Pharmacology – Exam 1, Merry christmas nerds

Safety & The Nursing Process

  • "Safety First" mantra (guiding principle)— Know and understand the patient’s needs, medical history (past health information), allergies (bad reactions to certain things), and their current understanding of medications (how well they know their drugs).

    • Know and understand every drug you give (what it does, the amount to give, bad effects, how it interacts with other drugs).

  • 9-Step Nursing Process (NCLEX/HESI emphasis)— Assessment (gathering information): full-set vital signs (body’s basic functions like heart rate, blood pressure, temperature, breathing), focused head-to-toe (a complete physical examination from head to foot), allergy check (checking for reactions), med history (past medications taken), modified labs (blood or other test results), swallowing ability (how well a patient can swallow).

    • Diagnosis & Outcomes Identification (identifying problems & setting goals): connect data to nursing diagnoses (identifying specific health problems based on collected information); set measurable, time-limited goals for each med (creating specific, achievable goals with deadlines for each medication).

    • Planning (creating a plan): prioritize interventions (decide which actions are most important), prepare equipment/drug (get ready the necessary tools and medication), verify lab & drug levels (check the amounts of substances in the blood and drug concentrations).

    • Implementation (carrying out the plan): administer using the 9 Rights (see below) (give the medication using the 9 safety checks), include patient education (teach the patient about their medication), documentation (recording all actions and observations), age/culture adjustments (modifying care based on age and cultural background).

    • Evaluation (checking the results): monitor for desired/undesired effects (watch for good and bad reactions), toxicity (harmful levels of the drug), therapeutic response (how well the drug works), adherence (patient following the treatment plan).

  • Core labs (main tests) before/while giving most meds

    • Liver (organ that filters blood): \text{ALT}, \text{AST}, \text{ALP} (liver enzyme tests that show liver health).

    • Kidney (organ that cleans blood and removes waste): \text{BUN}, \text{Creatinine}, \text{GFR} (glomerular filtration rate, a measure of how well kidneys filter blood).

The 9 Rights of Medication Administration

  • Original 5 (The fundamental five safety checks):

    • Right Drug (correct medication)

    • Right Dose (correct amount)

    • Right Time (correct scheduled hour)

    • Right Route/Form (correct way to give it, e.g., by mouth, shot / correct type, e.g., pill, liquid)

    • Right Patient (correct person)

  • Four additional rights:

    • Right Documentation (recording the medication accurately)

    • Right Reason (why the patient is getting the medication)

    • Right Response (observing how the patient reacts to the medication)

    • Right to Refuse (patient's right to say no to medication)

Medication Safety Extras

  • Never give a drug without assessing patient first (VS, allergies, labs) (always check the patient’s vital signs, allergies, and lab results before giving medication).

  • Look-Alike/Sound-Alike (drugs that look or sound similar), high-alert meds (medications that can cause serious harm if given incorrectly) ("P-I-N-c-H": Potassium, Insulin, Narcotics, Cardiac/Chemo, Heparin).

  • Black-Box Warnings (strongest FDA safety alerts, indicating serious side effects) = strongest FDA safety alert (a stern warning from the FDA); nurses must monitor for the specific risk (e.g., suicidal ideation (thoughts of self-harm) with SSRIs (antidepressant medications)).

  • Medication Errors:

    • common causes (abbreviations (shortened words), mis-read orders (incorrectly understanding a doctor's instruction), wrong pt/route/time (giving to the wrong patient, via the wrong method, or at the wrong moment), work-arounds (bypassing safety procedures)).

    • 3 checks \times 9 rights (triple-checking the medication and following the 9 safety rules), limit telephone orders (reduce orders given over the phone to prevent mistakes), call pharmacist if unsure (consult the drug expert if you have doubts).

    • If error occurs: stay with pt (remain with the patient), notify provider (inform the doctor), document facts (record only what happened), complete incident report (not charted) (fill out a formal report about the error, but do not write it in the patient’s chart).

Pharmacologic Principles

  • Drug Nomenclature (system of naming drugs)

    • Chemical name (exact structure) \to exact structure (scientific description of the drug's atoms and their arrangement).

    • Generic (NCLEX testable) (common, non-brand name used worldwide) \to e.g., \text{acetaminophen}.

    • Trade/Brand (manufacturer's brand name) \to Tylenol®.

  • Classifications (major buckets) (main categories): GI agents (medications for the gastrointestinal system), anticoagulants (blood thinners), anti-infectives (drugs to fight infections), antipsychotics (medications for mental health conditions), respiratory meds (drugs for breathing problems), etc.

