Pharm Exam 4 Study Guide

Type 1 Diabetes

• Cannot be prevented or cured

• The body does not create enough insulin

• Cause are unknown, but genetics may play a role

• Requires insulin injections for life

Type 2 Diabetes

• Can be prevented through lifestyle modifications

• The body does not create enough insulin or develops insulin resistance

• Causes include genetics, aging, inactivity, obesity, and more

• Requires insulin as needed, injected or oral

Type 1 and Type 2 Diabetes in Common

• Can cause other serious health problems and complications

• Requires a healthy lifestyle and medical supervision

• Symptoms include thirst, frequent urination, and blurry vision

Signs of hypoglycemia and hyperglycemia

• Hypoglycemia

  • Severe

    • Unable to eat or drink

    • Seizures or convulsions (jerky movements)

    • Unconsciousness

  • Mild to Moderate

    • Shaky or jittery

    • Sweaty

    • Hungry

    • Headache

    • Blurred vision

    • Sleepy or tired

    • Dizzy or lightheaded

    • Confused or disoriented

    • Pale

    • Uncoordinated (appears drunk)

    • Irritable or nervous

    • Argumentative or combative

    • Changed behavior or personality

    • Trouble concentrating

    • Weak

    • Fast or irregular heartbeat

• Hyperglycemia

  • Severe

    • Diabetic ketoacidosis

  • Symptoms

    • Fruity odor to breath

    • Polyuria progressing or oliguria, polydipsia, polyphagia

    • Kussmaul's respirations (rapid and deep)

    • Sluggish, drowsy, stupor

    • Hypotension, tachycardia

    • Skin warm and dry, dry mucous membranes

Glucagon injectable

• Used to treat hypoglycemia in diabetes patients who are unconscious or unable to take sugar by mouth

• GLP-1 agonist Semaglutides

Aspart (Novolog)

• Rapid acting: Aspart (Novolog)

  • Onset: 15-30 minutes

  • Peak effect: 1-3 hours

  • Duration: 305 hours

  • a form of insulin

  • Administration Considerations: give within 15 minutes before a meal or immediately after a meal

  • SE: hypoglycemia, hypokalemia

Humulin R or Regular insulin

• Regular/short acting: Humulin R or Regular insulin

  • Onset: 30 minutes

  • Peak effect: 3 hours

  • Duration: 8 hours

  • Administer 30 minutes before a meal

  • SE: hypoglycemia, hypokalemia

Humulin NPH

• Intermediate acting: Humulin NPH

  • Onset: 1-2 hours

  • Peak effect: 6 hours (range 2.8-13 hours)

  • Duration: up to 24 hours

  • Administer once or twice daily

  • SE: hypoglycemia, hypokalemia

Glargine (Lantus)

• Long acting: Glargine (Lantus)

  • Onset: 3-4 hours

  • Peek effect: none

  • Duration: >24 hours

  • Administer once daily

  • SE: hypoglycemia, hypokalemia

Glipizide oral (Class: Sulfonylurea)

• Indication: stimulate pancreatic insulin release

• MOA: the beta cells of the pancreas secretes insulin has a sulfonylurea receptors

  • When stimulated the receptor causes the beta cell to release insulin

    • Stimulate beta cells to increase insulin secretion

    • Increase peripheral insulin sensitivity

    • Reduce hepatic glucose production

• Contraindications: type 1 diabetes, diabetic ketoacidosis, severe renal or hepatic failure

• Education: caution in pregnant, breastfeeding, and elderly patients, take medication before meals

• 5-10 mg daily

• SE: hypoglycemia

• Monitor blood glucose levels

• Glipizide and Glyburide (G for Glucose)

  • Glide down as slide, as your blood sugar comes down

Metformin oral (Class: Biguanide)

• Indication: treat type 2 diabetes mellitus, specifically when diet and exercise are insufficient

