Pharm Final

6 Rights of Med Admin

1. Right Patient

2. Right Time

3. Right Drug

4. Right Dose

5. Right Route

6. Right Documentation

Remembering Analgesics (NOT OPIOIDS)

• NSAIDS: suffix is -profen (ex: ibuprofen, fenoprofen), -olac (diclofenac, celecoxib, ketorolac, naproxen,)

• Salicylates: aspirin (ASA)

• Nonsalicylates: acetaminophen

Acetaminophen (Tylenol - class, therapeutic uses, must know effects)

Class: Nonsalicylates, analgesics, antipyretics

Therapeutic Uses: mild to moderate pain, fever or flu-like sx’s, aspirin substitute

Side-Effects: GI upset, impaired liver function

Nursing Considerations: assess alcohol use before admin and educate to limit or discontinue alcohol use

Patient Ed: limit dosage to less than 3k mg a day, have pt limit or discontinue alcohol use

Mechanism of Action for Tylenol and Antidote

• Mechanism of Action inhibits prostaglandin synthesis by blocking the Cyclooxygenase (COX) enzyme - ends up blocking pain and inflammation

• Antidote: acetylcysteine - acetylcysteine think acetaminophen

NSAIDS (class, uses etc.) —> Ibuprofen, Naproxen + Ketorolac

Class: analgesic, anti-inflammatory

Use: mild to moderate pain, menstrual cramps, antipyretic, musculoskeletal disorders

Side Effects: GI upset, impaired renal function, HTN, clot formation (those w/o aspirin) - think N like NEPHROTOXIC

Patient Ed: take w/ food, take ppi’s, report signs of GI bleed.

MOA: inhibits prostaglandin synthesis by blocking the cyclooxygenase (COX) Enzyme

Describe Hydantoins: Phenytoin

• AKA Dilantin - traditional AED

• Adverse Effects: sedation, ataxia, gingival hyperplasia, acne, hirsutism, coarsening of facial features, arrythmias, osteoporosis

• narrow therapeutic index

• Highly protein bound = drug interactions

• Contraindicated: known drug allergy, teratogenic

• DO NOT STOP SUDDENLY

Describe Phenytoin - IV admin

• very irritating to veins

• slow IV directly into a large vein with a large gauge catheter

• diluted in normal saline for IV infusion

• filter must be used

• saline flush

Opioids - What to Remember from Final Guide

• Short term for acute pain or end of life care

• Morphine: acute pain such as post-op, injury, MI, sickle cell crisis

• Assess Pain Scale, Resp. Rate, LOC (level of consciousness) before admin

• Adverse Effects: sedation, dizziness, urinary retention, risk of respiratory depression/OD.

• THESE DRUGS ARE NOT ANTI-PYRETIC OR ANTI-INFLAMMATROY

PT Ed for Opioids

• Constipation is a common adverse effect, ensure adequate fluid & fiber intake, ambulation when ready

• Paralytic Ileus should be suspected if no bowel sounds, not passing gas or stool, abdominal pain/cramps. If it is suspected, do not give opioids due to the suppression of propulsive contractions in the bowel

• Instruct patients to follow dosing directions and never change dosage without consulting provider

• Increased sedation effects in the older patient, increased risk of confusion, sedation & falls

Nursing Actions for Assessment of Pain

use OLDCARTS or PQRS, assess pain, document pain severity, known allergies, medications, alcohol, substance use, medical, family, and social history

Assess for potential contraindications

Obtain baseline vitals

Do NOT admin opioids if RR <12, abnormal LOC - call provider and have naloxone at bedside w/ resus equip

How to ID Opioids (prefix/suffix?)

Look for the O’s

• hydrOmOrphOne

• cOdeine

• OxyContin

• OxycOdOne

• Fent

• mOrphine sulfate

Long Term Adverse Effects for Opioids + Killer Adverse Effects

CONSTIPATION - everything becomes Slow and Low on Opioids

• LOW RR - respiratory depression: hold dose for under 12 breaths per min

• LOW BP - hypotension or orthostatic hypotension: if client becomes dizzy help them into a seated position and DO NOT LET THEM UP UNASSISTED