  • Controlled Schedules (categories for drugs with abuse potential)

    • Schedule I (highest abuse potential, no accepted medical use in the US): no accepted medical use, high abuse (e.g., LSD).

    • Schedule II–V (decreasing abuse potential from highest to lowest); Schedule II = morphine, fentanyl (strong painkillers with high abuse potential); Schedule V = cough syrups w/ codeine (cough medicines with very low abuse potential).

How Drugs Work

  • Pharmaceutics (how drugs are prepared and behave in the body) – dosage form (the physical form of the drug, like a pill or liquid) determines rate/extent of dissolution (how quickly and completely the drug dissolves) (enteral (through the digestive tract) vs parenteral (by injection, bypassing the digestive tract) vs topical (applied to the skin)).

  • Pharmacokinetics ("what the body does to the drug") (how the body processes the medication)

    1. Absorption: movement \to bloodstream (how the drug gets into the blood); affected by route (how it's given), first-pass hepatic metabolism (CYP450) (drug breakdown by the liver before it reaches the rest of the body, involving liver enzymes), bioavailability (the amount of drug that reaches the bloodstream unchanged and is available to work).

    2. Distribution: plasma \to tissue (how the drug moves from the blood to body tissues); protein binding (drug attaching to proteins like albumin) (albumin), blood-brain barrier (a protective filter that prevents many substances from reaching the brain), drug–drug displacement (one drug pushing another off a protein binding site).

    3. Metabolism: biotransformation mainly in liver via CYP450 (chemical changes of the drug, mostly in the liver, using CYP450 enzymes); may inactivate (make it stop working), activate (make it start working) or make drug more soluble (easier to dissolve and excrete).

    4. Excretion: kidneys (primary) (main organ for removing drugs), bile/feces (waste removed through the digestive system), sweat (through skin), breast milk; renal dysfunction (kidney problems) \to toxicity (harmful buildup of the drug).

    • Time metrics (measurements over time):

      • Half-life = time for 50\% elimination (time for half of the drug to be removed from the body).

      • Onset/Peak/Duration (when the drug starts working/works best/stops working) guide dosing (help determine how often and when to give a drug).

  • Pharmacodynamics ("what the drug does to the body") (how the drug affects the body).

    • Receptor interactions (how drugs attach to specific sites on cells) (agonist (activates the cell), antagonist (blocks the cell), partial (partially activates/blocks)), enzyme inhibition/induction (blocking or speeding up enzyme activity), non-selective membrane actions (affecting cell membranes broadly without specific targets).

Patient-Specific Considerations

  • Therapy Types: Acute (short-term treatment for sudden problems), Maintenance (long-term, regular use to manage a chronic condition), Supplemental (adds to existing body substances, like insulin), Palliative (relieves symptoms, improves quality of life without curing), Supportive (helps maintain bodily functions), Prophylactic (prevents disease).

  • Lifespan (considerations based on age)

    • Pregnancy: FDA categories A \to X (drug safety during pregnancy, where X means known fetal harm and should be avoided).

    • Pediatrics (children): weight-based dosing \text{mg}/\text{kg} (dosing based on body weight), immature liver/kidney (organs not fully developed), consider taste/form (making sure the medication is palatable and in an easy-to-take form).

    • Older Adults (>65 yr): poly-pharmacy (taking many medications at once), \downarrow renal/hepatic clearance (reduced kidney and liver ability to remove drugs from the body), financial limits (cost of medications).

  • Culture/Genetics: pharmacogenomics (how genes affect a person's response to drugs), language barriers (difficulty communicating due to different languages), CAM/herbal usage (Complementary and Alternative Medicine/natural remedies), religious constraints (restrictions based on religious beliefs).

General & Local Anesthetics (Chapter 11)

General Anesthesia

  • Goal: loss of consciousness & reflexes (a state of deep sleep where the patient is unaware and unresponsive to pain), muscle relaxation, analgesia (pain relief); requires airway/ventilation support (help with breathing).

  • "Balanced" approach = multiple drugs (IV propofol (a fast-acting intravenous anesthetic), inhaled sevoflurane (a gas anesthetic breathed in), opioids (strong pain relievers), benzodiazepines (sedatives), NMBAs (drugs that relax muscles for surgery)) for induction \to maintenance \to emergence (the process of putting the patient to sleep, keeping them asleep during surgery, and waking them up).

