!!EXAM 1 PATHO DRUGS FINAL REVIEW

Patient education for OTC, herbs, & Supplements

natural doesnt mean safe, information about safe use, dosing, and frequency, discuss possible food/drug/herb interactions, teach that supplement manufactorers DO NOT have to prove safety/effectiveness

Nursing considerations for OTC/Herbs

• all meds used

• level of education

• contraindication

• body system functioning

• life span considerations

Contraindications for corticosteroids

• peptic ulcer disease and severe infections

Corticosteroid drug interactions

• Non potassium sparing diuretics (can lead to severe hypocalcemia/kalemia

• NSAIDs: increase change of gastric ulcers

the 5 S’s of side effects for steroids

• Sick: easier to get sick

• Sad: causes depression

• Sex: decreases libido

• Salt: retain more, causes weight gain

• Sugar: raises blood sugar

Prednisone

PO glucocorticoid

• most common

• anti-inflammatory or immunosuppressant purposes

• exacerbations of chronic illnessess (COPD, chrons ulcerculitis)

• give with food or milk to minimize GI upset

PO corticosteroid education

give with food or milk to minimize GI upset

steroid side effects

• C: cushings syndrome

• O: osteoporosis

• R:

• T:thinning of skin

• I: immunosuppression

• C: cataracs and glaucoma

• O: edema

• S: suppression of HPA axis

• T: teratogenic

• E: emotional disturbances

• R: raised BP / HF

• O: obesity

• I: Increased body hair growth

• D: diabetes

• S: striae or stomach ulcers

NSAID indications

• arthritis

• headaches

• myalgia

• neuralgia

• arthralgia

• postop pain

• gout

NSAID MOA

inhibition of prostaglandin synthesis by preventing conversion of COX1 and/or COX2

COX 1

beneficial body effects
- maintain GI mucosa
- blood clotting
- renal blood flow

COX 2

triggers inflammation and pain

NSAID contraindications

• pt with aspirin allergy

• conditions that place pt @ risk for bleeding (vit k deficiency or peptic ulcer disease)

• renal disease

NSAID BBW

(except aspirin)

• Increases risk of CV thrombotic events, including fatal MI and stroke

• may counteract cardioprotective effects of aspirin

NSAID AE’s

• bleeding

• GI pain and/or ulcers

• Acute Renal Failure

• Increased stroke of MI or stroke

• Hepatotoxicity

• Hypersensitivity Reactions

• Tinnitus

• Hearing Loss

NSAID interactions

Anticoagulants
Aspirin
Corticosteroids and other ulcerogenic drugs
Protein bound drugs
Diuretics and ACE inhibitors
Herbals (feverfew, ginger, garlic)

Ibuprofen

• most common NSAID

• proprionic acid derivative

Celecoxib

• COX-2 Inhibitor. NSAID

• decreases risk of GI bleed

• 1st and only cox 2 inhibitor

• AE’s: HA, sinus irriaiton, diarrhea, fatigue, dizzi, lower extremity edema and HTN

• little effect on platelet function

• contraindications: pts with sulfa allergy

Ketorolac

• NSAID— acetic acid derivative

• some anti-inflammatory activity

• used primarily for its powerful analgesic effects

• indication: short term use (up to 5 days) to manage moderate-severe acute pain

• AE’s: renal impairment, edema, GI pain, dyspepsia and Nausea

Aspirin

• NSAID— salicylate

• inhibits platelet aggregation, shown to reduce cardiac death after MI

• irreversible inhibitor of COX 1

• Indications: first sign of MI if no contra’s, HA, pain, fever

Reyes syndrome

• from aspirin

• acute and potentially life threatening , common ages 4-12

• progressive neurologic deficits

• can lead to come and liver damage

• triggered by viral illness plus salicylate therapy

• damage can be permanent

• eduation patient to read labels (pepto bismol)

