Pharm Unit 4

propylthiouracil (PTU)

-*hyperthyroidism* -*radioactive iodine treatment* -*Thioamide derivative* -*action*: interferes with synthesis of T3 and T4 in thyroid gland -100-150 mg/day -take with meals -*may take up to 6-12 weeks* -decreases WBCs, bone marrow suppression, agranulocytosis, leukopenia, thrombocytopenia

screening for DM: Pre-DM signs

-HbA1C = *5.7-6.4%* -fasting glucose *higher or equal to 100 mg/dL* but *less than 126 mg/dL* -impaired glucose tolerance test (oral glucose challenge) recommended every 3 years for 45+

diabetes insipidus is a rare condition that results in a deficiency in which hormone?

ADH

A patient receiving propylthiouracil (PTU) asks the nurse, "How does this medication relieve symptoms?" What is the nurse's best response?

PTU inhibits the formation of new thyroid hormone, thus returning your metabolism to normal.

appropriate patient teaching for type 2 DM?

a person with type 2 DM still has working beta cells in their pancreas

thyroid gland secretes T4 and T3, which control what body function and affect every cell in the body?

basal metabolic rate

rapid-acting insulin

*Bolus-Lispro/Aspart: Humalog/Novolog)*: -SubQ, continuous SubQ infusion -adjusted according to blood glucose level (sliding-scale) -5-15 minutes -must eat after injection (within 15 mins) -able to mimic the body's natural rapid insulin output closely after eating a meal

short-acting insulin

*Humalin R "regular"*: -SubQ, IV bolus, IV infusion, IM -adjusted according to blood glucose level (sliding-scale) -30-60 mins -only insulin that can be administered IV

intermediate-acting insulin

*NPH (Insulin Isophane Suspension)*: -SubQ -cloudy,combine often with regular insulin (Humalin R) -1-2 hours

Sliding-Scale Insulin dosing

*SQ rapid-acting (lispro/aspart) or short-acting (Humalin R)* -adjusted according to blood glucose test results -typically used in hospital situations/total parenteral nutrition/enteral tube feedings -*delays insulin admin until hyperglycemia occurs> large swings in glucose control*

hypoglycemia

*blood glucose = less than 70 mg/dL or above 50mg/dL* -reversed if pt eats glucose tablets or gel, corn syrup, honey, fruit juice, non-diet soft drink -*early symptoms*: CNS manifestations of confusion, irritability, tremors, sweating -*late*: hypothermia, seizures -*if unconscious*: admin IV glucose 50% dextrose -coritcosteroids antagonize hypoglycemic effects of insulin, resulting in elevated blood glucose levels

Insulin combos "fixed combos"

*each contain 2 different insulins:* -one intermediate-acting (NPH) -either one rapid-acting (Humalog/Novolog) OR one short-acting (Humalin R)

hyperglycemia

*fasting blood glucose = 126 mg/dL or higher* OR *non-fasting glucose = 200 mg/dL or higher* OR *HgA1C greater or equal to 6.5%*

long-acting insulin

*glargine (Lantos, Detemir)*: -"basal insulin" -clear, colorless, constant level -once or twice/day, every 12 hrs -1-2 hours -basal-bolus therapy delivers constant doses of insulin, mimics healthy pancreas, and then as needed as a bolus

addison's disease

*low plasma cortisol*, accompanied by high ACTH levels, indicating that the adrenal gland is not responding to ACTH stimulation

tertiary hypothyroidism

*reduced* level of the *TRH from hypothalamus*, which reduces TSH and thyroid hormone levels

fludrocortisone (Florinef)