• MOA: lowers hepatic glucose production and enhancing insulin sensitivity

• 500 mg twice a day

• Max 200mg/day

• SE: nausea, diarrhea, bloating, usually decrease with time

• Contraindications: severe renal and hepatic impairment, acute or chronic metabolic acidosis

• Education: rare lactic acidosis, eat with meals, avoid alcohol

Sitagliptin (Januvia) oral (Class: DPP4 inhibitor)

• Indications: improves glycemic control

• MOA: inhibits DPP4 that breaks down incretins which increases active incretin hormone levels (GLP-1 and GIP)

• 50-100 mg daily

• Risk of pancreatitis

• Dose adjustment needed for patients with kidney disease

• SE: weight neutral, hypoglycemia, acute pancreatitis⭐, upper respiratory infections

• Serious skin reactions (blisters)

• Nursing considerations

  • These medications should be used with caution in clients with renal disease

• Education: used along diet and exercise

• Contraindications: type 1 diabetes, diabetic ketoacidosis

Empagliflozin (Jardiance) oral (Class: SGLT2 inhibitor)

• Drug: Empagliflozin (Jardiance)

• Indications: with diet and exercise it improves blood sugar control

• MOA: inhibits SGLT2, which transports sodium-glucose, so it reducing glucose and sodium reabsorption, increase urinary glucose excretion and sodium delivery to distal tubule

• Advantages: weight loss (5-10 lbs), decrease CV risks

• Adverse effects: Glucosuria, increased urination

  • May cause serious UTIs

• Contraindicated: patients with decreased renal function

• 10 mg daily

• Education: reduce CV death in adults with heart disease,  manages heart failure or chronic kidney disease, take once daily

Semaglutide (Wygovy) injectable (Class: GLP-1 agonists)

• Indication: once a week injection to reduce appetite

• MOA: GLP-1 receptor in the brain makes patient feel more full after a meal

  • Stimulating the release of insulin by the pancreas after eating, even before blood sugars start to rise

  • Inhibiting the release of glucagon by the pancreas

• Dosing 0.5-2.5 mg, injectable (pen), weekly

• Common SE: nausea, vomiting, diarrhea- diminished with time, HA, dizziness, increased sweating, indigestion, constipation, loss of appetite

• Semaglutide (Wegovy)- weekly

• Dulaglutide (Trulicity)- weekly

• May contribute to medullary thyroid carcinoma

  • Black box warning: Thyroid Cancer

• Education: once a week for chronic weight management, change injection sites

Treatment Goals

• Normal glucose level of 80-130 mg/dl

• A1C < 7%

• Average over 3 months of ABG must be under 7%

Hormones Associated with Endocrine System (Adrenal, Pancreas, Thyroid)

• Adrenal Gland Hormones

  • Glucocorticoids (cortisol)

    • Secrete from zonae fasciculata and reticularis

    • Regulates body's response to stress

    • Regulates metabolism

  • Mineralocorticoids (aldosterone)

    • Secrete from zonae glomerulosa

    • Regulates sodium and potassium levels

  • Sex hormones (androgens)

    • Secreted from zonae fasciculata and reticularis

    • Regulate reproductive function

• Thyroid Hormones

  • TSH

    • Thyroid Stimulating Hormone

    • Regulates the thyroid production of T3 and T4 hormones

  • T3

    • Regulates metabolism, body temperature, heart rate, and development

  • T4

    • Regulate metabolism, body temperature, energy levels, and heart rate

• Pancreas

  • Insulin

    • Absorbs glucose for energy

    • Regulates blood sugar

  • Glucagon

    • Raises blood sugar levels when they are too low

Negative Feedback Loop

• Body slows release of hormones when there are adequate levels

• When hormone concentrations reach a high threshold, they inhibit further production, bringing levels back down to a set point

Hypothalamus-Pituitary Complex

The primary command center of the endocrine system, linking the nervous system to the pituitary gland to maintain homeostasis

Cushing’s Disease and Syndrome

• Excess production of cortisol and aldosterone

• Caused by a benign pituitary tumor secreting excessive ACTH leading to overproduction of cortisol

