Pharmacology Exam 2 (CV pt 1, Respir, GI)

How is TB diagnosed?

TB skin test → X Ray → sputum culture

When is the best time to collect a TB sputum specimen?

morning → b/c best quality sputum time

What should you know about the PPD test?

Purified protein derivative done intradermally
Read 48-72 hrs after placement
observe thickness of testing area (not redness)

Describe findings in a latent TB patient

PPD & blood test +
Normal X-ray
Sputum -
No symptoms, not infectious
Needs treatment

Describe findings in an active TB patient

PPD & blood test +
Abnormal X-ray
Sputum +
Symptoms + infectious
Needs treatment & airborne isolation

Isoniazid (INH) MOA

Stops mycolic acid production in bacteria cell wall, stopping growth

Isoniazid (INH) AE

Hepatotoxicity

Peripheral neuropathy (Vit B6 interference) → administer pyridoxine (vitamin B6)

Isoniazid (INH) Nursing Actions

Liver testing
Pts w/ slow acetylation higher risk for toxicity
administer pyridoxine (B6) for diabetes, alcoholic pts

Isoniazid (INH) contraindications

pts w/ liver disease, alcohol use

Ethambutol MOA

bacteriostatic

Ethambutol AE

Optic neuritis: inflammation of optic nerve, causing blurry vision (stop medication)

Ethambutol Nurse teaching

Tell pt report blurry vision
Not for kids

Pyrazinamide (PZA) MOA

unknown, bactericidal

Pyrazinamide (PZA) AE

Hepatotoxicity
Non-gouty polyarthralgia (joint pain)

Rifampin MOA

inhibit RNA synthesis of bacteria

Rifampin AE

hepatotoxciity
red/orange bodily fluids (not damaging)

Rifampin Nursing actions

Better absorbed on empty stomach (1 hr before / 2 hrs after meals)
CYP450 inducer, increase metabolism of other drugs → teach patient to use physical birth control
Caution use in pt with alcoholism, liver disease
Monitor LFTs

What is direct observation treatment?

Pt take treatment in front of provider
Enhances compliance with TB treatment
Helps prevent TB from becoming resistant
Med taken under supervision to ensure adherence

A nurse is giving Rfampin as TB treatment to a patient. Which of the following statements from the patient ensures that teaching was effective? SATA
A) Red/orange bodily fluid is a normal and expected SE
B) I should use additional birth control methods with this medication
C) I should take this medication with a meal to prevent GI upset
D) I should report any history of liver disease to my provider before taking this medication
E) Join pain is a side effect of this medication and must be reported to the provider immediately

A, B, D
A → Expected finding of red/orange bodily fluid
B → CYP450 inducer, leading to less effective oral contraceptives
C → Do not take with meal as it reduces effectiveness
D → Rifampin is hepatotoxic
E → This is the side effect of Pyrazinamide

Intranasal Glucocorticoids Common Medications

-sone or -salone
Beclomethasone diproprionate
Flunisolide
Triamcinolone acetonide
Budesonide
Fluticasone proprionate
Mometasone furoate`

Intranasal Glucocorticoids MOA

decreases inflammation and edema

Intranasal Glucocorticoids Indication

Most effective for allergic rhinitis

Intranasal glucocorticoid AE

Drying of mucosa
burning/itching
sore throat
headache
Epistaxis (nose bleed)

Intranasal glucocorticoid administration

Tilt head forward, point nozzle away from septum and midline
Dont blow nose for 1 min.

Antihistamines 1st gen Drugs

-amine
Chlorpheniramine
Diphenhydramine
Promethazine

Antihistamine 1st gen AE

Diphenhydramine: Drowsy
Promethazine: Not for <2 yr old (Respir Dep), No IV (tissue damage)
Neurotransmitter reduction
Sedation/drowsiness
cognitive performance reduction
Xerostomia (dry mouth)
Urine retention
Hypotension, dizziness
increase appetite
QT interval prolongation

Antihistamines 2nd Gen Drugs

-dine or -tidine
Fexofenadine
Cetirizine
Loratadine
Desloratadine

Why are 2nd gen antihistamiens preferred over 1st generation antihistamines?

Less risk of drowsiness

Decongestants/Sympathomimetics MOA

Active a1 receptors on nasal blood vessels which causes vasoconstriction (stops runny nose and congestion)

Decongestants/Sympathomimetics AE

Rebound congestion (topical) → if used >5 days
CNS stimulation (oral) → anxiety/restlessness, insomnia (oral), headache (nasal)
CV: tachycardia/ increase BP, cerebrovascular disease

Decongestant/Sympathomimetics Nursing Implication

Careful in pts with: HTN, Dysrhythmias, cerebrovascular diseases
Abusable medication → Pseudoephedrine used to make methamphetamiens
Tell pt not to overuse
Limit caffeine
Take in day (insomnia)
Take med when sitting
Report any excessive dizziness, heart palpitations, weakness, sedation, or excessive irritability