  • Contra-indications (reasons not to use): allergy, pregnancy, malignant hyperthermia (MH) (a rare, severe reaction to certain anesthetic drugs), narrow-angle glaucoma (an eye condition), severe hypotension/respiratory depression (very low blood pressure/dangerously slow breathing).

  • Malignant Hyperthermia (MH) (a life-threatening condition during general anesthesia)

    • Trigger: succinylcholine or volatile gases (specific anesthetic drugs that can cause MH); S&S (signs and symptoms) = rigidity (muscle stiffness), \uparrow \text{CO}_2 (increased carbon dioxide in the blood), tachycardia (fast heart rate), hyperthermia (very high body temperature), hyper-K^+ (high potassium levels in the blood).

    • Treatment: dantrolene 2\,\text{mg}/\text{kg} q5 min (a specific medication given to treat MH, 2 milligrams per kilogram every 5 minutes), rapid cooling (lowering body temperature quickly), 100% \text{O}_2 (giving pure oxygen), correct acidosis (fixing the blood's acidity) & K^+ (correcting potassium levels).

  • Prototype: Propofol – IV (given intravenously), onset <1 min (starts working in less than a minute), duration \approx10 min (lasts about 10 minutes); causes amnesia (memory loss) & hypotension (low blood pressure); avoid St John’s Wort/valerian (herbal supplements that can interact with the drug).

Neuromuscular Blocking Agents (NMBAs)

  • Use: intubation (inserting a breathing tube), OR immobilization (keeping the patient still during an operation); HIGH-alert (drugs that carry a high risk of harm if misused).

  • Depolarizing: Succinylcholine (acts like ACh (acetylcholine, a neurotransmitter that causes muscle contraction); 5–9 min); risks MH (malignant hyperthermia), hyper-K^+ (high potassium), post-op myalgia (muscle pain after surgery).

  • Non-depolarizing: vecuronium, rocuronium (25–40 min) (cause muscle relaxation by blocking acetylcholine receptors without initial muscle twitching).

  • Monitor K^+ (check potassium levels), hx of MH (history of malignant hyperthermia), airway plan (a plan for managing the patient's breathing); anticholinesterases (drugs that help reverse the effects of certain NMBAs) can reverse some non-depolarizers.

Local / Regional Anesthetics

  • No LOC (no loss of consciousness); block Na^+ influx on axons (stop sodium from entering nerve cells) \to no depolarization (prevent nerve signals from being transmitted, thus blocking pain).

  • Forms: topical (applied to the skin, e.g., lidocaine cream/patch), infiltration (injected directly into a small area of tissue around a surgical site), nerve block (injected near a nerve to block sensation in a specific region), spinal/epidural (injected near the spinal cord).

  • Drug families

    • Esters (procaine, tetracaine) – \uparrow allergy potential (higher risk of allergic reactions).

    • Amides (lidocaine, bupivacaine) – widely used (more commonly used due to lower allergy risk).

  • Risk: Local Anesthetic Systemic Toxicity (LAST) (a serious condition that occurs when too much local anesthetic enters the bloodstream), spinal HA (headache after spinal anesthesia), MH (malignant hyperthermia), allergy.

  • Lidocaine prototype: onset <1 min (starts working in less than a minute), duration 30–120 min (lasts from 30 to 120 minutes); often mixed with epinephrine (a hormone that constricts blood vessels) (\downarrow bleeding, \uparrow duration) (reduces bleeding and makes the anesthetic last longer).

Substance Use Disorder (Chapter 17)

  • Chronic relapsing disease (a long-term condition that involves periods of use and recovery with a tendency to return to substance use) w/ tolerance (need higher dose) (needing more of the substance to get the same effect) & dependence (physical & psych) (the body needing the substance to function normally, involving both physical and mental aspects).

  • Common abused classes: CNS depressants (alcohol, opioids, benzos) (substances that slow down brain activity), stimulants (cocaine, meth) (substances that speed up brain activity), nicotine.

  • Withdrawal/Toxicity (symptoms when stopping use / harmful effects from too much substance)

    • Opioid: flu-like (symptoms similar to the flu), cramps, dilated pupils (enlarged black circles in the eyes); antidote = naloxone (a medication that reverses opioid overdose); tx (treatment) = methadone, clonidine.

    • Stimulant: depression, suicidality (thoughts of self-harm); support (emotional care) + sedation (calming medication).

    • Alcohol: autonomic hyperactivity (overactivity of the involuntary nervous system leading to symptoms like sweating and rapid heart rate), tremors (shaking); benzodiazepine taper (gradually reducing the dose of a sedative medication), thiamine (Vitamin B1), magnesium (a mineral), disulfiram for abstinence (a medication to help prevent alcohol consumption).

