neuro status - due to possible CNS issues • GI status • Contraindications/interactions with other foods/meds • S/sx superinfections

Dermatologic chemo AEs

• Alopecia - can be slow or fast hair loss ----teach hair regrowth may be different color/texture • Stevens-Johnson syndrome ----fatal skin sloughing - emergency! • Toxic epidermal necrolysis • Hand-foot syndrome ---swelling, redness, blistering • Protect from sun exposure ---not just sunscreen, avoid sun, use hats ---increased risk of skin cancer when immunocomprom. Report any changes to skin!

Phentolamine Class What does it do? What do we use it for? Administration?

• Alpha blocker • Rapid vasodilation • We use when epi or nor-epi infiltrate IV in order to restore blood flow to tissue • Inject sub-Q around affected area

Asthma or COPD implementation

• Always focused respiratory assessment - before, during, after • Know proper admin of inhaled forms (MDIs) • Use of peak flow meter to monitor disease • Encourage increased hydration • Monitor blood theophylline levels • Monitor for beneficial effects (decreased dyspnea, wheezing, anxiety, improved ABGs, improved O2 sats, able to ADLs better, etc) • Monitor AEs • Encourage to wear a medical alert bracelet that discusses/alerts their condition

What is Addisonian crisis?

extreme Addisonian disease symptoms hypovolemia dehydration hyponatremia hyperkalemia can be fatal

What is syncope?

fainting due to hypotension

What is a good choice of laxative for kids?

glycerin - suppository safe and gentle for kids do not cut adult suppositories because can't get accurate dose. can use liquid form as a suppository

Lactulose class? alternate use? interactions? contraindications? AEs

hyperosmotic laxative Also used to reduce elevated serum ammonia (cephalic encephalopathy - alcoholics) Interaction: oral Abx can decrease the effect Contraindicated: do not use if patient is on a low lactose diet AE: • consistent, constant diarrhea

Chemotherapy has the most effect on cells that are ___________

in active growth The more rapidly dividing, proliferative, chemo will work better Hair follicles, GI tract cells and bone marrow cells are rapidly dividing and this is why we lose our hair, have so many GI effects and bone marrow effects with chemo

hyperosmotic laxatives AEs Example drugs

increase fecal water content • results in bowel distention, ↑ peristalsis, ↑ evacuation AEs: • abdominal bloating • electrolyte imbalances • rectal irritation • ↑ CNS depression in combo w/ other CNS depressants Example drugs: • Polyethylene glycol (PEG) - used for bowel prep, oral or GI lavage (IE Miralax) • Sorbitol, glycerin - increases osmotic pressure and draws water into the colon (safe/gentle for kids) • Lactulose • saline NOT TO BE USED IN OLDER PATIENTS d/t sensitivity

What happens with oversecretion of mineralcorticoids?

increased aldosterone = increased retention of sodium/water and increased excretion of potassium/hydrogen

Dermatological therapeutic drugs: Implementation

• Always wear gloves or use applicator • Cleanse area of debris, drainage, residual meds • Apply dressings as ordered (most don't require) • Educate on wound care and home application • Wound assessment: drainage, swelling, temp, odor, color, pain, size, shape, location, depth • Protect from air or sun as necessary • Monitor for improved condition, healing, decrease in size/number • Monitor for worsening: new s/sx, fever, drainage, swelling, pain, redness, even systemic effects

Cholinergics - implementation

• Ambulation, fluids and fiber to enhance GI effect • Monitor bowel sounds, flatus, bowel movements • Have atropine readily available for OD • Help with ADLs and ambulation in Alzheimers • Monitor BP, HR, EKG • Monitor for SLUDGE, hypotension, cardiovascular collapse • Teach up to 6 weeks for Donepezil • SAFETY - dizziness/gait issues (Alz/Donepezil) and with dosage changes • SAFETY - do not stop taking abruptly

Complications long-term antibiotic use (couldn't find in lecture or book so this is speculation)

• Antibiotic resistance • Decreased gut flora = decreased vitamin k = decreased clotting • Increased risk of superinfections

AEs of anti-histamines

• Anticholinergic effects (drying) > Due to drying effect can cause constipation, urinary retention, dryness of mouth/nose/throat • Hypotension • Palpations • Syncope (fainting due to hypotension) • Lack of focus • Drowsiness (depending on which one used) • Dizziness • Muscular weakness • Paradoxical excitement (usually benadryl) • Restlessness • Nervousness • Seizures • Vertigo • Vision changes • Tinnitus • Headache

Which types of respiratory drugs do not provide healing or a cure, but are used for symptom relieve/palliative care?

• Antihistamines • Decongestants • Antitussives • Expectorants

Anticholinergic interactions and contraindications

• Anything with similar effects: drying, decreased secretions, decreased GI/GU, etc > antihistamines > tricyclic antidepressants • Angle-closure glaucoma • GI/GU obstruction • Acute cardiovascular instability • Acute asthma • Antihistamines

Coagulation modifing drugs teaching

• Carry ID card/med alert bracelet • avoid injuries • be consistent with vitamin K rich foods • avoid cranberry juice and alcohol with warfarin • avoid dietary and herbal supplements • clot preventative measures : minimize sluggish circulation (avoid sitting for long periods, long bed rest), avoid tight-fitting clothing, stay hydrated • be careful with razors, trimming nails, gardening • brush teeth with soft bristle brush

Patient teaching for MAOIs

• Change position slowly - dizziness and possible orthostatic hypotension • Avoid tyramine-containing foods if on non-selective or high dose MAO-B inhibitor

What is cholinergic crisis? What is a patient teaching we can use for this?

• Circulatory collapse • Hypotension • Cardiac arrest • Shock • Bloody diarrhea • Abdominal cramps • Salivation • Flushing of skin • N/V Mnemonic SLUDGE for patient teaching, but nurse needs to remember more than that! S - salivation L - lacrimation U - urinary incontinence D - diarrhea (bloody) G - GI cramps E - emesis Important for nurse to remember circulatory collapse and hypotension especially! CASH? Circulatory collapse Abdominal cramps Salivation Hypotension

Which patient groups are indicated for statins?

• Clinical atherosclerotic CVD • LDL levels 190+ • Diabetes 40-75 years old w/LDL 70-189 and no CVD • No CVD or diabetes but LDL 70-189 and 10 year risk for CVD

Why is a prolongated QT interval so concerning? p389

it has the potential to induce "torsades de pointes" which can lead to v-fib and death

What is a syptom indicative of an allergy, except in morphine?

itching Itching is a normal reaction to morphine and does not indicate an allergy

What is thrombocytopenia?

low platelet count

which antacids can cause diarrhea?

magnesium containing

Anticholinergic assessments

• Closer assessment of older or young patients - increased susceptibility of AEs • Assess urinary frequency, urgency, nocturia, incontinence > Any bladder disorders? > improvement? • Assess for glaucoma and eye conditions > increased intraocular pressure AE > safety for driving, falls due to blurred vision • Assess for GI conditions > Ulcerative Colitis, reflux, poor motility to avoid exacerbation • Assess skin > patch placement > temperature due to decreased sweating

What are signs of improvement with TB?

• Cough reduction (less infectious) • Fever resolves • Weight gain • Lab studies and cultures improving • Chest x-ray improving • Adverse effects tolerable? • Decrease in symptoms >>cough >>fever >>chills >>night sweats

antimotility drugs: opiates What do they do? Used for? Example drugs?

• Decrease bowel motility and reduce pain by relief of rectal spasms ----decrease transit time through the bowel, allowing more time for water and electrolyte absorption ----decrease GI secretions Used for: severe diarrhea Example drugs: • paregoric • opium tincture • codeine (not for children!) • OTC loperamide • diphenoxylate AEs: opioid AEs - CNS depression: • drowsy • dizzy • lethargy • N/V • constipation • respiratory depression • hypotension • urinary retention • flushing

calcium salt antacids

many forms but carbonate most common may cause constipation and kidney stones calcium carbonate often causes gas & belching - combined w/simethicone to counteract not recommended w/ renal failure, may accumulate to toxic levels long duration of acid action - may cause rebound acid often advertised as extra source of dietary calcium (IE Tums) - use with vitamin D for best absorption

What is thimerosal?

mercury-based preservative that used to be included in vaccines but is no longer used since 2001 This ingredient is the one in question r/t autism and vaccines

Hematopoietic drugs What do they do? Benefits? Drug examples? AEs? Interventions?

• promote synthesis of RBC, WBC, platelets • allow higher doses of chemo by tx myelosuppression • reduces recovery time after chemo • avoids need for transfusions of RBCs and platelets Epoetin alfa • synthetic hormone erythropoietin • stimulate RBC production Filgrastim (Neupogen) • stimulate WBC production • give before infection • can't use within 24hr of myelosuppressive drugs • d/c once ANC is over 10,000 AEs: • fever • blood dyscrasias • bone pain (may need analgesics) Interventions: • monitor baseline CBC and continuing cell counts • watch s/sx anemia • watch s/sx infection

Non-pharm treatments for mental health issues List some and why?

• psychotherapy/counseling • support groups • social and family support systems • spiritual support systems • physical exercise • good nutrition • mental exercises - mediation, visualization Studies show that outcomes are greater when the pharm methods are combined with these

S/sx left sided heart failure

• pulmonary edema • crackles • coughing • pink, frothy sputum • SOB • dyspnea • cool, clammy extremities

S/sx of acetaminophen (Tylenol) overdose

• rapid & weak pulse • dyspnea • cold/clammy extremities • jaundice • pain in area of liver • bleeding • loss of energy • fever • sore throat • easy bruising

Severe reactions to vaccine? What do they do?

• really high fever • neuro responses - convulsions, change in LOC • anaphylaxis • full-body rashes • dyspnea • cyanosis Contact medical personell right away - will be reported to VAERS

Safe handling of chemo agents

• requires special training to handle/admin chemo • do not prepare or administer IV chemo if pregnant due to risks to fetus • use double bagging technique, biohazard container, leak & puncture proof - anything that comes in contact with the patients • double flush toilets after patient uses • special spill kits for chemo spills • do not remove any needles from syringes to avoid leak of any kind • if drug touches nurse, wash with soap/water immediately, remove clothing and/or flush eyes • all material used are disposed of by incineration • use standard precautions with all body substances

Heart failure drugs: nursing assessment implementation teaching

• s/sx heart failure (edema, breath sounds, ecg, renal function tests, serum electrolytes, BP, daily weights) • do not give digoxin if HR less than 60 or over 100 - hold and notify provider • serum digoxin levels if ordered • monitor s/sx for digoxin toxicity • changes in vision - blurred, halos, yellow • check for compatibility of drugs, flush/use 2nd line if needed Teaching: • daily weights at same time every day • never abruptly stop heart failure drugs • take digoxin at same time daily • check HR before taking digoxin • avoid antacids, milk products, bran, fiber within 2 hours of drugs

acid-controlling drugs: education

• space 2 hours before/after antacid • take antacid w/ 8oz water • antacids can cause enteric coatings to dissolve too early • don't take for more than 2 weeks without talking to provider • report prolonged constipation, diarrhea, GI bleed sx • take PPIs before meals • With GERD - harsh spices, extreme in food temp, black pepper, caffeine, carbonated beverages, alcohol - can all make it worse

What impacts chances of cure for cancer for a patient?

• stage at time of dx • doubling time • type of cancer • efficacy of treatment (how good it is) • general health of the patient

nursing process: implementation immunosuppressants

• take with food to minimize GI upset EXCEPT tacrolimus PO is empty stomach! • Oral forms are preferred if we can (prevent infection) • keep allergy/anaphylaxis supplies nearby --may need to premedicate --watch for facial flush, urticaria, wheeze, dyspnea, rash • oral hygeine, admin oral antifungal PRN (thrush) • monitor serum drug levels • provide emotional, financial, social, spiritual support -- think of expense of these drugs, emotional impact of worrying about rejection and AEs for life

Corticoids - implementation and teaching

• teach - make sure seeing eye doctor regularly (IOP) • check for interactions • adrenal hormones peak in early AM - administer then is best, 6-9AM • cortisol levels increase with stress - they may need increased dose "stress dose" • admin a GI drug to help prevent ulcer formation - avoid ulcer generating things: alcohol, caffeine, ASA • can admin into joints, topical, nasally • Inhalers RINSE MOUTH risk of fungal infection • avoid ill people, report flu-like symptoms • report SOB (risk heart failure) • report mood swings, changes in mood • encourage vitamin D and calcium supps • fall prevention if osteoporosis • low sodium diet and increase potassium if needed

Antiemetics: implementation

• teach about drowsiness, driving, attentive tasks, hypotension safety • avoid other CNS depressants • alleviate dry mouth • monitor for extrapyramidal reactions • non-pharm ways to handle mild nausea

Important points to remember with older adults and analgesics

• May have to use alternative scale or rely on family or behavioral cues for pain rating due to neuro impairment • Start LOW, go SLOW • May be stoic about pain • Drugs may have higher peak and longer duration due to renal/liver changes • Increased sensitivity to CNS depressing drugs - smaller doses • Paradoxical reactions may be more likely • Polypharmacy can increase interaction risk • Keep regimen simple to increase compliance • Hypotension and respiratory depression may occur more frequently • Fall precautions / bed alarms / side rails • Pay attention to urinary output especially if enlarged prostate • Acetaminophen is drug of choice before getting into more

Antiepileptics - nursing process Assessment

• Medication history very important d/t interactions • Type of seizures they have • What do you experience before/during/after seizure? - Do you get an aura? • Neuro assessment for baseline - reflexes - motor/sensory - photosensitivity - speech clear, formed & expressed w/out problem - auras? - headaches? - PEERLA • EEG • VS - d/t possible CNS depression • Environment safe? • Baseline energy levels • Eye/vision exam

What are the classifications of opioids?

• Meperidine-like • Methadone-like • Morphine-like • Other 💥 If patient experiences an allergy to a drug, choose a different class

What are glucocorticoids responsible for? Example hormone?

• Metabolize carbs, fats & proteins • Antiinflammatory • Maintain normal blood pressure • Influences stress reactions (fight/flight) (some effect on sodium and water retention and potassium and hydrogen loss, but not as drastic as with mineralcorticoids) --Cortisol

Immunizing drugs: implementation

• Must provide VIS (vaccine information sheet) and document that it was given • provide written vaccination record • route and sites of administration - preferred for adults (deltoid for IM) vs children (lateral thigh for IM) • have epi available in case of unexpected anaphylaxis • educate on AEs - minor vs concerning • anti-vaccine patients/parents

What should we monitor in patients on opioids / considerations for patient safety?

