NRSE 310: Final Exam

What is pharmacokinetics (ADME)?

• Kines = move

• How drugs move throughout the body

  1. Absorption

  2. Distribution

  3. Metabolism

  4. Excretion

Pharmacokinetics: Absorption

• Movement from admin site into the bloodstream

• Intensity and quickness of effects depend on dose/route

Pharmacokinetics: Distribution

Transport of drug by bloodstream to the target area

Pharmacokinetics: Distribution affected by (3)

• Circulation

• Permeability

• Plasma protein binding

Pharmacokinetics: Metabolism

• Transformation of med into less active/inactive forms by enzymes

• Mostly liver

• But also kidneys, lungs, intestines, or blood

Pharmacokinetics: Metabolism affected by

• Age

  • decreased in very young/old

• Enzyme amounts

  • genetic variability

• First pass

• Similar pathway

  • drugs not metabolized as fast

• Malnutrition

  • decreased enzymes

Pharmacokinetics: Excretion

• Elimination of drug

• Mostly kidneys

• Also liver, lungs, intestines, exocrine glands

What is pharmacodynamics?

• What drug does to body

• MOA

  • Mechanism of Action

What are the 6 rights of Medication Administration?

• The Right…

  • Patient

  • Medication

  • Dose

  • Route

  • Time

  • Documentation

Enteral (PO) routes

• Oral

• Sublingual

• Buccal

• Nasogastric

• Gastrostomy tube

Topical routes

• Transdermal

• eye

• ear

• nose

• rectal (PR)

• vaginal

Inhalation routes

• MDI

• DPI

Parenteral routes

• IM

• SQ

• ID

• IV

• Epidural

In general- Which medications can cause Orthostatic Hypotension?

• Tamsulosin

• Anesthetics

• Opioids

  • Antidote: Naloxone

• Cardiac meds

• Neuro medications

  • bezos

Pharmacokinetics older adults

• Absorption

  • decreased (higher pH stomach acid)

• Distribution

  • slower

• Metabolism

  • slower

• Excretion

  • slower

  • possibly incomplete

CV changes of older adult affect which part of pharmacokinetics the most…

Distribution

Factors affecting pharmacokinetics…

• Decrease in the number of receptors & reduced affinity

• Altered pharmacokinetics

• Polypharmacy

  • taking several medications at a time

• Comorbidities

Menopause: Clinical Manifestations

• Decreased sexual characteristics, irritability, anxiety, depression

• Decreased skin elasticity

• Decreased body hair, breast & subcutaneous tissue

• Dyspareunia (painful intercourse)

• Urinary incontinence

• UTIs

• Vasomotor symptoms

  • hot flashed

  • night sweats

  • insomnia

• Increased in total cholesterol, LDL up, HDL down

  Long term:

  • bone remodeling deficiency

Pharmacologic treatment for BPH: Medications

• Finasteride

• Tamsulosin

Finasteride: MOA

Decreases usable test by inhibiting the converting enzyme causing a reduction of the prostate size and increased hair growth

Finasteride: Complications

• Decreased libido

• Decreased ejaculation volume

• Gynecomastia

  • breast in males

Finasteride: Contraindications

• Pregnancy Cat X

• Caution…

  • Patients who have Liver Disease

Finasteride: Interactions

NONE

Finasteride: Nursing Implications

• Can’t donate blood during treatment and until 1 month after treatment

• Monitor for decrease in prostate size and effective urination

• Monitor prostate specific antigens

• Monitor for increase hair growth

Finasteride: Patient Teachings

• Do not handle med if pregnant

• Therapeutic effects can take 6 months or longer

Tamsulosin: MOA

• Decrease mechanical obstruction of the urethra by relaxing smooth muscle of the bladder neck and prostate

• Can cause vasodilation & low BP

  • adverse effect

Tamsulosin: Complications

• Hypotension

• Dizziness, faintness

• Nasal congestion

• Sleepiness

• Ejaculation problems

• Floppy iris syndrome

  • following cataract surgery

Tamsulosin: Contraindications

• Caution in PT…

  • who have hepatic or renal impairment

Tamsulosin: Interactions

• Antihypertensives

• PED5 inhibitors

  • a class of drugs that treat erectile dysfunction

• Nitroglycerin

Tamsulosin: Nursing implication

• Monitor BP

• Fall Risk

• Monitor for improved urinary flow

Tamsulosin: PT Teaching

• change position slowly

• Administer 30 min after a meal, same time everyday

• Do not drive until effects are known

Clinical manifestations of inflammation

• Pain/Tenderness

• Redness

• Swelling (Edema)