-*Addison's disease*, *partial replacement therapy for adrenocortical insufficiency* -*mineralcorticoid* -modifies enzyme activity -take PO with food or milk -*contraindication*: NSAIDs, aspirin, ulcerogenics -*abrupt withdrawal*: adrenal crisis -*adverse effects*: fluid retention> HF and HTN -report weight gain more than 5 lbs+ in 1 week -*addison's*: hyposecretion of adrenocortical hormones, decreased blood sodium and glucose, increased potassiums, dehydration, weight loss

prednisone

-*Many Uses*: most commonly used oral glucocorticoid for anti-inflammatory/immunosuppressants -COPD/asthma exacerbations *inadequate for Addison's* -*intermediate-acting oral glucocorticoid* -inhibits or helps control inflammatory and immune responses -also used as weaning dose off IV Solucortef to prevent adrenal insufficiency -*long-term*: Cushing's syndrome, weight gain, delayed wound healing, alters K levels (hypoglycemia), high incidence of peptic ulcer disease -*multiple drug interactions*: non-K sparing diuretics, NSAIDs, aspirin, ulcerogenics -rinse after use of corticosteroid inhalers to prevent oral fungal infections

methyl prednisone (Solu-Medrol)

-*cerebral edema, COPD, asthma, organ transplants*, chronic respiratory illness, anti-inflammatory/immunosuppressant) -*immediate-acting IV glucocorticoid* (systemic) -modifies enzyme activity -*interactions*: NSAIDs, aspirin, ulcerogenics -*adverse*: hypokalemia (K depletion), hyperglycemia, hypernatremia -*contraindication*: peptic ulcer disease, cataracts, glaucoma, mental health problems, DM, vericella, septicemia, can not give children under 28 days, do not abruptly withdraw

congenital hypothyroidism (youth)

-*cretinism*: low metabolic rate, retarded growth and sexual development, possible mental retardation -hyposecretion of thyroid hormone during youth

levothyroxine (Synthroid, Levoxyl)

-*hypothyroidism* -*synthetic thyroid hormone T4* -*action*: weight loss, improved tolerance to environmental temperature, increased activity, increased pulse rate -*increases CO, increases renal blood flow, increase glomerular rate, increased diuresis* -*contra*: MI, adrenal insufficiency, hyperthyroidism -*1/2 life: *long enough for once daily dosing -* dosed in mcg* -1-3 weeks for full effects -take in morning to avoid insomnia on empty stomach -don't switch brands -life-long therapy -*interactions*: phenytoin, cholestyramine, antacids, calcium salts, iron products, estrogens, warfarin

buguanides metformin (Glucophage)

-1st line, most commonly used oral drug -decreases glucose production by liver, decreases intestinal absorption, improves insulin receptor sensitivity in liver, skeletal muscle and adipose tissue, increased glucose uptake by tissues -*results in decreased insulin resistance* -does not cause hypoglycemia -take with meals to reduce GI effects -*adverse*: GI symptoms, metallic taste, vitamin B12 reduction, lactic acidosis (rare) - *contraindication*: discontinue if undergoing contrast dye studies (renal effects)

this organ secretes 3 classes of steroid hormones including glucocorticoids, mineralcorticoids, and gonadocorticoids? corticosteroid release is stimulated by this hormone secreted by the pituitary?

-adrenal cortex -ACTH

somatotropin (Humatrope, Nutropin, Serostim)

-anterior pituitary (adenohypophysis) -GH -*hypopituitary dwarfism* -dosage may be adjusted

Type 1 diabetes

-autoimmune destruction of pancreatic beta cells, resulting in lack of insulin secretion -lack of insulin production or the production of defective insulin -fewer than 10% DM cases (one of most common diseases of childhood), 25% develop during adulthood -*complications*: -DKA (25-30% newly diagnosed present) -HHNS (Hyperosmolar non-ketotic syndrome)

hypothyroidism symptoms

-cold intolerance -unintentional weight gain or weight loss (anorexia) -depression -dry/brittle hair/nails, hair loww -fatigue -lethargy

myxedema (adulthood)

-decreased metabolic rate, loss of mental and physical stamina, weight gain, loss of hair, firm edema, yellow/dull skin -hyposecretion of thyroid hormone during adulthood

during long-term corticosteroid therapy, which lab results need to be monitored for adverse effects?