• Cushion of steroids High

• Big, round, hairy

• Treatment options

  • Surgery

  • Radiation

  • Medication (chronic use)

Addison’s disease, treated with Corticosteroids

• Inadequate production of cortisol and aldosterone

• Adrenal insufficiency as a result of adrenal glands not receiving ACTH

• Treatment of Addison's Disease

  • Add -sone

  • Diet: high in protein, carbs, and sodium

  • Don't abruptly stop steroids

  • Don't believe this medication will cure you

  • Indefinitely: lifelong hormone replacement

Prednisone (PO) and Methylprednisolone (IV)

Indication: short term to reduce inflammation

• Long term for immunosuppression

Administration considerations: never abruptly stop corticosteroid therapy, use the lowest dose possible to control disorder and taper when feasible, may require concurrent treatment for osteoporosis⭐ or elevated blood glucose levels⭐, regularly monitor for development of symptoms of adrenal

Contraindication: patients with untreated systemic infections

SE: fluid and electrolyte imbalances, increase in blood glucose⭐, muscle weakness, peptic ulcers, thin and fragile skin that bruises easily, poor wound healing, development of Cushing's syndrome⭐, may mask some signs of infection, and new infections may appear, psychic derangement may appear when corticosteroid are used, ranging from euphoria, insomnia, mood swings, personality changes to severe depression

Fludrocortisone

Indication: aldosterone replacement in Addison's disease

Administration considerations: monitor for signs that indicate dosage adjustment is necessary, such as exacerbation of the disease or stress (surgery, infection, trauma)

SE: from the retention of sodium and water: hypertension⭐, edema⭐, cardiac enlargement, congestive heart failure, potassium loss, and hypokalemic alkalosis

Hyperthyroidism

• Low TSH production

• High T3 and T4 production

• Causes: sweating, weight loss, emotional lability, appetite increased, tremor, tachycardia, intolerance of heat/irritability

Graves' Disease

Graves' Disease: autoimmune hyperthyroidism

• Physical presentation

  • Goiter

  • Eyelid retraction

  • Exophthalmos

Hypothyroidism

• High TSH production

• Low T3 and T4

• The Thyroid Gland does not produce enough thyroid hormone

• Weight gain, poor memory, intolerance to cold, feeling of tiredness

• Causes: memory loss, obesity, menorrhagia, slowness, skin and hair dryness, onset gradual, tiredness, intolerance to cold, raised BP, energy levels fall, depression/delayed relaxation of DTR- Patellar and Achilles

Hyperparathyroidism

• Overactivity of the parathyroid glands causing excessive PTH production, leading to high blood calcium, bone loss, and kidney stones

• treatment: regulate calcium and PTH

Differences between Hyperthyroid and Hypothyroid and lab tests used for each

• Hypothyroidism causes a low and slow metabolism

  • High TSH production

• Hyperthyroidism speeds up body functions

  • Low TSH production

Drug: Levothyroxine

Indication- thyroid replacement drug used to treat hypothyroidism

MOA- oral levothyroxine is a synthetic T4 hormone that exerts the same physiologic effect as endogenous T4, thereby maintaining normal T4 levels when a deficiency is present

Adverse Effects- nervousness, tremors, insomnia, tachycardia, palpitations, dysrhythmias, angina, shortness of breath

• We are replacing the thyroid hormone, so potentially AE are like signs and symptoms of hyperthyroidism

Contraindications- hyperthyroidism, adrenal insufficiency

Nursing Intervention/Patient Education- take at the same time every day, take with water, space from calcium, iron, or antiacids supplements

Drug: Propylthiouracil (PTU)

Indication- an antithyroid medication used to treat hyperthyroidism or to ameliorate symptoms of hyperthyroidism in preparation for thyroidectomy or radioactive iodine therapy

MOA- inhibits the synthesis of thyroid hormones

Adverse Effects- nausea, vomiting, heartburn, rash, joint pain, and symptoms of hypothyroidism

