Exam 1 Review Guide Pharmacology Part 1

1 Exam 1 Review Guide NUR Pharmacology Quiz 1 1. 2. 3. Nursing process as it relates to med administration a. 6 Rights of Med Admin i. Patient ii. Drug iii. Dose iv. Time v. Route vi. Documentation b. Extra rights to med admin i. Assessment ii. Evaluation iii. Patient to education iv. Patient to refuse care c. Biggest medication error is misinterpreting prescriptions i. Do not assume if something is unclear about an order. Clarify with prescriber. ii. TORB and VORB d. Pre- and post- medication administration assessment and interventions i. Pre 1. If patient is complaining of pain 10/10, intervene (prn meds, standing orders, call physician for new orders) then assess. 2. Collection of baseline data to evaluate therapeutic effects and adverse effects 3. Identification of high-risk patients 4. Assessment of the patient’s capacity for self-care 5. Allergies? a) Collect history. What happens during an allergic reaction? b) If patient is having an allergic reaction: primary intervention is to STOP THE MEDICATION THAT IS CAUSING THE REACTION. 6. If patient refuses drug, determine why. INVESTIGATE. ii. Post 1. Therapeutic response 2. Adverse reaction and interaction 3. Adherence to treatment 4. Satisfaction with treatment Patient teaching for medication therapy in general (safety, compliance, etc.) a. Teaching i. Safety 1. If medication causing certain side effects, consult physician. ii. Compliance 1. It is important not to stop or change a medication without consulting the physician. 2. Take medications as prescribed and for the reason they are prescribed. Side effects vs adverse effects vs allergies a. Side effects i. Nausea, vomiting, expected and unavoidable reactions, drug effects produced at therapeutic level. b. Adverse effects 2 4. 5. i. Noxious, unintended, and undesired effect that occurs at normal drug doses, harmful at therapeutic level. c. Allergies i. Redness, itching, hives, swelling; A condition in which the immune system reacts abnormally to a foreign substance. Intended effect, teratogenic effect, paradoxical effect, tolerance a. Intended effect i. Maintenance of vital signs within expected limits ii. Decrease in the risk of seizures iii. Decrease in the intensity of withdrawal manifestations iv. Substitution therapy during alcohol withdrawal b. Teratogenic effect i. Drug-induced birth defect ii. Birth defects are not limited to distortions of gross anatomy; they also include neurobehavioral and metabolic anomalies c. Paradoxical effect i. Opposite the intended drug effect ii. Common example 1. Insomnia and excitement that may occur when some children and older adults are given benzodiazepines for sedation. d. Tolerance i. Pharmacodynamic tolerance 1. Reduced responsiveness to a medication that clients take over time. ii. Metabolic tolerance 1. Metabolism of medication increases over time and the effectiveness of the medication declines. iii. Cross-tolerance 1. Become tolerant to a medication that is chemically similar to another medication they became tolerant of. Half-life of medications a. Defined as the time required for the amount of drug in the body to decrease by 50% b. Percentage versus amount c. Determines the dosing interval d. Modafinil (CNS suppressant; narcolepsy) i. about 15 hours e. Phenytoin (Seizures) i. 8-60 hours 1. lower doses: 8 hours 2. higher doses: 60 hours f. Fluvoxamine (SSRI) i. About 15 hours g. Citalopram (SSRI) i. About 35 hours h. Duloxetine (SNRI) i. 12 hours Quiz 2 6. Donepezil (Aricept) therapy in patients with Alzheimer’s disease a. Alzheimer’s Disease i. uncurable, cannot be delayed/slowed, or reversed. However cognitive decline can be slowed down with meds. Cholinesterase inhibitors may cause fainting due to hypotension and bradycardia. 3 7. 