-decreased serum potassium levels -increased sodium levels -hyperglycemia

goiter

-enlarged thyroid gland -results from overstimulation by elevated TSH -TSH elevated because there is little or no thyroid hormone in circulation -certain med lead to hypothyroidism

what lab should be monitored when taking a corticosteroid?

-glucose -K+ can be decreased when taking corticosteroid

DI causes what 2 symtpoms?

-large amount of dilute in urine -increased thirst

Type 2 DM Treatment recommendations

-lifestyle interventions -careful blood glucose monitoring -therapy with one+ drugs -treatment of associated comorbid conditions (high cholesterol/high BP) *if lifestyle modifications + max tolerated metformin dose do not achieve recommended HbA1C goals after 3-6 months, additional treatment should be given with 2nd oral agent*: -*GLP-1 agonist* (liraglutide, exenatide, abligutide) OR *insulin*

Type 2 DM

-most common (90%) -*target cells become unresponsive to insulin due to a defect in insulin receptor function* -insulin deficiency and resistance -receptors are less responsive -appears in middle-aged adults "age-onset diabetes", "insulin-resistance"

vasopressin (Pitressin) desmopressin (DDAVP)

-posterior pituitary (neurohypophysis) -*potent vasoconstrictor* -has identical structure to ADH, acts on renal collecting tubules to increase their permeability to water, enhancing water reabsorption -can cause symptoms of water intoxication *(monitor daily weight)* -*Diabetes insipidus* -*hypotensive emergencies (septic shock), polydipsia, decreases urinary output* -*contraindication*: kidney disease (fluid overload) and interacts with *lithium*

Basal-Bolus Insulin dosing

-preferred method of treatment for hospitalized DM -*mimics healthy pancreas by delivering basal insulin constantly as a basal and then as needed as a bolus* -*Basal-insulin*: long-acting (Glargine) -constant -*Bolus-insulin*: rapid-acting (lispro/aspart)

sulfonylureas glipizide (Glucotrol)

-second generation -stimulates insulin secretion from beta cells of pancreas, improves sensitivity in tissues -*results in lowered blood glucose* -used alone or in combo -take in morning, 30 min before breakfast -contraindicated: pt with sulfonamide antibiotics -*adverse*: hypoglycemia, weight gain, nausea, rash, fullness, heartburn

hyperthyroidism

-tachycardia, weight loss, elevated body temp, anxiety, heat intolerance, increased appetite, diarrhea, flushing, sleep disorders, altered menstruation, irritability -most common type: -*Grave's disease* is most common -Thyroid storm: induced by stress/infection (severe and life-threatening) -plummers disease (rare): toxic nodular disease

CHAPTER 32: DIABETES

1. Insulins 2. Oral diabetic meds

CHAPTER 33: ADRENAL

1. fludrocortisone (Florinef) 2. methylprednisone (Solu-Medrol) 3. prednisone

CHAPTER 31: THYROID

1. levothyroxine (Synthroid, Levoxyl) 2. propylthiouracil (PTU)

Insulins: (Type 1 diabetes)

1. rapid-acting 2. short-acting 3. intermediate-acting 4. long-acting -mixing: clear insulin (regular) drawn up first -insulin therapy for pregnant women (switched from oral drugs)

CHAPTER 30: PITUITARY

1. somatropin (Humatrope, Nutropin, Serostim) 2. vasopressin (Pitressin)/Desmopressin (DDAVP)

Oral insulin drugs: Type 2 diabtetes

1. sulfonylureas glipizide (Glucotrol) 2. biguanides metformin (Glucophage)

3 hormones essential for proper regulation of metabolism (carb, lipid, protein)

1. thyroxine (T4) 2. triiodithyroxine (T3) 3. calcitonin

The nurse is reviewing the adverse effects of antithyroid medications for a patient prescribed propylthiouracil (PTU). What potential serious adverse effects should the nurse discuss with the patient during discharge teaching? (Select all that apply.) A Joint pain Correct B Liver toxicity Correct C Kidney damage Incorrect D Increased urination E Bone marrow toxicity