• Respiratory rate because of CNS depression • Urinary output because of urinary retention • Bowel sounds/movements because of constipation • Pupil reaction to light because pinpoint pupils indicate overdose • May need to institute fall precautions

Patient teaching: diabetic drugs

• Rotate injection sites to prevent lipodystrophy • Make sure pt can recognize symptoms of hyperglycemia and hypoglycemia and what they should do when they experience one • During fever, illness, stress, increased activity or inactivity, surgery, emotional distress can change serum glucose levels - watch blood sugar well! • Check blood sugar before giving themselves insulin • Plan ahead for vacations - plenty of insulin or other drug, meds for hypoglycemia, storage, etc • Monitor blood sugar before and after exercise because sugar moves into cells and they can get hypoglycemic - snack before exercise • Some oral antidiabetics can cause photosensitivity - protect skin, no tanning beds

Nursing process: assessment thyroid

• S/sx hyper and hypothyroidism • Baseline VS • history of cardiac issues? feeling palpitations? • monitor levels of T, T4, TSH • clotting studies if on anticoagulants • S/sx thyroid storm (AKA thyroid crisis) and triggers

Implementation considerations for adrenergic drugs

• Safe drug calculations and accurate dosing! > Use IV pump for consistency/accuracy • Watch IV site for infiltration • Monitor cardiac system • Monitor for AEs > hypertension, tachycardia, overstimulation • Monitor for therapeutic effect > improved CO > increased urine output > vital signs WNL > improved respiratory function > improved peripheral pulses > improved respirations • Remember teaching for midodrine > Increase fluids, don't take before bed, safety • Report to provider > chest pain, palpitations, heart attack, seizure

Beta Blockers - implementation and teaching

• Safety - change positions slowly • Safety - be careful with ANYTHING that causes vasodilation: avoid alcohol, excessive exercise and exposure to hot climates/hot tub/sauna • Monitor for therapeutic effects: decrease in BP, HR, palpitations • Count apical pulse for one full minute, want more than 60 • Wean off drug slowly • Avoid caffeine • Alert us if they have SOB, edema, weight gain, palpitations

Anticholinergic implementation

• Same time every day • Adequate fluids if allowed (they are drying!) • Manage dry mouth: frequent mouth care, hard candies, oral rinses, sugar free gum • Manage dry eyes: eye drops • Prevent/treat constipation • Patches - rotate sites, clean off old medication • Caution changes in vision, alertness, sunglasses • Improved patterns in voiding if giving for overactive bladder • Teach toxic effects > Delirium > Hallucination > Cardiac dysrythmia

Toxic effects with adrenergic drugs? What is one positive about toxicity with these? What should we do for someone facing toxicity?

• Seizures • Intracranial bleeding due to high BP • Hypertension • Dysrythmias Positive: they have a short half-life, which is beneficial in toxicity situations Manage symptoms, support respiratory and cardiac systems until the drug passes out of their body

Contraindications for adrenergic drugs?

• Severe hypertension > Because vasoconstriction could send into hypertensive crisis • Known allergy

Benzodiazepines How long do we use them for? Contraindications? AE? OD s/sx? Black box warning? Treat OD with what?

• Short-term • Contraindicated with glaucoma and pregnancy • AE: headache, drowsiness, paradoxical excitement/nervousness, dissiness or vertigo, cognitive impairement • OD s/sx: diminished reflexes, coma, confusion, somnolence (and rarely hypotension, respiratory depression, death) • Treat OD with: flumazenil

Main patient teaching points for analgesics

• Signs/symptoms of overdose/toxicity • Report changes to us • How to avoid constipation

Opioid-induced adverse effects

• Sleep disturbances, sexual dysfunction • Also dry mouth - can give sugar free candies to help • Skin irritation is patchy

Prominent viral illnesses

• Smallpox • Sore throat • Conjunctivitis • Warts • Influenza • Respiratory infections (most viral) • Gastroenteritis • HIV/AIDS • Herpes • Hepatitis

Why do we give adults vaccines?

• Some were never vaccinated as children • Some vaccines we have now were not available when they were young • Immunity can fade over time (Tdap especially here)

What do you do if you feel like your patient is overdosing on opioids/becoming too respiratory depressed?

• Stimulation, try to wake them up • Report to provider • Ventilatory assistance, possible intubation • Administer antagonists >>> Noloxone, Narcan >>>effects are short-lived and may need to be re-dosed

Adverse effects of antibiotics

• Superinfections >>>watch for s/sx yeast infection >>>watch for s/sx C.diff • Antibiotic-associated colitis (diarrhea) • Nephrotoxicity (kidney) • Ototoxicity (ears) • Neurotoxicity (neuralgia, pain, paralysis) • Hepatotoxicity (liver)

Lipid reducing drugs: implementation

• Supplements of vitamins ADEK with some classes • Minimize constipation with some classes • Perform liver function test - pt in fasted state 12-14hr • Encourage nonpharm therapy -eat fish, take fish oil supplement -exercise, diet, etc • Mix powder forms thoroughly, dissolve for 1 full minute, never take dry form • May use ASA or NSAIDs 30 mins prior to med for treatment of flushing w/niacin • Notify dentist of medication - because of drug interactions and clotting issues

Remember AEs for beta-agonists (specific ones she brought up seperately again at end of lecture)

• Tachycardia • Cardiac stimulation

HTN drugs: implementation

• Teach pt how to evaluate own BP and HR before taking drug - journal can be helpful • Teach pt to do daily weights - same time every day, same amount of clothing, same scale - report gain/loss 2lb in a day or 5lb in a week • Make sure they get their eye exam every 6 months • AntiHTN drugs can cause depression, report depression to provider • Change positions slowly • High temperature can add to hypotension • Take at bedtime or supine for 30 mins after • Monitor for AEs • May tolerate meds best with meals • Promote wellness - stress reduction, weight management, smoking/alcohol cessation, diet changes • Monitor serum potassium with ACE and ARBs

What is equianalgesic?

• The equivalent dose of one drug to provide the same pain relief as a dose of another drug • Knowing which drugs are stronger than others

Why don't we use barbituates very often?

• They have many unwanted AEs • Low therapeutic index (small window) • Physiologically habit-forming Benzodiazepines have a favorable safety profile and efficacy so we use those instead of barbituates now except for specific situations.

What is included in a lipid panel?

• Total cholesterol • Triglycerides • HDL • LDL • VLDL (very LDL)

Opioid contraindications ***know which patients are at greatest risk***

• True allergy (not "itching" with morphine or "nausea" with codeine) • If the opioid is going to cause an adverse effect that makes a patient's condition worse >IE asthma: opioids can worsen asthma >IE prostate enlargement: opioids and prostate enlargement both can cause urinary retention >IE COPD >IE Sleep apnea • Use with any other CNS depressants >IE alcohol

Dermatological therapeutic category: Immunomodulators

• Tx of atopic dermatitis (ecxema), actinic keratosis (precancerous lesion), superficial basal cell carcinoma, anogenital warts

Peripherally acting opioid antagonists

• Tx of constipation r/t opioid use and bowel resection therapy Blocks entrance of opioid into bowel cells - allows bowel to function normally with continued opioid use Strict regulations for use

How is insulin dosing expressed?

• UNITS per ml: 100 or 500 units/ml common

Lipid reducing drugs: assessment

• Use of alcohol (potential for liver dysfunction) • Family hx • Presence of risk factors for stroke, coronary heart disease (CHD) -HTN -diabetes -obesity -PVD -smoking • Serum lipid values, liver enzymes, PT time • Musculoskeletal complaints, urine characteristics • Hx of PKU for bile acid sequestrants • Hx of gout, PUD or active bleeding for niacin

Considerations for pediatrics with moderate anesthetics p 171 - pink box on left

• Use often with pediatrics d/t children having higher anxiety with procedures and being fearful, uncooperative • Allows for restraint-free procedures • Weight-based dosing important to be accurate! • Always have reversal agents at the bedside - naloxone for opioids - flumazenil if using benzodiazepines • Discharge criteria must be met - return of swallow, gag reflex - back to baseline (within 15% usually) - independent ambuation if old enough • Adult must remain with patient for set amount of time after procedure (2-3x half-life of drug they had)

Cytotoxic antibiotics AEs common suffix?

• bone marrow suppression • pulmonary fibrosis -rubicin (daunorubicin, doxorubicin, epirubicin, idarubicin, valrubicin) -mycin (bleomycin, dactinomycin, mitomycin, plicamycin) • watch CBC • watch SOB • watch for bleeding • gentle with patient, no ASA/NSAIDS, soft toothbrush • focused respiratory assessment

Laxatives: assessment

• bowel patterns, abdominal assessment • dietary and fluid intake (fiber), exercise • VS, weights, I&O • electrolyte lab values • laxative abuse - elderly dependent, teens eating d/o • rectal bleeding? • assess for recent weight loss, surgery, degree of peristalsis • baseline renal function - ↓ fx = no for magnesium saline laxatives

Antidiarrheals assessment

• bowel patterns, frequency, color, consistency, amount, odor, blood? • recent illnesses • all GI complaints (pain - PQRST) • any diet changes recently? • been traveling? out of the country? camping? • allergies? food intolerances? medications taking? • Full GI assessment (inspect, listen, palpate) • palpation - soft and non-tender? masses? bulges? visible peristalsis waves? • hydration status, mucous membranes, I&O, daily weights, edema, tugor, tears? • S/sx dehydration & F/E imbalance: dizzy, muscle weakness, muscle cramping

S/sx of Digoxin toxicity What can increase the risk for Digoxin toxicity? Treatment of digoxin toxicity?

• bradycardia • dysrythmias • heart block • headache • dizziness • confusion • nausea • visual disturbances (halo around lights, blurred, yellowing) Increased risk for tox: • low potassium • low magnesium • poor renal function Treatment: digoxin immune fab (DIF) - it makes the body think digoxin is an antigen, so the immune system inactivates it

AEs for insulin

• brain damage, shock, death if BG is brought too low • lipodystrophy at injection sites - hard bumps under skin if sites aren't rotated • weight gain • allergic reactions (rare)

S/sx of DVT "I expect you to know these"

• calf pain • redness over vein • calf swelling • painful on calf flexion • legs are uneven in diameter

Buproprion (Wellbutrin) Used for? Benefit? Contraindication?

• can be used for smoking cessation • can help with sexual side effects from SSRI • non-sedating - take in morning Contraindication: • seizure disorder • pt taking MAOI

Nursing implications: H2 antagonists:

• caution older patients who are confused/disoriented • assess for allergies, impaired renal or liver fx • take 1-2 hours before antacids • assess bowel sounds • if given IV, monitor IV and BP d/t possible hypotension • monitor for black, tarry stools and bloody vomit

What characteristics of RBC does a CBC look at that helps a provider suspect which type of anemia is present?

• color • size • shape

S/sx hypoglycemia?

• confusion • irritability • tremor • sweating • seizures s/t low body temperature

How can we prevent heart failure?

• control HTN • manage diabetes and possibly use cardio-protective med due to being at higher risk • prevent coronary artery disease • prevent obesity

S/sx serotonin syndrome

• delirium • agitation • tachycardia • sweating • myoclonus (muscle spasms) • hyperreflexia • shivering • course tremors • extensor plantar muscle responses More severe cases have: • hyperthermia • seizures • rhabdomyolysis • renal failure • cardiac dysrythmias • disseminated intravascular coagulation (blood clots forming all over the place and coagulation factors are being used up, so can result in severe bleeding) Educate patients on SSRIs!

Antidepressants What kinds of conditions do we use these for?

• depression • dysthymia • schizophrenia • eating disorders • personality disorders • migraines • chronic pain syndromes • sleep disorders • premenstrual syndrome • hot flashes associated w/menopause Work by: Increase serotonin, dopamine and norepinephrine Measured by

laxatives: nursing implications

• do not take if N/V, abdominal pain or already have diarrhea (electrolyte and fluid loss) • high-fiber diet and ↑ fluid intake encouraged • long term use can lead to dependency • powders need to be mixed with water and drink immediately - choking hazard • Bisacodyl - take w/ water - interacts w/ milk, antacids, juice - best on empty stomach • contact provider if severe abd pain, muscle weakness, cramps, dizzy (poss electrolyte issues) • take all laxatives w/ 6-8oz water

Mental health drugs general info How do we select the drugs? What may cause mental health issues? How do we measure therapeutic response? What is a common problem?

• drug selection often trial-and-error • possibly due to abnormal levels of neurotransmitters which is what drug therapy centers around • therapeutic response is often measured subjectively • nonadherence is a common problem -----they don't start working for a long time -----AEs are challenging and unpleasant -----mental health problems already make it hard

What do CNS stimulants do? Scheduled?

• elevate mood • increase energy/alertness • decrease appetite • enhance task performance impaired by fatigue/boredom • decreased fatigue/drowsiness • prolonged wakefulness ***Similar to actions of the sympathetic nervous system - bronchial smooth muscle dilation/vasodilation*** Schedule II

Reproductive chemo AEs

• extremely teratogenic - must be on very good birth control and continue it for quite some time after chemo is over (8 weeks - 2 years after ending) • biggest risks after first trimester • sterility possible- sperm banking • premature menopausal sx • decreased libido, sexual dysfunction

S/sx of anemia

• fatigue • easily tired • dizziness • lightheadedness with position changes • brittle and/or misshapen nails • changes in color of skin • cracks in corners of mouth

What signs of improvement will the nurse see to indicate an antibiotic is therapeutic?

• feel better • look better • normalizing vitals • temperature normalizing • increased energy • increased appetite • negative culture • normal CBC, white blood cells no longer elevated ***make sure you take a culture before starting treatment so you can assess changes***

Minor adverse effects from vaccines? How are they treated?

• fever • rash • soreness • urticaria / itchy red patches • lump at site of injection • swollen lymph nodes • pruritis/itching • arthritis/achy joints Treat with acetaminophen and rest, can use warm compress on injection site

Antidysrythmics: nursing assessment

• full cardiac assessment, HR and rythm (reg or irreg!) • chest pain? palpitations? • s/s decreased cardiac function or output because dysrythmias could lead to these -----pulse deficit, change in JVD, edema, crackles, prolonged cap refill, decreased urine output, fatigue, activity intolerance, dyspnea • s/sx hypoxia -----O2 sat, LOC, skin color, anxiety, restless • drug interactions? no grapefruit juice? • monitory respiratory for amiodarone d/t respiratory toxicity • Liver, thyroid, kidney function • monitor skin for rashes, changes (blue/gray/yellowing notify provider!)

What are some signs for evidence of bleeding? "I expect you to know these"

• gums bleeding when brushing teeth • nose bleeds • blood in stool • blood in urine • bruising • blood in sputum • blood in emesis • blood in secretions • restlessness • LOC changes • BP/HR • abdominal/chest/back pain • heavy menstruation

What are the main differences between different types of SSRIs?

• half-life • level of impact to sexual dysfunction • level of sedation

Nursing process: assessment for pituitary drugs

• height, weight and VS documenting • Baseline BG due to glucose effects • Liver/Kidney function tests (octreotide) • baseline thyroid, calcium levels (GH meds)

Assess/implement for chemo drugs

• height/weight dosing • head-to-toe assessment because AEs everywhere • monitor CBC • keep epi, antihistamines, antiinflam drugs available • oncologic emergencies • patient education

What types of receptors do parietal cells have? what is the significance of blocking these?