• Black box warning of severe liver injury and fatal liver failure

Contraindications- hypersensitivity

Nursing Intervention/Patient Education- report any hepatic dysfunction, monitor weight

• Administered orally

• Can cause hypothyroidism

Condition: Osteoporosis

• Treatment: calcitonin and alendronate

• Decrease density and structural deterioration, making bones weak and brittle

Drug: Calcitonin

Indication- used to treat osteoporosis

MOA- calcitonin receptor agonist; released by the thyroid gland; acts primarily on bone and also has effects on the kidneys and the GI tract

Adverse Effects- serious hypersensitivity reactions, hypocalcemia, nasal mucosa adverse events, malignancy

Contraindications- not to be taken during pregnancy

Nursing Intervention/Patient Education- take as directed

• Administered via nasal spray

Drug: Alendronate

Indication- used for the prevention and treatment of osteoporosis in postmenopausal women, to increase bone mass in men with osteoporosis, and for glucocorticoid induced osteoporosis

MOA- a biphosphate that inhibits osteoclast-mediated bone resorption; by preventing the breakdown of bone and enhancing the formation of new bone, alendronate assists in reversing bone loss and decreases the risk of fractures

Adverse Effects- upper Gi tract adverse events, severe musculoskeletal pain, risk of osteonecrosis of the jaw

Contraindications- pregnancy, hypocalcemia, kidney disease

Nursing Intervention/Patient Education- administer before 1.5 hours of consuming food/drink, should sit or stand for 30 minutes after administration, concurrent calcium vitamin D supplements may be required

Gastroesophageal Reflex Disease (GERD)

• GERD

  • Pathogenesis of gastric acid reflux to the esophagus or esophageal injury

  • Symptoms of heartburn, chest pains, nausea, belching

  • Treatment: remove acid causing food and drugs, administer proton-pump inhibitors, administer H2 receptor antagonists

Peptic ulcer disease (PUD)

• Peptic Ulcer Disease

  • Breakdown in the lining of the GI mucosa which can lead to bleeding ulcers

  • Caused by bacterial infection by Helicobacter pylori bacteria

Antacids - calcium carbonate (Tums)

Indication-  symptomatic relief of heartburn, acid indigestion, and upset stomach

MOA- neutralize stomach acid and elevate pH

Adverse Effects- constipation, hypercalcemia, rebound acidity when stopped

Contraindications- kidney disease, GI obstruction, affects the absorption of many other drugs

Nursing Intervention/Patient Education- come in tablets, chewable, capsules, and liquids

• It can be taken 3-4 times a day

• Do not administer within 1-2 hours of other medication

• Drink a full glass of water after administration

H2 receptor antagonist - Famotidine

Indication- heartburn, GERD, peptic ulcer disease, erosive esophagitis. Adjunct treatment for upper GI bleeding

MOA- blocks histamine-2 receptor sites of parietal cell which reduces hydrochloric acid

Adverse Effects- may lead to increased bacterial growth, constipation, diarrhea, headaches, dizziness, hepatic or renal dysfunction

Contraindications- hypersensitivity, renal impairment

Nursing Intervention/Patient Education- available OTC, given IV in hospital settings, take 15-16 minutes before eating or drinking⭐

PPI – pantoprazole

Indication- for GERD, erosive esophagitis, prophylactic with surgery, in combination with antibiotics for H. Pylori infection, short term treatment of active duodenal ulcers

• Most effective in controlling acidity

• Directly block gastric acid production

• Can cause increased bacterial growth

• Decrease bioavailability of some drugs

MOA- blocks the secretion of hydrochloric acid at the proton pump

Adverse Effects- headache, abdominal pain, diarrhea, constipation, acute renal dysfunction, long term use can cause osteoporosis and bone fracture⭐, potential zinc, magnesium, or B12 deficiency, immediately report signs of bleeding ulcers such as coughing/vomiting blood

Contraindications- hypersensitivity

Nursing Intervention/Patient Education- available orally, with an NG tube, or as IV injection in the hospital setting, can be taken with or without food