A. Joint pain B. liver toxicity E. bone marrow toxicity

After administering somatropin (Genotropin) to a patient, the nurse would assess for potential adverse effects of this medication by monitoring which laboratory test result? A Glucose B Platelets C Potassium D Magnesium

A. glucose Hyperglycemia and hypoglycemia are potential adverse effects of somatropin therapy.

Which long-acting insulin mimics natural, basal insulin with no peak action and a duration of 24 hours? A Insulin glargine (Lantus) B Insulin glulisine (Apidra) C Regular insulin (Humulin) D NPH insulin

A. insulin glargine (Lantus)

Which actions describe the beneficial effects produced by sulfonylurea oral hypoglycemics? (Select all that apply.) A Stimulate insulin secretion from beta cells B Increase hepatic glucose production C Enhance action of insulin in various tissues D Inhibit breakdown of insulin by liver

A. stimulate insulin secretion from beta cells C. enhance action of insulin in various tissues D. inhibit breakdown of insulin by liver The sulfonylureas stimulate insulin secretion from the beta cells of the pancreas; enhance the actions of insulin in muscle, liver, and adipose tissue; and prevent the liver from breaking insulin down as fast as it ordinarily would (reduced hepatic clearance). Increased hepatic glucose production would serve to increase serum glucose levels, the opposite effect of oral hypoglycemic drugs.

hormone secreted from posterior pituitary gland when hypothalamus senses plasma volume has decreased or osmolarity of the blood has become too high, it acts on the collecting ducts in the kidneys to increase water resorption

ADH

The nurse would question a prescription for somatropin (Genotropin) in a patient with which condition? A Dwarfism B Acromegaly C Growth failure D Hypopituitarism

B. acromegaly Somatropin is a synthetic form of human growth hormone. Acromegaly is caused by excessive growth hormone, and thus this drug would be contraindicated.

When caring for a pregnant patient with gestational diabetes, the nurse should question a prescription for which drug? A Insulin glargine (Lantus) B Glipizide (Glucotrol) C Insulin glulisine (Apidra) D NPH insulin

B. glipizide (Glucotrol)

For a patient taking levothyroxine (Synthroid) and warfarin (Coumadin) concurrently, the nurse would closely monitor for which possible serious adverse effect? A Acute confusion B Increased bruising C Cardiac dysrhythmias D Orthostatic hypotension

B. increased bruising Levothyroxine can compete with protein-binding sites of warfarin, allowing more warfarin to be unbound or free, thus increasing effects of warfarin and risk of bleeding. Bleeding commonly presents as bruising.

The nurse would suspect a patient is taking too much levothyroxine (Synthroid) when the patient exhibits which adverse effect? A Lethargy B Irritability C Feeling cold D Weight gain

B. irritability Irritability is a symptom of hyperthyroidism and may indicate toxicity of the medication. The other choices are signs of hypothyroidism.

When discussing glucocorticoids to a patient, what statement by the nurse is accurate regarding the action of these medications? A They decrease serum sodium and glucose levels. B They regulate carbohydrate, fat, and protein metabolism. C They stimulate defense mechanisms to produce immunity. D They are produced in lower amounts during times of stress.

B. regulate carb, fat, and protein metabolism Glucocorticoids play a major role in carbohydrate, lipid, and protein metabolism within the body. They are produced in increasing amounts during stress, increase sodium and glucose levels, and suppress the immune system.

Assuming the patient eats breakfast at 8:30 AM, lunch at noon, and dinner at 6:00 PM, he or she is at highest risk of hypoglycemia after an 8:00 AM dose of NPH insulin at what time? A 10:00 AM B 2:00 PM C 5:00 PM D 8:00 PM

C. 5:00 PM Breakfast eaten at 8:30 AM would cover the onset of NPH insulin, and lunch will cover the 2 PM time frame. However, if the patient does not eat a mid-afternoon snack, the NPH insulin may be peaking just before dinner without sufficient glucose on hand to prevent hypoglycemia.