• histamine 2 • acetylcholine • gastrin We can't block gastrin, but blocking one or both of the other two will decrease the amount of hydrochoric acid that can be made

Patient education on chemo

• hydration is super important - protect kidneys • minimize/manage constipation • minimize/manage pain • avoid spicy, gas producing foods, caffeine, alcohol • daily weights (monitor for HF) • monitor BP and pulse

S/Sx of lactic acidosis p 508

• hyperventilation • cold/clammy skin • muscle pain • abdominal pain • dizziness • irregular heartbeat

diuretics: nursing assessment

• if someone is on a diuretic, must assess fluid volume status: breath sounds, heart sounds, turgor, cap refill, mucous membranes • VS, weight, I&O • Postural BP - orthostatic hypotension common • BUN, creatinine, ALP/AST/LDH, uric acid, glucose • ABGs • Serum electrolytes (K, Ca, Cl, Na) • Skin assessment - tell us if any changes or rash

Muromonab-CD3 she said we don't need to know this drug, but DID bring up two points about it:

• it's used to prevent skin graft rejection • we can use it to stop/reverse skin graft rejection that is happening already

Assess, implement, education for biologic response modifying drugs

• labs: specific parts of CBC • obtain accurate weights for dosing • administer pre-medications: high incidence of drug interactions (antihistamines, steroids, acetaminophen) • follow dilution directions • advise to avoid hazardous tasks: CNS effect, fatigue • report any s/sx of infection • use of contraception for up to 2 years

S/sx pancreatitis or pancreatic toxicity

• left upper quadrant pain • nausea • vomiting • severe hyperglycemia Monitor serum lipase and amylase

nursing process: teaching immunosuppressants

• teach always have an extra week of meds to avoid running out of meds - we don't want rejection! • explain dosing clearly and thoroughly - take same time every day, complex schedule likely • avoid large crowds, sick people • tell doctor if have sx of illness • women be on contraceptives and remain on contraceptives for 3 months after if they end using immunosuppressants • Avoid UV! protect skin (↑ skin cancer risk) • Avoid grapefruit! • No live vaccines! • No alcohol • limit fats and saturated fats in diet, follow up with nutritional counseling

S/sx of PE "I expect you to know these"

• very acute dyspnea • chest pain • cough • tachypnea • decreased O2 sats • tachycardia • possible BP drop

Laxatives: teaching

• warnings of overuse - can become dependent • safety - some have sedation • minimize constipation w/ fiber, fluids, activity • stool softeners and bulk-forming are preferred to other types due to less F&E loss ----nurse can bring up bulk-forming and stool softeners but other types leave to provider to recommend

stimulant laxatives how do they work? AEs? Interactions? Example drugs?

↑ peristalsis via intestinal nerve stimulation • increases fluid in colon = increased bulk, soften stool AEs: • nutrient malabsorption • skin rashes • gastric irritation • electrolyte imbalances • discolored urine • rectal irritation Interactions: • decrease absorption of: digoxin, Abx, anticoagulants, other drugs Example drugs: • senna (senokot) - may cause abd pain, may be combo w/ stool softener - avoid any other meds within 1 hour • bisacodyl (dulcolax - take on empty stomach) Higher dose = more laxative effect Most likely laxative to be abused & become dependent

Coagulation modifier drugs: assessment

• medications for interactions • risk factors for clot formation: immobility, smoking, obesity, CHF, major surgery, PVD, hx of DVT or PE, MI, a-fib, clotting disorders, oral contraceptives? • risk factors for bleeding: HTN, ulcer, UC, alcoholism, head injury, aneurysm • Evidence of bleeding - gums, nose, stool, urine, bruising, sputum, emesis, secretions, restlessness, LOC, BP/HR, abdominal/chest/back pain, heavy menstruation • VS: BP, HR, strength of peripheral pulses • Lab testing - CBC, H&H, clotting studies, liver function, occult blood • does their job or their activities putting them at risk for trauma? why are they on this drug? autoimmune disease that impacts clotting? (hemophilia?)

What are the goals of treatment for angina?

• minimize frequency, intensity and duration of attacks • improve functional ability of the patient with few AEs • prevent or delay an MI • improve blood flow to ischemic mycardium • decrease myocardial oxygen demand

nursing process: assessment immunosuppressants

• need thorough FULL BODY assessment • pre-existing diseases that affect immune system? (cancer? diabetes?) • any infection or inflammatory symtoms? • renal and hepatic function tests --urinary function/patterns -dark urine, jaundice, ascites, edema, bleeding tendency • baseline ECG (a-fib, palpitation AE) • VS - blood pressure (HTN AE) • weights (edema, ascites) • baseline oral assessment (gingival hyperplasia) • s/sx infection (fever, cough, UTI burning/pain) • Labs: CBC, ESR, CRP, anemia, WBC, platelets ---s/sx bleeding, bruising, petechia, GI bleed (bone marrow suppression!) • get full list of drugs and supplements taking

Nursing process: implementation for pituitary drugs

• never shake growth hormone • make sure everything is clear and free of sediment • follow water intake guidelines with diabetes insipidus • educate family on administration - especially growth hormone - injection techniques and sites

Antidysrythmics: nursing implementation

• notify provider HR less than 60 or over 100 and teach patient how to do at home • notify provider systolic less than 90 and teach patient how to do at home • monitor QT interval since some drugs prolong • minimize Gi upset by giving with food • teach protection from sun (amiodarone) • watch for therapeutic effects • limit or avoid caffeine, alcohol (dizzy/vasodilation) • high fiber diet & fluids d/t constipation • take daily weights - same time every day • never stop abruptly

diuretics considerations for older adults

• older adults are really sensitive to diuretics, so may need to be on lower dose • more likely to experience AEs - watch more closely for dehydration and other AEs

S/sx right sided heart failure

• peripheral edema • JVD • ascites • hepatomegaly

S/sx hyperglycemia?

• polyuria (frequent urination) • polydipsia (very thirsty) • polyphagia (very hungry) • glycosuria (glucose in urine) • weight loss • fatigue (sugar can't get to tissue)

S/sx of heart failure in children

• poor feeding/growth • tachypnea • activity intolerance (can't play as long or hard as other kids)

Why would we want to use an immunosuppressant on someone? When are they contraindicated?

• prevent rejection of transplant • auto-immune diseases • some chronic conditions Contraindicated: • renal failure • hepatic failure • HTN • concurrent radiation therapy • caution in pregnancy • NO live vaccines! **regardless of contraindications, patient may need an immunosuppressant anyway**

When do we use anticoagulants?

• preventing thrombo-embolic events • MI • unstable angina • a-fib • periods of immobilization • mechanical device implants • history of stroke, DVT, pulmonary embolus • major orthopedic surgery

Penicillins ✍️✍️✍️ Names? Spectrum? Static or cidal? Contraindicate? ADE / ADR? Assessments? Interventions?

✍️ Names end in "cillin" Brand names may not, IE "Augmentin" Most treat gram + Some "extended spectrum" 🎭 gram + and - 🔪 Bacteriocidal 👍 Generally safe & well-tolerated, even in pregnancy 🙅‍♀️ Allergies - Asthma and aspirin or cephalosporin allergy increases risk of anaphylaxis 💥Interact with many things some positive, some harmful (separate flashcard) 💥 Do not take with juice, decreases effect! 😱 ADE/ADR Minor: urticaria, pruritus, maculopapular rash 😱 ADE/ADR Major: angioedema 🕵️ Assess - monitor electrolytes and cardiac system (some penicillins are high Na / K) 👷 Implement - Watch for C.diff, probiotics

Carbapenems 🍞🍞🍞 **Know who is at risk for serious AEs** Names? Spectrum? Static or cidal? Contraindicate? ADE / ADR? Assessments? Interventions?

🍞 (she said she wouldn't ask us names) 🎭 Broad spectrum - broadest that we have now 🔪 Bacteriocidal 🙅‍♀️ If pt had anaphylaxis with penicillin, risk of allergy to carbapenems 💥Can cause siezures - increasing seizure risk for older adults and those with renal impairment 🕵️ Assess for history of seizure 👷 Implement - MUST be infused over 60 minutes

Codeine ***understand this***

🔊 Agonist • Codeine turns to morphine in the body • It does have a ceiling effect • Used often in combination with cough medicines because it is anti-tussive • Commonly combined with acetamenophen for mild pain 🙅‍♀️ Contraindicated for pediatrics 🕵️ Assess for any past/present neuro disorders like alzheimers, dementia, stroke 🕵️ Get baseline vitals

Oxycodone

🔊 Agonist • Often combined with other drugs >>>"Percocet" = Oxycodone + Acetamenophen >>>"Percodan" = Oxycodone + Aspirin • Oxycontin is sustained release form - weaker but commonly used >>>remember "contin" like "continuous" 🕵️ Assess for any past/present neuro disorders like alzheimers, dementia, stroke 🕵️ Get baseline vitals

Methadone ***understand this***

🔊 Agonist • Opioid of choice for treating opioid addicts 💥 Possibly can cause cardiac dysrhythmias 🕵️ Assess baseline cardiac function first 🕵️ Get baseline vitals 🕵️ Assess for any past/present neuro disorders like alzheimers, dementia, stroke 🎓 Teach to report any palpitations

Meperidine (Demerol)

🔊 Agonist • Synthetic opioid • Rarely used 🕵️ Assess for any past/present neuro disorders like alzheimers, dementia, stroke 🕵️ Get baseline vitals

Fentanyl & Fentanyl patches ***know patient education***

🔊 Agonist • Used for sedation and pain • Very potent analgesic Patches only used on patients that are opioid tolerant When a patch is used, discontinue ALL other opioids Peak effect of patch in 24 hours, change patch every 72 hours 💥 Never apply heat to a patch for risk of overdose 💥 Apply to a clean, non-hairy site. Rotate sites, remove all residue when removed 🎓 Disposal of patches - fold in half and flush down toilet at home 🎓 Be very careful around children!! 🎓 Never cut the patch, it changes the way the drug is absorbed 🕵️ Assess for any past/present neuro disorders like alzheimers, dementia, stroke 🕵️ Assess for skin irritation where patch has been 🕵️ Get baseline vitals

Hydrocodone

🔊 Agonist • Weaker form of opioid • Often combined with acetamenophen "Vicodin" 🕵️ Assess for any past/present neuro disorders like alzheimers, dementia, stroke 🕵️ Get baseline vitals

Morphine

🔊 Agonist 👍 Gold standard for opioid agonists 👍 Used in severe pain 👍 Safe choice for those with renal problems 💊💉💧🍑Available in many forms 🕵️ Assess for any past/present neuro disorders like alzheimers, dementia, stroke 🕵️ Get baseline vitals

Vancomycin **Know IV considerations**

🔪 Bacteriocidal 👍 Antibiotic of choice for MRSA 👍 Good for sepsis Gram positive - but not gram neg 😱 "Red man syndrome" - flush and itching 😱 Can cause C-diff 😱 Risk of ototoxicity 💥Give infusion over 60 minutes to prevent hypotension and "red man syndrome" 💧 Usually given IV - good for treating infections in the blood - infuse over 60 minutes 💊 Only given orally if treating something in GI tract because poorly absorbed from GI 🕵️ Monitor for ototoxicity (hearing/balance) and get baseline first 🕵️Monitor for nephrotoxicity (BUN, creatinine, proteinuria) and get baseline first 👷 Implement - check trough level before dosing 🎓 Educate on symptoms to report - hearing or balance

Clindamycin

😱 Often causes C-diff 😱 May enhance neuromuscular blocking drugs - risk for paralysis 🙅‍♀️ Do not use in pts with ulcerative colitis or any IBS conditions - risk for necrotizing IBS 💥 Never give IV push - if given too rapidly, causes hypotension and possible cardiac arrest 🎓 "not much teaching to give, usually they are pretty sick if they are getting clindamycin" "misc category"

Adrenergics (decongestants) 🙅‍♀️ Contraindications 😱 AE 🕵️ Assessment

🙅‍♀️ Glaucoma 🙅‍♀️ Hypertension 🙅‍♀️ Diabetes 🙅‍♀️ Hyperthyroidism 🙅‍♀️ History of cardiovascular disease 🙅‍♀️Asthma Due to constriction of blood vessels, all of the above can be exacerbated 😱 Insomnia 😱Nervousness/anxiety 😱Palpitations 😱 Dry nose 😱Mucosal irritation 😱Burning (topical) 🕵️ Assess HR and BP before administering

Tetracyclines 🚲🚲🚲 **Know patient education**

🚲 Names end in "cycline" 🎭 Broad spectrum: gram + and - ⚡ Bacteriostatic 👍 Inhibit bacterial protein synthesis 👍 Use for syphilis, chlamydia, Lyme disease, PIV, H.pylori, acne 🙅‍♀️ Do not use in pregnancy or nursing moms or with children under 8 years due to tooth discoloration 💥Interact with dairy products, antacids, iron, magnesium 💥Interact with warfarin / anticoagulants 😱 Photosensitivity 😱 Tooth discoloration in children 😱 Can increase BUN levels 🎓 If going to take antacids, dairy, magnesium or iron, only 2 hours before or after a tetracycline

Patient teaching with anticholinergic r/t overactive bladder, urge incontinence, overflow incontinence

Advise that they need lifestyle changes in addition to the medication: • Reduce caffeine • Reduce alcohol • Reduce spicy foods Teach kegel exercises

Some factors that influence pain tolerance - worse and better?

Worse • Anxiety • Sleeplessness • Past experiences Better • Rest • Diversion

Beta Blockers Common suffix? Types? What do they do?

"-olol" Beta 1 blockers - block cardio selective receptors • Lower HR > Monitor HR • Slows conduction through AV node • Decreases contractility > lowers O2 demand of cardiac muscle Beta 2 blockers - block resp. selective receptors • Bronchial constriction > possible AE: SOB • Narrowing of airways • Peripheral vasoconstriction • Block glycogenolysis > considerations for diabetes We also have non-selective that block both Labs may show increased triglycerides and lower HDL

Alpha Blockers Common suffix? How do they work? What do they do? What do we use them for? Teaching? Important assessment?

"-osin" (except phentolamine) Block stimulation at Alpha1 receptors • Vasodilation • Reduced blood pressure • Pupil constriction • Reduced organ smooth muscle tone > bladder > prostate Used for HTN, BPH, urinary retention, infiltration of epi and nor-epi, Teaching: • Take first dose before bed for safety Assess: • Orthostatic hypotension

Hydrochlorothiazide Common abbreviation? What is it? Form? Things to know?

"HCTZ" Thiazide diuretic. PO form Has a ceiling effect, so high dose does no better than a lower dose Derivative of sulfonamide antibiotics, but sulfa allergy risk is not as great

Why do we get cardiac side effects from beta-adrenergic agonists?

