Real Final Flashcards
(236 cards)
1
Q
degenerative disease of the CNS*
A
aka neurodegenerative diseases
they are progressive, irreversible loss of neuron function in the brain and/or spinal cord
can affect any age group
pharmacotherapy treats symptoms -> no cure
depression is a common problem with these chronic/irreversible disorders
2
Q
parkinson disease
A
progressive neurodegenerative disorder characterized by abnormal motor movement
onset 40-70yrs
men are more affected
fatigue, slow movement, slight tremor
3
Q
cardinal sign of Parkinson disease
A
tremor
- hands and head develop palsy-like continuous motion, shaking when at rest
- pill rolling -> rub thumb and forefinger together in circular motion
muscle rigidity
- resistance to passive movement of arms/legs
- may resemble arthritis
- uncontrollable drooling -> rigidity of facial muscles
bradykinesia
- involuntary slowness of movement and speech
- difficulty chewing, swallowing, speaking
- shuffling gait
postural instability
- stooped over
-stumbling
- difficulty balancing
4
Q
cause of Parkinson disease
A
caused by a lack of sufficient amounts of dopamine produced by the substantial nigra (part of the brain that plays a key role in controlling movement)
if dopamine levels decline, acetylcholine has a more dramatic stimulatory effect -> PIG
5
Q
dopamine
A
is a chemical messenger and hormone that plays a role in many body functions
in the case of Parkinson disease it impacts movement
degeneration of 60% to 80% of dopamine producing neurons leads to Parkinson disease
6
Q
pharmacotherapy of Parkinson disease*
A
the goal is to balance dopamine and Ach
may take 2-3 weeks of tx to see the benefits of the drug
dopamine agonists and anticholinergic drugs
7
Q
dopamine agonists*
A
increase the available dopamine by:
- directly replacing dopamine,
- decreasing breakdown,
- increasing release,
- activating dopamine receptors
8
Q
anticholinergic drugs in the tx of Parkinson*
A
block the excitatory actions of Ach in the striatum, reducing stimulation of abnormal muscle movements
9
Q
striatum
A
cluster of interconnected nuclei that form a part of the basal ganglia
involved in decision making such as motor control, emotion
10
Q
levodopa
A
most effective therapy for treating Parkinson disease
dopamine replacement therapy
usually is combined with carbidopa
dramatic improvement in symptoms early in treatment -> effects may diminish over time
-> on-off syndrome may worsen
11
Q
extrapyramidal symptoms
A
major adverse effects that develop from deficiency of dopamine in striatum
can be treated with antiparkinson drugs
12
Q
carbidopa
A
inhibits the peripheral metabolism of levodopa
greater proportion of peripheral levodopa will cross the blood-brain barrier for CNS effect
13
Q
adverse effects of levodopa
A
- N/V
- anorexia
- headache
- choreiform (rapid, jerky movement)
- dry mouth
- urinary retention
- confusion/agitation
serious ADR
- agranulocytosis - low level of granulocytes
- leukopenia
- hemolytic anemia - blood cells break down faster than the body can replace them
14
Q
considerations with taking Levodopa*
A
- take on an empty stomach
- avoid multivitamins/B6
- avoid high protein diets
- watch ANS VS -> BP, pulse, RR
- monitor safety with ambulation due to dizziness, assist with ADLs
- monitor liver and kidney function
- avoid alcohol;
- watch for mood or behavioural changes -> aggression/confusion
15
Q
dopamine agonists
A
may be used as monotherapy for early symptoms of Parkinson disease or adjuncts to levodopa in pts with advances disease
less effective than levodopa
no dietary restrictions, no toxic metabolites produced, less likely to cause dyskinesias (abnormality or impaired voluntary movement)
pramipexole
16
Q
pramipexole
A
antiparkinson agent
dopamine receptor agonist, nonergot
used to treat Parkinson’s disease:
- monotheraply early on
- with levodopa in advanced stages
17
Q
non ergot
A
a class of dopamine agonists used to treat Parkinson’s disease
are not associated with the risk of heart damage
ex. pramipexole
18
Q
dyskinesias
A
abnormal or impaired voluntary movement
levodopa worsens it
19
Q
considerations when using pramipexole*
A
- assess baseline vital signs and symptoms of parkinsons disease
- monitor for orthostatic hypotension
- monitor for tar dive dyskinesia
- assess mental status
- alert pt and family about sleep attacks
- ensure family knows that PD tx is not a cure but might help with symptoms for a period of time
20
Q
tardive dyskinesia*
A
stiff, jerky movements of your face and body that you can’t control
involuntary repetitive body movements
21
Q
anticholinergics for tx of PD
A
are effective at reducing the tremor
less effective at reducing bradykinesia
restores the balance between Ach and dopamine, blocks reports that inhibit the effects of Ach which results in more available dopamine
most common is benzotropine and trihexyphenidyl
22
Q
adverse effects for benztropine *
A
- sedation
-constipation - blurred vision
- dry mouth
- decreased sweating
- urinary retention
- confusion
serious:
- paralytic ileus
23
Q
contraindication/precautions for benztropine*
A
- ALCOHOL!!!!!
