Pharmacology Final Exam Study Guide

Final Exam study Guide Concepts:  Bioavailability: portion of the drug that reaches the systemic circulation  Metabolism (bypass effect): Metabolism (also called biotransformation) is the method by which the drugs are inactivated by the body  Absorption: Absorption is the movement of a drug from its site of administration into the bloodstream for distribution to the tissues.  Excretion: refers to the elimination of the drug from the body o Requires adequate functioning of the circulatory system and organs of excretion:    Kidneys via urine First-pass effect: If a drug is metabolized by the liver before it reaches the systemic circulation, some of the active drug will be inactivated before it can reach the general circulation: o Most drugs administered by mouth have less than 100% bioavailability o Drugs administered by the intravenous route have 100% bioavailability. Normal physiology: How do medications work within this context? Nursing responsibilities for medication administration:  Identifiers o Pre-administration assessment  List of current medications  History of allergies  Vital signs and physical exam  Lab values (renal, liver, peak, trough) o Response to medication needs to be evaluated  Was the medication effective?  Did the patient have an adverse response? o Education needs to be provided for patient to safely care for self at home Enteric coatings and capsules: Purpose  Capsules o Medication encased in gelatin shell o Often designed to be sustained or extended release  Enteric Coated Tablets: o Tablets are coated so that they do not break down in the stomach o Absorption of the drug takes place in the small intestine o Cannot be divided into smaller doses Routes of administration:  PO, IV, SubQ, IM, sublingual Enteral vs Parenteral:  Know the difference between the two and how it affects pharmacokinetics & pharmacodynamics o Enteral: Absorbed through mucosa of stomach or intestine  Examples: Oral (PO) medications  altered by: GI motility, presence of food in the stomach, pH of stomach, amount of bowl surface area o Parenteral: Refers to injection by pass  Examples: Intradermal, subcutaneous, intramuscular, intravenous  altered by blood flow to the area, tissue type, IV is immediately in circulation Cardiac Remodeling  What is occurring to the heart: change in the size, shape, and structure of the myocardial cells (myocytes) that occurs over time in HF  What is the result: heart failure Coronary Artery Disease  Identify good (HappyDL) and bad cholesterols (LDL)  CAD: atherosclerosis of the coronary arteries that reduces the blood supply to the heart muscle Asthma: Triad of S&S  Nasal polyps, asthma, and sensitivity to aspirin and NSAIDS Anaphylactic Reactions:   Know S&S o include hives, ↓ in blood pressure, ↑ heart rate, swelling of the throat, difficulty breathing, loss of consciousness What medication do you administer? epinephrine (EpiPen) which stimulates alpha1, beta1, and beta2 receptors. Opioids: Morphine, Fentanyl, Demerol  Side effects/adverse effects o Common adverse effects:  Cardiovascular: hypotension, flushing, bradycardia  Central nervous: sedation, disorientation, euphoria, lightheadedness, dysphoria  GI: N/V, constipation, biliary tract spasm  GU: urinary retention  Integumentary: itching, rash, wheal formation  Respiratory: respiratory depression and possible aggravation of asthma o Severe Adverse effects: respiratory depression o Caution in obesity (sleep apnea), head injury (LOC) and paralytic ileus  Nursing assessment and safety o Pain assessment before medication and 30 minutes after  Respiratory status (respiratory rate of less than 12 breaths/min or shallow breathing)  Safety measures, such as keeping side rails up, and call light within reach to prevent injury  Watch for opioid tolerance and physical and psychologic dependence with opioids. o Patient education:  Constipation is a common adverse effect and may be prevented with adequate fluid and fiber intake  Change positions slowly to prevent possible orthostatic hypotension  Co administration of opioids with alcohol, benzodiazepines or barbiturates will lead to increased respiratory depression  Nursing measures while patient is on pain patches: rotate sites  Reversal agent: naloxone (Narcan) Administer until full reversal  Opioid tolerance: A normal physiologic condition that results from long-term opioid use, in which larger doses of opioids are required to maintain the same level of analgesia and in which abrupt discontinuation of the drug results in withdrawal symptoms (same as physical dependence). Antiplatelets: Aspirin: suppress plt aggregation  Nursing assessment and safety o Assess for GI issues, PUD or bleeding disorders o o o o o Not given for peds (Reyes syndrome) Better tolerated if taken with food, milk, or an