8. b. Donepezil i. Indicated for mild, moderate or severe AD ii. Affects ACh levels iii. Take acetaminophen (Tylenol) instead of NSAIDs (aspirin or ibuprofen) iv. Inhibition/prevention to breakdown Acetylcholine (ACh) v. Common side effects 1. Nausea/vomiting 2. GI discomfort (diarrhea) 3. dyspepsia (indigestion) 4. headache 5. fainting 6. falls/fall-related fractures vi. Cholinesterase Inhibitors vii. Inhibitors prevent acetylcholinesterase from inactivating ACh (prevents from doing their job.) viii. This causes an increase of ACh, therefore there is a decrease in dopamine. ix. Too much ACh and too little dopamine is Parkinson’s x. Too little ACh and too much dopamine is Alzheimer’s Cholinesterase inhibitors and indications, side effects, cardiac effects a. Cholinesterase inhibitors (donepezil, galantamine, rivastigmine) i. Treatment of AD with these drugs can yield improvement that is statistically significant but clinically marginal. (ex: taking a “weight loss drug” and losing half a pound in 6 months). ii. Goal for AD treatment s to improve symptoms and reverse cognitive decline. iii. Inhibitors prevent acetylcholinesterase from inactivating ACh (prevents from doing their job). Prevent breakdown of ACh. iv. This causes an increase of ACh, therefore there is a decrease in dopamine. b. Indications i. Mild to moderate AD c. Side effects i. Cholinergic side effects 1. Increased sweating 2. Loss of bladder control 3. Muscle weakness, cramps 4. GI upset (diarrhea, N/V, stomach cramps or pain) 5. Bronchoconstriction a) SOB, tightness in chest, wheezing 6. Watering of mouth ii. Fatigue iii. Insomnia iv. Dizziness v. Headache d. Cardiac effects i. Slow or irregular heartbeat ii. Dysrhythmia iii. Hypotension Interferon beta therapy (indications, side effects, etc.) a. Interferon beta i. Multiple Sclerosis ii. Immunomodulators 1. How it works: a) Reduces severity and frequency of attacks 4 2. 3. 4. 5. 6. 7. 8. 9. b) Reduces development of brain lesions detectable by magnetic resonance imaging (MRI) c) Delays progression of disease Naturally occurring glycoprotein with antiviral, antiproliferative, and immunomodulatory actions. Immunosuppressive quality a) Inhibits WBC b) Inhibits T-helper cells Does not prevent or cause infection but can make an infection worse. May cause FLU-LIKE symptoms, not actually cause the flu. Injection reactions a) No warm or cold compress i. Do not change the temperature of the tissue b) Benadryl if needed c) Hydrocortisone cream if needed d) Rotate injection sites to avoid injection site reactions and skin break down Can cause depression and suicidal thoughts Allow 48 hours between injections Start with low dose then increase too more. b. Indications i. Multiple sclerosis 1. Immune system attacks itself 2. Inflammation and destruction of myelin in CNS c. Side effects i. Flu-like reactions ii. Hepatotoxicity iii. Myelosuppression iv. Injection-site reactions v. Depression vi. Suicidal thoughts vii. Neutralizing antibodies viii. Drug interactions 9. Baclofen therapy a. Therapeutic uses: i. MS, spinal cord injury, and cerebral palsy ii. Not used with stroke! iii. Decreases flexor and extensor spasms iv. Suppresses resistance to passive movement v. No direct effect on skeletal muscle vi. Centrally Acting Muscle Relaxer for Spasticity vii. May mimic the action of GABA on spinal neurons. b. Adverse effects i. Withdrawal ii. GI symptoms (nausea, constipation) iii. Urinary retention iv. Miss one dose, cause seizures! c. Considerations: There is no antidote for an OD. It is a CNS depressant. Withdrawal needs to be gradual or there is a risk of serious complication. Do not use with alcohol! d. Caution: seizure patients and renal impairment. e. May take with food to avoid GI upset. 10. Levodopa/Carbidopa in PD (action, side effects, interventions for side effects) 5 a. Levodopa/Carbidopa (dopaminergic agent) i. Parkinson’s Disease 1. Incurable, cannot be slowed down, chronic degenerative disease 2. Treatment is to treat symptoms! 