Unit 3 Exam Practice - Nursing Pharmacology

Unit 3 Comprehensive Exam Review Guide

Estrogens, Estradiol, and Conjugated Estrogens

• Primary Purpose: Used as hormone replacement therapy for menopause.
• Formulations:
  • Tablet: Instruct the patient to take one tablet by mouth every day exactly as ordered.
  • Patch: May be applied to the abdomen or the shoulder. Patches must be applied daily as prescribed, and the patient must rotate the application site every day. Do not place the patch in the same spot repeatedly.
• Discontinuation Protocol: Do not stop hormone therapy suddenly even if the patient feels better. Hormones may require a tapering schedule to be discontinued safely.
• Alcohol Interaction: Avoid alcohol consumption while on estrogen or steroid hormone therapy. Alcohol can suppress the Central Nervous System (CNS) and negatively impact immune and gut function.
• Testable Risk: Thromboembolic Events: Estrogen, progesterone, and birth control (alone or combined) are strongly associated with an increased risk for blood clots.
• Smoking Contraindication: Patients must not smoke while taking estrogen or birth control. Smoking significantly increases the risk for thromboembolic events.

Raloxifene (Selective Estrogen Receptor Modulator)

• Purpose: Used to treat and prevent osteoporosis, particularly in women during or after menopause when low estrogen levels increase bone loss risk.
• Mechanism of Action: Raloxifene acts as an estrogen agonist in the bone. It behaves like estrogen to help move calcium into the bone, preventing it from remaining in the blood.
• Effect on Osteoclasts: It helps prevent bone breakdown by affecting the activity of osteoclasts.
• Bone Health Significance: Osteoporosis causes bones to become weak, brittle, and easily broken; this medication mitigates those risks.

Birth Control and Norethindrone

• Norethindrone: A progesterone-only birth control pill.
• Systemic Mechanism: Circulating estrogen and progesterone levels signal the brain that the body may be pregnant. This suppresses the release of hormones from the anterior pituitary gland.
• Hormones Suppressed:
  • Follicle-Stimulating Hormone (FSH): Responsible for creating and maturing the egg and supporting sperm production.
  • Luteinizing Hormone (LH): Responsible for maturing the egg and supporting overall reproductive function.
• Main Effects: Prevents ovulation and affects the menstrual cycle. Patients may still have a monthly cycle depending on the specific formulation.
• Patient Teaching:
  • Maintain effectiveness by taking the pill every day at the same time.
  • Do not skip pills. If a dose is missed, follow specific medication instructions (generally take it as soon as it is remembered).

Testosterone and Oxandrolone

• Testosterone: A strong hormone used for males with hypogonadism.
• Definition of Hypogonadism: A condition where the gonads (testes in males, ovaries in females) do not produce enough sex hormones.
• Testosterone Physiological Effects: Responsible for increased muscle mass, fat redistribution, male sexual development, sperm maturation, and physical strength.
• Oxandrolone (Anabolic Steroid):
  • Indications: Hypogonadism, severe burns involving muscle loss, and rebuilding muscle mass after severe injury.
  • Safety Concerns: This medication is hard on both the liver and the kidneys.
  • Hepatotoxicity Risk: If a patient exhibits unexpected increased muscle mass, be concerned about overuse/abuse. Monitor for liver damage and notify the provider.
  • Contraindications: Older patients (e.g., $69\text{--}70$ years old) with cirrhosis, liver inflammation, liver disease, or kidney problems should not receive it.
  • Appropriate Candidates: A healthy $25$-year-old with hypogonadism or a severe burn patient with healthy liver and kidney function.

Sildenafil (Viagra)

• Purpose: Used for erectile dysfunction (ED) and specialized strengths for pulmonary hypertension.
• Adverse Effect: Priapism: Defined as an erection lasting longer than $4$ hours. This is a medical emergency that can cause permanent damage and loss of future erectile function. Patients must go to the emergency room immediately.
• Adverse Effect: Hypotension: Sildenafil can cause a significant drop in blood pressure.
• Contraindication: Nitroglycerin: Never take sildenafil with nitroglycerin. Nitroglycerin is a vasodilator used for angina/chest pain to open narrowed or plaque-hardened arteries.
• Drug-Drug Interaction Risk: Combining sildenafil and nitroglycerin can cause severe hypotension, a dangerous drop in blood pressure, and a possible coma.
• Patient Teaching: Do not take these on the same day; they must be spaced at least $1$ day apart. Sildenafil is typically taken $1$ hour before sexual activity.

Misoprostol (Cytotec)

• Reproductive Uses: Used to induce labor, cause uterine contractions, evacuate the uterus, or for medication abortion under medical direction.
• Gastrointestinal Uses: Used to treat or prevent peptic ulcer disease. It protects and coats the ulcerated area so stomach acid does not irritate it, preventing GI bleeding.
• Pregnancy Warning: Misoprostol is a powerful medication that can cause abortion. If a patient taking it for ulcers discovers they are pregnant, they must stop the medication immediately and contact their provider.
• Memory Tip: "Misoprostol/Cytotec cannot get pregnant" (meaning pregnancy is a strict contraindication due to the risk of uterine contractions and loss).