Mucosal protectants - Sucralfate

Indication- promote ulcer healing

MOA- locally covers the ulcer site and protects the sites against acid, pepsin, and bile salts

Adverse Effects- constipation

Contraindications- renal failure or dialysis⭐

Nursing Intervention/Patient Education- administer on an empty stomach, 2 hours after or 2 hour before a meal

Bismuth subsalicylate (Pepto-Bismol)

Indication- diarrhea and heartburn

MOA- coats the lining of the GI tract and decreases the flow of fluids and electrolytes into the bowel, reducing inflammation

Adverse Effects- black tongue, black stool

Contraindications-⭐

Nursing Intervention/Patient Education- avoid taking other salicylates, aspirin, avoid taking simultaneously with antibiotics, they will not work

Loperamide (Imodium)

Indication- control and symptomatic relief of acute, nonspecific diarrhea and chronic diarrhea associated with IBS; reduction of volume of discharge from ileostomies

MOA- inhibits intestinal peristalsis through direct effects on the longitudinal and circular muscles of the intestinal wall, slowing motility and movement of water and electrolytes

• Has a direct effect on the muscle layers of the GI tract; slows peristalsis and allows increased time for absorption of fluid and electrolytes

• Opioid agonist

• Most effective

• Recommended for short-term therapy

Adverse Effects- constipation, dizziness, tiredness, nausea, and abdominal cramping/pain

Contraindications- infectious diarrhea and various forms of colitis

Nursing Intervention/Patient Education- take as prescribed

Black Box Warning: may cause abnormal heart rhythm

Fiber supplements- psyllium (Metamucil)

Indication- treats constipation

MOA- absorbs water

SE: bloating, gas, stomach cramps, and diarrhea

• Safest class of laxatives

• Commonly used to treat chronic constipation

• May decrease absorption of some drugs

• Dissolve with 8oz of water

Stool softener- Docusate (Colace)

Indication- used to prevent constipation

MOA- absorbs water and fats into stool to make it soft

Adverse Effects- abdominal cramping

Osmotic laxative- Milk of Magnesia, polyethylene glycol (MiraLAX)

Indication- purging toxins and for fecal impactions

MOA- increases bowel movement by causing water to be retained with stool

SE: diarrhea, nausea, stomach cramping, bloating, gas

Stimulant laxative- Bisacodyl (Dulcolax)

Indication- often used as bowel prep, BM within 1 hour

MOA- promotes bowel movements in the large intestines

Adverse Effects- abdominal cramps, pain, diarrhea, and nausea

Contraindications- do not take with milk or antacids

Nursing Intervention/Patient Education- available as oral or rectal suppository

Anticholinergic - Scopolamine

Indication- motion sickness and postop NV

MOA- blocks cholinergic nerve impulses, reducing parasympathetic activity

Adverse Effects- sedation, drowsiness, blurred vision, pupil dilation

Contraindications- angle-closure glaucoma

Nursing Intervention/Patient Education- prescription medication, commonly used as a transdermal patch

Dopamine antagonist – Metoclopramide (Reglan)

Indication- reduce nausea and vomiting

MOA- blocks dopamine receptors to improve nausea

Adverse Effects- CNS depression, drowsiness, fatigue, tardive dyskinesia, neuro-malignant syndrome

Contraindications- alcohol, narcotics, tranquilizers

Nursing Intervention/Patient Education- apply 4 hours before travel or surgery

Serotonin antagonist- Ondansetron (Zofran)

Indication- control of severe nausea and vomiting associated with cancer treatments and postop NV

MOA- blocks specific receptor sites associated with nausea and vomiting, peripherally and in the CTZ

Adverse Effects- HA, dizziness, drowsiness, myalgia, urinary retention, constipation, pain at injection site