Mast Cell Stabilizer MOA

Used for allergic rhinitis
Decrease release of mast cell chemicals
Mast cell chemicals cause: bronchoconstriction, edema, inflammation
Interrupts migration of eosinophils & decreases symptoms

Mast Cell Stabilizer Drug

Cromolyn Sodium

Short Acting Beta 2 Agonist Indication/Use

Acute asthma/COPD (rescue)

Long Acting Beta 2 Agonist Indication/Use

maintenance treatment for asthma/COPD (prevention) → reduce inflammation

SABA & LABA MOA

Bronchodilator, relaxes smooth muscle
Activates beta 2 receptors in smooth muscle relaxation/bronchodilation

SABA drugs

Albuterol
Levalbuterol
Pirbuterol
Terbutaline
Metaproterenol

LABA Drugs

Arformoterol
Formoterol
Salmeterol

LABA w/ ICS Drugs

Formoterol + budesonide
Formoterol + mometasone
Salmeterol + fluticasone

SABA and LABA AE

Albuterol: Hypokalemia w/ frequent use
CNS: anxiety, restless, insomnia, tremors, headache
CV: palpitations/dysrhythmias
Respiratory: rebound bronchospasms (not common)
GI: nausea, acid reflux
GU: urinary retention
Oral infection

SABA and LABA Contraindications

LABA contraindicated for Asthma, black box warning
Laba must be given in combination w/ corticosteroids
Be careful in pts w/ HTN, dysrhythmias, smoking

SABA & LABA Nursing Management

Albuterol: dont use too frequently → excessive use → paradoxical bronchospasms: immediate airway constriction
Pt should always have inhaler around them (all the time)
Caution in patients w/ HTN, dysrhythmias
Frequent pulmonary assessment
Use inhaler before physical activity
Stop smoking

What mediation is used for acute asthma attacks?

SABA (albuterol)

Xanthines Use

Asthma & COPD

Xanthines MOA

inhibits phosphodiesterase → increase levels of cAMP → Bronchodilation

Xanthines Common Drugs

Theophyline & aminophylline

Xanthines AE

CNS: tremors, nervousness, insomnia, agistation, convulsions
CV: Tachycardia, dysrhythmias, angina, hypotension, palpitations
GI: N/V, anorexia

What is the therapeutic range of theophylline and what are the mild/severe SE?

10-20 mcg/mL
Mild: insomnia, restlessness, N/V, diarrhea
Severe: dysrhythmias, convulsions (>30 mcg/mL)

Xanthines Nursing Care

Avoid caffeine
Watch blood levels for toxicity
Give in daytime (insomnia)
Smoking increases metabolism of drug
Be especially careful in elderly pt

Leukotriene Receptor Antagonist MOA

inhibits leukotrienes in smooth muscle, preventing inflammation

Leukotriene Receptor Antagonist Use

Only chronic asthma (not COPD), not acute asthma

Leukotriene Receptor Antagonist AE

Not common
Headache, N/V, diarrhea

Leukotriene Receptor Antagonist Drugs

Montelukast, Zafirlukast, Zileuton

Leukotriene Receptor Antagonists Pt education

Only for chronic asthma

Inhaled Corticosteroids MOA

non-bronchodilating! Suppress inflammation by decrease synthesis/release of inflammatory mediators, inflammatory cells, and decrease edema

Inhaled Corticosteroids AE

Thrush, Oropharyngeal candidiasis
Pt should rinse mouth or use spacer
Dysphonia (horaseness)
Long term use: suppresses adrenal glands → prevent by tapering doses
Slows growth of children

A patient using a topical decongestant for nasal congestion reports worsening of symptoms after 10 days of use. The nurse suspects:
A) Anaphylaxis
B) Rebound congestion
C) Thrush
D) Optic neuritis

B, use of nasal decongestants for >5 days can lead to rebound congestion

A patient with chornic asthma is prescribed montelukast. The nurse explains that this medication works by:
A) Dilating bronchi via beta-2 receptor activation
B) inhibiting leukotriene-induced inflammation
C) Blocking acetylcholine receptors
D) Suppressing the adrenal glands

B

Which instructions should the nurse provide to a patient using an inhaled corticosteroid?
A) Rinse your mouth after each use to prevent thrush
B) Take this medication only during an asthma atatck
C) Expect orange discoloration of bodily fluids
D) Use it with a topical decongestant for best results

A

Anticholinergics Indicaiton/Use

COPD, Asthma

Anticholinergics MOA

Binds to Acetylcholine (ACh) receptors and prevents ACh from binding → Breonchodilation

Anticholinergics Common Drugs

Ipratropium bromide
Tiotropium bromide

Anticholinergics AE

Not absorbed systemically, but if it is…
Dry mouth/throat
GI distress, urine retention (prostate enlargement), intraocular pressure increase
Headache, cough, anxiety

Anticholinergics Contraindication

Pts w/ glaucoma due to risk for increased intraocular pressure

Expectorants Use

relief of productive cough

Expectorants MOA

increase flow of fluids in resp tract
decrease viscosity of bronchial/tracheal secretions
Helps removal of secretion w/ cough