• Heat

• Fever (Systemic

HIV Pathogenesis

• Retrovirus

  • Genetic information contain within RNA

• Transmission to a new host

• Binding of virus to CD4 T-lymphocytes

• It uses reverse transcriptase to convert RNA to DNA

  • Virus enters the nucleus of CD4 T-lymphocytes

• Replication of viral CD4 lymphocytes occurs

  • Impaired immune functioning

NSAID: Medications

• Aspirin

• Ibuprofen

• Naproxen

• Indomethacin

• IV: Ketorolac

NSAID: Complications

• GI discomfort

• Increased bleeding

  • easy bruising

  • nosebleeds

  • hematuria

  • petechiae

• Impaired kidney function

NSAID: Contraindications

• Bleeding disorders/Peptic ulcer disease

• Pregnancy cat D

• Advanced kidney disease

  • Medication: Ketorolac

Nursing implications for a patient is receiving Opioids?

• Monitor Heart Rate, Respiratory Rate, and Blood Pressure (discontinue if RR is less than 12)

• Assess pain level before & after administration

• IV doses slow, over 4-5 mins

• Monitor/medicate for constipation, Nausea, Vomiting

• Two nurses for wasting the medication

• Fall precautions

• Monitor Input +Outputs

• Assess for urine retention

• If physical dependence, never stop abruptly, taper down over 3 days

What is the antidote for Opioids?

Naloxone

What are the antidotes for Acetaminophen?

Acetylcysteine (Mucomyst)

Deep Vein Thrombosis: Clinical Manifestations

• Swelling in the affected leg

• Cramping or pulling discomfort

• Swelling or localized redness in the leg

• Pitting Edema

• Shoulder or neck discomfort

• Paresthesia of the affected arm

• Hands or arm swelling

Deep Vein Thrombosis

The formation of a static blood clot in a deep vein, predominantly in the lower leg.

What patient teaching is important for someone taking Epoetin Alfa?

• May need to take iron concurrently

• Notify the provider if Signs & Symptoms of blood clot

  • Monitor for DVT

• Monitor Blood Pressure frequently

• Based on the Patient’s weight

• Monitor Hg and Hct 2x per week until therapeutic

Cytotoxic Immunosuppressive: Medication

Methotrexate

Nursing implications: Methotrexate

• Baseline CBC with diff every 3-6 months

  • Complete blood count

• Inspect mouth, gums, throat daily

• Can give with Folic Acid

Patient Teaching of Methotrexate

• Can take 3-6 weeks

  • Full therapeutic effect can take several months

• Use soft toothbrush

• Use contraception during/after therapy

• DO NOT GET PREGNANT

Antidote: Warfarin

Vitamin K

Antidote: Heparin

Protamine Sulfate

Antidote for Rivaroxaban and Apixaban

Andexanet Alfa

What are normal/ therapeutic and concerning hematology labs: Platelets

150,000- 350,000

What are normal hematology labs: Prothrombin Time (PT)

11 seconds to 12.5 seconds

What are normal/ therapeutic and concerning hematology labs: aPTT

• Non Anticoagulated = 30 - 40 seconds

• Anticoagulated = 60 - 80 seconds

  • Heparin

What are normal/ therapeutic and concerning hematology labs: International Normalized Ration (INR)

• NORMAL: less than 1.1

• NORMAL While On warfarin

  • 2.0 to 3.5

Anti-tuberculosis: Medications

• Isoniazid

• Pyrazinamide

• Rifampin

Patient teaching for Anti-tuberculosis Medications?

Body fluids may turn orange on Rifampin.

Which Anti-Infectives have cross-sensitivity?

• Cephalosporin & -Cillin

  • C: Cross-sensitivity with

  • C: Ceph/Cef\

  • C: -Cillin

  • DO NOT MIX

Antifungal (-azole): Common Medications

• Amphotericin B

• Nystatin

• Ketoconazole

• Clotrimazole

• Fluconazole

What are the Nursing Implications of Antifungal Medications?