Contraindications- angle-closure glaucoma

Nursing Intervention/Patient Education- take as prescribed

Anticholinergic – dicyclomine

Indication- IBS

MOA- blocks Ach at muscarinic receptors and directly relaxes smooth muscle

Adverse Effects- drowsiness, constipation, dry mouth

Contraindications- infants under 6M, nursing mothers, GI/urological disease, glaucoma, severe ulcerative colitis, myasthenia gravis, or unstable CV status

Nursing Intervention/Patient Education- avoid alcohol, operating heavy machinery, or becoming overheated

UTI: urinary tract infection

• inflammation of the urinary epithelium usually caused by bacteria from gut flora

• Urinalysis will show high nitrite, leukocyte esterase, and WBC levels

Cystitis

Cystitis: inflammation of the bladder (lower tract)

• Bacterial or nonbacterial

• Complicated vs uncomplicated

• Treatment with oral antibiotics

• Signs and symptoms: dysuria, frequency, urgency, nocturia, suprapubic discomfort, incomplete emptying sensation, mild incontinence, gross hematuria

Pyelonephritis

Pyelonephritis: infection in kidneys from a rising UTI (upper tract)

• Chills, fever, and flank pain accompanied from bacteriuria and pyuria (WBC)

• Complicated

• Not managed outpatient/ should be in hospitalization for IV treatment

• Signs and symptoms: fever, chills, malaise, flank pain, CVA tenderness, nausea, vomiting

Trimethoprim-sulfamethoxazole

Indication- treats uncomplicated UTIs

MOA- inhibits bacterial synthesis

Adverse Effects- serious skin reactions, abnormal CBC, allergic reaction

Contraindications- hypersensitivity, renal/hepatic insufficiency, liver damage

Nursing Intervention/Patient Education- stay well hydrated and avoid sunlight

• 160 mg/800, 1 PO bid

• Standard therapy in women

Nitrofurantoin

Indication- treatment for UTIs caused by E. coli

MOA- disrupts cell metabolism

Adverse Effects- peri, neuropathy, pneumonitis, GI upset

Contraindications- severe kidney disease, pregnancy, infants under one month

Nursing Intervention/Patient Education-

• Dose 250 mg, q12 hrs

• Treatment for UTI caused by E. coli

• Disrupt cell metabolism

• For uncomplicated UTI

Ciprofloxacin

Indication- treats UTIs

MOA- Stops DNA replication

Adverse Effects- nausea, vomiting, diarrhea, abdominal pain, headache, skin rash, tendon rupture, arrhythmias, angina, convulsion, GI bleeding, nephritis

Contraindications- hypersensitivity

Nursing Intervention/Patient Education- take with water

• 250 mg, q12 hrs

• Fluoroquinolones

  • First line for complicated UTIs

  • Second line for uncomplicated UTIs

Levofloxacin

Indication- treats serious bacterial infections like UTIs

MOA- inhibits bacterial DNA replication

Adverse Effects- nausea, vomiting, diarrhea, abdominal pain, headache, skin rash, tendonitis, tendon rupture, arrythmias, nephrotoxicity, hepatotoxicity

Contraindications- hypersensitivity, tendon rupture history, epilepsy, and in children or adolescents

Nursing Intervention/Patient Education- stop taking if you experience any pain, swelling, numbness, or psychiatric

• Dose 750 mg, qd

• Fluoroquinolones

  • First line for complicated UTIs

  • Second line for uncomplicated UTIs

Fluconazole (Diflucan)

Vaginal yeast – Fluconazole (Diflucan)

Indication- treatment for vaginal yeast infections

Metronidazole

Bacterial vaginosis – Metronidazole

Indication- to treat bacterial vaginosis

Acyclovir

Genital herpes - Acyclovir

Indication- genital herpes

• STI

Doxycycline

Chlamydia - Doxycycline

Indication- chlamydia

• STI

Ceftriaxone

Gonorrhea - Ceftriaxone

Indication- Gonorrhea

• STI

Metronidazole

Trichomonas - Metronidazole

Indication- trichomonas

• STI

Estradiol

Menopause: Estradiol

Indication- for symptoms of menopause

MOA- the most potent endogenous female sex hormone, responsible for estrogen effects on the body