"Non-selective" beta-adrenergic agonists constrict blood vessels and stimulate beta 1 (cardiac) receptors

Alpha-Glucosidase inhibitors Class? How do they work? When to take? Contraindications? AEs?

(Oral antidiabetic) • Inhibit enzyme alpha-glucosidase in the small intestine, delaying glucose absorption • Effective in controlling postprandial glucose levels • Do NOT cause hypoglycemia or weight gain MUST be taken with the first bite of a meal! Contraindications: • Pts with intestinal issues due to intestine effect -IBS -Intestinal obstruction AEs • GI - diarrhea, abdominal pain • elevated liver enzymes

Anemia drugs: patient education

• Cannot crush iron tablets • Cannot change different forms of iron for each other • Educate diet high in iron: animal proteins, liver, dark leafy greens, spinach, fortified cereals • Avoid overcooking vegetables d/t decreased iron

What are the limits for weight gain that need to be reported to providers?

2 lbs in 24 hr 5 lbs in 1 week

What are the standards for alerting providers about patient weight gain?

2 lbs or more in 24 hours 5 lbs or more in a week Concern about edema

What BMI is the marker for obesity?

30 or higher is obese

How long does it take for the patient to feel if an antidepressant is working for them? How long does the patient usually stay on the medication?

4-6 weeks. Providers often tell patients to give it 2 full months before they return to say it's not working They stay on them until remission (no depression sx anymore) - usually about a year. 14-18 months. Must be tapered. Do not stop taking abruptly

You have to be ______ years or older to get the shingles vaccines.

50

Dosing for daily aspirin?

50 - 325mg Baby aspirin (81 mg) is most common, but depends on patient

What do you use to treat a beta-adrenergic agonist overdose? What do you need to remember about this?

A beta-blocker Puts patient at risk for bronchospasm because the agonist was to relieve it and we are reversing those effects. Watch patient carefully!

What is milk-alkali syndrome? s/sx?

A condition in which the chronic ingestion of milk and/ or calcium carbonate antacids leads to hypercalcemia and metabolic alkalosis. • headache • nausea • metabolic alkalosis

Adrenergic-blocking drugs AKA ____________ AKA ________________ AKA _______

Adrenergic blocking drugs • AKA adrenergic antagonists • AKA sympatholytics • AKA "alpha blockers"/"beta blockers"/"alpha-beta blockers"

Adrenergic drugs are AKA _________________ and AKA _____________________ and AKA _________________.

Adrenergic drugs • AKA sympathetic drugs • AKA adrenergic agonists • AKA sympathomimetic

Cosyntropin Class? What does it do? Used for?

Adrenocorticotropic hormone (ACTH) Stimulates secretion of cortisol. Has antiinflammatory effects and promoter renal retention of sodium Used to diagnose adrenocortical insufficiency - if they do secrete cortisol in response to this, then we know their adrenal cortex is functioning. If we give it and it doesn't secrete cortisol then we know there is a dysfunction AEs: • HTN • edema (d/t retaining sodium) Assess BP and monitor edema

Octreotide What is it? What do we use it for? AEs? Assessment?

Antagonist of growth hormone Used for: • some carcinogenic tumors to decrease symptoms. • esophageal varices AEs: • really bad diarrhea • N/V • dyspnea • arthralgia • conduction abnormalities Monitor for dehydration and metabolic acidosis d/t the diarrhea

Adrenocorticotropic hormone (ACTH) Anterior or posterior pituitary? What do we use it for?

Anterior Promotes synthesis of steroid (adrenocortical) hormones • glucocorticoids • mineralocorticoids • androgens (male hormones) **does not produce them, the adrenal gland does that, but this stimulates it to produce them

Growth Hormone Anterior or posterior pituitary? What does it do? Who do we give it to? AEs?

Anterior pituitary Promotes linear growth in children. Promotes growth of organs, muscle, connective tissue. Stimulates synthesis of proteins, simulates liver glycogenolysis, helps move fat from body stores. Stimulates retention of sodium, potassium, phosphorus Given to children that have a growth delay or some forms of dwarfism. Given to HIV patients with wasting. AEs: • hyperglycemia • hypothyroidism • hypercalciuria

Which hormones does the anterior gland produce? Which does the posterior gland produce?

Anterior: Gonadotropic (FSH, LH) Prolactin Adrenocorticotropic (ACTH) Thyroid-stimulating hormone (TSH) Growth hormone Posterior: Vasopressin (ADH) Oxytocin

What are the two lobes of the pituitary gland? Which lobe secretes more hormones?

Anterior= adenohypophysis Posterior = Neurohypophysis The anterior lobe

Dicyclomine (Bentyl) What class? what does it treat?

Anticholinergic Treats • Antispasmodic • IBS (overactive type)

Scopolamine What class? What does it treat? What form?

Anticholinergic Treats • Motion sickness • N/V post-op Form: usually a patch

Oxybutynin (Ditropan) What class? what does it treat?

Anticholinergic Treats • Overactive bladder • Neurogenic bladder > spina bifida or spinal cord injuries

Rifampin ***know AEs*** Interactions, ADR, Education? ON KAPLAN

Antibioitic used for treating TB 💥Many drug interactions - look them up before giving 💥Oral contraceptives 💥Anticoagulants 😱 Potential hepatitis, liver function concerns 🎓 Can cause urine, tears and sweat to be red/orange/brown colored - harmless but will stain contacts

What are beta-lactams? What classes fall under this group? What is something special to know about it?

Antibiotics that have a structure that includes a "beta-lactam ring". • Penicillans • Cephalosporins • Carbapenams • Monobactams If have an allergy to one, may have an allergy to another. Some organisms produce beta-lactamase that causes these classes not to work, but we have been able to create beta-lactamase inhibitors which are often added to antibiotics and allow them to work again.

Atropine What class? what does it treat?

Anticholinergic Naturally occurring Treats • Bradycardia • Ventricular asystole • Antidiarrheal (lomotil)

Tricyclic Antidepressants (TCA) Used for? AEs? OD consideration

Antidepressant - Not used as often anymore, but we will still see it in use. Mainly used now for neuropathic pain, insomnia, OCD, anorexia and severe cases of enuriesis (bedwetting) AEs: • Anticholinergic effects: drying (constipation, urinary retention, blurred vision, dry mouth etc) • dysrythmias, disturbed cardiac conduction • sexual dysfunction - bad enough patients quit the drug • hypotension • sedation • lowered seizure threshold • altered BG OD - often fatal from seizures or dysrythmias Contraindications: • Pregnancy category D • Do not use with St Johns Wort

MAOIs Class? Used for? Interactions AEs? Notify provider? Example drug

Antidepressant - but not used as much for depression anymore, now used primarily for Parkinson's Interactions: • many! Often a wash-out period is needed • Do not take with tyramine! • Do not take with sympathomimetics or stimulants! • SSRI's - increased risk of serotonin syndrome • TCA's - hyperpyretic crisis (↑ temperature) • avoid OTC cold and flu products AE: • postural hypotension (change position slowly, take BP) Notify provider: (sx of toxicity) • tachycardia • seizures • hyperthermia Example drug: Selegiline

Mirtazapine

Antidepressant but used often to stimulate appetite in nursing home patients

Vasopressin Class? What does it do? What is it used for? Important thing to remember? Contraindications? Monitor?

Antidiuretic hormone Potent vasoconstrictor in large doses Used for: • slow down or stop bleeding • severe hypotension Remember: If it infiltrates, this can lead to necrosis due to that vasoconstriction Contraindications: • caution in renal disease • caution in asthma • caution in seizure disorder • caution in CVD AEs: • increased blood pressure Monitor heart/breath sounds and VS

Prokinetic drugs Used for? How do they work? Example drug? Not for use in? Admin consideration? AE?

Antiemetic Stimulate peristalsis in GI tract, enhance stomach emptying to help with nausea. • also used w/ GERD and delayed emptying Metoclopramide (Reglan) • not for use in seizure disorder • not for use in breast cancer • not for use in GI obstruction • given 30 min before meals and at bedtime • IV form must be protected from light • long term use can cause irreversible tardive dyskinesia

Neurokinin blockers What is it? Used for?

Antiemetic Usually used in conjunction with serotonin blockers and glucocorticoids Used for chemotherapy induced emesis

Phenytoin (Dilantin) - know both names she says Class? AEs? Contraindications? Special considerations?

Antiepileptic AEs: • Gingival hyperplasia (good dental & oral care!) • Abnormal movements • "Dilantin facies" (fluffy/padded face) • Thrombocytopenia (low platelets) • Hepatitis • Measles-like rash Contraindications: • Bradycardic conditions (CNS depression) • Warfarin (increases bleeding risk) Special considerations: • Watch CBC • Watch liver function • If given IV, dilute with saline and use a filter • If patient has low albumin, can become toxic quickly!

Interactions with immunizing drugs?

Anything that suppresses the immune system • chemotherapy • anti-rejection drugs • steroids • tami-flu (wait until a few days after to give flu vaccine) • if they have been given immunoglobulin (it will stop an immune response from mounting because they have the antibody right now already - wait 3 months after) Caution with patients on anticoagulants (bleeding)

Opthalmic erythromycin Class? Used for?

Antimicrobial - macrolide Abx Used on newborn babies to prevent conjunctivitis d/t chlamydia or gonorrhea

Alteplase (t-PA or Activase) Class? Used for? Form? Big risk? Special consideration?

Antiplatelet Fibrin specific, so it will not produce systemic lysis 5 minute half-life so reopens artery rapidly - given with heparin to prevent re-occlusion Parenteral only RISK: intracranial bleed that can be significant and cause severe problems. we still use it even with the risk because it can break down clots so quickly **Most thrombolytics we would question with heparin, but this one particularly does get it with heparin to prevent re-occlusion**

Aspirin Class? How does it work? What do we use it for? Contraindications? Interactions Allergy? Teaching? p414

Antiplatelet Prevents platelets from aggregating and dilates vessels Used in stroke prevention Contraindications: • No for children or teens! Can cause Rey's syndrome in the presence of a virus • Pregnancy, lactation • Vitamin K deficiency • bleeding disorders • PUD Interactions: • ASA + steroids or NSAIDS can cause ulcers Teaching: • take with food or water, remain upright for 30min Allergy to ASA can mean allergy to other NSAIDS

Clopidogrel (Plavix) Class? Contraindication? AEs? Form?

Antiplatelet very commonly used Contraindicated: • BLACK BOX for patients with some genetic abnormalities, can have poor outcomes AE: • bleeding Assess: Baseline cardiovascular assessment Form: PO only

Haloperidol (Haldol)

Antipsychotic (conventional, old drug) Can help with scary hallucinations near death AEs • extrapyrimidal symptoms • neuroleptic malignant syndrome • tardive dyskinesia • hypotension • hyperpyrexia • gynecomastia • weight gain • photosensitivity

What is a common comorbidity with depression?

Anxiety

Buspirone (BuSpar) Class? Benefits? Administration? AEs?

Anxiolytic Benefits: • less sedating • less risk for addiction • less AEs Cannot give PRN, must be given on a regular basis AEs: • risk for seratonin syndrome • paradoxical anxiety • dizziness, headache, nausea

antidiarrheals: interactions

Any major acute GI condition Increase or decrease absorption of other drugs ---adsorbents decrease (think activated charcoal) Therapeutic effects can be decreased when given with antacids (2 hours apart) Young and old patients more prone to dehydration and electrolyte imbalances Contact provider if abdominal distention, severe pain, stiff abdomen, blood in stool Pay attention to potential for eating disorders

Metformin Class? Things to know? Contraindications? AE? IMPORTANT DRUG, KNOW THIS ONE

Biguanides (Oral antidiabetic) • Metformin is the only one First drug that anyone gets before we go to insulin • Does NOT stimulate insulin secretion, so it is not associated with weight gain hypoglycemia when used alone • Monotherapy or in combination • May cause moderate weight loss • May be used in pre-diabetes, can prevent full-blown Contraindication • renal disease - primarily excreted by kidneys • any condition that predisposes patient to tissue hypoxia (d/t lactic acidosis) - alcoholism, liver disease, heart failure • Contrast dye - super hard on kidneys, so we stop metformin if they need to take contrast dye until we see their kidneys have recovered AEs • GI very common! (bloating, nausea, diarrhea) - start low, titrate up, take with food • Lactic acidosis - can be fatal! - hyperventilation, cold/clammy skin, muscle pain, abdominal pain, dizziness, irregular heartbeat

Antiepileptics Black box warning? AEs? Contraindications? Interactions? Important dosing consideration

Black box warning: • Risk for suicidal thoughts and behavior AEs • LOTS OF THEM • Each drug has its own AEs, but most have: - N/V, diarrhea, GI upset - Dizziness - Drowsiness Contraindications • Pregnancy - birth defects - sometimes have to weigh risks of seizures during pregnancy and give it to mom anyway Interactions • MANY! May even interact with each other. • Oral contraceptives • MAOIs • Warfarin • Enhance hepatic metabolism of other drugs Important dosing consideration: Narrow therapeutic range (small window)

Mycophenolate mofetil she said we don't need to know this drug, but DID bring up something important about it:

Black box warning: increased risk for congenital malformations and spontaneous abortions when used during pregnancy memory trick: mofetil sounds like "no fetal"

Beta Blockers Black Box Warning AEs ODs Interactions

Black box: NEVER STOP ABRUPTLY • Acute withdrawal can lead to: > Rebound HTN, usually even higher > Heart attack > Angina AEs • Bradycardia • AV block • Delayed hypoglycemia recovery in Type 1 Diabetes • Bronchospasm • Impotence • Constipation • Fatigue • Dizziness ODs • Bradycardia • Severe hypotension Interactions • Antacids decrease absorption (2 hr window) • Oral diabetic drugs (and/or insulin) + beta blockers can mask symptoms of hypoglycemia

Aluminum salt antacids

Constipating - often combo w/magnesium to offset Often recommended in renal disease d/t more easily excreted Aluminum binds w/ phosphate and may lead to hypercalcemia

If patient has fever while taking antihistamines, antitussives or expectorants what do they need to do? Why?

Contact physician. These drugs treat symptoms of the upper respiratory tract, but a fever could indicate an infection moving into the lower respiratory tract. We don't want to mask symptoms of something more serious.

What type of precautions for MRSA?

Contact precautions, contact isolation

Fixed-combo insulin What are they? Benefits?

Contains two different insulins - intermediate + short - intermediate + rapid • Good option for patients who cannot afford to test BGs multiple times per day • Good option for patients who refuse to inject multiple times per day

Amphetamines Contraindications? AEs?

Contraindication: • Don't take with other CNS stimulants • Cardiac structural abnormalities • Do not use with MAOIs (within 14 days of use) • Anxiety, agitation, hypertension • Tourette's • Glaucoma AEs: • "speeding up" (HR, BP, metabolism) • insomnia (don't take 4-6hr before bed) • angina • headache • worsening psychiatric disorders • GI distress • anorexia • tremors

Contraindications for alpha blockers? AE for alpha blockers?