• Obtain specimens before starting antifungal therapy

• Amphotericin B

  • Highly toxic

  • ONLY on deadly fungal infections

  • Monitor kidney function

• Assess IV site for pain/redness/swelling

• Monitor BUN and Creatinine, BMP (especially potassium) and CBC- hematocrit

Aminoglycosides: Medications

• Gentamicin

• Tobramycin

• Neomycin

• Streptomycin

Complications of Aminoglycosides (-mycin)

• Ototoxicity

• Nephrotoxicity

• "its a sin to give -amycin/-omycin because they are toxic to the kidney and the ears”

Abnormal kidney function labs and which anti-infectives mess with them.

• BUN over 20 Aint good honey

• Cr over 1.3 = bad Kidney

• Urine 30 mL of less = Kidneys in distress

Pre Diabetes & Gestational Diabetes

• Pre-diabetes

  • Elevated glucose levels that do not meet the diagnostic criteria for Diabetes

• Gestational diabetes

  • Temporary form of diabetes in pregnancy

Diabetes Mellitus: Type 1

• Destruction of Beta Cells

• Pancreas Secretes NO Insulin

  • Require exogenous insulin replacement

• Etiology

  • Some Genetic Component (10%)

  • Autoimmune Response

Diabetes Mellitus: Type 2

• Insulin resistance

• reduced tissue sensitivity to insulin

• Deranged insulin secretion

• reduced number of beta cells

• beta cells reduced response to glucose

• Increased glucose production

• Etiology

  • Large Genetic Component (90%)

  • Obesity

Insulin: Rapid Acting (Lispro/Aspart)

• Onset

  • 15 minutes

• Peak

  • 1 hour

• Duration

  • 3 hours

Insulin: Short Acting (Regular)

• Onset

  • 30 minutes

• Peak

  • 2 hours

• Duration

  • 8 Hours

Insulin: Intermediate Acting (NPH)

• Onset

  • 2 hours

• Peak

  • 8 hours

• Duration

  • 16 hours

Insulin: Long Acting (Lantus/Levemir)

• Onset

  • 2 hours

• Peak

  • NONE

• Duration

  • 24 Hours

Oral Antidiabetics (-ide): Common Meds

• Sulfonylureas

  • Chlorpropamide

  • Glipizide

  • Tolazamide

  • Glyburide

  • Glimepiride

• Biguanides

  • Metformin

Which drug/food/drink interactions are there with patients taking oral antidiabetic medications?

• Alcohol

• NSAIDS

• Sulfonamides

• Ranitidine

• Cimetidine

  • (additive hypoglycemic effect)

• Beta-blockers

  • (decrease effectiveness)

• Iodine-containing contrast

  • With Metformin

What are the therapeutic effects of thyroid hormone?

Synthetic thyroxine T4 is converted to T3 in the body

Adverse effects: Bisphosphonates (-dronate)

• Esophagitis, esophageal ulceration (PO forms)

• Visual disturbances

• Musculoskeletal pain

• GI distress

Biphosphonates: Common Medications

• Alendronate

• Ibandronate

• Risedronate

Clinical manifestations of Right-Sided Heart Failure

• Weight Gain

• Peripheral edema

• Jugular Vein Distention

• Shortness of Breath

• Chest Pain

Clinical manifestations of Left-Sided Heart Failure

• Dyspnea

• Cough

• Oliguria

  • Low urine output

• Nausea

• Shortness of Breath

• Whistling lung sounds

• Arrhythmia and Pulmonary Edema

What are the Signs & Symptoms of Digoxin Toxicity?

• Digoxin toxicity

  • Serum levels: greater than 2 ng/mL

• Fatigue

• Weakness

• Vision Changes

• GI effects

• Palpitations

What are the Nursing Implications of Digoxin Toxicity?