• LOW Brain - CNS Sedation: they may easily fall asleep or become unarousable

Benzo’s What to recall from the Final Guide

• Alprazolam, diazepam

• understand SE’s such as drowsiness, confusion, slowed response

• risk of dependence (do not use daily), risk of OD - antidote is flumazenil

• NO GRAPEFRUIT JUICE. these drugs may be crushed and mixed with foods

Name some Benzo’s

alprazolam (Xanax) - short term relief

clonazepam (Klonipin)

diazepam (Valium)

lorazepam (Ativan)- immediate acting

Benzodiazepines - what they treat and contraindications

Used to treat:

• anxiety

• premedication for procedures

• status epilepticus

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Contraindications:

• acute narrow-angle glaucoma

• respiratory insufficiency

Adverse effects of Benzos + Nursing Considerations

Most common side effects:

• dizziness

• drowsiness

• lethargy

Severe adverse effects:

• delirium

Assess/Monitor

• Level of consciousness, sedation

• Presence or resolution of anxiety

• Resolution of seizure if being used to control

status epilepticus

• Respiratory Status

Administration

• Use caution when administering opioids or other

sedating medications

• Give the lowest ordered dose that is effective

Patient Education

• This drug has the potential for misuse

• Do not discontinue abruptly

• Avoid alcohol and other CNS depressants

Loop Diuretics According to the Finals Guide

• treatment of heart failure and edema

• Furosemide - K+ and Na+ wasting (both decrease)

• Risk of hypokalemia = muscle weakness/cramps, cardiac arrythmia

• Electrolyte monitoring (K+ normal 3.5-5.0)

• Risk of fall due to orthostatic hypotension

K+ Sparing Diuretics according to the Finals Guide

• Spironolactone - K+ SPARING but Na+ WASTING

• Electrolyte monitoring (K+ normal 3.5-5.0)

• Risk of falls due to orthostatic hypotension

Important actions to remember for Diuretics - general

Remember the 3 D’s!

D = decreases BP

D = diuresis - draining fluid or urination

D = dehydrate or dry the body - cardiac benefits or HF

How to remember Loop Diuretics

suffix of _mide or -nide

examples include: Bumetanide, torsemide, furosemide

Loop Diuretics Bumetanide, torsemide, furosemide complications

• Hypotension, Hypovolemia, electrolyte imbalances

• Ototoxicity

• Hypokalemia, hyperglycemia, hyperuricemia, hypocalcemia, hypomagnesemia

Loop Diuretic Furosemide - Contraindications and Precautions

• DO NOT GIVE to pt with anuria

• TAKE CAUTION: those with liver issues, diabetes, dehydration, electrolyte depletion, hypoproteinemia (ototoxicity), and gout (hyperuricemia)

• TAKE CAUTION W/ MEDS LIKE: digoxin, lithium, ototoxic meds, NSAIDS, antihypertensives

Loop Diuretic Furosemide - general discussion

• potent loop diuretic, used for emergencies, causes extensive diuresis even with severe renal impairment

• used for pulmonary edema, non responsive edema, uncontrolled HTN, and off label is used for hypercalcemia

What happens when you take a loop diuretic w/ Digoxin

drug toxicity (cardiac dysrhythmias) can occur with

hypokalemia (due to potassium excretion)

• Nursing actions: monitor potassium and digoxin levels, monitor cardiac

status (EKG), administer K+ supplements as prescribed

What happens when you take Loop Diuretics w/ Lithium

drug toxicity can occur with hyponatremia (due to sodium

excretion).

• Nursing actions: monitor lithium & Na+ levels

What are some nursing implications for Loop Diuretics

• Perform thorough history and physical exam.

• Assess baseline fluid volume status, intake & output (I&O), serum

electrolytes, daily weight, and vital signs (& orthostatic BP).

• IV: must be given SLOWLY to prevent ototoxicity and abrupt

hypotension.

• Administer in the morning, if possible, to avoid interference with

sleep patterns.

• Monitor K+ and hold if <3.5 mEq/L. Monitor EKG (for cardiac

arrhythmias), notify the provider. May need K+ supplement.

• Fall precautions for elderly patients on diuretics.