Contraindication: • Peripheral vascular disease > because they reduce peripheral vascular resistance AE: • First dose phenomenon • Orthostatic hypertension • Edema • Tachycardia • Palpitations • Dizziness

Anorexiants Contraindications AEs Teaching Assessment

Contraindications • MAOI use within last 14 days • Uncontrolled HTN • Glaucoma • Hyperthyroidism • NO if patient has eating disorder • NO if history of drug abuse AEs • Increased BP • palpitations • dysrythmias • dry mouth • anxiety, agitation, headache (stimulant) Teaching • Do not take within 4-6 hours of bedtime • Must be weaned before discontinuation Assessment Weekly weights

Bile Acid Sequestrants Contraindications? AEs? Interactions? OD? Teaching?

Contraindications: • Bowel obstruction • PKU - contain aspartame which is metabolized into phenylalanine which these patients can't have AEs: • GI: constipation, nausea, belching, bloating • Increase triglycerides Interactions: • Reduces absorption of all other medications! Take 1 hour before other meds or 4-6 hours after other meds. • Can reduce absorption of fat soluble vitamins from diet, so may need a supplement OD: • Can get an obstruction in GI tract needing surgical correction if OD Teaching: • GI related AEs tend to disappear over time and if taken with meals, can help with nausea. Increase fiber and fluids to help with constipation. Very important teaching here because the GI effects are bad enough that they really impact patient compliance. • Take 1 hour before other meds or 4-6 hours after other meds. • Powder forms can be choking hazards, dilute very well

Calcium channel blockers Contraindications? Teaching? Implementation?

Contraindications: • Not with acute MI • Not with AV block • Not with hypotension Teaching: Interacts with grapefruit juice. Reduces metabolism = toxicity Implement: • daily weights • monitor for edema • monitor for SOB AEs: • hypotension • palpitations • tachycardia/bradycardia • peripheral edema

Drugs contraindicated with insulin -those that work against insulin -those that increase insulin effects p 495 - box 32.5

Counteracting effects: • thyroid drugs • corticosteroids • diuretics • estrogen These are contraindicated because they increase blood glucose levels, so they are working against the insulin Additive effects: • alcohol • sulfa antibiotics • salicylates (aspirin) • other hypoglycemic/diabetes drugs These are contraindicated because they decrease blood sugar already, so with insulin can result in severe hypoglycemia

What causes pernicious anemia?

Deficiency in Vitamin B12 or folic acid - they are needed to make DNA and proteins, so they are needed to make RBCs Most likely not getting enough in diet, or have malabsorption in the small intestine (maturation defect anemia)

What causes iron-deficiency anemia? Who is most at risk?

Deficiency in iron or globin. Often caused by blood loss: trauma, heavy menstruation, GI bleed, peptic ulcer, hemorrhoids Most common anemia - women at higher risk d/t menstruation, pregnant women at higher risk, children at higher risk (maturation defect anemia)

Black box warning for benzodiazepines?

Do not combine with opioids. Do not combine with alcohol. • Can lead to extreme sleepiness, respiratory depression, coma and death.

What are we evaluating for after giving antihistamines, antitussives or expectorants?

Do we have relief of symptoms?

How does dopamine help with heart failure? Which drug mimics dopamine? How is it administered?

Dobutamine Increases contractility and stroke volume Admin via continuous IV infusion

What are adrenergic drugs?

Drugs that stimulate the sympathetic nervous system (SNS)

What are adjuvant drugs? Why do we use them? What kinds of drugs are these? ***know all of this***

Drugs we use in addition to narcotics - they work with opiods in a synergistic way Why • So we can use a lower dose of the narcotic • The narcotic is not relieving enough pain Types • NSAIDs • Antidepressants • Antiepileptic • Corticosteroids

What is anticholinergic activity?

Drying of secretions - can be uncomfortable IE: dry mouth, dry eyes

Epoetin Alpha (Epogen) Class? How does it work? What do we use it for? Contraindications? AEs? Important to remember?

Erythropoiesis stimulating drug (anemia drug) Promotes synthesis of RBCs - manufactures large numbers of immature RBC and speeds up their maturation. In order for it to work, have to have adequate iron stores and bone marrow has to function properly. Injectable only, Tx for anemia d/t: • End stage renal disease • Chemo induced anemia • Zidovudine therapy Contraindication: • Uncontrolled hypertension - can raise BP • Some cancers d/t increased tumor growth • At risk for thrombosis AEs: HTN, Fever, Headache Important: • DO NOT use if hemoglobin is greater than 10-11 because has potential for very serious AEs. • Abuse potential from athletes!

Antimetabolites - pyrimidine antagonists Drug example? How does it work? Remember about it?

Fluorouracil (5-FU) Works by interrupting DNA and RNA synthesis, hopefully leading to cancer cell death • must be administered alone • protect patient from sun exposure

Assessment considerations for adrenergic drugs

Focused respiratory assessment > Any preexisting resp. conditions? - To avoid exacerbations - Asthma? > Peak flow meter > Measure A:P ratio Focused cardiovascular assessment > Any preexisting cardiac conditions? - To avoid exacerbations - BP issues, stroke? > Baseline EKG due to potential dysrythmias? • Medication history for drug interactions • Baseline vital signs • Postural blood pressure (lying and standing) > to assess for orthostatic hypotension > safety

Prednisone Class? AEs? Indications Contraindications She said "if you know the class, you know this one" and no specifics, adding some of the major stuff from the class in general for review

Glucocorticoid AEs: • hyperglycemia even if not diabetic • osteoporosis if long-term use • growth suppression in children (long-term) • exacerbate muscle weakness/fatigue in elderly • moon face, buffalo hump - long term • psychosis, anger, agitation, irritable, mood swings • adrenal suppression • weight gain • HTN Indications: (there are more but she said these) • dermatological issues (topical) • GI diseases • Autoimmune diseases • Organ transplant patients • Asthma and COPD Contraindications: may intensify diseases • fungal and bacterial infections • cataracts, glaucoma, increased IOP • diabetes melliuts - increases BG • serious infections: sepsis, fungal, varicella • PUD, reflux, gastritis - perforation risk • cardiac/heart failure - fluid retention • renal/liver dysfunction - alterations in elim

Dermatologic form: Gel Characteristics/benefits Examples

Good at enhancing the active ingredient, helps it penetrate into the skin well Lubricating Examples: • K-Y jelly • Saligel • Surgilube

Antifungal adverse effects

Hepatotoxicity Drug interactions

When might you need an antiviral in your eye?

Herpes simplex contamination of eye

What is "cheeking"? Why is it important to pay attention to this with mental health drugs? What is a solution?

Hiding a drug inside their cheek. AKA hoarding Important with mental health drugs because if a patient can gather up a few tablets, they can commit suicide with them If you have a patient where cheeking is an issue, you can check with provider about a liquid form of the drug instead.

When do we typically see AEs with cholinergics?

Higher doses usually - it happens most often when we jump to stimulating nicotininc receptors instead of the muscarinic receptors

What are the s/sx of hypokalemia? hyperkalemia? She said to know these

Hypokalemia: • lethargy • decreased appetite • nausea • muscle weakness • mental confusion • low blood pressure Hyperkalemia: • cardiac rythm abnormalities - possible fatal • N/V • diarrhea

In asthma that is related to immune factors, which of the 5 immune factors is typically involved?

IGE

Anticholinergics Example of one? What are these? How do they work? Short or long acting? 🙅‍♀️ Contraindications 😱 AEs 🕵️ Assessments 🎓 Teaching

Ipratropium (Atrovent) • Long-acting muscarinic antagonist (LAMA) • Blocks acetylcholine receptors = airway relaxation/dilation, reduce secretions • Long-acting, slow, prevent bronchospasm (not for acute treatment of one) 🙅‍♀️Glaucoma patients (due to ocular pressure) 🙅‍♀️Prostate enlargement patients (due to UR) 😱 Increased intraocular pressure 😱 Urinary retention 😱 DRYING - dry mouth, dry eye, constipation 😱 Nasal congestion, cough, headache (due to irritation to mucosa) 😱 Palpitations 😱 GI upset 🕵️ Assess for palpitations before and during 🕵️ Prostate enlargement? Glaucoma? 🎓 Teach to rinse mouth after using to minimize dry mouth and irritation 🎓 Increase fluids due to drying

Interaction of iron with vitamin C? Interaction of iron with antacids or calcium? Interaction of iron with some antibiotics?

Iron + Vitamin C = enhanced iron absorption, good idea Iron + antacids/calcium = decreased iron absorption, avoid Iron + some antibiotics = can decrease antibiotic absorption, time them 2 hours apart

Iron What does it do? Forms and most common form? Contraindications? AEs? What happens with OD? ON KAPLAN

Iron is what carries the oxygen in hemoglobin and myoglobin. Oral, injectable, IV forms. Ferrous sulfate is most common oral form, usually dosed 3x daily. • Oral - sit upright 30 mins after d/t esophageal corrosion • IM - deep and use Z-track method Contraindications: • Use of iron in a type of anemia that's not iron-deficient • Iron overload • Conditions of excessive iron stores in body AEs: • Constipation (common) • N/V, diarrhea, stomach cramps • Black and tarry stools (melena) • Temp discoloration of teeth/eyes (sip through straw if oral form to prevent teeth discoloration) OD = corrosive to GI mucosa. Chelation therapy can help remove iron but it's not a cure. Give on empty stomach if patient can tolerate.

Irritant vs Vesicant

Irritant - irritate IV site, vein, tissues if it were to leak Vesicant - will cause cell death, necrosis, ulcerations where it leaks We use a port for chemo because a lot of chemo drugs are vesicants

Dopamine Replacements Example drug? Why do we use them for Parkinson's? What do we need to give along with levodopa? AEs (p 234 table 15.3) Patient teaching?

Levodopa Precursor for brain to synthesize dopamine. Direct replacement for dopamine. Metabolized readily, so we need to use carbidopa to enhance the effect and allow us to use lower doses of levodopa. "Carbidopa is the car that drops off levodopa in the brain" Also reduces side effects of high-dose levodopa. AEs • palpitations • hypotension • urinary retention (monitor output/frequency) • constipation • depression • dyskinesia Teaching • Best on empty stomach if can tolerate GI effect • Take several hours before bed to avoid insomnia • Vitamin B6 may reduce effectiveness • Do not take with or near a high protein meal or absorption could be reduced. • Increase intake of fluids and fiber d/t urinary retention and constipation

Glaucoma and levodopa?

Levodopa and carbidopa are contraindicated with angle-closure glaucoma. Can be used cautiously with open-angle glaucoma.

Why do we assess skin before administering levodopa and we do not give it if there is an unknown skin condition or rash?

Levodopa can activate malignant melanoma! Assess/investigate skin rashes!

Dermatologic form: Lotions Characteristics/benefits Examples

Lighter than creams Works well for a large area of the body Works well on hairy areas Examples: • Calamine lotion • Lubriderm lotion • Kwell lotion

Contraindications for TB drugs

Major renal and liver disfunction >> We are still going to treat someone who has a severe infection and monitor their liver/kidneys throughout

What is melena and what is something to consider about it with iron supplementation?

Melena = black, tarry stools Iron supplementation AE is black tarry stools. GI bleed symptom is black tarry stools. Iron supplementation can mask symptoms of GI bleed.

What is a spinal headache? Treatments? p 179

More common with epidural anesthesia over intrathecal anesthesia d/t larger needles Result of penetration through the dura mater of the spinal cord, cerebrospinal fluid leaks from the insertion site. Said to be worse than any other type of headache, may occur up to 5 days after the procedure. Treatment: • supine • bedrest 24-48 hours • hydrate via IV • consume caffeine • if previous don't work, create blood patch by injecting small amount of patient's blood into the epidural space and letting it clot to seal the hole

Calcium channel blockers Common suffix? How do they work? Used for?

Most (not all) end in -pine Blocking calcium prevents muscle contraction, meaning these promote smooth muscle relaxation = decreased oxygen demand in the heart and also = dilation = increased blood flow to heart Used for angina, HTN, dysrythmias, tachycardia, Afib, migraines, PVD. Not as effective for exercise tachycardia angina.

Which H2 blocker has the most interactions? Which have the least?

Most - cimetidine Least - ranitidine and famotidine

Drug interactions with adrenergics

Most are simply with drugs that compete with receptor sites and diminish therapeutic effects • With anesthetics can increase risk for dysrythmias • With antihistamines and thyroid meds can increase effects

Fibric Acid Derivatives (fibrates) Common name? How do they work? Contraindications? AEs? Interactions?

No common prefix or suffix, but tend to have "FIB" in the middle of the drug name (IE gemfibrozil) Primarily affect triglycerides, not first line drug Activates an enzyme that breaks down cholesterol. Suppressess release of free fatty acids, inhibits liver synthesis of triglycerides. Contraindications: • Severe liver or kidney disease • Cirrhosis • Gallbladder disease AE: • Decreases platelet adhesiveness and cause clots to break down • Increased risk of gallstones • Prolonged PT time • Increase liver enzymes • May decrease WBC, H&H Interactions: • Anticoagulants (increase effect) • Statins (increase risk myopathy)

General interactions for immunosuppressants?

Remember increased risk for interactions because patients are on these for a lifetime • narrow therapeutic window • grapefruit!! can inhibit metabolism, increasing level of drug in blood = toxic! • St John's Wort can cause organ rejection by reducing therapeutic levels • Cat's claw and echinacea work against by boosing immune system

General AEs for most immunosuppressants?

Remember lots of black box warnings (on their own card) • risk for opportunistic infections -----often fungal (UTI, yeast infection, thrush) -----opportunistic cancer • HTN • fluid retention • pulmonary edema • hepatotoxicity • nephrotoxicity • neurotoxicity including tremors • leukopenia, thrombocytopenia more on p 758 - table 48.2, these are the ones she explicitly mentioned

GI chemo AEs

Stomatitis: • inflammation of oral mucous membranes • painful!!! • good oral hygeine before/after eating • avoid mouthwash w/alcohol, lemon, peroxide, glycerin • avoid spicy, rough, hot/cold foods • avoid tobacco • OTC saliva substitutes and sugarless candy to help • soft bristle toothbrush or foam swabs - avoid flossing (waterpik is a good idea) • lidocaine (numbing swish before eating) • nystatin solutions (help with oral thrush) N/V: • nurse remove all odors and noxious sights out of room • oral hygeine, especially after vomiting • small, frequent meals and bland diet • antiemetics, pre-tx before chemo, ginger • report blood in stool or vomit • ulcerogenic Diarrhea: • avoid spicy food, hot/cold food, alcohol, caffeine • increase fiber intake • admin opioids to reduce diarrhea Nutrition: • manage pain • provide oral care • admin antiemetics • small, frequent meals, soft foods, easy to swallow food • high protein, high calorie diet • appetite stimulants (THC)

Patient education related to antihistamines?