• Monitor HR/rhythm (apical for 1 minute) prior to administration, hold for Heart Rate under 60 beats per minute

• Admin at the same time each day

• Antidote = Digibind

• Fall Risk

Beta Blocker: Medications

• Metoprolol

• Atenolol

• Propranolol

• Carvedilol

• Labetalol

Beta Blockers: Nursing Implications

• Monitor Blood Pressure, Heart Rate, and EKG before and after admin

• Take apical pulse before admin, if less than 50/min hold medication

• Monitor I+Os, daily weights, and signs & symptoms of Heart Failure

• Extended-release sprinkles available for certain meds

• Tell patient not to stop abruptly

• Fall Risk

• Antidote: Glucagon

Loop Diuretics: Common Medications

• Ethacrynic Acid

• Furosemide

• Bumetanide

• Torsemide

Potassium-Sparing Diuretics: Medications

• Spironolactone

• Amiloride

• Triamterene

Thiazide diuretics: Medications

• Hydrochlorothiazide

• Chlorothiazide

• Methyclothiazide

What are the possible lab complications of Loop Diuretics and Potassium-Sparing Diuretics?

• Normal Potassium level

  • 3.5 to 5

• If Potassium levels are less than 3.5 hold medication and call the provider

General Patient Teaching for all Diuretics.

• Fall Risk

• Monitor potassium levels

• Obtain baseline…

  • Labs

  • Vitals

  • Weight

  • Electrolytes

• Monitor…

  • Blood Pressure

  • Inputs & Outputs

  • Take daily weights

Ethacrynic Acid, Furosemide, Bumetanide & Torsemide: Nursing Implications

• Administer during the day to avoid nocturia

• Administer IV doses per guidelines

  • too quick can cause ototoxicity

Thiazide diuretics: Nursing Implications

• If diabetic; closely monitor your blood sugar levels

• Take the dose before 2 pm

  • Prevention of Nocturia

Potassium-sparing diuretics: Nursing Implications

• Triamterene can turn urine a bluish color

• Avoid salt substitutes and reduce intake of potassium-rich foods

  • Oranges

  • Bananas

  • Potatoes

  • Dates

Antihistamines: Medications

• Diphenhydramine

• Dimenhydrinate

• Chlorpheniramine

• Loratadine

• Cetirizine

• Fexofenadine

Antihistamines: Use

• Relieve mild allergic reactions

• Anaphylaxis

• Motion sickness

• Insomnia

• Nasal decongestion

  • Rhinitis

Antihistamines: Complications

• Sedation

• Anticholinergic effects

  • DRIES YOU OUT

  • CANT SEE, SPIT, SHIT, PEE

• GI discomfort

• Respiratory depression

How do you treat an Acute Asthma Attack?

• Ipratropium: Short-acting

• Albuterol (short acting)

• Levalbuterol (short acting)

• Use the -buterols then the tropium

Inhaled Glucocorticoids: Common Medications

• Beclomethasone

• Fluticasone

• Budesonide

• Combination inhaled meds

  • Symbicort

  • Advair

  • Duoneb

  • Combivent

Inhaled Glucocorticoids: Common Complications

• Candidiasis

• Difficulty speaking/hoarseness

Oral Glucocorticoids: Common Medications

• Prednisone

• Methylprednisolone IV

Prednisone & Methylprednisolone: Complications

• Suppression of adrenal gland function

• Bone loss

• Hyperglycemia

• Myopathy

• Peptic ulcer disease

• Infection

• Fluid/Electrolyte imbalances

Inhaled Glucocorticoids: Therapeutic Effect

• Use

  • Long term Asthma

• Therapeutic effects

  • Decrease Inflammation

Inhaled Glucocorticoids: Patient Teachings

• Do not stop abruptly; must taper down

• Rinse mouth after each use (1 min between puffs)

• Avoid NSAIDs- use Tylenol instead

• Take oral forms with food

• Increase fluid intake

• Take enough calcium and vitamin D

Etiology of Parkinson’s disease

Overstimulation of the basal ganglia by acetylcholine which causes degeneration of the substantia nigra that results in decreased dopamine production. Too much acetylcholine causes smooth, controlled movements difficult.

Signs & Symptoms of Parkinson’s Disease

• Characterized by four primary findings:

  • Tremor

  • Muscle rigidity

  • Bradykinesia (slow movement)

  • Postural Instability

Anticonvulsants: Common Medications

• Phenytoin

• Phenobarbital

• Levetiracetam

• Carbamazepine

• Valproic acid

• Lamotrigine

• Gabapentin