- close angle glaucoma
- myasthenia gravis -> weakness in the voluntary muslces
- tardive syskinesia
-GI/urinary obstruction - prostatic hypertrophy
- peptic ulcers
- tachycardia
24
Q
benztropine drug interactions*
A
Additive toxicity:
- antihistamines
- tricyclic antidepressants
- phenothiazines
- MAOIs
-Quinidine
Additive sedative effect:
- alcohol
- CNS depressants
Slow GI motility/decreased absorption
- antidiarrheals
Pregnancy category C -> benefits may outweigh the risks, but may be harmful to fetus
tx of overdose:
- physostigmine, 1-2mg subcutaneous or IV
- repeat in 2 hours if necessary
- will reverse symptoms of anticholinergic intoxication
25
alzheimers disease
the most common dementia, leads to a progressive loss of cognitive function
26
pharmacotherapy of Alzheimers *
pharmacotherapy for Alzheimers produces only modest result and is ineffective at stopping the progress of the disorder
works by intensifying the effect of Ach at the receptor
27
cholinesterase inhibitors*
ex. Tacrine (cognex)
cholinesterase breaks down Ach
the goal is to improve functions in ADLs, behaviour, and cognition
all drugs in this classification have equal efficacy
GI system most adversely affected including liver
- N/V, diarrhea
28
nursing consideration for cholinesterase inhibitors*
- cognition
- safety
- independence
- symptoms
- baseline labs
- VS
- vision
- weight
- liver and kidney function
29
reversible cholinesterase inhibitors*
- raise Ach concentration in the brain
- fewer side effects than tacrine (cholinesterase inhibitor)
- side effects are typically GI-related
30
parkinsons vs alzheimers
PD has an increase of Ach with inhibits the effects of dopamine -> kicks the pig
alzehimers has a decrease in Ach -> leads to the loss of cognitive and behavioural functions
31
serious side effects of reversible cholinesterase inhibitors*
- A-fib
- sinus bradycardia
- seizures
32
nursing consideration for reversible cholinesterase inhibitors*
- cognition
- safety
- independence
- symptoms
- baseline labs
- VS
- vision
- weight
- liver and kidney function
33
donepezil
anti-alzheimer agent
reversible cholinesterase inhibitor
raises Ach levels in the brain
is moderately selective for cholinesterase in CNS-> fewer peripheral adverse effects
34
cholinesterase
cholinesterase breaks down Ach
35
adverse effects of donepezil*
- N/V/D, anorexia
- muscle cramps
- syncope
- ecchymosis
- fatigue
- arthralgia (joint pain)
- abnormal dreams/ hallucinations/ confusion/ depression
- headache
36
serious adverse effects of donepezil*
- life threatening dysrhythmias
-> a fib, sinus bradycardia
- seizures
- renal failure or hepatotoxicity -> watch liver enzymes
37
donepezil tx of overdose*
use anticholinergic drugs to reverse symptoms of a cholinergic crisis
38
considerations for donepezil*
- determine cognitive functioning/safety issues
- obtain baseline lab values, especially liver and renal
- determine symptoms of Alzheimers -> degree of depression, agitation, anxiety, aggression, confusion
39
nursing considerations for donepezil
- ensure family know to monitor pt for irregular heart beat or if pt feels butterflies in their chest
- evaluate need for alternative living arrangements
- encourage participation in support group
- avoid alcohol
40
multiple sclerosis*
exact cause unknown
characterized by the demyelination secondary to inflammatory response -> is considered an autoimmune disease
leave cause of neurologic disability in 20-40 age group
pattern of symptom exacerbation with periods of remission
symptoms:
- difficulty balancing
- muscle weakness
- cold sensitivity
41
immunomodulators
drugs used to modify the progression of MS
stimulate the immune response
suppress some aspect of immune function
used to prevent exacerbations
42
tx of muscle spasms*
NSAIDS and skeletal muscle relaxants are used to treat muscle spasms
NSAIDs = ibuprofen, naproxen and aspirin (Advil and ASA)
43
cyclobenzaprine
skeletal muscle relaxant
acts centrally no direct action on skeletal muscle
increase nor-epinephrine activity (Bear), produces anticholinergic effect
44
considerations for cyclobenzaprine*
- History and prognosis -> include VS
- baseline neurologic status
- assess for pain
- protect from injury related to falls from drowsiness
- assess for urticaria, rash pruritis
- inform pt not to drive
45
drugs similar to cyclobenzaprine*
methocarbamol (relaxin, robaxin)
- adjunct to physical therapy interventions
- don't drive
metaxalone (skelaxin)
- ineffective in treatment of spasticity-related neurologic disorders
orphenadrine (banflex, myophen, norflex)
- anticholinergic drug to the antihistamine class, closely related to diphenhydramine
tizanidine (zanaflex)
- spasticity related to brain or spinal cord injury of MS
46
muscle spasticity*
continuous state of contraction
pain is more intense than spasms and cause greater impairment
irritable deep tendon reflexes
scissoring movements in lower extremities
fixed joint movement
not a disorder itself but rather caused by neuromuscular diseases -> spinal cord injury, stroke, advanced MS, cerebral palsy, ALS, dystonia
47
dantrolene
direct acting skeletal muscle relaxant
anti spasticity agent
calcium release blocker
48
dantrolene considerations*
- history and prognosis
- baseline neurologic and pain status
- assess VS during IV admin
- assess cardiopulmonary changes -> monitor breath and heart sounds
- watch liver -> liver function, signs of jaundice, avoid alcohol
- teach not to drive
49
nonpharmacologic therapies for muscle spasms and spasticity
- physical therapy -> increases movement, prevents contractures
herbal remedies
- black cohosh, topical
- castor oil packs, topical
- capsaicin, topical -> includes active chili peppers so wear gloves
B complex vitamins, specifically B6
50
renal physiology*
the kidneys are major organs of excretion and homeostasis
role of kidneys in homeostasis:
- fluid balance (think HR and BP)
- electrolyte balance (think arrhythmias)
- acid-base balance (think K+<-> H+)
endocrine function of the kidney
- renin -> enzyme that helps regulate BP and electrolyte balance
- erythropoietin -> stimulates the production of RBC
- calcitrol (vit D) -used to treat low levels of calcium
51
diuretic therapy*
used for
- edema
- hypertension
- heart failure
- renal failure
- liver failure, cirrhosis
- pulmonary edema
52
common adverse effects of diuretic therapy*
- electrolyte imbalances, especially potassium
- dehydration
- hypotension -> monitor BP and HR
53
loop diuretics (high-ceiling)*
block Na+ reabsorption at the loop of Henle
either oral or parenteral admin
extensively bound to plasma proteins
indications = edema
54
Furosemide
furosemide (Lasix)
antihypertensive
Loop diuretic
used in acute edema and HTN
prevents the reabsorption of sodium and chloride by blocking the sodium/potassium/chloride symporter in the loop of Henle
55
consideration for loop diuretics
- complete health hx
- monitor VS -> apical HR, rhythm, and BP
- establish safety precautions
- observe older adults carefully
- ensure ready access to bathroom
- administer early in the day
- watch K+ levels!!!!!