Thyroid Disorders and Levothyroxine

• Levothyroxine (Synthroid): Synthetic thyroid hormone used for hypothyroidism.
• Administration Guidelines:
  • Take in the morning with a full glass of water.
  • Take $30\text{--}60$ minutes before eating to aid absorption.
• Drug Interactions: Levothyroxine binds with vitamins, calcium, and Vitamin D supplements. Spacing must be at least $30\text{--}60$ minutes, though $4$ hours is emphasized as a strong test answer for medication spacing.
• Hyperthyroidism (Graves Disease): Characterized by a "speeding up" of all body systems.
  • Symptoms: Heat intolerance, weight loss, muscle wasting, hypertension, exophthalmos (bulging eyes), and goiter.
• Radioactive Iodine Therapy: Used to destroy overactive thyroid tissue. Risks include developing hypothyroidism if too much tissue is destroyed.
• Parathyroid Risk: Damage to the nearby parathyroid glands during thyroid treatment can lead to hypocalcemia (low blood calcium).

Alendronate for Osteoporosis

• Administration Teaching: Take with a full glass of water and sit upright for at least $30$ minutes afterward.
• Risk of Esophagitis: Lying down too soon after taking alendronate can irritate the esophagus.
• Interaction Spacing: Separate from calcium and other medications; $4$ hours is the safest testable interval for spacing.

Growth Hormones: Somatropin and Octreotide

• Somatropin: Growth hormone used for growth hormone deficiency. Administered via subcutaneous injection (abdomen or arm).
• Injection Technique: Pinch fatty tissue, clean with alcohol, and inject at a $45$-degree angle. The best way to evaluate understanding is a patient demonstration (teach-back).
• Octreotide: Suppresses growth hormone. Used for gigantism and acromegaly (excessive growth of body parts/tissues). Also given subcutaneously.

Diabetes Insipidus (DI) and Desmopressin

• Pathophysiology: DI is a water problem involving Antidiuretic Hormone (ADH), not blood sugar. It involves the failure to release ADH or the kidneys' failure to respond to it.
• Signs/Symptoms: Excessive urination, excessive thirst, dehydration, poor skin turgor (skin tents), and low blood pressure.
• Electrolytes: Monitor Sodium and Potassium. Potassium is critical for heart rhythm.
• Desmopressin (Vasopressin/DDAVP): Synthetic ADH replacement. Given via subcutaneous or IV routes (usually in the hospital).
• Major Complication: Hyponatremia: Water retention can dilute sodium levels. Low sodium causes cerebral swelling and altered levels of consciousness (confusion).
• Nursing Monitoring: Check daily weights, monitor intake and output ($I\&O$), and monitor for edema or water intoxication. Not urinating while on desmopressin is an emergency.

Adrenal Insufficiency (Addison’s Disease)

• Definition: The body lacks adrenal hormones/steroids (Adrenal Cortex produces corticosteroids and mineralocorticoids like Aldosterone).
• Signs/Symptoms: "Everything goes down"—hypotension, bradycardia, altered level of consciousness, and possible coma.
• Treatment: Fludrocortisone: A synthetic aldosterone that retains sodium and water to maintain blood pressure. Memory tip: "Addison has the flu (fludrocortisone)."
• Side Effects: High blood pressure and fluid retention. Patients must not stop steroids abruptly as it can cause a rebound adrenal crisis.

Cushing’s Syndrome

• Definition: Excess adrenal cortex hormones/steroids.
• Signs/Symptoms: Weight gain, moon face, truncal obesity (large abdomen), buffalo hump (humpback), hypertension, and hyperglycemia.
• Management: Reducing steroid doses, surgery, or symptom control.

Diabetes Mellitus and Medications

• Type 1: Autoimmune destruction of insulin-producing cells.
• Type 2: Gradual development; often managed with oral meds first.
• Metformin: Not "kidney friendly." Must be held for $24$ hours before and $48$ hours after any procedure involving contrast dye to avoid kidney damage.
• Semaglutide (Ozempic): GLP-1 agonist. Common side effects include nausea and vomiting. Monitor for hypoglycemia.
• Glyburide (Sulfonylurea): Used for Type 2. Contraindicated in patients with sulfonamide (sulfa) allergies.

Insulin Types and Administration

• Rapid-Acting: Give $15\text{--}30$ minutes before eating. Ensure food is present.
• Regular Insulin: Starts working in $30$ minutes. Eat within $30$ minutes.
• NPH Insulin: Intermediate-acting and naturally cloudy. Peaks around $6$ hours; patient should eat a snack at this time to prevent hypoglycemia.
• Insulin Glargine (Lantus): Long-acting ($24$ hours). Monitor for hypoglycemia throughout the day (especially around $12$ hours).
• Mixing Rules: Always draw Clear (Regular/Rapid) before Cloudy (NPH).
• Storage: Store in the refrigerator. Warm to room temperature by rolling in hands before administration. Never microwave insulin.

Hypoglycemia Management

• Symptoms: Shaky, weak, moody, lightheaded, dizzy, nauseous, or stomach rumbling.
• Alert Patient: Give fast carbohydrates (orange juice, crackers, peanut butter). A blood sugar of $69$ is considered low and warrants treatment.
• Unresponsive Patient: Give glucagon as ordered. This is an emergency.

Math and Dosage Calculations

• Calculations may include: Insulin dosage, Insulin IV rates, Heparin calculations, and Pediatric dosage calculations.