Expectorants Drugs

Guaifenesin

Antitussives Opioid MOA

Suppress cough reflex → act on cough center in medulla

Antitussives Opioid Drugs

Codeine, Hydrocodone

Antitussives Nonopioid MOA

Suppress cough reflex
Numb stretch receptors in respiratory tract
Prevent reflex stimulation of medullary cough center

Antitussives Nonopioid Drugs

Dextromethorphan, Benzonatate

Antitussives Indications

Nonproductive cough

Antitussives SE

Codeine: sedation, N/V, constipation
Benzonatate & Dextromethorphan: Dizziness, drowsy/sedation, nausea

Antitussive Nursing management

Respiratory & Cough assessment
Report if: cough last more than 1 week, persistent headache, fever
Dont use w/ pt who has productive cough
Dont give w/ drug allergy
Dont give if pt has opioid dependency, resp depression
Drowsiness, sedation → avoid driving, operating heavy equipment

Mucolytics Drug

Acetylcysteine

Mucolytic MOA

Splits disulfide linkage of mucoproteins; reduces viscosity, facilitates removal of secretions, liquefies secretions

Mucolytics Use

Viscous mucous secretions w/ bronchopulmonary disease
Acetaminophen antidote → hepatoprotective agent, restores hepatic concentration of glutathione necessary for inactivation of hepatotoxic acetaminophen metabolite
Pulmonary issues from CF
Tracheostomy care

Mucolytics AE

Respiratory distress
Bronchospasms
Angioedema
Hypotension

Mucolytics Cautions

Smells & taste very bad (rotten), disguised with juice/straw
Offer face cloth b/c sticky on the face
Careful use in asthma, elderly, debilitated pts (bronchospasm risks)
Drug may be given via nebulizer, IV, orally, or instilled into endotracheal tube

Phosphodiesterase Type 5 inhibitors (PDE-5) MOA

PDE-5 inhibitors reduce pulmonary arterial pressure by causing dilation of pulmonary blood vessels

Phosphodiesterase Type 5 inhibitors (PDE-5) Drugs

Sildenafil, Tadalafil

Phosphodiesterase Type 5 Inhibitors (PDE-5) Contraindications

Do not give with nitrates due to lifethratening hypotension

Decongestants oral Drug

Pseudoephedrine

Decongestant Oral

No rebound congestion

Nasal Decongestant Drugs

Ephedrine, Oxymetazoline, Phenylephrine, and Tetrahydrozoline

Nasal Decongestant Risks and Explanation

Prompt onset
Potent
Sustained use for more than 5-7 days causes rebound congestion, making condition worse

Down sides of Mast Cell Stabilizers

For pts who dont tolerate other agents
Less effective than glucocorticoid nasal sprays or 2nd gen antihistamines
Need for frequent dosing (3-4x daily)

Respiratory medication classes that work to Bronchodilate

Beta Adrenergic Agonist
Anticholinergics
Xanthine Derivatives

Respiratory Medication Classes that do not have bronchodilating effects

Leukotriene receptor antagonist
Corticosteroids

Xanthine Theophylline Mild and Serious Toxic effects

Mild: N/V, diarrhea, insomnia, restlessness
Serious: severe dysrhythmias, convulsions

Xanthine Nursing Implicaitons

Teach pts taking caffeine can increase AE
monitor blood levels for toxicity (1-2x yearly)
give daytime to prevent insomnia
Have patient take on full stomach or w/ milk if GI distress
avoid smoking — increase metabolism of drug
Can interact with many other drugs
Elderly: administer cautiously due to less drug metabolism, report palpitations and increase BP, lower dose may be necessary for elderly

Inhaled Corticosteorids Drugs

Beclomethasone
Budesonide
Ciclesonide
Fluticasone
Triamcinolone acetonide
Flunisolide

Inhaled Corticosteroid AE

Oropharyngeal candidiasis
Dysphonia (hoarseness) → rinse mouth after each use, use spacer
Long-term high dose → supression of adrenal gland → not as severe as with oral steroids
Slow growth in children & adolescents

Lung Surfactant Use

Porcine extract of lung surfactant given to neonates w/ respiratory distress syndrome

Lung surfactant drugs

Poractant alfa
Calfactant
Beractant

Lung Surfactant AE

Bradycardia, O2 desat (RT administration)
Pulmonary hemorrhage, mucus plugging, endotracheal tube reflux

Loop Diuretics MOA

block Na & H2O reabsorption in loop of Henle; promotes excretion of H2O, Na, K, decrease stroke volume

Loop Diuretics Use

HTN, Heart failure, edema

Loop Diuretic Drugs

Furosemide
Bumetanide
Torsemide

Loop Diuretics AE

Hypokalemia → muscle cramps, weakness, fatigue, dysrhythmias — cardiac monitoring
Severe dehydration, hypovolemia, hyponatremia, hypotension, fall risk, monitor BP → dizziness, orthostatic hypotension, tachycardia
Ototoxicity