antacid to avoid GI irritation Do not take with anti-coagulants, ASA (other NSAID), corticosteroids Stop taking aspirin 5-7 days prior to invasive surgical procedures Watch for blood in stool, don’t crush enteric coated tablets Analgesics (pain relievers) and antipyretics (fever reducers): Tylenol  Know all reasons it is prescribed  pain, little to no inflammation, fever reducer  Reversal agent o acetylcysteine (Mucomyst)  Lab monitoring o cardiac o renal and liver function studies o CBC Antibiotics: PCN, Gentamycin, Vancomycin, Aminoglycosides. Major focus: adverse effect and lab (hepatoxicity – check BUN and creatinine before and after) Take antibiotics in empty stomach  Drugs given during anaphylactic reaction: Epinephrine  Are these meds hepato, nephro, ototoxic o hepatotoxicity: Macrolides- erythromycin, azithromycin o nephrotoxicity:  Tetracyclines- tetracycline, doxycycline  Aminoglycosides- gentamicin  Vancomycin o ototoxicity: Aminoglycosides- gentamicin, vancomycin  Vanco peak and trough levels- what to do if they are high o peak level: 18 – 50 mcg/mL; trough level: 10 – 20 mcg/mL o Give antihistamine, and infuse over at least one hour to avoid red-man syndrome  What is the time period for peak and trough levels? o Peak levels: refers to amount of drug present in blood plasma within  30 minutes of IV drug administration  30 to 90 minutes of IM drug administration o Trough levels: refers to lowest level of drug present in the blood plasma.  Since the drugs can cause severe adverse effects the excretion of the drug needs to be monitored.  Blood drawn just before the next dose given. right before the 3rd dose.  Purpose and timing of culture and sensitivity lab draws o Always collect the culture (urine, sputum, blood, wound drainage) prior to starting antibiotic therapy   o If lab technician is drawing the blood culture make sure it has been done before starting antibiotics 3 antibiotic classes for Peptic Ulcer Disease (PUD) o amoxicillin and clarithromycin (penicillin, macrolide, tetracycline) Nursing measures while administering antibiotics Class: Sulfonamides  Prototype drugs: sulfamethoxazole/trimethoprim (combo drug, trimethoprim is folic acid inhibitor)  Mechanism of action  Bacteriostatic: Inhibits the bacterial synthesis of folic acid.  Indications: o Broad spectrum (gram negative and gram positive organisms) including Enterobacter, Escherichia coli, Klebsiella, some Proteus, and Staph aureus. o High concentration in the kidney makes it very useful in treating urinary tract infections.  Contraindication: Oldest generation antibiotics, broad spectrum (wide range bacteria), MOA, sulfa drug is not good for anemic, pregnant women d/t inhibition synthesis of folic acid. Without folic acid, a lot of anemia situation can happen.  Common adverse effects: o Crystalluria, proteinuria, GI upset, stomatitis, photosensitivity  Severe Adverse effects: o Peripheral neuropathy o Steven Johnson’s Syndrome, toxic epidermal necrolysis: fever followed by rash • Nursing Assessment: • Culture and sensitivity before treatment • Encourage fluids • Patient education: • Good mouth care • Take on an empty stomach with full glass of water • Take around the clock • report allergic reaction, what kind of allergic reaction • side effect: C-diff Class: Penicillin  Prototype drugs/Indications:  Aminopenicillins: ampicillin, amoxicillin, Amoxicillin/clavulanic acid (Augmentin) (bronchitis, sinusitis, otitis media)  Extended-spectrum penicillins: Piperacillin/tazobactam (Zosyn) (pneumonia, sepsis)  Mechanism of action o Bactericidal: disrupts cell wall synthesis  Common adverse effects: o Glossitis, stomatitis o Gastritis, diarrhea o Superinfection  Severe Adverse effects:  Anaphylaxis: When giving IV or IM observe for ½ to 1 hour after giving for adverse reactions. • Nursing Assessment: • Culture and sensitivity before treatment • Monitor serum electrolytes and cardiac status if given IV • Monitor and rotate injection sites • Patient education: • Good mouth care • Give yogurt if diarrhea develops • Take missed dose as soon as possible, but do not double dose Class: Cephalosporins  Prototype drugs/indications: o 1st generation: cefazolin, cephalexin (surgical prophylaxis, staph infections), good for gram positive bacteria o 2nd generation: cefoxitin (Mefoxin), better cover for gram negative bacteria and Anaerobic. o 3rd generation: ceftriaxone (Rocephin) IM or IV (meningitis – crosses meninges well) good coverage for gram negative o 4th generation: cefabime (Maxipime) IV. Most advanced, good for complicated respiratory infection o Level of gram-negative coverage ↑ with each successive generation. Anaerobic coverage with second generation.  