Adverse Effects- corneal, changes, photosensitivity, peripheral edema, chloasma, hepatic adenoma, nausea, vomiting, abdominal cramping, bloating, breakthrough bleeding, change in menstrual flow, dysmenorrhea, premenstrual-like syndrome

Contraindications- breast cancer, abnormal genital bleeding, DVT, hypersensitivity

Nursing Intervention/Patient Education- long term use increases risk of breast and cervical cancer, heart disease, stroke, and blood clots

Estrogen

• Indication: Menopause; hormone replacement therapy

• Retaining calcium in the bones to prevent osteoporosis

• In combination with progesterone as contraceptive

• Long term use: increased risk for breast and cervical cancer, heart disease, stroke, and blood clots

Progestins

• Indication: contraceptives, most effectively in combination with estrogens

  • Amenorrhea: absence of period

  • Abnormal uterine bleeding

Hormonal contraceptives

• Hormonal IUD

• Implant

• Pill

• Patch

• Ring

• Shot

Non-hormonal methods

• Condoms

• Fertile awareness

• Non-hormonal IUD

• Sterilization

Estrogen/Progestin Combinations and Oral Contraceptive Pills (OCP)

• MOA: suppresses LH and FSH, inhibiting ovulation; alters cervical mucus and endometrium

  • Ovaries become smaller

• Indication

  • Contraception

  • Abnormal uterine bleeding

  • Endometriosis

  • PCOS

  • Acne

• Common SE

  • Breakthrough bleeding

  • Nausea

  • Breast tenderness

  • Hypertension

• Severe Adverse Effects

  • GI effects: progestin component can cause symptomatic gallbladder disease

  • Eyes: cornea and retina problems, glaucoma, related to stroke

  • Vascular risk: heart attack, blood clot, stroke

  • Potential risk of breast cancer

• Instructions

  • Start day 1 of menstrual cycle

  • Take daily

  • Smoking increases risks for blood clots and vascular risks

• Contraindication

  • Smoking

  • High BP, heart disease

  • Breast, cervical cancer

  • Migraine headaches

OCPs and Antibiotic Interactions

When on oral birth control and taking antibiotics they should use a barrier contraceptive because the antibiotic interacts with the birth control making pregnancy possible

Progestin implants

• Drug: Nexplanon

• Inserted in the bicep

• Pros: long term birth control, no estrogen

• Controls: can have amenorrhea or abnormal bleeding, weight gain, headaches, and acne

Progestin intramuscular injection

• Every 3 months

• Pros: no estrogen

• Cons: delay return in fertility, amenorrhea or irregular bleeding while receiving an injection, weight gain, HA, acne

• Boxed warning: women who use for more than 5 yrs have significantly reduced bone mass density of the lumbar spine and femoral neck

FDA Pregnancy Medication Categories and fetotoxic medicines

• Prior to 2015: Pregnancy and Lactation Labeling Rule (PLLR)

• Now: narrative decision to use/not to use a drug

  • Based on what is optimal for both the mother and baby

• Teratogenic: birth defect

• Fetotoxic: toxic to fetus

Physiological changes in pregnancy

• Increased blood plasma volume

• Increased cardiac output

• Increased renal flow

• Increased oxygen consumption

• Increased plasma lipid levels

• Increased hormone production

• Gestational diabetes

  • Increased in human placental lactogen and human placental growth hormone

  • Cause resistance to insulin

• Gestational hypertension

  • More common after 20 weeks' gestation

  • Diagnostic criteria: BP 140/90

• Placental transfer of drugs

  • Occurs by 5th week after conception

• Drugs and fetal organs

  • Organs formation during weeks 3-8

• Nutritional needs

  • Prenatal vitamins (folic acid)