Salicylate toxicity

• potentially fatal

• increased HR

• tinnitus, hearing loss, dimness of vision

• HA, dizzi, mental confusion, lassitude drowsiness

• N/V/D

• sweating, thirst, hyperventiliation, hypo/hyperglycemia

• metabolic acidosis

Opioid Contraindications and interactions

contraindications:

• severe asthma, respiratory insufficiency, elevated intracranial pressure, morbid obesity or sleep apnea, paralytic ileus, pregnancy

interactions

• any CNS depressants: alcohol, benzodiazepines, barbiturates, antihistamines, antidepressants

opioid AE’s

CNS depression: bradycardia, meiosis of eyes, urinary retention

Morphine Sullfate

natural opioid, derived from poppy plant

fentanyl

0.1mg = 10mg morphine

Oxycodone

weaker opioid, often combined with acetaminophen; IR and SR forms

Acetaminophen

analgesic and antipyretic; can be OTC and used in combination with opioids

• MOA: inhibits prostaglandin synthesis
  - useful if pt can't take NSAIDS

Acetaminophen AE’s:

liver failure, hepatotoxicity, hypersensitivity, red, peeling, blisters

Acetaminophen Contra’s & interactions

contraindication

• liver disease, G6PD deficiency

interactions: alcohol, hepatotoxic meds

Tramadol Hydrochlroide

centrally acting analgesic

• weak bond to mu opioid receptors and inhibits reuptake of norepinephrine and serotonin
  - caution with SSRIs, MAOIs, and neuroleptics

sedatives and hypnotics

both inhibit CNS and reduce nervousness, excitability, and irritability

Benzo MOA

CNS depressant; enhances GABA binding to receptors
- controlled substance, sedative hypnotic
- risk dependence and withdrawl

• onset of action: 30-60 minutes

Benzo’s contra’s , interactions and AE’s

contraindications:

• narrow angle glaucoma, pregnancy (category D)

interactions

• CNS depressants, numerous other medications

AE’s:

• headache, paradoxical excitement/nervousness, cognitive impairment, dizziness, hangover effect

• life threatening withdrawls

Benzo’s toxicity symptoms

somnolence, confusion, coma, diminished reflexes
- if combined with other CNS depressants, can cause hypotension and resp depression

• antidote: flumanezil

barbiturates (moa)

• controlled substance, sedative hypnotic; habit forming with a low therapeutic index

MOA:

• works at brainstem; potentiates action of GABA, inhibits nerve impulses traveling through cerebral cortex

barbiturates contraindications

pregenacy, significant resp impairment, severe renal or hepatic disease, caution in older adults

Barbiturates AE’s

vasodilation, hypotension; drowsiness/lethargy, vertigo; resp depression, cough; NVD, constipation; agranulocytosis and thrombocytopenia; decreased REM; hypersensitivity, Steven Johnson's Syndrome

barbiturate toxicity

OD=emergency
- symptomatic and supportive care
- maintain airway
- fluids
- urine alkalization to hasten elimination

Malignant Hyperthermia

• occurs from inhaled anesthesia or use of NMBD (succinycholine)

• sdden elevation in body temp , >104

• tachypnea, tachycardia, muscle rigidity

• life threatening

• antidote: dantrolene

Dexmedetomidine

alpha 2 agonist, sedative adjunct
- decreased anxiety and analgesia without resp depression
- short half life

uses:

• procedural sedation, short surgeries, sedation of mechanically ventilated PTs

Ketamine

• for general anesthesia, moderate sedation

• routes: IV/IM/SQ

• rapid onset of action

• lower impact on cardiac, respiratory, bowel function

• AE’s: disturbing psychomimetic effects including hallucinations

Propofol

• for general anesthetic, sedation for mechanical ventilation, moderate sedation

• some states prohibit administration by nurses

• lipid based

• short procedure

Neuromuscular Blocking Drugs

• paralyze the skeletal muscles required for breathing (intercoastal muscles and the diaphragm)