Mechanism of action o Bactericidal: interferes with cell wall synthesis o Related to penicillin  Common adverse effects: o Rash o GI disturbances  Nursing Assessment:  Potential cross-sensitivity with penicillin if allergy exists (1-4%) Class: Macrolides  Prototype drugs: erythromycin (older) azithromycin (newer)  Mechanism of action o Bacteriostatic: inhibits protein synthesis (bactericidal in large doses)  Indications: pneumonia, H. Pylori, STDs (gonorrhea and chlamydia)  Common adverse effects:    o Abdominal cramps, diarrhea o Confusion, uncontrollable emotions Severe Adverse effects: o Hepatotoxicity o Superinfections (C-diff) Nursing Assessment: o Monitor liver function Patient education: o Take oral meds 1 hr. before, or 2-3 hrs. after a meal, with full glass of water o Educate on signs of hepatic toxicity Class: Tetracyclines  Prototype drugs: tetracycline, doxycycline  Mechanism of action  Bacteriostatic: Inhibit bacterial protein synthesis  Indications: Acne, H. pylori, syphilis  Common adverse effects: o Photosensitivity o GI effects: Glossitis, Dysphagia, Diarrhea o Rash  Severe Adverse effects: o Binds to Ca++. During gestation it can cause staining of deciduous teeth. Will lead to discoloration and inadequate calcification of permanent teeth in children. It is contraindicated in children under 8 years of age, pregnant and nursing mothers.  Nursing Assessment: o Monitor renal function o Note expiration date (becomes highly nephrotoxic)  Patient education: o Take 1 hr. before or 2-3 hrs. after meals o Do not take with milk, antacids, iron preparations (give 3 hrs. after medication) o Use contraceptive method in addition to oral contraceptives. d/t oral contraceptive are less effective when taking tetracycline. Class: Aminoglycosides • Prototype drugs: gentamicin • Mechanism of action • Bactericidal – prevents protein synthesis in bacteria. • Indications: Serious gram-negative infections and some gram-positive infections • Common adverse effects: • Anorexia, nausea, vomiting, diarrhea • Severe Adverse effects: • Very potent antibiotics with serious toxicities  • Nephrotoxicity (5-25%): Toxicity to kidneys, often drug induced and manifesting in compromised kidney function. • Ototoxicity (3-14%): Toxicity to the ears, often drug-induced and manifested by varying degrees of hearing loss than is likely to be permanent. Nursing Assessment: o Check eighth cranial nerve function o Check renal function (BUN, Creatinine) o Requires therapeutic drug monitoring (peak and trough blood levels)  Peak levels: refers to amount of drug present in blood plasma within  30 minutes of IV drug administration  30 to 90 minutes of IM drug administration  Trough levels: refers to lowest level of drug present in the blood plasma.  Since the drugs can cause severe adverse effects the excretion of the drug needs to be monitored.  Blood drawn just before the next dose given. right before the 3rd dose. Class: Floroquinolones  Prototype drugs: ciprofloxacin, levofloxacin  Mechanism of action o Bactericidal: alters bacterial DNA o Broad spectrum  Indications: UTIs, GI infections, respiratory illness, anthrax exposure  Common adverse effects: o Headache o Nausea, diarrhea o Decreased WBC and hematocrit o Rash, photosensitivity  Severe Adverse effects: o Achilles tendon rupture o Elevated BUN, AST, ALT, serum creatinine, alkaline phosphate  Nursing Assessment: o Assess for tendon pain o Evaluate labs (kidney and liver function)  Patient education: o Take 1 hr. before, 2 hrs. after meals o Encourage fluids Class: Vancomycin  Prototype drug: vancomycin  Mechanism of action o Bactericidal: binds to the bacterial cell wall, producing immediate inhibition of cell wall synthesis and death.  Indications: MRSA, C. difficile  Common adverse effects: o Red man syndrome o Thrombophlebitis/Abscess formation at IV site  Severe Adverse effects: o Nephrotoxicity o Ototoxicity  Nursing Assessment: o Hearing assessment (CN8) o Kidney function labs o Peak ( 18-50mcg/mL) and trough (10-20mcg/mL) levels o Give antihistamine, and infuse over at least one hour to avoid red-man syndrome Loop Diuretics: furosemide (Lasix)  Mech of action o Acts in the thick segment of the ascending limb of Loop of Henle to block reabsorption of sodium and chloride o Since 20% of filtered NaCl is reabsorbed here, it produces profound diuresis o Most effective diuretic.    