56
drugs similar to furosemide *
bumetanide (bumex)
- indicated in ascites and peripheral edema
ethacrynic acid (edecrin)
- can be used in pts allergic to sulphonamides
- causes most severe hearing loss
torsemide (demadex)
- twice as potent
57
loop diuretics adverse effects
- ototoxicity
- hypovolemia
- orthostatic hypotension
- N/V
- tachycardia
- dysrhythmias
58
thiazide diuretics
most commonly prescribed class of diuretics for HTN
no ototoxicity associated
blocks Na+ absorption at the distal tubule,
indications = HTN, edema
ex. hydrochlorothiazide
59
considerations for thiazide and thiazide like diuretics*
- encourage water intake, rather than alcohol or caffeinated drinks
- caution with electrolyte drinks
- baseline and periodic determination of serum electrolytes
- measure BP before therapy and at regular intervals
- monitor ins/outs
- monitor for therapeutic effectiveness
- monitor adverse effects
- ensure ready access to bathroom
Pregnancy category B -> no shown risk to fetus but no controlled studies on pregnant women
60
overdose treatment for thiazide diuretics*
infusions of fluids containing electrolytes
61
potassium sparing diuretics
have low effectiveness but can help prevent hypokalemia
sodium channel inhibitors -> Na+ is blocked from reabsorption and excreted in urine, K+ is not excreted in urine and stores are not depleted
indications = mild HTN
ex. spironolactone
62
potassium-sparing diuretic drug interactions
- acidosis with ammonium chloride
- decreased diuretic effect with aspirin and other salicylates
- decreased effects of digoxin (control heart rate , rhythm, and/or strength of the heart)
- can cause hyperkalemia with potassium supplements, ACE inhibitors (increase potassium), ARB (angiotensin receptor blockers, treat HTN, HF, CKD)
- additive hypotensive results with other antihypertensives
63
principle of fluid imbalance*
body fluids continuously travel between intracellular and extracellular compartments via semipermeable membrane
- water
- ICF = 2/3 water in body
- ECF = 1/3 water in body
balance problems between intake and output can lead to fluid imbalance disorders and cause shock and dehydration
64
hormones and fluid imbalance
ADH - tells kidneys to increase water reabsorption, keep water in the body
Aldosterone - tells kidneys to hold on to Na, electrolytes, and water
65
electrolytes *
are charged substances (+ or -) and are essential to homeostasis
imbalance is a sign of a medical condition
- tx = diagnose and correct the underlying cause of disorder
Na2+, K+, Mag2+, and Ca2+ are most important
66
Na+
sodium balance is closely associated with water balance
135- 145 mEq/L
hypernatremia = sodium serum level greater than 145
hyponatremia = sodium serum level less then 135
treat with sodium chloride
67
adverse effects of giving sodium chloride
- hypernatremia -> watch near status/LOC
- lethargy
- confusion
- muscle tremor or rigidity
- hypotension
- restlessness
- pulmonary edema
68
K+*
potassium unbalances must be quickly corrected to prevent serious cardiac consequences
3.5 - 5 mEq/L
most abundant intracellular cation
insulin is a key hormone for maintaining potassium balance
hyperkalemia = serum level greater then 5
hypokalemia - serum level less than 3.5
usual cause is pharmacotherapy with loop and thiazide diuretics
treat with potassium chloride
69
indications for administering K+
- preventing hypokalemia
- treatment of hypokalemia
- treatment of mild alkalosis
70
diuretic pharmacotherapy
common to combine two or more drugs
71
2 Gs with NSAIDS
watch for GI bleeds and the GFR (must be above 60)
72
Mag2+ *
magnesium imbalances significantly affect cardiovascular and neuromuscular function
second most abundant intracellular cation
levels controlled by kidneys
0.65 - 1.05 mmol/L
hypomagnesemia= serum levels below 0.65
cause by renal problems and loop diuretics
hypermagnesemia = serum level about 1.05
advanced renal failure is only major cause
give magnesium sulfate to treat hypomagnesemia
73
adverse effects of giving magnesium sulfate *
- diarrhea
- magnesium overdose
- flushing of the skin
- sedation
- confusion
- intense thirst
- muscle weakness
74
serious adverse effects of giving magnesium sulfate*
- neuromuscular blockade
- respiratory paralysis (watch RR)
- heart block
- circulatory collapse
75
Ca2+
the most abundant mineral in the body
2.1 - 2.5 mmol/L
hypercalcemia = serum level greater than 2.5 mmol/L
most commonly results from overactive parathyroid glands
hypocalcemia = serum level less that 2.1 mmol/L
sign of underlying pathology
caused by
- lack of calcium of vitamin D
- hypothyroidism
- drug therapy
serum ionized calcium (iCa) = ionized 1.15 - 1.35 mmol/L
76
adverse effect of administering calcium*
- constipation
-N/V
- metallic tast
77
serious adverse effects of administering calcium*
- hypercalcemia
- dysrhythmias
- cardiac arrest
- confusion
- delirium
- stupor (near unconsciousness)
- coma
78
contraindications/ precautions of administering calcium
- hypercalcemia
- hyperparathyroidism
- digoxin toxicity
- renal or cardiac insufficiency
- dysrhythmias
- dehydration
- diarrhea
- sarcoidosis (metastatic bone disease)
- renal calculi (kidney stones)
- hyperphosphatemia
- cardiac abnormalities caused by hypercalcemia
79
Gingko biloba *
the flavones of gingko can be dangerous to patients on anticoagulants
80
natural supplements and safety*
natural does not always been safer -> opium and digoxin are technically natural
some active chemicals are the same strength as in prescription and OTC medications
allergic reactions can occur with the use of natural products
don't necessarily have fewer SE
not always less expensive
can reduce the need for prescriptive meds
81
herb-drug reactions*
herbal products can interact with prescribed medication action
- synergistic reactions
- additive effects
- antagonistic effects
82
ginseng*
- decreased blood sugar
- increased energy
- decreases stress
- decreased blood pressure
- decreases sexual dysfunction
avoid use with insulin and oral hypoglycaemic agents
American ginseng may lower blood sugar levels
Avoid caffeine or other substances that stimulate the CNS when taking asian ginseng as ginseng may increase their effects
Morphine -- Asian ginseng may block the painkilling effects of morphine.