• Teach patients - slow position changes, monitor BP, diet & K+

• Signs and symptoms of hypokalemia include GI symptoms, fatigue,

leg / muscle cramps, irregular pulse, dizziness

• Evaluate for effectiveness: decrease in pulmonary or peripheral

edema, BP, and increase in urinary output

Therapeutic use of thiazide diuretics - hydrochlorothiazide

• HTN - can also be stacked w/ other anti-hypertensives

• mild to moderate HF edema

• renal failure + cirrhosis

• edema treatment

Complications of thiazide diuretics

• Dehydration and hyponatremia

• Hypokalemia + Hypochloremia

• Hyperglycemia

• Hyperuricemia + hypomagnesemia

Thiazide diuretics - Interactions + Contraindications

caution patients taking digoxin, lithium, NSAIDs, antihypertensive medications (same as loop diuretics)

• Thiazide diuretics do not cause hearing loss and can be combined with ototoxic medications

• Pregnant People: use with caution, risk of jaundice and thrombocytopenia in newborns

• those w/ severe renal impairment - med will be ineffective

• Caution: CV disease, DM, hypokalemia, hyponatremia,

  hypomagnesemia, gout

Patient education when on K+ wasting diuretics (spironolactone)

• fluid status is important - diuretics should be taken in the AM

• weight daily in morning and report changes

• patients could eat K+ rich foods when they take meds that deplete K+ —→ foods like bananas, legumes, oranges, dates, apricots, raisins, broccoli, green beans, potatoes, meat, and fish

• if K+ supplement is ordered - DONT CRUSH IT and take it with a full glass of water

Therapeutic Uses - Spironolactone (K+ Sparing)

• HTN + HF

• K+ sparing and K+ wasting diuretics are combined to treat HTN and edema

• treats hyperaldosteronism by blocking the aldosterone receptors and inhibiting their action - ex treatment of PCOS

K+ Sparing Diuretics Adverse Effects + Contraindications

WARNING: pregnant people

• don’t give to someone w/ hyperkalemia

• do not admin to someone w/ severe kidney failure or anuria

• CAUTION: those w/ hepatic or kidney disease, electrolyte imbalance, metabolic acidosis

• Angiotensin-converting enzyme inhibitors (ACEI) or angiotensin receptor

  blocker (ARB) = increases risk of hyperkalemia. Avoid concurrent use!

  • Do not take potassium supplements OR salt substitutes = increases

  risk of hyperkalemia. Do not take with another K+ sparing diuretic.

  • NSAIDs = reduce effect of diuretic and may worsen kidney function

  • Digoxin = increased risk of digoxin toxicity

  • Lithium = increased risk of lithium toxicity

Antihypertensives + HF Meds According to the Final Guide

• Fall Risk dt Orthostatic Hypotension

• ACE Inhibitors: lisinopril (-pril) lowers BP

• Think ACE = Angioedema, #1 Priority (swelling of face and tongue, trouble breathing, etc). Cough, Electrolyte imbalance + risk of hyperkalemia

Alpha and Beta Blockers like Carvedilol and Labetalol are contraindicated in

• pt’s w/ asthma, bronchospasm, and bradycardia

• caution w/ liver or kidney disease

• Labetalol: is unique as it can be used in pregnancy or lactating mothers

Beta Blockers like Metoprolol and Atenolol Indications

treatment of cardiovascular diseases

• angina, HTN, dysrhythmias, MI, HF

• May also be used in migraine prophylaxis, anxiety/tremors, glaucoma, hyperthyroidism/thyroid storm

Adverse Effects of Beta Blockers (Atenolol Propranolol)

• Cardiovascular: bradycardia, orthostatic hypotension, AV block, worsening of HF

• Metabolic (Nonselective Beta Blockers): hyperglycemia, hyperlipidemia, masking of hypoglycemia (lowers HR)

• CNS: fatigue, depression, lethargy, dizziness, hypotension, fainting

• other: bronchoconstriction (wheezing) - caution w/ asthmatics (use beta 1 blockers), impotence

Nursing Actions - Beta Blockers

B = bradycardia and AV block risk, monitor HR and EKG

B = breathing problems (astma, COPD)

B = blood glucose, monitor sugars

B = bad for acute HF pt’s

B = BP LOW, check before e/ dose

baseline EKG and telemetry, check vitals before e/ dose, no effect on K"+

CCB – Diltiazem – adverse effects

• Peripheral edema, orthostatic hypotension, constipation

• dysrhythmias, reflex tachycardia, bradycardia, nausea, dyspnea