Stop taking antihistamines a few days before an allergy test so you don't block the response.

Insulin storage considerations Insulin administration considerations p 507 - box 32.2

Storage: • Good 1 month at room temperature • Good 3 months refrigeration • Prefilled syringes refrigerate up to 1 week • Never freeze insulin • Avoid sunlight exposure Admin: • HIGH ALERT - always check with another nurse • Make sure clear/cloudy/color is appropriate • Insulin is given SubQ or SubQ infusion pump -ONLY regular insulin can be given IV in an emergency • Room temperature for current use • Never give cold insulin • Give freshly mixed insulin within 5 minutes • Never shake insulin, stir by rolling between hands • Pinch skin, inject at 90 degree angle - if emaciated, may have to do 45 degrees • Rotate 1-2 inches in same section of body for up to 1 week, then move to another section of body • Can use thigh, abdomen, outer upper arm • Stay 2+ in away from umbilicus, incision or a stoma

When you see "mimetic" what does that mean?

The drug is mimicking the action identified. IE: Sympathomimetic - mimics the action of the sympathetic nervous system's neurotransmitters: norepinephrine, epinephrine and dopamine

What is the purpose of using a corticosteroid in a blend of otic antibiotics?

The corticosteroid helps to relieve the inflammation and pruritis associated with ear infections

What are the differences between different antihistamine drugs?

The different drugs are very similar, but they vary in: • AEs • Potency • Degree of drowsiness

What is VAERS?

Vaccine Adverse Event Reporting System If there is an adverse reaction to a vaccine, we must report. this is the only way we can gather info about vaccines (IE thimerasol in the past)

Angiotensin Receptor Neprilysin Inhibitors (ARNi) Example drug? How do they work?

Valsartan/sacubtril (Entresto) is the only one (it is a combination with an ARB which is why generic name has -sartan) Works by inhibiting an enzyme that degrades BNP, so we have increased levels of BNP which in turn causes diuresis and vasodilation AEs: • hypotension • hyperkalemia • increased serum creatinine • angioedema • renal function deterioration Contraindications: • pregnancy category D (black box) • hx of angioedema with past ACE or ARBs • ACE inhibitors within 36 hours Memory trick: Valsartan/Sabubtril you "sartanly" (certainly) don't want to take this with a -pril Memory trick: ARNi Schwarzenegger would have to BNPee out all his water before he would enter (Entresto) a bodybuilding show and everyone else would sartanly ("certainly" - valsartan) succumb (sacubtril) to him winning

Where is VRE most commonly seen?

With UTIs - catheters & dialysis

Consideration for oral contraceptives with antibiotics?

With all or almost all antibiotics, they interact. Patient education!!

Consideration for warfarin with antibiotics?

With all or almost all antibiotics, they interact. Patient education!!

Magnesium sulfate What do we use for? ON KAPLAN

Women who are pregnant with preeclampsia can have seizures - we treat with mag sulfate Decreases amount of acetyl choline release

Muscle Relaxants How do they work? Uses? AEs? Special considerations?

Work on the CNS, not the skeletal muscle directly (most of them) and the effect is due to the sedation Uses: • Treat muscle spasms - injury - chronic disease IE multiple sclerosis, cerebral palsy AEs: • Can develop tolerance Special considerations: • Best if combined with physical therapy • Don't continue with activity they should be avoiding just because feel better d/t med • Abuse potential is there, but is lower, not scheduled

Opthalmic anesthetics Onset and DOA? Used for? Administration? AEs? Teaching?

Work within 30 seconds but only last 20-30 minutes Used for short procedures, surgeries, exams Patients do not self-administer AEs: • Loss of blink reflex with overuse. May need an eye patch to protect eye from drying Teaching: do not rub, itch or touch eye at all because cannot feel it and could hurt the eye

Which substances stimulate the secretion of hydrochloric acid?

all food, but especially: • caffeine • chocolate • alcohol • large fatty meals also emotional stress **good to know for teaching patients with GERD to avoid

Biologic response modifying drugs What do they do? What do they do when used against cancer?

alter the body's response to certain diseases (cancer, auto-immune, inflammatory) as well as some infectious diseases like viruses and responses to chemotherapy ---can weaken or strengthen immune system ---can stimulate hematopoiesis (RBC, WBC, platelets) ---can be used to prevent disease When used against cancer cells: • enhances immune system against tumor cells • directly toxic to tumor cells • adversely effect the tumor's biology • inhibition of metastases

Which antacids can cause constipation?

aluminum and calcium containing

What's a drug example that can cause hypothyroidism?

amiodarone (the "yucky" antidysrythmic) hypothyroidism is an AE

What does -esterase indicate something is?

an enzyme

Which types of insulin CANNOT be mixed? p 494 Table 32.4

• Regular insulin U-500 • Insulin detemir • Insulin glargine • Premixed insulins - 70/30 NPH and regular insulin - 50/50 NPH and regular insulin - 75/25 NovoLog - 75/25 Humalog

what is the funciton of prostaglandins?

anti-inflammatory and prevent action of proton pump

Immune globulins AKA?

antibodies

belladonna alkaloids (donnatal)

anticholinergic antimotility drug combination drug - multiple anticholinergics Contraindicated: • narrow angle glaucoma • GI obstruction • myasthenia gravis • paralytic ileus • toxic megacolon • Pregnancy - Cat X Only available by Rx

Promethazine (Phenergan) what is it? AE? Do not use with what? Special admin consideration?

antidopaminergic antiemetic AE = sedation Do not use under 2 years old! Admin: • Usually IM or orally. • Tissue necrosiss if accidentally admin to artery - can lead to amputation! Use a larger vein and dilute it!

Prochlorperazine (Compazine) what is it? do not use with what conditions?

antidopaminergic antiemetic Not for use in: • coma • seizures • bone marrow suppression • encephalopathy

What is the biggest, most common antiplatelet drug?

aspirin

What is the difference between bacteriostatic and bacteriocidal?

bacteriostatic stops growth bacteriocidal kills organism

What drugs have additive effects with general anesthesia?

beta-blockers and anti-hypertensives

what is intrinsic factor?

protein in stomach that is needed for absorption of B12

What are NSAIDS? ***understand this*** What are the used for? ADR? Black box warning? Contraindications? Assessment? Teaching?

non-steroidal anti-inflammatory drugs - aspirin, tolmetin, celecoxib, meloxicam, ibuprofen • analgesic, anti-inflammatory and antipyretic 💥 Stop taking 1 week before surgery to prevent bleeding 😱 Ulcerogenic, GI bleeding, antiplatelet effects 😱Acute renal failure, risk for heart failure 😱Hepatotoxicity, hearing loss 🗃️ Black box warning: Increased chance of heart attack or stroke 🙅‍♀️ Contraindications - anyone at risk for bleeding 🙅‍♀️ Do not use in pregnancy 🙅‍♀️ Do not use in breastfeeding 🙅‍♀️ Do not give to someone on anticoagulants 🕵️ Assess bleeding risk 🕵️ Assess for infection before initiation so as not to mask symptoms 🎓 Educate take with milk, food or antacids to help offset GI upset 🎓Teach don't take with other ulcerogenics - alcohol, other NSAIDs

What is epistaxis?

nose bleed

Where are the adrenal glands located?

on top of each kidney

Where are insulin and glucagon produced?

pancreas

What is NADIR?

point in time where white blood cells are at the lowest point they will go during chemotherapy Usually 10-28 days after treatment, different depending on which drug

Dermatological therapeutic drugs: Education

• Apply dressings as directed - thorough instructions and teachback • Ensure full understanding about how to prepare skin and apply drug • Educate about how to prevent sun exposure • Vitamin D supplement if avoiding sun exposure, using sunscreens • If putting a cream on a viral outbreak (IE herpes lesion on the lip), use a gloved hand because you could spread that infection • Wash fingers immediately after application of antineoplastics to prevent systemic. Applicator or gloves good idea. • Do not use sunscreen on infants under 6 months old. Hats, protective clothing, shade only! • Barrier creams like zinc are better than the common sunscreens. There's a clear form out now that might have better compliance • Heat reduces effect of hair growth drugs, so do not use hair dryers. Also can take up to 4 months to see effect, but doesn't work for everyone.

Cholinergics - assessment & teaching

• Assess for pre-existing conditions > IE Heart block • Assess VS - BP & HR > potential for orthostatic hypotension • Baseline neuro status > memory, alertness, cognition (to evaluate Donepezil if working or not) • Baseline urinary pattern • Baseline GI function • Baseline cardiovascular function Teaching • Change positions slowly • Report dizziness

Anemia drugs: assessment

• Assess for s/sx of anemia: fatigue, easily tired, dizziness, lightheadedness with position changes, brittle and/or misshapen nails, changes in color of skin, cracks in corners of mouth • Adequate iron stores? Adequate bone marrow function? • VS - BP and HR may rise • Assess cause of anemia before treating • Labs: RBC, H&H, reticulocyte count, bilirubin level, B-vitamin and folate levels • Nutrition: 24hr diet recall for iron, protein • Take iron with juice or water but NOT with milk

Immunizing drugs: nursing assessment

• Assess reactions to drugs in the past - serious? • On any immune suppressing drugs? ---corticosteroids, chemo • Autoimmune or immunosuppressive diseases - in a high risk population? • pregnancy or lactation status • general health status - any active infections today? any reason not to get a vaccine today? (severe illness?) • VS for baseline • encourage high risk to get vaccines: ---healthcare workers, elderly

Nursing Process: Assessment -benzodiazepines, non-benzodiazepines and barbituates

• Assess sleep patterns - what time do you go to bed? - how long do you sleep? - how long takes to fall asleep? - pain? - do you wake during the night? - Smoke? Alcohol? - Emotional stressors? - Herbals or OTCs? • Baseline neuro status, cognitive abilities - so we can identify changes • Level of sedation • VS - rythm, HR, RR, BP • Use of alcohol, substance abuse • Renal/hepatic labs/function

Beta Blockers - assessment considerations

• BP and HR due to vasodilation, decrease in conduction/contractility/HR • Supine & standing BP due to orthostatic hypotension • Respiratory status & breath sounds due to bronchoconstriction • Cardiac conditions, hypo/hypertension, dysrythmias • Daily weights to assess for edema • Blood glucose

What do we assess for with antivirals?

• Baseline VS and nutrition • Weight loss • Visible lesions • Pregnancy • Renal function • Liver function • CBC & clotting studies • Pain • Onset of symptoms? • Vitamin D and calcium levels • S/sx opportunistic infections

Opthalmic assessments

• Baseline redness, swelling, pain, drainage (color and consistency), tearing • Visual acuity - Snellen chart - changes in vision important! • Allergies - to meds and seasonal • Exposure to chemicals that could be irritants, occupational and environmental • Systemic disease process - IE glaucoma

Antiemetics: anticholinergics How do they work? Used for? Example drug?

• Bind to and blocks ACh receptors in inner ear & brain --block transmission of nauseating stimuli Used for: • pre op - dry GI secretions, ↓ smooth muscle spasms • motion sickness (scopolamine in patch form) Scopolamine • corrects imbalance btw ACh and Norepi • typically given in 72 hour patch for motion sickness • NO for glaucoma

Cholinergic AEs

• Bradycardia • Tachycardia (nicotinic response) • Hypotension • Hypertension (nicotinic response) • Conduction abnormalities • Increased GI secretions • Increased bronchial secretions • Bronchospasm • Sweating • Salivation • Lacrimation

What are the two components of COPD that we treat with medication?

• Bronchoconstriction • Inflammatory component

What are beta-adrenergic agonists? What do we use them for? When do we use them? What are the different types?

• Bronchodilators • Relax smooth muscle and relieve bronchoconstriction • Prevent or relieve bronchial asthma and sometimes COPD if we have an issue with bronchospasm. They are quick and a short-acting form can be used. "Non-selective" will stimulate alpha and beta adrenergic receptors. (IE: Epinephrine) "Beta 1" - Cardiac receptors "Beta 2" - Respiratory receptors

Xanthine Derivatives What type of drugs are these? Name two How do they work? What do you treat OD with? 😱 AE 💥Interactions 👍 Good things to know 🕵️ Assessments 🎓 Education

• Bronchodilators • Theophylline, aminophylline • Inhibit IGE release that drives allergic portion, we use to treat asthma and COPD 😱 Stimulate the CNS (less than caffeine) 😱 Stimulate cardiac system 😱 N/V 😱Anorexia 😱Tachycardia 😱Ventricular dysrythmias 😱 Diuresis 😱Hyperglycemia 💥 Interacts with caffeine, smoking 💥 Interacts with char-broiled foods 👍 OD treated with activated charcoal 👍 Can be used to enhance respiratory drive in patients (not necessarily only asthma and COPD pts) by stimulating the CNS 🕵️ HR and rythm, BP, CVD 🕵️ Urinary patterns because stimulating cardiac increases kidney filtration rate, we don't want to have overdiuresis 🕵️ Serum drug levels required because very small window of therapeutic benefit - easily toxic 🎓 Teach patient to take pulse

Non-opioid antitussives Types 🙅‍♀️ Contraindications 😱 AE

• Can be used alone or in a combination • Less effective than opioid based, but no CNS effects or analgesia Dextromethorphan - most popular -Popular drug of abuse -Not for chronic productive coughs -Some products contain alcohol 🙅‍♀️ NO asthma or emphysema 🙅‍♀️ NO pregnancy Benxonatate (Tessalon Perles) -Works by numbing stretch receptors of resp tract 🙅‍♀️ NO pregnancy 🙅‍♀️ NO if someone has a productive cough because we want to mobilize secretions if they are present

Influenza vaccine Forms? How created? Who is recommended to get it? Who really should get it? Teaching? Who should NOT get it?

• IM - inactive (Adults get 1 shot, children/infants get 2) • Nasal spray - live vaccine Created: • Choose anticipated strains • Usually contains 3 different strains in the shot • H1N1 strain is included • Grown in eggs (allergies) Recommended for anyone over 6 months old Who really should get flu shot? • healthcare workers • elderly • children • immunocompromised • encouraged for pregnant women Teaching: • Increases chances of not getting flu to 70% - still teach to wash hands, avoid ill people, etc since it's not 100% • Might still catch flu depending on age, health, strain selection that year Who should NOT get the live/nasal form? • Teens or preteens with chronic health conditions (asthma, diabetes, heart disease) • People who are immune compromised • Severe allergy to eggs unless allergist approve

Teaching for statins

• If on a statin, no grapefruit juice • Report muscle pain or change in color of urine ASAP • Take with meals or water d/t GI upset • Give time to see changes, can take

Who is at higher risk for TB?