83
ginkgo biloba information*
an antioxidant
- increases blood flow
- decreases blood pressure
- increases memory
interacts with anticonvulsants = decreased seizure control
tricyclic antidepressants (SSRIs) = risk of serotonin syndrome
increase effects of anticoagulants
decrease insulin levels in diabetics
84
ginko and ginseng*
may decrease blood pressure
both have blood thinning properties, should not be used with anticoagulant meds
taking these remedies with SSRIs may cause serotonin syndrome -> rigidity, tachycardia, hyperthermia , restlessness, and diaphoresis
85
black liquorice *
regulates hormone, decreases stress, decreases fat
large amounts (+ 4 weeks) = HA, increased blood pressure, decreased potassium (DANGEROUS)
increased effect on digoxin, aspirin GI irritation, steroids, and potassium loss with laxatives
86
ginger *
- decreased nausea
- decreased IBS/stomach issues
- decreased inflammation
- increased effective on anticoagulants
87
feverfew*
- decreased fever
- decreased inflammation
- decreased migraines/dizziness
- decreased N/V/ tinnitus
- decreased blood pressure
increased effect on anticoagulants and NSAIDs
88
garlic*
- thins blood
- increased immunity
- decreased cholesterol
increased effect on anticoagulants
89
valerian*
used for sleep disorders
- decreases anxiety
- decreased BP
increase effect of CNS depressants -> bentos, barb., anticonvulsants, sedatives
90
kava kava*
used for sleeping problems
- decreased stress and anxiety
- decreased convulsions, relaxes muscles
increased effect on CNS depressants, adderall, 5-HTPs
91
St. John's wort*
- decreases depression and anxiety
- decreases insomnia
- increases appetite
increased effect on CNS depressants
92
melatonin*
decreased insomnia
decreased effect on antidepressants effects of desipramine and fluoxetine (prozac)
calcium channel blockers may decrease melatonin
93
saw palmetto*
- decreased BPH
- decreased urinary retention
- decreased nocturne and assists in initiating urination**
decreased absorption of iron
decreased effect of oral contraceptives
has a hormone like effect
- avoid in pregnancy, lactation, and hormone sensitive cancers
do not take with finasteride -> similar effects
94
turmeric*
- decreased inflammation
- decreased tumors
- decreased infections
- decreased stomach problems
enhances anticoagulants
decreases effect of proton pump inhibitors and H2 blockers -> increases amount of stomach acid
95
CAM
complimentary and alternative medicine
96
water soluble vitamins
stored briefly, than excreted
B complex and C
97
fat soluble vitamins
stored in liver and fatty tissues
A, D, E, K
"DEAK"
found in fatty foods and oils
excessive intake can be harmful
98
vitamin K (aquamephyton)
helps produce RBC and synthesize clotting factors
used to treat neonatal hemorrhagic disease
drug of choice as antidote for warfarin overdose (blood thinner)
takes 3-8 hours to stop bleeding
99
Riboflavin *
vitamin B2
works by catalyzing cellular respiratory responses
large amounts of bright yellow urine
100
Pyridoxine (Vitamin B6) contraindications/precautions*
renal impairment/immaturity
cardiac disease
*caution with parkinsons medication* -> decreased effects of levodopa
101
Vitamin C (ascorbic acid) *
enhances iron absorption
used to enhance wound healing -> is essential for synthesis and maintenance of collagen
helps maintain the immune system
102
trousseau's sign
observed in patients with low calcium
this sign may become positive before other gross manifestations of hypocalcemia
believed to be more sensitive (94%) than the Chvostek sign (29%) for hypocalcemia
103
2 kinds of corticosteroids
glucocorticoids and mineralocorticoids
104
steroid hormones
a class of hormones secreted by the adrenal cortex
includes aldosterone, cortisol, androgens, estrogens, and progestins
105
glucocorticoids
ex. cortisol
control carbohydrate, fat, and protein metabolism
controls anti-inflammatory effects due to decreased phospholipid release and decreased eosinophil action
106
mineralocorticoids
ie. aldosterone
controls electrolyte and water levels
promotes sodium retention in the kidney
107
general info corticosteroid medications
- well absorbed, widely distributed to all body tissues -> expect when inhaled
- highly bound to plasma proteins
- metabolized by the liver
- excreted by kidneys
- secreted in breast milk
108
long term treatment of corticosteroids*
corticosteroids are frequently used to
- suppress the inflammatory process
- decrease the immune responses
pts on long term steroid therapy:
- leads to adrenal atrophy from lack of stimulation
-must avoid LIVE vaccines
- report weight gain over 2lbs in ONE day
- oral route is the best option for chronic vs acute
higher doses = faster atrophy of the adrenal gland (2-4 weeks)
109
adverse effects of chronic corticosteroids *
- suppression of immune system
- decreased inflammatory responses
-GI bleeds/ peptic ulcers
- behavioural changes
- metabolic changes/fat redistribution and fluid retention
110
preventing adverse effects of corticosteroids
- lowest dose possible
- alternate day dosing
- for acute conditions : large doses, then gradually taper -> NEVER stop suddenly
give locally when possible, decreases change of producing systemic adverse effects when inhaled
111
adrenal crisis
usually occurs when corticosteroids are abruptly withdrawn
- hypotension
- lethargy
- N/V
- renal failure
- asthenia (weakness, tired)
tx:
- immediate IV administration of hydrocortisone (glucocorticoid)
112
Cushing syndrome
caused by high levels of corticosteroids over a long period
high mortality rate
113
hydrocortisone
treats:
- adrenocortical insufficiency
- inflammation
- allergic disorders
restores deficient levels of glucocorticosteroids
114
hydrocortisone drug interactions*
- potassium wasting drugs
-anti-cholinesterase agents
- no LIVE vaccines
- toxoids
- insulin and oral hypoglycaemic drugs
- aloe, senna, cascara, buckthorn
increases effect of:
erythromycin (antibiotic)
ketoconazole (used to treat fungal infections)
decreases effectiveness of
salicylates
barbiturates
phenytoin
rifampin
115
fludrocortisone
mineralocorticoid
drug for hypoaldosteronism
treats adrenocortical insufficiency
acts on distal renal tubule to promote sodium and water reabsorption and increase urinary potassium excretion
116
physiology of the thyroid gland*
low blood levels of T3 and T4 triggers the negative feedback loop
hypothalamus -> releases TRH (thyrotropin releasing hormone) -> acts on the anterior pituitary -> releases TSH (thyroid stimulating hormone) -> acts on the thyroid -> produces T3 and T4
117
diagnosis of thyroid disorders*
TSH is the preferred lab value
low TSH = good
primary hypothyroidism = low serum T4 and elevated TSH
Hashimoto thyroidits = abnormal levels if antithyroid antibody -> attacks thyroid cells
118
T3
tri-iodothyronine
119
T4
thyroxine
120
hypothyroidism
treated by replacement therapy with thyroid hormone
with levothyroxine (T4) or levothyroxine plus liothyronine (T3)
121
Levothyroxine contraindications*
CARDIAC DISEAESE
- acute MI
- angina pectoris
- cardiac dysrhythmias
- sensitivity to the drug
- adrenal insufficiency
- hypertension
- impaired kidney function
- diabetes
- elderly pts
-tx of obesity
122
levothyroxine drug interactions*
phenytoin (an anticonvulsant) -> accelerates the metabolism of levothyroxine
123
levothyroxine food interactions*
- soybean
- walnuts
- dairy
- calcium
- iron supplements
- strawberries
- peaches
-pears
- cabbage/brussels sprouts
124
TEST QUESTION! What foods should the nurse instruct a client to avoid when taking thyroid replacement medication?