    • Baby can get spina bifida if there is a lack of folic acid

  • Iron

Conditions arising in pregnancy

• Constipation

  • Focus on prevention

  • Drug options

    • Fiber supplements

    • Stool softeners

• Diabetes mellitus

  • Type 1: insulin replacement therapy

  • Type 2: hypoglycemic medications

• Heartburn

  • Prevention measures

  • Drug: Ranitidine

• Hypertension in pregnancy

  • Mild: lifestyle changes

  • Severe: antihypertensive drugs, with caution

Magnesium sulfate

Indication- preterm labor

MOA- smooth muscle relaxant to decrease uterine contraction

Adverse Effects- low BP, respiration depression

Contraindications- severe renal failure, myasthenia gravis, significant heart block, hypersensitivity

Nursing Intervention/Patient Education- may feel flushing, sweating, or warmth, report loss of deep tendon reflexes, dyspnea, or significant hypotension

• Given IV

Indomethacin

Indication- delay pre-term labor in 3rd trimester

• Given with corticosteroids to help prevent early delivery for lungs to develop

• Risk to fetus: premature ductus arteriosus closure (PDA) in heart, and brain bleed

MOA- NSAID that inhibits COX-1 and COX-2 enzymes

Adverse Effects- GI distress, severe headaches, dizziness, and indigestion

Contraindications- hypersensitivity to NSAIDs, CABG surgery

Nursing Intervention/Patient Education- take with food

• NSAID

Misoprostol

Indication- cervical ripening and to stop postpartum hemorrhage

MOA- acts as an agonist on prostaglandin receptors

Adverse Effects- diarrhea, stomach cramps, nausea, vomiting, fever, chills, uterine bleed

Contraindications- during pregnancy, hypersensitivity

Nursing Intervention/Patient Education- take as directed, seek care if bleeding or an allergic reaction occurs

• If cervix is not favorable misoprostol inserted vaginally to ripen cervix

Oxytocin

Indication- to initiate or improve uterine contractions for early vaginal delivery; to stimulate or reinforce labor in selected cases of uterine inertia

MOA- synthetic form stimulates the uterus, especially the gravid uterus; causes myoepithelium of the lacteal glands to contract, resulting in milk ejection in lactating women

Adverse Effects- nausea, vomiting, uterine hyperstimulation, headaches

Contraindications- cephalopelvic disproportion, baby's head is too large for the maternal pelvis

Nursing Intervention/Patient Education- requires continuous fetal and maternal monitoring

• If cervix is favorable IV administration of oxytocin

Butorphanol tartrate (Stadol)

Indication- relief of moderate to severe pain during early labor

MOA- synthetic opioid for pain relief in labor

Adverse Effects- maternal sedation, dizziness, nausea, vomiting, dysphoria

Contraindications- hypersensitivity, opioid addiction, severe respiratory depression

Nursing Intervention/Patient Education- monitor maternal and fetal safety and mitigating side effects

Nalbuphine-hydrochloride (nubain)

Indication- treats moderate to severe pain during labor and delivery, particularly when other analgesics are insufficient

MOA- relieves labor pain by acting as a strong kappa receptor agonist and my receptor antagonist

Adverse Effects- maternal sedation, dizziness, nausea, vomiting

Contraindications- hypersensitivity, significant respiratory depression, asthma, GI obstruction

Nursing Intervention/Patient Education- monitor maternal and fetal sedation and respiratory depression

Epidural anesthesia (fentanyl)

Indication- rapid onset pain relief management

MOA- synthetic opioid acids as opioid receptor agonist to the dorsal horn of the spinal cord

Adverse Effects- itching, nausea, vomiting, sedation, hypotension, urinary retention

Contraindications- opioid tolerance, respiratory depression, asthma

Nursing Intervention/Patient Education- monitor for respiratory depression, hypotension, motor blocks, urinary retention, and pruritus/itchy skin

Considerations with drugs during Lactation

• Most drugs penetrate the milk supply

• Few drugs are contraindicated

  • Chemotherapy drugs

  • Drugs of abuse

  • Radioactive isotopes

• Consideration of timing and dosage