Pharm Final Exam Part 2

Common NSAIDs

1. aspirin

2. ibuprofen

3. naproxen

4. ketorolac

(AINK)

How much ibuprofen is appropriate to give

MAX dose is 3200 mg a day for an adult (this goes for all NSAIDS)

Purpose of NSAIDs

- decreased inflammation

- cure mild to moderate pain

- decreased fever

- decreased platelet aggregation (this will decrease blood clots that would cause a stroke and myocardial infarction - aspirin)

Complications of NSAIDs

-GI issues/bleeding(dark colored stool, vomiting, nausea)

- IMPAIRED KIDNEY function - Nephrotoxic

- increased risk of M.I. and stroke (non-aspirin NSAIDs)

- Salicylism (occurs when taking aspirin) symptoms include: tinnitus(hearing ringing sounds), respiratory alkalosis

- Reye's Syndrome (caused when aspirin is given to children, so DONT give aspirin to children)

Take NSAIDs with

milk or food or 8oz glass of water to reduce gastric discomfort

what can we do to get the aspirin toxicity out of your system?

Activated Charcoal is the NSAID antidote

also can use:

- gastric Lavage(pumping stomach)

- sodium bicarbonate

- if it gets bad enough hemodialysis

Acetaminophen

Analgesic - relief of pain

Antipyretic - reduce fever

(can take with or without food)

What is the drug of choice for fever reduction in CHILDREN?

Acetaminophen

Complications of Acetaminophen

liver damage

early symptoms : nausea, vomiting, diarrhea, sweating, abdominal discomfort

Late symptoms: Jaundice, yellow sclera

severe: hepatic failure, coma, death

Recommended doses for Acetaminophen

- most patients - 4g a day

- Undernourished/older patients - 3g a day

- Patients who consume 3+ servings of alcohol daily - 2g a day

Antidote for Acetaminophen

acetylcysteine (smells like rotten eggs)

Contraindications of Acetaminophen

in pregnant woman: ruins formation of fetus

avoid patients with: liver damage, kidney issues, alcohol use(increases liver damage), and malnutrition

Opioid Agonists - Morphine purpose

- treats moderate to severe pain

- sedation

- relief of diarrhea

Complications of Opioid Agonists

- NARCS U

- orthostatic hypotension

- cough suppression

- biliary colic (blockage of bile duct in the stomach)

- opioid toxicity triad (coma, respiratory depression, pinpoint pupils)

Nursing Admin for Opioid Agonists

- Assess pain

- double check doses with a second nurse

- do not stop opioids abruptly

- closely monitor Patient Controlled Analgesia settings (PCA= only PATIENT can push the button on the machine)

NARCSU

N- nausea

A - Acute Toxicity

R- respiratory depression

C - Constipation

S - sedation

U - Urinary retention

Antidote for Opioids

Naloxone

treating opioid abuse

decreasing euphoria

reversing effects of opioids

decreasing constipation

reversal of respiratory depression in an infant

Complications of Naloxone

tachycardia

tachypnea

abstinence syndrome (hypertension, cramping, vomiting)

Ergotamine

2nd line to STOP a migraine

Complications: Muscle pain, paresthesia (numbness and tingling), cold ischemia extremities (poor circulation) if these happen STOP medication and notify provider

DONT give to pregnant women (can cause fetal harm/abortion)

DONT TAKE SUMA AND ERGO TOGETHER

NSAIDs Labs & Acetaminophen Labs

NSAID ----> kidney (nephrotoxic) (NSAIDs think bleeding) BUN/creatine

Acetaminophen ----> liver (hepatotoxic) AST/ALT

Penicillin's

Penicillin G, Amoxicillin

- typically ends in "-cillin"

- bactericidal

- all of the penicillin and cephalosporins CANNOT be taken together

complications:

- anaphylaxis

- renal impairment (BUN and Creatinine)

- hyperkalemia & hypernatremia

- Can be taken with meals

Antidote for all anaphylaxis reactions

Epinephrine

Anaphylaxis

worst case of an allergic reaction

- hypotension, tachycardia, body rash, respiratory distress

1. STOP MEDICATION, administer an EPINEPHRINE

2. if patient is at home they need to call 911 and give epi if possible

Vancomycin

Also called: Aztreonam or Fosfomycin

- antibiotic

- inhibits cell wall synthesis (bactericidal)

- saved for severe infections

(PO: treatment of choice for C. diff)

(IV: treatment for staphylococcus and streptococcal)

Vancomycin Complications

1. BIG EARS - ototoxicity (hearing impairment)

2. Big KIDNEYS (nephrotoxicity - BUN/CREAT

Draw through levels immediately before next dose

3. Red Man Syndrome - due to rapid infusions; rashes, flushing, tachycardia, etc;

- give vancomycin slowly over 60 min

Rifampin

anti-Tuberculosis that is usually administered with Isoniazid in the active stage of TB