- soy sauce
- yougurt
- milk
- strawberries
- red meat
soy sauce
yogurt
milk
strawberries
RED MEAT IS INCORRECT
125
TEST QUESTION! A client with inflammatory arthritis asks about adding an anti-inflammatory herb to the medication regimen to decreases the use of prescription drugs. The nurse suggests the client discuss the efficacy of which herbs with the health care provider?
- tumeric
- feverfew
- ginger
- ginseng
- bilberry
- tumeric
- feverfew
- ginger
NOT GINSENG OR BILBERRY
126
levothyroxine considerations*
- assess for allergy to aspirin
- if HR greater than 100 bpm do not administer
- watch for S+S of increased or decreased thyroidism
- assess vital signs and cardiovascular status if catecholamines (class of amines that include epinephrine and dopamine) are use concurrently (THINK BEAR)
- monitor pts who are taking warfarin for bleeding
- monitor bloos glucose in diabetics
- monitor monthly height, weight, growth, development in infants
127
graves disease
too much thyroid hormone
hyperthyroidism
128
Addisons disease
not enough cortisol or aldosterone
need to "add" steroids
129
Question
Answer
130
*critical care drug/ narrow safety margin
is NOT appropriate for a generic drug to be substituted for a brand name version
131
*bioavailability
the rate and extent that active ingredients are absorbed from a drug product and is available at the site of action
132
*factors affecting bioavailability
- different trade vs generic
- inert or active ingredients
- rate of absorption
- tablet compression -> extended release
133
*nurse "need to knows" before administering drug
- what drug is ordered and why
- name of drug
- intended use
- effects on the body
- contraindications/precautions
- special considerations
- adverse effects
- how to administer the drug
- how drug is supplied by the pharmacy
134
*nurses must obtain ____ before giving med
- physical assessment
- past medical history
- any known allergies
- previous medications
- pts learning capabilities
135
* first pass effect
drugs absorbed from the stomach and small intestine travel to the liver -> might be inactivated before reaching target organ
pt. may require a larger does of oral meds than IV meds because of the first pass effect
IV meds surpass the first pass effect
136
*rectal route
avoids the first-pass effect
137
*Absorption during pregnancy -> increased progesterone levels
- increases pulmonary blood -> higher absorption rates of respiratory agents (ex. cromolyn)
- decreased intestinal motility -> delayed gastric emptying
138
* absorption during pregnancy -> increased levels of estrogen
- decreased intestinal motility and increased stomach acid
- extended/decreased absorption time for oral drugs
due to nausea and vomiting some pregnant women are unable to take oral meds early in pregnancy
139
* nicotine during pregnancy
use of nicotine during pregnancy stimulates the production of certain enzymes in the placenta
can affect how drugs and other substances are processed -> may alter the effectiveness or toxicity of meds and can impact fetal development
140
* drug metabolism in pregnancy
it is significantly altered throughout pregnancy
increased hormones -> influence liver enzyme activity
increased blood volume -> dilute drug concentrations
altered liver function -> liver enzyme activity can change, leading to faster or slower metabolism of drugs
141
*fetal liver
is still developing and lack the ability to metabolize most drugs taken by the mother
medications must be used very cautiously in pregnant women
142
*drug excretion during pregnancy
is enhance during pregnancy
dosage of many meds must be adjusted
143
*medication dosage
is ALWAYS based on mg per kilo weight per day and NOT age
144
*medications toddlers are often poisoned by
poisoning is extremely common -> due to curiosity, putting things in their mouth
- analgesics
- cough syrups
- topical ointments (norma story of daughter putting ointment cream all over her body, absorbed a lot of the med quickly)
- vitamins
145
OTC medications
- cough and cold meds
- analgesics
- NSAIDS
- antihistamines
- expectorants (meds to treat mucus that is coughed up)
- GI
don't require prescriptions
146
Drawbacks of OTC
masks the S+S of an underlying problem -> makes it difficult to diagnosis problem
labels aren't read correctly
"if one makes me feel good, 2 will make me feel really good"
increased incidence of drug interactions
pts consider OTC drugs not "real drugs", don't report to HCP
147
nurses role with OTC drugs
must know past medical/medication history
know allergies
pt education
148
*Therapeutic index (TI)
therapeutic index is the ratio of a drugs median lethal dose to its median effective dose
the higher the value -> the safer the med
therapeutic index = serum blood level monitoring
must monitor amount of med in the blood stream for the following ->
gentamicin
tobramycin
vancomycin
lithium
digoxin
warfarin
149
*Margin of safety
MOS
the amount of drug that is lethal to 1% of animals divided by the amount of drug that produces a therapeutic effect in 99% of animals
150
*prescription drug with a high MOS
a prescription drug that shows a high MOS may be reclassified as an OTC drug
151
*dose-response relationship
drug dose correlates to the degree of response
phase 1 = lowest doses (sub therapeutic)
phase 2 = most desirable range
phase 3 = plateau reached
once phase 3 is reached increasing dose will NOT increase therapeutic effect -> could cause toxicity
antibiotics will cause toxicity if surpassed phase 3