• Immunocompromised >> Cancer/Chemo patients >> HIV/AIDS positive patients >> Those taking immune suppressing drugs such as long term steroids • Homeless • Undernourished • Drug abusers • Those who live in crowded or poorly sanitized housing • Certain races or ethnic minorities

Anticholinergics AEs

• Increased HR • Dysrythmias • Bronchodilation • Decreased secretions • Decreased GI motility • Urinary retention • CNS effects > excitation, drowsy, irritability, confusion • Pupil dilation > intraocular pressure > blurred vision (safety) "Can't see, can't pee, can't spit, can't shit"

General anesthesia considerations for older adults p 168 - top left box

• Increased risks of toxicity and effects last longer: - decline in liver function can affect metabolism of anesthesia - decline in renal function can affect excretion of anesthesia • Cardiac or respiratory chronic diseases put them at increased risk during and after anesthesia • Older adults are more sensitive to CNS effects • Older adults are more likely to have polypharmacy, so increased risk of AEs and drug-drug interactions

Virus entry routes:

• Inhalation • Ingestion • Transplacentally • Inoculation

Opthalmic implementation

• Inspect solutions for clarity, expiration • Mix contents thoroughly - roll/swirl • Avoid touching eye with container tip • Apply inner canthus pressure for 1 minute • Apply to conjunctival sac, tilt head back and look at ceiling • Be aware of ordered timing and give ON TIME (remember IOP!) • May need to patch the eye in cases of injury or decreased blink reflex • Wait standard 5 minutes between different drugs

Remember AEs for corticosteroids (specific ones she brought up seperately again at end of lecture)

• Irritation of mouth • Cough • Thrush

What are the four drugs that we use to treat TB? Why do we use all four in a regimen?

• Isoniazid • Rifampin • Pyrazinamide • Ethambutol or Streptomycin We use a four-drug regimen because it's a difficult infection to clear, but also because it reduces the possibility of drug resistance.

Nursing process: Implementation for anesthetics p177-80

• Keep resuscitative equipment and antidotes available -naloxone for opioids -flumazenil for benzodiazepines -anticholinesterase for NMBDs (anticholinesterase doesn't work for succinylcholine) • Monitor breath sounds, may admin O2 • Monitor neuro parameters for return of function • Monitor distal pulses, color and temp for anything distal to local or spinal anesthesia • Admin pain meds with caution • Keep HOB elevated after spinal anesthesia (except if treating spinal headache)

What are the drugs that are combination alpha 1 and beta blockers? How do they work?

• Labetalol • Carvedilol (notice they are -lol but NOT -olol) Work by reducing heart rate and causing vasodilation

What is respiratory depression and what considerations for it?

• Less than 10 breaths per minute • Monitor respirator status • Make sure rescue intubation equipment is nearby

If patient has bad problems with tachycardia (or is high risk) on albuterol, what can they be switched to? Why? Why don't we just use this one for everyone?

• Levalbuterol (xopenex) • Because it has less tachycardic effects • It is expensive

What do we assess for with pain and analgesics?

• Level on pain scale • Characteristics (sharp, stabbing, etc) • Type of pain • Intensity • History of alcohol, illegal drugs • Monitor renal function • Monitor neuro status, LOC • Assess respiratory status • Urinary status/output • Cardiac status • Vital signs • Pupils • Bowel sounds • Assess administration sites • Pain relief after giving • Fall risk due to dizzy/lightheaded (bed alarms & side rails) • Subjective and objective data!

Rapid acting insulin Example drugs? Onset of action? Duration of action?

• Lispro (Humalog) • Aspart (Novalog) • Glulisine (Apidra) • Afrezza (inhaled and has BB warning for bronchospasms) • Onset within 15 minutes • Duration 3-5 hours • Use within 15 minutes of a meal - specifically for treating high glucose once a patient eats. - if given, patient MUST eat

Complications long-term antiviral use (couldn't find in lecture or book so this is speculation)

• Liver disease/hepatitis • Bone demineralization / osteoporosis

Non-sedating antihistamines Drugs included? Benefits? Major AE specific to this type?

• Loratadine (Claritin) • Cetirizine hydrochloride (Zyrtec) • Fexofenadine (Allegra) • Non-sedating / less grogginess • Longer duration of action (better compliance) • Associated with dysrythmias in sensitive individuals

Atorvastatin Used for? Pregnancy? Dosing consideration? ON KAPLAN

• Lowers LDL, triglycerides • Raises HDL • Pregnancy category X! • Dosed 1x daily in the evening with a meal, or at bedtime. The reason why at this time is because body naturally makes more cholesterol at night.

What do we use pituitary drugs for? How do they work? Important to remember?

• Replace for hormone deficiency • Diagnostic aids to determine hormone function MOA: Varies. Either augments or antagonizes the natural hormone effects Even small amounts can initiate major physiologic changes - be very careful with dosing!

nursing implications: antidiarrheals

• NO bismuth sulfate for kids/teens • use adsorbents carefully in older patients, those with decreased bleeding time, clotting disorders, recent bowel surgery, confusion • do not admin anticholinergics to patients with hx of narrow-angle glaucoma, GI obstruction, myasthenia gravis, paralytic ileus, toxic megacolon • teach pt to take meds exactly as prescribed, be aware of their fluid intake • teach to be aware of diarrhea triggers • teach pt to notify provider if no relief of sx after a couple days • warn of overuse, constipation • no driving, heavy machinery until they know how the drug affects them Pediatrics: • Call DR if: sluggish, lethargic, confused, bloody stools, no better or worse 24-48hrs after tx, abdominal distention, rigidity • have parents count stools, diapers • assess for eating disorders

OTC nasal steroids What are some types? How do they work? 🎓 Teaching 🙅‍♀️ Contraindications

• Nasacort • Flonase • Rhinocort Can relieve congestion by decreasing swelling of nasal tissue. 🎓 If using bronchodilator, use FIRST 🎓 If using decongestant, use FIRST ^^^because bronchodilator or decongestant will open up the airways so the steroids can get to where it needs to be 🙅‍♀️ NO steroids if have an infection because steroids counteract the immune system and we don't want to make infection worse

Glucocorticoid interactions

• Non-K sparing diuretics: hypocalcemia & hypokalemia • ASA/NSAIDS: increased risk for GI ulcers, perforation • Antidiabetic drugs - reduce effects, increase hyperBG • Increase effect of warfarin • Thyroid hormones sometimes benefit outweighs the risk

Anemia drugs: implementation

• Oral iron - sip through straw, give with plenty of fluids, preferably not with meals • 2 hour window before/after milk or antacids • Remain upright for 30 mins after oral iron to minimize esophageal irritation/corrosion • IM iron must be given deep IM with Z-track method

Anti-angina drugs: assessment

• Orthostatic BP • Hold dose and report systolic BP of less than 90 before admin • Hold dose and report apical pulse of less than 60 or over 100 • Assess rythym - provider may want ECG • Assess chest pain - provider may want ECG • Older adults can have heightened hypotension effect - fall risk! • Assess for tolerance - increased angina or "it doesn't seem to work as well as before" it could be that patient getting tolerant to nitrates

S/sx of inflammation

• Pain • Fever • Swelling • Redness • Dilation of vessels

Remember AEs for xanthines (specific ones she brought up seperately again at end of lecture)

• Palpitations • Cardiac stimulation

What do we want to see before treating patient for TB?

• Patient s/sx of TB? • Have they gotten a diagnosis? • What was the result of their PPD test? • Baseline liver and renal studies

Otic drugs: implementation

• Pay attention to age of patient and know anatomy differences in order for proper administration • make sure ear has been cleaned and cerumen has been removed if necessary or ordered before instilling meds • make sure at room temperature before instilling to prevent dizziness • admin to adults: pinna up and back • admin to child under 3 years: pinna down and back • gently massage tragus area to help ensure complete coverage (flap of cartilage that protrudes near ear canal area)

Concerns with spinal local anesthesia?

• Possible that it could move up the spine and affect the respiratory muscles and diaphragm • Risk for sudden drops in blood pressure, hypotension • Urinary retention - patient can't feel and can't relax sphincter, catheter is commonly needed Monitor patient!

Hypothyroidism Types? Example drugs?

• Primary: most common, abnormality in thyroid gland itself, such as coupling iodine with tyrosine, releasing thyroid hormones from storage, etc • Secondary: issue with pituitary gland - ↓ thyroid stimulating hormone • Tertiary: hypothalamus issue - ↓ thyrotropin releasing hormone -- Congenital hypothyroidism: very detrimental, every newborn is screened. severe mental retardation Cretinism: hypothyroid in children. Low BMR, delayed growth and sexual development, mental retardation Myxedema: hypothyroid in adults. Decreased BMR, loss of physical and mental stamina, weight gain, hair loss, firm edema, yellow dull skin that can resemble jaundice -- Example drugs: • Levothyroxine (T4 and most common) • Liothyronine (T3) • Liotrix (combo T3, T4)

Nursing process: Patient education for anesthetics p180 purple box

• Provider needs to know all of your drugs because some may need to be stopped/held/tapered • May not be able to ambulate well after anesthesia, have assistance to prevent falls • May have decreased sensory so keep bed rails up, possible bed alarm, keep call light close • Pain meds around the clock to keep pain under control

Phenylephrine (Neo-synephrine) What do we use it for?

• Raise blood ressure in shock • Superventricular tachycardia • Nasal decongestant • Control some dysrythmias

What are the s/sx of an allergic response to an antibiotic? What is the key to knowing this is an allergy is what?

• Rashes are common - usually with itching and hives • Fever • Chills • Joint pain • Difficulty breathing/wheezing >>>The key is itching. If there's a rash but it's not itchy, it likely isn't an allergic reaction.

Anti-angina drugs: implementation

• Record VS (BP, HR) description of chest pain • Nitrates: admin while seated to avoid falls from hypotension, remain seated 30 minutes • Assess for headache, dizzy, lightheaded. Acetaminophen can be used for headache • Nitrates: avoid drug contact with light, plastic, cotton filler, moisture. • PVC tubing for IVs can break down nitrates into cyanide! • Nitrates will cause a slight burn/sting if they are potent. • Topical - do not rub in, apply in areas above knees and elbows (more central areas), hairless area, cover with occlusive dressing, rotate sites, remove residual med, measure with given measuring tape for dosing Teaching: • Flush patches at home • Avoid alcohol and heat with vasodilators • How to self-eval BP, HR • Recognize their triggers to take nitrate before

Teaching: lifestyle changes to reduce cholesterol?

• Reduce cholesterol in the diet - lower saturated fats, replace animal protein with plant protein • Exercise, weight control • Increase omega-3s in diet (fish, avocado) because it helps to raise HDLs • Stop smoking, stop drinking alcohol • Increase fiber in diet

Amiodarone Used for? How does it work? AEs? Important to remember? "you will see more than one question about this" ON KAPLAN

• Used to manage life threatening v-tach and v-fib • Used to treat difficult dysrythmias that aren't responding to other treatment • Drug of choice in SVT (HR 200+) --Prolong or inhibit relaxation --Block both alpha and beta recepters AEs: • contains iodine - think allergies and hypo/hyperthyroid • microdeposits in cornea - visual disturbances like halos, dry eye, light sensitivity and light intolerance/photophobia (most patients get this after 6mo use) • BLACK BOX - pulmonary toxicity - cough and dyspnea that damages alveoli and causes fibrosis • BLACK BOX - provokes dysrythmias • BLACK BOX - hepatotoxicity • constipation, N/V, dizziness Interaction: • Digoxin-can get dig toxicity (need to ↓ dig dose 50%) • Warfarin-increase INR (need to ↓ warfarin dose 50%) • Grapefruit juice Remember: • Concentrates in fat cells, so has a very long half-life • Monitor for blue/gray/jaundice in skin d/t hepatotox

What is included in focused respiratory assessment?

• VS - HR, BP, O2 Sat • Rate • Rythm • Depth • Breath sounds • Cough? > Is cough dry or productive? > Describe cough. (barking, high-pitched, etc) > Sputum present? (include color, consistency) • S/sx respiratory disress • Skin color and nail bed changes • Allergies > environment, food, drug? • Dysrythmias? (due to drugs used to treat respiratory) • Caffeine use? (due to drugs used to treat respiratory) • Smoking? Former or current? • ABGs • Restlessness? (sign of hypoxia)

What are alpha receptors in control of?

• Vasoconstriction • Stimulating the CNS

What assessments are we constantly making in those on TB drugs?

• Vision changes • Hearing changes • Liver function • Renal function • Symptoms of gout • Peripheral neuropathy

Opthalmic patient teaching

• Warn patient drugs may cause blurred vision • If eyes will be dilated, bring sunglasses • Do not touch or rub numb eye • Eye patch if decreased blink reflex • Know which drugs will and won't let patient wear contacts • Don't put meds into eye while contacts are in

Nursing process: evaluation r/t diabetic drugs

• Watch A1C since it tells us the most about long-term compliance (3 month history) • Monitor glucose level closely if switched from one insulin to another kind • Stop metformin before patient takes imaging dye • When pt is NPO, get orders regarding antidiabetic meds (may still give if have dextrose IV)

What non-pharm interventions can help with type 2 diabetes? Do they help with type 1?

• Weight loss and regular exercise can increase response to insulin. • Diet higher in protein and lower in carbs can help regulate blood sugar. • Stop drinking, stop smoking. Some people with type 2 can manage their diabetes with these interventions only and not have to go on medication. These won't help with type 1 because no matter what we do, it's not going to make the pancreas start producing insulin.

Varicella-zoster immuneglobulin

• When we need to prevent chickenpox in a person who has a high risk for a bad outcome if they have had recent exposure ---newborn babies ---immune compromised adults • Have to give within 96 hours of exposure, provides protection for 3 weeks

What does someone with GI obstruction look like?

• abdominal distention • areas of hypoactive or no bowel sounds • can't pass gas • no bowel movements • abdominal pain

Contraindications with immunizing drugs?

• allergy to the vaccine (severe reaction in the past - may prevent them from getting the vaccine) • allergy to a component (IE eggs, yeast - not a hard stop, but we take into consideration and monitor them, maybe prophylaxis antihistamines) • severe fever or immunocompromised may hold vaccine and wait for later (minor illness is okay)

What is cytokine release syndrome? What drug class is this a worry for?

• allergy-like reaction, can be severe up to anaphylaxis • if we know there is risk for this, we will premedicate with antihistamines and/or steroids as prophylaxis S/sx: • fever • dyspnea • tachycarida • sweating • chills • headache • N/V/D • muscle pain • joint pain • general malaise Immunosuppressants = risk for cytokine release syndrome

Antiemetics: assessment

• assess N/V history, including triggers • assess current medications or alternative therapy • precipitating factors/triggers • I&O, VS, weight loss, turgor, mucous membranes, cap refill, longitudinal furrows (cracks in tongue, severe dehydration) • baseline electrolytes, CBC - ↑ H&H could be d/t low volume • CNS depression, extrapyramidal symptoms • metabolic alkalosis (confusion, restless, tremor, muscle twitching, spasms)

acid-controlling drugs: assessment

• assess for GI tract disorders --s/sx PUD (LUQ pain) and GERD (reflux when supine, hoarseness or chronic cough, sore throat) --bowel patterns, consistency, changes, frequency • assess for cardiac conditions (sodium bicarb) • F&E imbalances, edema • Renal disease • GI obstruction (no magnesium!) • HF and HTN • pregnancy?

nursing implications: PPIs

• assess for allergies and hx liver disease • assess for swallow ability - some capsules are large • assess for osteoporosis or risk for it • capsule contents may be opened and mixed w/ apple juice but don't crush or chew if sustain release granules

What foods are high in potassium?