Indication: Edema from HF Important lab(s) to monitor o Fluid volume status o Vital signs o Potassium levels Nursing education o Monitor weight and blood pressure o Change positions slowly o Eat potassium rich foods (i.e. potatoes, tomatoes, bananas, spinach, dried fruit, citrus fruits) o Take early in the day Laxatives: Nursing Responsibility  o Obtain a thorough history of presenting symptoms, elimination patterns, and allergies o Assess fluid and electrolytes before initiating therapy o Inform patients to contact their physician if they experience severe abdominal pain, muscle weakness, cramps, and/or dizziness, which may indicate possible fluid or electrolyte loss o A healthy, high-fiber diet, increased fluid intake and activity should be encouraged as an alternative to laxative use o Long-term use of laxatives often results in decreased bowel tone and may lead to dependency o Patients should take all laxative tablets with 6 to 8 ounces of water o Some diagnostic procedures require the bowel to be still and not moving. Proton Pump Inhibitors: Protonix  What is it given for o GERD not responsive to H2Blockers, H.pylori treatment, Stress ulcer prophylaxis, active ulcers, GI bleeds, erosive esophagitis  When: taken 30-60 minutes before meals Sympathetic/parasympathetic nervous systems  What are the receptors for each o SNS: Adrenergic receptors  Alpha1, Alpha2, Dopamine (responds only to dopamine) o PNS: Cholinergic receptors  Nicotinic N, M, Muscarinic1, 2, 3 Anticholinergics: Atropine  Mech of action o Block ACh or cholinergic drugs at muscarinic receptors in the PSNS  As a result, ACh is unable to bind to the receptor site and cause a cholinergic effect  Heart: block the parasympathetic/cholinergic effects on pacemaker cells of the SA and AV node.  Bladder: relaxes detrusor muscles of the bladder and increase constriction of internal sphincter  What is it the drug of choice for? systematic bradycardia  Atropine toxicity and reversal agent: physostigmine Alpha1 Adrenergics: Norepinephrine, epinephrine, Sudaphed,  Mech of action o Alpha1 and Beta 1 agonist are used to support the cardiovascular system during cardiac failure, severe hypotension, or shock  What is it used for (Norepi, Epinephrine, & Sudaphed) o Norepi (Levophed): shock o Epi (adrenaline): anaphylaxis o Sudaphed: nasal congestion “stuffy nose”  Reversal agent: phentolamine  Nursing assessment and safety for each o Complete medical history/ medication list o Assess for contraindications such as allergy, angina, dysrhythmias, hypertension, history of MI/ CVA o Current vital signs (BP, HR) o Current labs including liver/ kidney function o Watch for therapeutic and adverse responses o Oral Adrenergic Decongestants: pseudoephedrine (Sudafed) o Use with caution with HTN o Prolonged decongestant effects, but delayed onset. Effect less potent than topical o BENEFIT: No rebound congestion  Remember where receptors live and how one drug can affect other organs o alpha 1: postsynaptic effector cells o alpha 2: presynaptic effector cells o beta 1: heart and kidney o beta 2: smooth muscle of lungs; coronary arterioles; uterus; liver; skeletal muscle Beta 2 Adrenergics: Inderal, metoprolol, atenolol (Beta Blockers), albuterol  Mech of action- how do they affect s the heart (3 Cs) o HTN: Beta blockers ↓ contractility which decreases stroke volume o Angina: Beta blockers ↓demand for myocardial oxygen o s/p MI: Beta blockers inhibit stimulation from circulating catecholamines  What are they used for o propranolol (non-cardio selective) (Inderal): HTN, angina, s/p MI o metoprolol (cardiac-selective): HTN, angina, s/p MI o atenolol (Beta Blockers): HTN, angina, s/p MI o albuterol: acute asthma attack  Nursing assessment for contraindications. Side/ adverse effects o Inderal, metoprolol, atenolol (Beta Blockers): Adverse Effects  Common adverse effects:   Constipation, bradycardia, dizziness Severe Adverse effects:  Bronchoconstriction, heart failure, masks the signs of hypoglycemia (tremor, tachycardia, nervousness) o Nursing Implications  Assess for underlying heart and pulmonary disease  Assess pulse and B/P prior to administration  Hold beta-blocker and contact MD for bradycardia (<60)  Non-cardio selective BB is not good for Asthma  BB masks the signs of hypoglycemia in DM pts o Albuterol: Common adverse effects:  Insomnia  Restlessness  Tachycardia  Palpitations  Vascular headache  Tremor  Severe Adverse effects:  If Beta1stimulated (more common with po dosing) – angina, tachydysrhythmias  Nursing Assessment:  Assess HR as medication may cause elevation  Remember where receptors live and how one drug can affect other organs (system effects) Anemia:  What primary and secondary vitamins are required for treatment? o iron o Vitamin B12 o Folic acid ACE Inhibitors:  Know all adverse effects  Common adverse effects: o Dry cough (related to bradykinin) o Hypotension (*first dose especially)  Severe Adverse effects: o Angioedema Calcium Channel Blockers: Verapamil  Mech of action o Prevents influx of calcium ion across cell membrane of vascular smooth muscle. o Dilation of peripheral and coronary arteries and arterioles (↓ afterload)  Why administered: HTN (angina, arrhythmia)  What is the therapeutic effect: lower bp, decreased angina Direct-acting Vasodilators: Hydralazine, Nitroglycerine  Mech of action o (Hydralazine) Works directly on arteriolar and venous muscles to cause relaxation