The nurse would question a prescription for steroids in a patient with which condition? A Asthma B Spinal cord injury C Diabetes mellitus D Rheumatoid arthritis

C. DM A common adverse effect of steroid therapy is hyperglycemia; therefore, diabetes mellitus is a contraindication to steroid therapy.

When assessing for potential serious adverse effects to propylthiouracil (PTU), the nurse will monitor which laboratory test? A Kidney function B Serum electrolytes C Complete blood count (CBC) D. Brain natriuretic peptide

C. complete blood count (CBC) With antithyroid medications, the nurse should monitor for possible serious adverse reactions such as agranulocytosis, leukopenia, and thrombocytopenia. An abnormal CBC result would indicate bone marrow dysfunction.

The nurse is caring for a patient with diabetes insipidus (DI) who is receiving vasopressin (Pitressin). What therapeutic effect does the nurse expect from this drug? A Increase in thirst B Improved skin turgor C Decrease in urine output D Normal serum albumin level

C. decreased urinary output Vasopressin increases the water reabsorption in the kidneys, thus decreasing urine output. It is used to treat DI, which presents with polydipsia, polyuria, and dehydration.

Which is a priority nursing diagnosis for a patient receiving desmopressin (DDAVP)? A Risk for injury B Acute pain C Excess fluid volume D Deficient knowledge regarding medication

C. excessive fluid volume Desmopressin is a form of antidiuretic hormone, which increases sodium and water retention, leading to an alteration in fluid volume. Although the other nursing diagnoses may be appropriate, they are not a priority using Maslow's hierarchy of needs.

Which oral hypoglycemic drug has a quick onset and short duration of action, enabling the patient to take the medication 30 minutes before eating and skip the dose if he or she does not eat? A Acarbose (Precose) B Metformin (Glucophage) C Repaglinide (Prandin) D Pioglitazone (Actos)

C. repaglinide (Prandin) Repaglinide is known as the "Humalog of oral hypoglycemic drugs." The drug's very fast onset of action allows patients to take the drug with meals and skip a dose when they skip a meal.

Based on the nurse's knowledge of glucocorticoids, what instructions should be given for this drug? A Take the medication every evening. B Inform the patient that the drug can be taken with coffee. C Advise that the drug does not have to be tapered before stopped. D Advise to take drug with milk, other dairy products, or food.

D. advice to take drug with milk, other dairy products, or food

A patient has developed DI after a head injury. Which medication should the nurse anticipate to be prescribed for the management of DI? A Corticotrophin (Acthar) B Octreotide (Sandostatin) C Somatropin (Genotropin) D Desmopressin (DDAVP)

D. desmopressin (DDAVP) Vasopressin (Pitressin) and desmopressin (DDAVP) are used to prevent or control polydipsia (excessive thirst), polyuria, and dehydration in patients with DI caused by a deficiency of endogenous antidiuretic hormone.

HgA1C

Hg molecules bound to glucose molecules; blood levels of HgA1C are used as *diagnostic measure* of average daily blood glucose levels in the monitoring and diagnosing of diabetes

when monitoring therapeutic responses to antidiabetics, you will look for?

HgA1C less than 7%

a pt scheduled insulin per sliding-scale, what type of insulin will be admin?

Humilin R- fast-acting -sliding-scale: check glucose and then admin insulin based on reading

hypothalamus secretes TRH that travels to pituitary gland with the message to secrete this hormone, this hormone then travels to thyroid gland to stimulate the release of what thyroid hormone

TSH

what levels to look for in pt taking levothyroxine for hypothyroidism?

TSH and T4

Which patient statement demonstrates understanding of radioactive iodine (I-131) therapy?

This drug will be taken up by the thyroid gland and destroy thyroid tissue

When teaching a patient about insulin glargine (Lantus), which statement by the nurse about this drug is correct?