152
-mycin
antibiotics
153
*drug potency and efficacy
potency = amount of drug needed to produce specified effect -> less drug with faster intensity drug response
smaller dose of drug A to get same therapeutic effect as drug B
efficacy = effect or outcome of drug, the greatest response produced by drug
drug A has better therapeutic effect than drug B while using the same dose
efficacy is more important in terms of pharmacotherapeutic effects
drugs in the same class can differ in potency and efficacy
154
*drugs effect on physiological processes
most drugs enhance or inhibit a physiological process
155
receptor theory
majority of drugs produce therapeutic effects by stimulating or inhibiting receptor sites
156
receptor
a cellular molecule to which a medication binds to produce its effects
157
intrinsic activity
there is high intrinsic activity when the drug has the ability to bind to a receptor and produce a strong action
158
antagonists
do NOT have intrinsic activity (don't activate receptors)
instead the block or inhibit the action of agonists which are substances that bind to receptors and activate them
159
agonists
substances that bind to receptors and activate them to produce a biological response
mimic the action of endogenous substances -> response may be greater than endogenous activity
160
partial agonists
produce a lesser endogenous effect
have a ceiling effect
161
mixed agonist-antagonist given with an agonist
when taking a mixed agonist-antagonist given with an agonist , the mixed agonist-antagonist will act as an antagonist
162
* additive effect
when two drugs with similar pharmacology actions are taken together -> 1+1=2
diuretic and beta blockers to lower BP = really lowers BP
163
*controlled substances
a drug or chemical whose manufacture, possession, or use is regulated by the government
- illicitly used drugs
- prescription meds that are designated a controlled drug
any drug that has a potential for abuse is a controlled substance and is restricted
164
* scheduled drugs
drugs are classified into 5 categories or schedules
schedule 1 (I) drugs -> high potential for a use and the potential to create sever psychological and physical dependance
ex. heroine, LSD, marijuana, ecstasy
schedule 5 (V) drugs -> least potential for abuse, contain limited quantities of certain narcotics
165
* adverse effects
aka ADEs (adverse drug reactions)
are undesirable effects that occur secondary to a medication
are potentially harmful
all drugs have potential for adverse effects
166
adverse drug reactions (ADRs)
are a type of ADE (adverse effect) where the cause is unknown
167
side effects
predictable
can occur at therapeutic doses
distinguished from adverse effects by severity
168
*allergic reactions
a previous drug exposure is necessary to inflict a allergic reaction
family history to a reaction of a specific drug typically does NOT increase chance of reacting to the same drug
S+S of a drug allergy usually occur within an hour after taking the drug, but can occur at ANY time while receiving the drug -> less common to react hours, days, weeks later
cross-sensitivity -> cephalosporins (broad spectrum antibiotics) to PCNs (penicillins) = 15%
169
*patient education/safety to reduce med errors
essential for safe med use -> especially with parents of small children
age appropriate language
includes:
- carry a list of ALL current meds, including non-prescription
- have allergies listed
- use one pharmacy if possible
- consult the pharmacist if your med looks unfamiliar -> ask questions
teach med names, uses, doses, and how/when to take them
teach adverse reactions and which ones to report ASAP
teach to read the drug label prior to EACH administration
all leftover meds should be properly disposed of -> don't save for future
170
*goals of pain management
- immediate goal -> reduce pain to a level that allows pt to perform reasonable ADLs
- pt is considered expert of their own pain
- pain management is a pt right
- non pharmacological interventions = lower prescription doses and fewer drug-related adverse effects of pain meds
- dosing is individualized and adjusted
- adverse effects should be anticipated/prevented whenever possible
171
*combo therapy
opioid and non-opioid therapies
best option as this helps to relieve pain synergistically and decreases risk of side effects
172
synergist effect
acts to enhance the action of another drug -> 1+1=3
ex. NSAIDs and opioids
local anesthetic and opioids
173
potentiate effects
drug that has no effect enhances the effects of the 2nd drug 1+0=2
folate added to psychiatric meds
174
*pain history
price experience with pain
previous methods of opioid control
attitude toward use of opioids
history of substance abuse
use a pain scale**
175
* common truths about pain
- pt may not appear to be in pain -> pts, in general, can sleep with in pain
- very few pts will become addicted to their medications
- pts that are addicted don't necessarily over report pain because they are drug seeking
- VS are NOT reliable indicators of pain -> ex. chronic pain, their bodies adjust so they are not constantly in fight or flight
176
adjuvant drugs
used to enhance the effects of pain medication and provide analgesia
can be used at all three steps of the analgesic ladder
Tricyclic antidepressants -> good for neuropathic (tingling/burning nerve) pain
Anticonvulsants
Anxiolytics (reduces anxiety)
177
*non-opioid analgesics
characterized by:
- they have a ceiling effect -> increasing the dose beyond an upper limit provides no greater analgesia
- they do not produce tolerance or physical dependence
- many are available without a prescription
2 categories:
-NSAIDS
- acetaminophen
178
*NSAIDs
non-steroidal anti-inflammatory drugs
3 major classes
- salicylates
- ibuprofen and ibuprofen-like agents (COX-1) inhibitors
- cyclooxyrgenase - 2 (COX-2) inhibitors
ASA used for MI NOT ibuprofen**
actions:
- anti-inflammatory**
- analgesic
- antipyretic
179
*treatment for MI
ASA used NOT ibuprofen
180
* inflammation
injury -> stimulate the release of prostaglandins, bradykinins, histamine -> makes a "soup" in the peripheral microenvironment
natural process causes the release of chemical that imitate the inflammation process
these chemicals increase permeability of blood vessels -> causes edema and infiltrations of WBC (macrophages)
ASA and ibuprofen inhibit the COX synthesis -> decreases inflammation
181
ASA (Aspirin)
properties:
- anti-inflammatory effect -> inhibits the synthesis of prostaglandin and causes direct cellular injury as it is absorbed across the stomach mucosa **
- antipyretic effect -> blocks prostaglandin mediator of pyrogens
- anti-platelet agent -> use with TIA, unstable angina, and MI patients (more effective in males than females)**, low dose aspirin (81mg)
182
*ASA (Aspirin) adverse effects
- stomach irritation
- heartburn
- nausea
- vomiting
- diarrhea
- stomach pain
183
* ASA (aspirin) serious adverse effects/OD
- occult bleeding (blood you can't see)
- nephrotoxic effects
- hepatotoxicity
- tinnitus (ringing or buzzing) and/or hearing loss**
treatment -> emesis, gastric lavage, hemodialysis
184
*salicylate poisoning
ASA overdose
-increased temp
-tinnitus (ringing/buzzing in ears)
-N/V
-lethargy
-hyperventilation leading to respiratory acidosis
severe toxicity = metabolic acidosis and seizures
toxic level for a 30lb child = 12 adult aspirin or 48 baby aspirin
185
* ASA (aspirin) considerations
check prothrombin time (test to evaluate blood clotting, prothrombin is a factor that helps it clot, produced by liver) and international normalized ratio (INR) (tells how long it takes for your blood to clot) with CONCURRENT anticoagulant use
check fasting blood glucose if diabetes is present
watch for aspirin toxicity
never give ASA to children (especially after a viral illness) = risk of Reye's syndrome
186
Reye's syndrome
fatty liver and encephalopathy that can lead to death
swelling of liver and brain
due to use of aspirin during viral infection
187
*NSAIDs COX 1 inhibitors
ibuprofen, naproxen, ketorolac
- have a ceiling
- inhibition of cox-1 (and some cox-2) will result in gastric ulcer, bleeding, renal damage
- analgesic, anti-inflammatory, and antipyretic properties
- most are weak acids = can damage GI mucosa -> watch for GI bleeds **
metabolized by the liver
nephrotoxic at high doses
caution with asthmatics (prostaglandins) -> can induce bronchospasm
188
cox -1
generates prostaglandins that are involved in the protection of gastrointestinal mucosa
189
cox-2
generates prostaglandins that mediate pain and inflammation
190
*acetaminophen
analgesic/antipyretic
COX 2 inhibitor
MAX DOSING 4g/day
has no anti-imflammatory properties
does not cause GI bleeding or ulcers
action:
- works directly on the hypothalamus -> causes sweating/vasodilation which decreases temp
action for analgesia has not been identified
comes in PO and rectal (PO is faster than rectal**)
often combined with opioid analgesics
IV route called Ofirmev (10mg/ml) -> not supplied in Canada
191
*opioid side effects -> orthostatic hypotension
orthostatic hypotension
-> decreases cardiac work load by decreasing venous return and arterial pressure
-> therapeutic in congestive heart failure and pulmonary edema
-> caution when getting patients up right after administration of opioid -> FALL RISK
192
opioid consideration
start low go slow
when dosing at each level of the ladder, start oral if possible, then transdermal of iv (unless in acute situation)
193
negative opioid side effects
work down from head to toe to remember
decreased LOC
N/V
respiratory depression
constipation
urinary retention
pruritus
myoclonus (muscle twitches)
194
OP3 agonists
OP3 is a major opioid receptor
these drugs have no ceiling effects3
195
individual opioid pain relief
there is no set amount of an opioid that will produce pain relief -> its individual
196
analgesic ladder
start at step 1 work your way up as needed
step 1 = non-opioid, +/- adjuvant
step 2 = opioid for mild to moderate pain, +/- non-opioid, +/- adjuvant
step 3= opioid for moderate to severe pain, +/- non-opioid, +/- adjuvant
197
step 2 drugs
considered to be "weak" opioids
not potent (codeine)
available in fixed formulations with other drugs like ASA or acetaminophen
limit the opioid dose due to the ceiling dose of the ASA or acetaminophen
codeine, oxycodone, hydrocodone,
198
step 3 drugs
when progressing up to step 2 and 3 remember to continue step one drugs
Remember oral first and then IV at each level
morphine, hydromorphone (cleaner than morphine), fentanyl, methadone
199
*fentanyl patches
patches applied every 3 days
if pt has an allergy to an opioid -> fentanyl is considered safe
200
* tramadol
centrally acting opioid analgesic
treats moderate pain
weak opioid agonist activity
may causes seizures** (ADR)
201
*tramadol drug interaction
- with certain antidepressants/MAOIs -> increased risk of seizures
- with ethanol (alcohol> -> sudden death, NO ALCOHOL!!