• artificial ventilation is required

• do not cause sedation or pain relief

• contraindications

  • malignant hyperthermia (family or personal)

  • narrrow angle glaucoma

  • recent crush injury

  • burns

Succinylcholine

depolarizing neuromuscular blocking drug

• binds receptors for neurotransmitter acetylcholine

• can cause malignant hyperthermia — dantrolene

empiric therapy

• ABX before culture results are available

prophylactic therapy

used to prevent an infection (before surgery)

Definitive therapy

treatment given after knowing infected culture

Cephalosporin

• Beta lactam ABX— disrupt cell wall synthesis (cell lysis , cidal)

• similar to penicillin

• 3rd gen : strongest affect on gram negative and some gram +

• ceftriaxone: IV/IM, long half life, crosses BBB, CNS infections

Macrolides

inhibit protein synthesis within bacterial cells

• AE’s: GI upset N/V/D

• risk of long QT syndrome/prolongation

• azithromycin/clarithromycin better tolerated

Tetracyclines

• inhibit protein synthesis

• reduced oral absorption with dairy products, antacids, iron salts

• not to be given for children <8 or pregnant or lactating women

  • permanent tooth discoloration

  • may retard fetal skeletal development

• AE’s: maculopapular rash, photosensitivity, risk of superinfections (pseudomembraneous colitis, enterocolitis, vaginal candidiasis)

Sulfonamides

• often given with another ABX

• prevents synthesis of folic acid needed by bacteria

• AE’s: risk of hemolytic and aplastic anemia, thrombocytopenia, photosensitivity, severe skin reactions (SJS)

• rare but serious: hepatoxicity, seizures, toxic nephrosis

Aminoglycosides

broad spectrum, inhibits protein synthesis

• gentamicin

• AE’s: otoxicity, nephrotxicity, super infections, HA< dizziness, paresthesia, skin rash

• monitor trough: gentamicin greater than 2 = higher risk of toxicitiy

  • normal= 0.3-2.0 mcg/mL

Quinolones

-floxacin, alter DNA of bacteria

• resistance common especially for UTIs

• need to take one hour before or after dairy products, antacids, tube feedings

• BBW: tendon rupture, tendonitis

• AE’s: Long QT, HA, Dizzi, depression, seiures, increased LFTs, rash, urticaria, peripheral neuropathy, hepatoxicity

Metronidazole

anaerobic coverage and protozoal coverage

• intraabdomina and gynecologic infection

• no alcohol 24 hours before or 48 hours after taking

Vancomycin

treatment of choice for MRSA—- gram + coverage

• oral form used for C dif

• risk for nephrotoxicity and ototoxicity

• desired trough level: 10-20mcg/ml

• red man syndrome: flushed feeling, facial itch, decrease blood pressure (slow administration and give antihistamines)

Antiretroviral Drugs

• strict adherence essential

• combination of 3 or more meds

• MOA: blocking different step in cycle, stopping it from replicating

• AE’s: elevated LFT , hepatomegaly, myopathy, rhabdomyolysis, lactic acidosis

nursing implications for antiviral meds

• inform patients that antiviral drugs are not cures (except hep c)

• instruct to start therapy at first sign of recurrence

• monitor for therapeutic effects

  • viral load

  • relief of symptoms such as crusting over of lesions

Amphotericin B

antifungal

• AE’s:

  • cardiac dysrhythmias

  • neurotoxicity, (seizures, tinnitus, paresthesia)

  • nephrotoxicity, hypomagnesdemia, hypokalemia

  • flu like symptoms such as fever chills headache nausea

  • hypotension

  • anemia

prevention and mitigation of amphotericin B AE’s

anticipate before treating

• PADS= pre treat

  • premedicate

  • acetaminophen and antiemetic

  • diphenydramine = antihistamine

  • steroids

• infuse slowly (2-6 hours )