3. Dyskinesias (motor symptoms) 4. Akinesias (nonmotor symptoms) 5. Goal for treatment is to improve patients ability to do ADLs b. Action i. Levodopa is only given with carbidopa ii. Given PO iii. Rapid absorption from small intestine iv. Reduces symptoms by increasing dopamine synthesis in the striatum v. Enters brain via active transport system that carries it across the blood-brain barrier. vi. In the brain: uptake into the remaining dopaminergic nerve terminals that remain in the striatum vii. Levodopa, no direct effect on its own, converts to dopamine 1. Prodrug form is converted to dopamine viii. Levodopa helps to restore a proper balance between dopamine and ACh c. Side effects and interventions i. Nausea and vomiting (neurotransmitter levels)- Giving additional carbidopa (without levodopa) can help reduce N/V. ii. Activation of dopamine receptors in the chemoreceptor trigger zone of the medulla iii. Low initial doses and administration with food can reduce therapeutic effects by decreasing levodopa absorption. iv. Cardiovascular- check vital signs v. Postural hypotension- increase salt and water intake to avoid hypotension and hyponatremia. vi. Psychosis vii. Visual hallucinations viii. Vivid dreams/nightmares ix. Paranoid ideation 1. Caused by activation of dopamine receptors x. Symptoms can be reduced by lowering levodopa dosage. This will reduce beneficial effects as well. xi. Dyskinesias (some just annoying, others can be disabling) 1. Reduce dosage 2. Amantadine 3. Surgery and electrical stimulation xii. Darkens sweat and urine xiii. Even with treatment, usually at about 5 years, the patient will go back to starting point/baseline, body builds tolerance and increase xiv. Adding an MAO-B Inhibitor slows the breakdown of levodopa and dopamine in the brain, and may boost the effect of levodopa xv. Dopaminergic Drugs xvi. Dopamine inhibits motor movement while ACh stimulates motor movement. xvii. Dopamine agonist 1. Stops dopamine production 2. High protein foods decrease therapeutic effect xviii. HTN crisis with MAOI xix. Increase salt and water intake to avoid hyponatremia and hypotension xx. Avoid vitamin b6 supplements because it decreases amount that reaches the brain 6 xxi. Activates malignant melanoma- important to perform a careful skin assessment of patients and ask about history of skin cancers. xxii. CNS effects 1. Anxiety and agitation 2. Memory and cognitive impairments 3. Insomnia and nightmares 4. Problems with impulse control a) Behavior changes associated with promiscuity, gambling, binge eating, and alcohol abuse. 11. Phenytoin and pregnancy, therapeutic level a. Phenytoin i. Class: Traditional antiepileptic agent ii. Uses: Seizures (partial and tonic-clonic seizures) and cardiac dysrhythmias iii. Mechanism of action: Selective inhibition of sodium channels iv. Fosphenytoin converts to phenytoin when metabolized b. Adverse effects i. Nystagmus ii. Sedation iii. Ataxia (impaired balance and coordination) iv. Diplopia (seeing double) v. Cognitive impairment vi. Gingival hyperplasia (swelling, tenderness, and bleeding of gums) 1. Gingivectomy 2. Folic acid may prevent gum overgrowth 3. Risk can be minimized by good oral hygiene, including dental flossing and gum massage. vii. Skin rash viii. Effect in pregnancy ix. Cardiovascular effects c. Drug interactions i. Decreases the effect of oral contraceptives (warning for child bearing women), warfarin, and glucocorticoids ii. Increases levels of diazepam, isoniazid, cimetidine, alcohol, and valproic acid 1. Do NOT drink alcohol with drug d. Administer i. With food, not on an empty stomach ii. Dosing is highly individualized. e. Pregnancy i. Teratogenesis ii. If taken during pregnancy, baby is at risk for birth defects. iii. Fetal hydantoin syndrome and malformations f. Therapeutic level i. 10-20 mcg/mL ii. Narrow and dangerous iii. Monitor closely! 