- turns bodily fluids (urine, sweat, saliva) red-orange - will go away once you finish taking

- Hepatotoxicity (jaundice, anorexia, fatigue)(LIVER)

- very long-term treatment bc mycobacterium organisms are waxy and tough to kill

Meds for chemotherapy

Tamoxifen & Methotrexate

- treat breast cancer

Common side affects for Chemotherapy

1. Bone marrow suppression:

- Low WBC/Neutropenia (fever/sore throat)

---> Report immediately to provider, Avoid crowds & contact with sick individuals, Frequent hand washing

- Monitor ANC (absolute neutrophil count) - when low the patient is more susceptible to developing an infection

- Low Platelets/Thrombocytopenia

(bleeding gums, abnormal bruising, blood in urine/stools, prolonged bleeding from cuts/lesions)

---> Use soft-bristled toothbrush/gentle oral care and use electric razor

- Low RBC/Anemia (fatigue/pale skin)

---> Monitor hemoglobin and hematocrit

More common side affects for Chemotherapy

2. GI effects - chemo-induced nausea/vomiting (CINV)

- Pre-medicate 30 minutes to 1 hour before chemotreatment!!!

3. Mucositis (mouth sores)

4. Alopecia (hair loss)

- 7-10 days after treatment begins

Chemo patients should not

Take live vaccines or get pregnant (Category x!!)

Anticoagulants

Heparin and Enoxaparin

Client Education for both heparin and enoxaparin:

BLEEEDINNNGG!! LIVER!!!

- prevents clots from occurring and growing

- report if they see any bleeding

- NO NSAIDs, aspirin, antiplatelets, or salicylates

- use soft bristled toothbrush or electric razor

- Antidote: Protamine (mostly for heparin but can also be used for enoxaparin)

Heparin

prevents clotting

prevents/treats an evolving stroke, deep-vein thrombosis, or pulmonary embolism

- can be given IV or subcutaneously

- HIGH ALERT! check with a 2nd nurse

- do not exceed 1600 units per hour

Labs: H&H, PLT (stop if less than 100,000), aPTT

Enoxaparin

- given only subcutaneously in the abdomen (pinch skin and inject at 45 to 90 degree angle)(45 degree if thin or a child)(obese/normal = 90 degree)(do not aspirate)(needs to be 2 in away from umbilicus)

- prevents/treats an evolving stroke, deep-vein thrombosis, or pulmonary embolism

- does not need excess monitoring; can be self-injected at home (report to provider if any adverse effects)

- often given for prophylaxis (prevention)

Heparin and Enoxaparin both....

do nothing for existing clots, just helps prevent future clots from forming

aPTT ranges:

- Normal range for someone not on med: 30-40 seconds

- Therapeutic range when patient IS on heparin: 60-80 seconds

Complications of Heparin and Enoxaparin

- Bleeding - bruising, petechiae, black tarry stools

- hemorrhage (severe bleeding)

- tachycardia

- hypotension

- Heparin-Induced Thrombocytopenia (HIT)(stop medication if platelets less than 100,000)

- overdose/toxicity (give protamine)

Warfarin

antagonizes vitamin K and for long term anticoagulation

- used for prosthetic heart valves or atrial fibrillation, Venous Thrombosis & Pulmonary Embolism(blood clots), ischemic attacks(stroke) or Myocardial Infarction

- LIVVVERRRR!! Monitor AST and ALT, as well as H&H and platelets

- PT and INR

- takes 3-5 days to take effect (usually taken w another anticoagulant since it takes 3-5 days, then once it is fully in system we can stop other anticoagulant and continue warfarin)

- wear medical alert bracelet in hospital indicating warfarin use

- teach client to take consistent intake of vitamin K (don't want to take too much though)

- Preg Cat X!!!!!!

- Antidote: Vitamin K

Warfarin complications

1. Hemorrhage: monitor for bleeding, tachycardia, hypotension, bruising, petechiae, black tarry stools (THIS IS LIFE THREATENING)

2. Hepatitis (liver!!!) (monitor for: nausea, vomiting, jaundice, anorexia, decreased appetite, confusion) (AST/ALT)

3. Overdose/Toxicity: severe bleeding (discontinue warfarin and administer IV vitamin K slowly and diluted)

Warfarin Interactions

1. NO alcohol(can lead to hepatotoxicity and increases action of warfarin and bleeding risks)

2. w NSAIDs can lead to increased bleeding

3. avoid increases in foods high in Vitamin K (green leafy vegetables such as lettuce, cooked spinach, and mayonnaise, canola and soybean oil)

PT levels:

Normal range - someone who is not taking warfarin: 10 to 11

Therapeutic range - someone who is taking: 18 to 24

INR

Therapeutic range for someone on warfarin: 2-3

- for patients w mechanical heart valves 3-4 is acceptable

Heparin and Warfarin bridging therapy

As Heparin levels decrease, stop heparin and Warfarin can be taken at home

Clopidogrel

Anti-platelet

- prevents platelets from clumping together, reducing the risks of blood clots

- used for prevention of MI and stroke

- med lasts 7 days (lifetime of a platelet)

adverse effects:

-prolonged bleeding

-gi effects (diarrhea)

-thrombocytopenia( low platelets in the blood)

Discontinue 5-7 days before surgery

Ace inhibitors

Lisinopril (end in -pril)

- lowers blood pressure

- INCREASES K+ (AVOID SOURCES OF K+, such as salt substitutes)

- Life Threatening Effects: hyperkalemia(potassium)(numbness/tingling) and angioedema (tongue and mouth swelling)

- dry cough, STOP med and notify provider

- Preg Risk Cat: D

- LABS: KIDNEY! BUN/Creatinine and Potassium

Beta Blockers

- end in OLOL

"LOL YOUR HEART TO SLEEP"; decrease HR(negative chronotropic), cardiac force of contractions (negative inotropic), and electrical conduction (negative dromotropic)

- Life Threatening Effects: Bradycardia, Atrioventricular block, Bronchoconstriction(clients who have asthma should receive beta 1: cardioselective beta blocker)

- HOLD if HR is less than 50/min or if systolic is less than 90

- don't stop abruptly!!

Cardioselective beta blockers

Beta 1

affects only the heart (bc only 1 heart)

Nonselective beta blockers

Beta 1 and Beta 2

affects both the heart and lungs

Furosemide

go-to for heart failure

- used for moderate to severe edema, heart failure, fluid volume excess, and renal disorders

Hyponatremia (sodium)

Complications:

- dehydration (look for dry mouth/tongue)

- hypotension

- hypokalemia

- ototoxicity

- take early in day (8am/2pm)

monitor potassium, sodium

What symptoms would indicate hypokalemia?What could you give them thats high in K+?

- leg cramps and general weakness- nausea/vomiting- fatigue - Bananas, potatoes, spinach, dates, prunes, raisins, nuts, dried fruit

Spirinolactone

Only diuretic that will be HYPERkalemia

- Complications:

- hyperkalemia

- gynecomastia: (MAN BOOBS)

- Impotence: deeper voice

- Irregular menstrual cycles

- Hirsutism (excessive hair growth)

Avoid K+ (salt substitutes)

Therapeutic effects can take 48 to 72 hrs

Preg Category x!!

Don't give to someone w severe kidney failure or experiencing anuria

Hydrochlorothiazide

first line treatment for hypertension after lifestyle changes; prevents reabsorption of sodium and water; also used for mild to moderate edema, heart failure, fluid volume excess, hypertension

- Complications: Hypokalemia, dehydration

- take early in day (8am/2pm)

Digoxin

second-line treatment for Heart Failure; slows and strengthens the heart (does not prolong life)

Positive Inotropic, Negative Chronotropic, Negative Dromotropic

- Complications: GI effects(nausea/vomiting), yellow/green/white halo around lights, dysrhythmias--> bradycardia, hypokalemia(increases risks for toxicity)

- HOLD if pulse less than 60/min (check APICAL pulse for 1 full minute)

- do not double dose; IV over 5 mins

- HIGH ALERT: have 2nd nurse

- Antidote: Digoxin immune fab (binds to the med)

Digoxin Therapeutic Level

0.5-0.8

Greater than 2.0 is TOXIC

Drug used to treat angina

nitroglycerin

Nitroglycerine

- Sublingual tablet (RAPID treatment of acute angina pain) (Sit/lie down, take 1st dose. Wait 5 minutes. If angina is still present CALL 911 and take second dose. After another 5 minutes a 3rd dose may be administered.)

- store in a cool, dark place

- don't take more than 3 tablets!!

- Complications: headache (NORMAL), orthostatic hypotension (STOP if BP too low), reflex tachycardia,

- NO VIAGRA (PDES5) for patient with erectile dysfunction

- long-acting = take in the morning; PRN = take before action

Other routes for Nitroglycerine

PO/Topical/Transdermal

- Long term prevention of angina

Intravenous

- Given during an emergency for angina/MI

Statins

Atorvastatin etc... end in -statin

- first-line treatment for hyperlipidemia (elevated cholesterol) (unless pregnancy, liver issues)

- Complications: myopathy (muscle aches; rhabdomyolysis can occur), hepatotoxicity

- Preg Cat: X!!!!!

- no alcohol! no grapefruit juice!