• bananas • oranges • apricots • dates • raisins • broccoli • green beans • potatoes • tomatoes • meats • fish • wheat bread • legumes

Otic drugs: nursing assessment

• baseline hearing • symptoms, past and present • medical history • use of Rx drugs, OTC drugs, herbals • allergies

Corticoids - Nursing process assessment

• baseline nutritional, hydration and immune status • baseline weight, I&O, VS (especially BP) • skin condition and turgor (fragile, thin?) • monitor K, Na, BG • muscle strength, body stature • weight and height in pediatric patients (stunt growth) • monitor for flu-like symptoms, sore throat, fever • monitor for wound healing

S/Sx of Nitrate OD

• blurred vision • dry mouth • severe headache

Aminoglycosides🍭🍭🍭 **Know AEs** Names? Spectrum? Static or cidal? Contraindicate? ADE / ADR? Assessments? Interventions?

🍭 End in "cin" - IE gentamicin 💧Given parenterally due to poor oral absorption 🎭 Broad spectrum, gram neg 🔪 Bacteriocidal 👍 Once daily dosing due to post-antibiotic effect - lowers toxicity risk 👍 Common used as prophylactic for GI surgeries 🙅‍♀️ Not for pregnancy or breastfeeding! Category D & C 💥 Interacts with warfarin 💥 Dangerous for kidneys if using with another nephrotoxic drug 😱 ADE/ADR : Ototoxicity (hearing/balance issues, tinnitis - possible temp or perm hearing loss) 😱 ADE/ADR : Nephrotoxicity 🕵️ Assess - Serum levels need to be monitored because concentration level is needed to remain bacteriocidal 🕵️ Monitor renal function (BUN, creatinine, proteinuria) apx every 72 hours as dose will be adjusted based on function 🕵️ Monitor hearing/balance functions 👷 Implement - check trough level before dosing

Cephalosporins 🐙🐙🐙 Names? Spectrum? Static or cidal? Contraindicate? ADE / ADR? Assessments? Interventions?

🐙 Names start with "cef" or "ceph" 🎭 Broad spectrum: gram + and - Higher generation = more gram neg coverage, 2nd gen+ if anaerobic 🔪 Bacteriocidal 👍 Generally safe & well-tolerated, even pregnancy (B) 👍 Common for surgical prophylaxis 🙅‍♀️ Allergies -if allergic to penicillins, higher liklihood allergic to cephalosporin 💥Interact with alcohol, antacids, iron 😱 ADE/ADR Minor: mild diarrhead, abd cramps, rash, pruritus, redness, edema 😱 ADE/ADR Major: angioedema 🕵️ Assess - monitor electrolytes and cardiac system (some penicillins are high Na / K) 👷 Implement - Watch for C.diff, probiotics

Metronidazole (Flagyl) **Know patient education**

👍 Often used for gynecological infections and trichomoniasis 🙅‍♀️ Do not use in 1st trimester of pregnancy 💥 Acute alcohol intolerance!! BIG TAKEAWAY Avoid alcohol 24hr before starting and 36hr after course otherwise "sick as a dog" "Matron doesn't drink alcohol" 💥 Don't take with warfarin 🕵️ Assess alcohol intake - if they drink often, might have compliance issues 👷 Implementation - if causes GI upsest, give with food 🎓 Educate on no alcohol very important! This includes cough syrup and other alcohol containing things. "misc category"

Terbinafine Indications and ADR ***know what you use this for***

👍 Treats tinea infections (terbina = tinea) 😱 ADR alopecia (hair loss)

Cephtriaxone (Rocephin)

👍 Urgent cares & clinics usually have in stock 👍 Used for infections 💉 IM 🙅‍♀️ Don't use with calcium infusions 🐙 Class: Cephalosporin

Nitrofurantoin (Macrodantin, Macrobid)

👍 Used for UTIs 👍 Can be used in pregnancy 🙅‍♀️ Do not take if have poor renal function because it concentrates in urine 😱 ECG changes 😱 Hepatotoxicity (can be fatal) 🕵️ Assess baseline liver and renal studies (BUN, creatinine, proteinuria, itching, jaundice) 🕵️ Monitor EKG changes 🕵️ Assess for numbness and tingling 👷 Implementation - Give with plenty of fluids 👷 Give with food or meals to avoid GI upset 🎓 Avoid antacids "misc category"

Nystatin Indications, ADR, teaching? ***know what you use this for and patient edcation***

👍 Used for oral thrush and diaper candida 😱 ADR GI, local irritation 🙅‍♀️ Don't use lozenge in kids under 5, choking hazard 🎓 Teach do not chew or swallow lozenge whole, must let dissolve completely 🎓If liquid form, swish around well and then swallow

Cephalexin (Keflex)

👍 Used for skin infections, cellulitis 1st generation cephalosporin 💊 PO 👷 Dosed 4x a day so difficult adherence 🐙 Class: Cephalosporin

Acyclovir (Zorivax) ***know patient education, administration***

👍 Used to treat herpes 💊 PO Topical ointments 💉 Injection form 💧 IV infuse over 60 minutes - Do not refrigerate IV 😱 Nausea, diarrhea, headache 👷Start treatment at the very first hint of an outbreak - within 24-48 hours 👷Can give as a prophylactic if someone is getting frequent outbreaks 👷💧 Hydrate IV acyclovir patients to prevent crystalluria

Valacyclovir

👍 Used to treat herpes 💊 PO only Less frequent dosing

Fluconazole (Diflucan) Indications, Form, ADR, Assessment? ***know patient education***

👍 Used to treat vaginal yeast infections 💊 Usually given orally in a single dose, stays in the body for a long time and almost fully absorbed 😱 GI adverse effects 🕵️ Assess for vaginal yeast infection: itching, burning, redness, sometimes thick white discharge 🎓 Abstain from sexual intercourse while treating, able to be treated during menstration

Diphenhydramine (Benadryl)

👍Good for allergies 👍Good for insomnia due to sedation 💊 PO form 💧 IV form ⛱️ Topical ointments 🙅‍♀️ NO older adults due to risk of falls - on BEERS list 🙅‍♀️ Avoid taking with other CNS depressants 😱 Drowsiness 😱 Some have paradoxical reaction (hyperactive) 😱 Anticholinergic (IE dry mouth) 😱 Anorexia 👍 Used for Parkinson's disease sometimes due to anticholinergic beneficial for it 👍 Often combined with epinephrine for anaphylaxis

Loratidine (Claritin) Good for? Contraindications? AEs? Teaching?

👍Good for seasonal allergic rhinitis and hay fever 👍Usually okay for breastfeeding 🙅‍♀️ Do not use in children under 2 🙅‍♀️ Avoid taking with other CNS depressants 😱 May cause photosensitivity 🎓 Teach methods to minimize dry mouth

Doxycycline

👍Treats Rocky Mountain Spotted fever 👍Treats anthrax, malaria, chlamydia, acne 😱 ADE/ADR - very hard on stomach, GI issues, abdominal pain 🕵️ Assess - allergic reaction - rash, itching, hives, edema, anaphylaxis. 🕵️ Ask pts about supplement use: calcium, iron, antacids, magnesium 🎓 Educate about likely GI/abdominal pain to help encourage adherence 🎓 If going to take antacids or iron only 2 hours before or after a tetracycline 🎓 Do not take with dairy products at all 🎓 Avoid sun exposure Class: Tetracyclines 🚲

Gentamicin

👍Used to treat systemic infections 👍Used for sepsis 💧 Parenteral Topical (including eye drops) 🕵️ Required to draw drug levels every 72 hours to monitor for ototoxicity, nephrotoxicity, neurotoxicity 👷 Implementation - make sure hydrated to help kidneys

Quinolones 👑👑👑 **Know AEs** **Know how we monitor for them** Names? Spectrum? Static or cidal? Contraindicate? ADE / ADR? Assessments? Interventions?

👑 End in "floxacin" Ciprofloxacin "Cipro", Levofloxacin "Levaquin" 🎭 Broad spectrum 🔪 Bacteriocidal 💊 Most have good oral absorption 💧 Infuse over 1-1.5 hours 👍 Good for complicated UTIs because it's excreted unchanged 🙅‍♀️ Not for children due to effect on cartilage development 💥 Interacts with warfarin / anticoagulants 💥 Do not take within 2 hours of dairy, antacids, iron, calcium, magnesium 💥 😱 Tendinitis & tendon rupture - can happen up to a year after course completed 😱 Prolonged QT interval, seizures, peripheral neuropathy 😱 Hard on kidneys, increase in liver enzymes, photosensitivity 🕵️ Assess - Baseline EKG, ask about seizure history, monitor for peripheral neuropathy 👷 Implement - 🎓 Educate to report palpitations 🎓 If going to take antacids, dairy, calcium, magnesium or iron, only 1 hours before or after a quinolone 🎓 Report ANY pain or sensitivity in tendons Resistance is becoming common

Amoxicillin

💊 Only in PO form Common for ear infections and sinus infections Common as prophylactic prior to dental procedures Common for H-pylori GI infections

Beta-adrenergic agonists Drug forms (administration) Drug types (methods of action, not ind. names) 😱 AEs 🙅‍♀️ Contraindications 💥 Interactions

💊 Oral 💨 Inhaled 💉 Injectable • "Non-selective" will stimulate alpha and both beta adrenergic receptors. (IE: Epinephrine) • "Beta 1" - Cardiac receptors • "Beta 2" - Respiratory receptors 🙅‍♀️ Uncontrolled HTN 🙅‍♀️ Cardiac dysrythmias 🙅‍♀️ Patients at high risk for stroke 😱 Vascular HA 😱 Cardiac stimulation 😱 Palpitations 😱 Tachycardia 😱 Increased BP 😱 Insomnia 😱 Tremors 💥Interacts w/ beta-blockers, they counteract each other Constriction within blood vessels will reduce swelling and edema, limits amount of secretions but can increase blood pressure.

Clarithromycin (Biaxin)

💊 PO 🙅‍♀️ Do not use under 6 months of age 😱 Increased risk of heart problems & death for pts with heart disease Class: Macrolides 💪

Ribavirin ***know patient education and administration***

💊 PO for hepatitis C 💨 Inhaled for newborn RSV 🙅‍♀️ Do not use for pregnancy due to teratogenic 🙅‍♀️ Nurses administering cannot be pregnant!

Celecoxib (Celebrex) ***know contraindications***

💊 PO only 👍 Little effect on platelet function, so good antiinflammatory option for someone at higher risk for bleeding 🙅‍♀️ Contraindicated for sulfa allergies

Tramadol

💊 PO only 🙅‍♀️ Not for anyone over age 75 😱 Some risk of seizures 🕵️ Assess for history of seizures 🎓 Teach that any tasks requiring mental focus/alertness might need to avoid 🎓 Increase fluid and fiber in the diet Acetaminophen + Tramadol = Ultracet

Monobactams 💋💋💋 Names? Spectrum? Static or cidal? Contraindicate? ADE / ADR? Assessments? Interventions?

💋 Aztreonam "Azactam" - only one there is 👍 Often used in pts with penicillin allergy 👷 Implement - Only injectable 💉 (she said this is all we needed to know and she is not going to ask specifics)

Sulfonamides 💣💣💣 ***know AEs*** Names? Spectrum? Static or cidal? Contraindicate? ADE / ADR? Assessments? Interventions?

💣 Sulfamethoxazole-trimethoprim (SMZ-TMP), "Bactrim", "Spectra" 🎭 Broad spectrum: gram + and - ⚡ Bacteriostatic 👍Great for UTI because concentrates in urinary system 🙅‍♀️ Sulfite allergies (preservatives) 🙅‍♀️ Infants under 2 months 🙅‍♀️ Term pregnant women 💥Interact with sulfonylureas, warfarin, oral contraceptives 😱 ADE/ADR Minor: fever, rash, photosensitivity, usually delayed 😱 ADE/ADR Major: Stevens-Johnson syndrome, crystalluria, anemia/dyscrasias 🕵️ Assess skin, assess kidney function (urinalysis, BUN, creatinine) 👷 Implement - increase oral fluids if tolerated

Ampicillin ON KAPLAN

💧 Given IV 😞 Used for gram negative

Macrolides 💪💪💪 ***know who should not get these*** Names? Spectrum? Static or cidal? Contraindicate? ADE / ADR? Assessments? Interventions?

💪 Names end in "thromycin" or "thromicin" Broad within gram + ⚡ Bacteriostatic 🔪 Can be bacteriocidal in high enough doses IF bacteria is susceptible 👍 gonorrhea, chlamydia, syphilis, URIs, C-diff, Lyme disease, opportunistic infections w/HIV 👍 may help with decreased GI motility 🙅‍♀️ If on another QT prolongating drug, increases risk further 💥 Interacts with warfarin, digoxin 💥 Competes in liver for metabolyzing enzymes 💥 Do not give with or near any fruit juice 😱 ADE/ADR Major: QT prolongation, palpitations, chest pain 🕵️ Assess - baseline cardiac function & baseline hearing 🎓 If experience palpitations or hearing changes, let nurse/provider know

Naloxone (Narcan) ***understand this***

🔇 Antagonist 👍 We use to reverse opioid effects, especially in overdose or respiratory depression 😱 Primary ADE is opioid withdrawal • Available without a prescription 🕵️ Has a short half-life, lasts about an hour - assess need to dose multiple times if patient is on an opioid with a long half-life

Naltrexone

🔇 Antagonist 👍 We use to treat addicted patients 🙅‍♀️ Not used for severe liver disease or dysfunction 🕵️ Has a short half-life, lasts about an hour - assess need to dose multiple times if patient is on an opioid with a long half-life

Opiod agonist-antagonist

🔉 Agonist-antagonist • Lower risk for misuse and addiction • Able to produce withdrawal symptoms in opioid dependent patients 👍 Used often in obstetrics ("Stadol") to provide pain relief for mom without overstimulating fetus 👍 Lower incidence of respiratory depression • Short term pain control, not strong enough for chronic pain • Do have a ceiling 🙅‍♀️ Do not use for patients 18 years or less 🙅‍♀️ Not to be given concurrently with full opioid agonsits 🕵️ Assess vital signs 🕵️ Monitor for withdrawal symptoms in those with opioid dependence or who has been given an opioid agonist

Hydromorphone (Dilaudid)

🔊 Agonist • 7x more potent than morphine "high"dromorphone like "high"ly potent 🕵️ Assess for any past/present neuro disorders like alzheimers, dementia, stroke 🕵️ Get baseline vitals