12. Oxcarbazepine therapy and antidiuretics a. Oxcarbazepine i. Seizures ii. May inhibit nerve impulses by limiting influx of sodium ions across cell membrane in motor cortex. iii. Indications 1. Monotherapy and adjunctive therapy of partial seizure in adults and children 7 iv. Antiseizure effects 1. Voltage sensitive sodium channels in neuronal membranes blocked, hyperexcitable neurons stabilized, and seizures suppressed. v. Contraindications: hypersensitivity vi. Medication route: PO/tablets vii. Adverse Effects: 1. Steven-Johnson Syndrome (can be deadly) 2. Toxic epidermal necrolysis (can be deadly) 3. Hyponatremia (concentration below 125 mmol/L) 4. Dizziness/drowsiness 5. Diplopia 6. Nystagmus 7. Headache 8. N/V 9. Ataxia 10. Suicidal thoughts 11. Gait disturbances 12. Fatigue viii. Caution: do not perform tasks that require mental alertness ix. Drug-drug: carbamazepine, phenobarbital, phenytoin, calcium channel blockers may decrease oxcarbazepine levels. b. Antidiuretics i. Not enough sodium in the body means too much fluid. Antidiuretics cause you to retain fluid, therefore, Oxcarbazepine should not be taken with antidiuretics. 13. Methylphenidate (Ritalin) therapy in children a. Methylphenidate i. Amphetamine-like drug for ADHD ii. Do not use with alcohol iii. Side effect 1. GI reactions 2. HTN 3. Headache 4. Insomnia 5. Xerostomia 6. Decreased appetite 7. Blurred vision 8. Anxiety 9. Tachycardia b. Therapy in children i. Do not administer to children under 6 years old; if given too early, it can stunt growth. ii. Do not give before bedtime because it will impair sleeping patterns iii. Do not give before meal, because it decreases appetite, give in the morning after breakfast. iv. No alcohol, avoid caffeine v. No MAOIs within 2 weeks vi. interaction drug-drug 1. diazepam 2. phenytoin 3. propranolol 4. tricyclic vii. Stick to treatment plan, do not cancel without consulting physician 1. Physical dependence, withdrawal, need to be weaned off 8 14. ADHD treatment goals a. Help with control over inattentiveness, impulsivity, and hyperactivity b. Reduce symptoms of disease c. Increase attention span and goal-oriented behavior while reducing impulsiveness, distractibility, hyperactivity, and restlessness. 15. Carbamazepine therapeutic level, indications a. Carbamazepine i. Class: Anticonvulsant (seizures) ii. Mechanism of action 1. Suppresses high-frequency neuronal discharge in and around seizure foci iii. Patient should not be in direct sunlight while on this drug; best to give drug at night. iv. Asian population should be genetic tested, if they have the HLA-B 1502G gene, the drug will give an adverse effect v. Anti-seizure, alcohol withdrawal, acute mania associated with bipolar disorder, trigeminal neuralgia b. Adverse effects: i. Neurologic effects: nystagmus and ataxia ii. Hematologic effects: leukemia, anemia, and thrombocytopenia iii. Birth defects iv. Hypo-osmolarity v. Dermatologic effects: rash and photosensitivity vi. Aplastic anemia vii. Agranulocytosis viii. Respiratory depression ix. Arrhythmias x. AV block xi. Stevens Johnson Syndrome c. Therapeutic level i. 4-12 mg/L d. Indications for use i. Epilepsy ii. Bipolar disorder iii. Trigeminal and glossopharyngeal neuralgias e. Interactions: i. Grapefruit juice ii. Phenytoin iii. Warfarin f. Treatment considerations i. Take as prescribed, adhere to strict regimen, don’t stop med without consulting doctor, check drug level often for therapeutic effect. g. Goal for treatment i. Reduce seizures to a level that allow the patient to live as normal a life as possible. Balance between therapeutic effect and side effects of drugs. ii. Balance the desire for complete seizure control with the acceptable side effects. iii. No such thing as a perfect treatment! h. Seizure chart i. How often, how long, date, time, type of seizure 16. Phenobarbital overdosing a. Phenobarbital i. Anticonvulsant barbiturate (sedatives) ii. Slows activity of brain and nervous system 9 iii. Used to treat Seizures without causing sedation (for seizures, the amount used builds tolerance so sedation is not achieved). iv. Do not mix with opioids or alcohol! b. Overdosing i. Can be fatal ii. Symptoms 1. Slow or shallow breath 2. Weak pulse 3. Cold or clammy skin 4. Little or no urination 5. Pinpoint pupils 6. Feeling cold 7. Fainting