- take in the evening (cholesterol synthesis=night)

- Monitor CK levels, AST/ALT and BUN/Creatinine

Expected actions by Atorvastatin, Simvastatin, and Lovastatin

decreased LDL: bad cholesterol (L=lazy)

increased HDL: good cholesterol (h= happy)

Prazoles

Pantoprazole (proton pump inhibitors)

-Prazole

reduce gastric acid secretion in the stomach

- Complications: osteoporosis and fractures (decreased calcium, especially in females)

- take once per day before eating breakfast

- report any GI bleeding

- do not crush, chew, or break tabs, do not open capsule and sprinkle over food; NO NSAIDs! alcohol and steroids

AST/ALT/BUN/Creatinine

Histamine receptor antagonist (tidines)

-suppresses acid

- Complications: Constipation nausea, CNS depression (lethargy, hallucinations, and confusion)

- AVOID smoking, alcohol, and foods that irritate the GI tract

- do not take an antacid 1 hr before or after

- take 2 times a day w or w out food and once ulcer is healed, maintenance dose is just once a day

BUN/Creatinine/AST/ALT

Insulin

treats hyperglycemia and hyperkalemia

Rapid Acting Insulin

Includes: Lispro

ONSET: 15 to 30 minutes

PEAK: 30 minutes to 3 hours

DURATION: 3 to 5 hours

- most deadly

- food MUST be at the bedside

Short Acting

Includes: Regular Insulin (looks clear)

ONSET: 30 to 60 minutes

PEAK: 1 to 5 hours

DURATION: 6 to 10 hours

- mainly given IV

Intermittent

Includes: NPH (cloudy)

ONSET: 1 to 2 hours

PEAK: 4 to 14 hours

DURATION: 14 to 24 hours

- never IV; given subcutaneously

- given 2x a day

Long Acting

Includes: Glargine

ONSET: 1 to 4 hours

PEAK: NONE

DURATION: 24 hours

- never mix with other insulins (will need to stick patient twice)

Medication PEAK for Diabetes

point at which the patient is at the greatest risk for hypoglycemia

Metformin

#1 choice med for Type 2 DM

reduces the production of glucose

-if using Iodine contrast dye, stop med 24-48 hrs before and start again 48 hrs after if kidney function is good

-BUN/ CREATININE

-LACTIC ACIDOSIS (hyperventilation, myalgia, sluggish)

-no alcohol (increases the risk for lactic acidosis)

Albuterol

THINK RESCUE INHALER!!!!

- treats bronchospasm by opening up the airway and prevents exercise induced bronchospasms

- used for acute episodes of bronchospasms

Immediate relief, gives fast results!!!!

Albuterol complications

1. tachycardia which can lead to angina(chest pain)

- mild tachycardia is normal but once it gets too high --> check pulse and report if there is an increase of greater than 20 to 30 bpm

2. tremors (usually resolved w continued med use)

Ipratroprium

long term; take everyday to maintain and control asthma resulting in bronchodilation (helps COPD patients)

Can't see(blurred vision), Can't pee(urinary retention), Can't spit(Dry mouth/hoarsness), Can't Poop(constpiated), & Tachycardia

- Give fluids and sugar free candy to control dry mouth/rinse mouth after

-don't use if PEANUT AND SOY ALLERGY

Beclomethasone/Prednisone

- glucocorticoid

- maintenance drug for asthma

- prevent and treat inflammation

-CLEAN TEETH AND MOUTH bc Candidiasis(monitor for white spots in mouth or sore throat)

- inhaled for long-term use of prophylaxis of asthma

If you are taking a beta 2 and a corticoid steroid, which one does the patient take first?

Take beta-2-agonists BEFORE glucocorticoids

- Albuterol before beclomethasone

Diphenhydramine

(Benadryl)

-first line of antihistamine, reduces allergic response

- (CANT see, CANT spit, CANT pee, CANT poop) (DRYS you out)

- take @ night due to sedating effects (avoid driving)

- don't give to newborns, breastfeeding, and 3rd trimester

- take w meal

Lortdaine

- 2nd generation antihistamine

- no sedating effects, can take everyday for seasonal allergies

-don't take before an allergy test, could give a false positive

Levothryroxine

- treats hypOthyroidism

- 6-8 weeks to work

- take daily on an empty stomach in the AM, 30-60 mins before breakfast and other meds

- check with provider before switching brands

-monitor signs of angina, dysrhythmia, palpitations

- complications: hyperthyroidism, weight loss, tachycardia, fever etc

Prednisone

-glucocorticoid used for long term use of asthma and Addison disease

-use only (3-10) days

NEVER STOP ABRUPTLY, taper slowly

longer than 10 days leads to:

-bone loss

- Cushing syndrome

-hyperglycemia

-myopathy

-peptic ulcers

-infection