You cannot mix this insulin with regular insulin and thus will have to take two injections Insulin glargine is a long-acting insulin with duration of action up to 24 hours. It should not be mixed with any other insulins. It is usually dosed once daily, but it may be dosed every 12 hours depending on the patient's glycemic response.

potential adverse effects of metformin?

abdominal bloating, nausea, diarrhea, metallic taste

primary hypothyroidism

abnormal *thyroid gland*, occurs when thyroid gland is not able to perform one of its many functions -*lab*: elevated TSH, with a decreased T3 and T4

teaching for drug propylthiouracil (PTU)?

avoid foods high in iodine, such as iodized salt, seafood, and soy

secondary hypothyroidism

begins at level of *pituitary gland* and results from *reduced* secretion of *TSH* (needed to trigger release of the T3 and T4 stored in thyroid gland)

American Diabetes Assoc Guidelines for therapeutic fasting blood glucose levels for diabetics

between 80 and 130 mg/dL

when admin vasopressin, what is the priority vital sign to monitor?

blood pressure

polydipsia

chronic excessive intake of water; common symptom of uncontrolled diabetes

when monitoring for therapeutic effects of prednisone, you will look for which outcome?

decreased inflammation

polyphagia

excessive eating; common; symptom of uncontrolled diabetes

what do you do when a patient with type 2 DM is scheduled for an MRI with contrast dye and is taking metformin?

expect to hold metformin the day of the test and for 48 hours after the test is performed

which type of drug raises concern before somatotropin therapy?

glucocorticoids

therapeutic effects to monitor after administration of somatropin (Humatrope)?

headache, flulike symptoms, hyperglycemia

When teaching a patient the adverse effects of desmopressin (DDAVP), the nurse will instruct the patient to monitor for which potential adverse effects?

headache, weight gain, nasal irritation Desmopressin works to decrease urine output; thus, the patient could retain fluid and gain weight. Other common adverse effects include increased blood pressure, fever, headache, abdominal cramps, and nausea. Desmopressin does not affect serum glucose levels. Because it is administered intranasally, it can be irritating; thus, nostrils should be rotated.

glucosuria

high levels of glucose in urine

DKA

high levels of ketoacids lower the pH of blood, cause a fruity odor of breath, can lead to stupor, coma, and possible death

glucagon

hormone produced by the alpha cells in islets of langerhans that stimulate the conversion of *glycogen to glucose in the liver*

drug of choice for adrenocortical insufficiency

hydrocortisone (Cortef)

when admin insulin, what is the most immediate and serious adverse effects of insulin therapy?

hypoglycemia

when monitoring lab values for antithyroid drugs, what should you watch for?

increased blood urea nitrogen level

polyuria

increased frequency or volume of urinary output; common diabetic symptom

major risk factor for development of type 2 diabetes?

liver disease

you should take prednisone (Deltasone) at which time to avoid reduced adrenal suppression?

morning

insulin

naturally occurring hormone secreted by the beta cells of the islets of langerhans in the pancreas in response to *increased levels of glucose in the blood* *Insulin therapy restores ability to*: -metabolize carbs, fats, proteins -store glucose in the liver -convert glycogen fat stores

cushing's disease

occurs when *high levels of corticosteroids* are present in the body over period of time, most commonly high doses of systemic corticosteroids -*symptoms*: adrenal atrophy, osteoporosis, HTN, increase risk for infection, delayed wound healing, acne, peptic ulcers, obesity, moon face, shoulders, and neck hump, and personality change

glucose

one of the simple sugars that serves as a major source of energy; found in foods (refined sweets) and is the final breakdown product of complex carb metabolism, "*dextrose*"

notify if which adverse effects are noted during thyroid hormone therapy?

palpitations, angina

prilosec was ordered once a day while taking prednisone (corticosteroid) due to a high incidence of patient developing what disease while taking prednisone?

peptic ulcer disease

another strategy to treat hyperthyroidism

radioactive iodide (1-131)

with a pt history in preparation to take metformin, what would be of concern?

renal disease

lab tests used to monitor thyroid hormone therapy?

serum TSH and free thyroid hormone levels

what is true regarding the dosage of thyroid replacement hormones for an older adult?

thyroid replacement requirements are approximately 25% lower