-reduced analgesic effect with drugs that inhibit the CYP2D6 enzyme (walking on the same path, might get elbowed off)
treatment of overdose = naloxone, may precipitate convulsions
202
*Naloxone (narcan)
narcan is a pure OPIOID antagonist that blocks all narcotic agonist activity for a short period of time -> competes for parking spots at opioid receptor sites
does nothing if pt has OD on street drugs or meds that aren't opioid based
only use in small doses for pts with chronic pain -> don't take all pain relief away, gentle reversal
narcan is a treatment for respiratory depression
onset = 1-2 mins IV, 2-5 mins IM/SC
203
general anesthesia
loss of sensation throughout whole body
204
*local anesthesia
loss of sensation to limited body are, no LOC changes
less control over onset, duration of drug action -> it depends on the drug's ability to diffuse from application site to surrounding nerves
can be used with epinephrine as a vasoconstrictor to :
- limit loss of blood at surgical site
- reduce systemic distribution of the drug
- extended duration of action of local anaesthetic
DO NOT use epinephrine and local anesthetic on
- fingers
-nose
- penis
- toes
205
Reginal anesthesia
similar to local, but encompasses a larger body area-> body limb
206
monitored anesthesia care (MAC)
responsive, respirations without assistance -> varying levels of pt responsiveness
207
*principles of general anesthesia
- incorporates a combo of meds to allow for lower and safer doses
- neuromuscular blockers -> are adjuncts to anesthesia, (succinylcholine) watch for respiratory paralysis
- short-acting benzodiazepines (slow down activity in brain and nervous system)
- opioids
- general anesthetics (inhaled and iv)
208
*forms of anesthesia
-IV -> given 1st
- inhaled/gas -> given second
- local/topical
commonly used classes
- benzodiazepines
- opioids -> used as IV anesthetics to provide analgesia and to accomplish neuroleptic anesthesia (feelings of indifference to pts surroundings)
209
neuroleptic anesthesia
feelings of indifference to pts surroundings
210
*adverse effects of IV anesthetics
- skeletal muscle rigidity**
- resp depression
- apnea
- bradycardia
- N/V
- constipation
- urinary retention
211
*IV anesthetic considerations
monitor for respiratory depression and LOC if systemic
-> meds like succinylcholine (paralytic) - watch for respiratory paralysis**
monitor ECG for cardiac dysrhythmias
monitor for dystonia = state of abnormal muscle tone resulting in muscle spasms -> abnormal posture means not working before procedure -> may need to make med adjustments to prevent dystonia
212
*Local anesthetic uses
infiltration anesthesia provides local coverage -> used for a chest tube**
213
*cholinergic medications
medications that mimic or stimulate cholinergic receptors -> pro pig
agonists = possible SE are increased salivation, digestion, airway constriction, slower HR, pupil constriction
use caution with other cholinergic agents -> has additive effects (1+1=2)
214
*physostigmine
is used as an antidote for anticholinergic poisoning (atropine) and common pesticide poisoning
215
* respiratory drugs
are meds used in the treatment of asmtha and COPD
- bronchodilators (B2 agonists and anticholinergics)
- anti-inflammatories
- mast cell stabilizers
- leukotriene modifers
- methylxanthines
- monoclonal antibodies
- mucolytics
216
* severity of asthma -> related to drugs
depending on the severity of a persons asthma, they may be on several of theses classification of anti-asthmatic meds
the more meds the more serious
217
*PNS pathway
has Ach (acetylcholine) binding sites
- muscarinic = (Ach) -> ex. slowed HR
- nicotinic receptors = (Ach)
218
*SNS pathway
has 2 different binding sites:
Ach -> norepinephrine/adrenalin
nicotinic receptors = Ach
Norepinephrine receptors = norepinephrine / adrenalin
219
*Parasympathetic
PNS
Think sloppy, drooly, pig / rest and digest
HR decreases
RR decreases
Airway decreases
BP decreases
Saliva increases
GI increases (stimulates peristalsis and release of bile)
GU increases
pupils decrease
220
*sympathetic
SNS
think BEAR!! / fight or flight
HR increases
RR increases
Airway increases
BP increases
Saliva decreases
GI decreases
GU decreases
Pupil increase
promotes the conversion of glycogen to glucose
221
*SNS synonyms
kick the bear meds
- sympathomimetic
- adrenergic agonists
- beta agonist
don't stimulate a sympathetic response, but block the PNS so you'll get a sympathetic type response
- anti-cholinergic ->atropine
- cholinergic antagonist
- muscarinic antagonist
- parasympatholytic
222
*PNS synonyms
sloppy drooly pig meds
- parasympathomimetic
- muscarinic agents
- cholinergic agents
cholinomimetic
don't stimulate a parasympathetic response, but block the SNS so you'll get a parasympathetic type response
- adrenergic antagonist
- beta antagonist
- beta blocker -> acetylcholine
223
*bronchodilators
sympathomimetic agents
- directly relax airway smooth muscle by stimulating beta 2 receptors -> results in bronchodilator
- inhibits release of some bronchoconstricting substances from the mast cells
- increase mucociliary transport
224
*Beta 2 agonists
= bronchodilators
are classified based on duration of action
short acting (SABA) -> salbutamol (Ventolin)
- immediate onset of action, last 2-6 hours
- used for ACUTE attacks
- rescue inhaler
- 1-2 puffs Q4H
intermediate
- slow onset
- last about 8 hours
long acting (LABA) -> salmeterol (serevent) : think parking meter
- slow onset
- lasts up to 12 hours
- take BID
- usually in combo with a steroid
Beta 2 agonists do not treat inflammation
225
*side effects and ADrs of beta 2 agonists (bronchodilators)
ADRs
- tachycardia
- tremors
- chest pain
Side effects
think all of the SNS symptoms
226
*Bronchodilators (beta 2 agonists) drug interactions
conflicting drugs:
- bete blockers
-MAOIs
- Thyroid hormone
- avoid caffeine
listed as a pregnancy category C -> potential maternal benefits may warrant use, despite potential risk
227
*anti-cholinergics
blocks the PNS and you see SNS effects
blocks the action of Ach at vagus nerve mediated sites
-> doing this relaxes smooth muscles in bronchioles
be careful with glaucoma pts and be aware that is can heighten effect of other anticholinergic drugs or beta agonist drugs
blocks the pig, doesn't kick the bear
used in combo with beta 2 agonists(bronchodilators) or if pt can't tolerate beta 2 agonists
228
short acting anticholinergics
ipratropium bromide = atrovent
- 1-5 min onset
229
long acting anticholinergics
tiotropium bromide = Spiriva
- half life of 5-6 days
230
* anticholinergics contraindications
- hypersensitivity to ipratropium, soya lecithin, soybeans, peanuts
- narrow - angle glaucoma
-BPH (benign prostatic hypertrophy) -> enlargement of the prostate gland
- urinary tract obstruction
- renal disorders
causes urinary retention
231
dry as the desert
think anticholinergic
drys everything up
232
*inhaled corticosteroids
Are anti-inflammatories
- prevent narrowing of airway inflammation
- relax smooth muscle of the lung -> promotes beta 2 activity
not used for acute asthma
used to prevent or reduce frequency of chronic asthma attacks, when not controlled by bronchodilators/non-steroid medications
most effective drugs for the LONG-TERM control of asthma *
suppresses inflammation without major adverse effects
use of inhaled steroids long-term, may affect bones, but minimal compared to oral steroids
rinse mouth to prevent thrush.
233
*mucolytics
works to breakdown mucous to aid in coughing it up
increases clearance of sputum
decreased tenacity of mucous -> mucomyst - acetylcysteine
given as a nebulizer, orally, or iv
234
*other uses for Acetylcysteine (mucomyst)
used to treat an acetaminophen (Tylenol) overdose
235
*MDI with a spacer
spacers allow for better medication inhalation and allow for use by pts with decreased dexterity
the areochamber
236
enteric coated drugs
dissolve based on pH
good for sensitive stomach, and to treat ulcers