    • Nicotine: irritability (feeling easily annoyed or angered); NRT (nicotine replacement therapy), bupropion, varenicline (medications to help quit smoking).

Analgesics (Ch 10 & 44)

Pain Physiology

  • Nociceptors (A\delta = sharp, C = dull) (specialized nerve endings that detect painful stimuli: A-delta fibers transmit sharp pain, C-fibers transmit dull pain) transmit \to dorsal horn (part of the spinal cord where pain signals arrive) \to thalamus (a relay station in the brain) \to cortex (the brain's outer layer where pain is perceived); Mu-receptor (a specific protein site in the brain) central to opioid action (the main target for opioid drugs).

  • Endogenous modulators (the body's natural pain-relieving substances): endorphins, enkephalins.

  • OLDCARTS assessment (a mnemonic framework for pain assessment: Onset, Location, Duration, Characteristics, Aggravating factors, Relieving factors, Treatment, Severity), numeric/FACES scales (tools used to rate pain intensity, either with numbers or facial expressions).

Opioid Analgesics

  • Full agonists (drugs that fully activate opioid receptors): Morphine (prototype) (a classic example of an opioid), hydromorphone, fentanyl, oxycodone, methadone.

  • Partial/Mixed (drugs that partially activate or block opioid receptors): buprenorphine, butorphanol.

  • Antagonist (drug that blocks opioid receptors): Naloxone.

  • Indications (uses): moderate–severe pain, cough (codeine), diarrhea (diphenoxylate), balanced anesthesia (using multiple drugs for anesthesia, including opioids).

  • Contra (contraindications, reasons not to use): severe asthma, paralytic ileus (paralysis of the intestine), \uparrow ICP (increased pressure inside the skull), pregnancy caution.

  • Major AEs (Adverse Effects, significant side effects): respiratory depression (dangerously slow breathing), CNS depression (slowed brain activity), constipation, orthostatic hypotension (a drop in blood pressure when standing up, causing dizziness), urinary retention (difficulty emptying the bladder), pruritus (itching).

  • Interactions: other CNS depressants (drugs that also slow brain activity), anticholinergics (drugs that block acetylcholine, a neurotransmitter), MAOIs (a class of antidepressant medications), hypotensives (drugs that lower blood pressure).

  • Toxic triad (OD) (three main signs of opioid overdose): coma (deep unconsciousness) + pinpoint pupils (very small pupils) + RR < 8/min (breathing rate less than 8 breaths per minute) \to give naloxone \mathbf{0.4}–\mathbf{2} mg IV q2–8 min (administer naloxone intravenously every 2 to 8 minutes).

  • Dosing pearls (key dosing advice):

    • Start low/go slow (begin with a small dose and increase gradually), esp. opioid-naïve (patients who have never taken opioids) & elderly (older adults).

    • Oral preferred when possible (taking by mouth is best if feasible); reassess at peak (check again when the drug's effect is strongest) (IV \approx30 min, PO \approx1 hr).

    • Consider bowel regimen (stool softener, fluids/fiber) (a plan to prevent constipation, including stool softeners, increased fluid intake, and dietary fiber).

  • Special formulations: PCA pumps (Patient-Controlled Analgesia, a device that allows patients to self-administer pain medication), transdermal fentanyl (a fentanyl patch applied to the skin) (change q72 h (change every 72 hours), avoid heat (can increase drug absorption), dispose safely).

Non-Opioid Analgesics
NSAIDs

  • Classes & examples (types of NSAIDs): Salicylate (aspirin), Acetic acid (ketorolac), Propionic (ibuprofen, naproxol), COX-2 selective (celecoxib).

  • MOA (Mechanism of Action) (how they work): inhibit COX-1/2 (block cyclooxygenase-1 and -2 enzymes) \to \downarrow prostaglandins (reduce chemicals responsible for pain and inflammation) \to analgesic (pain relief), antipyretic (fever reduction), anti-inflam. (anti-inflammatory).

  • BBW (Black Box Warning): \uparrow MI/stroke risk (increased risk of heart attack or stroke), GI bleed/ulcer (bleeding or sores in the stomach/intestines), renal failure (kidney failure).

  • Contra (contraindications): ASA allergy (aspirin allergy), peptic ulcer (stomach ulcer), bleeding disorders, 3rd-trimester pregnancy, peri-operative CABG (around the time of coronary artery bypass graft surgery), children (Reye’s) (risk of Reye's syndrome in children).

  • AEs (Adverse Effects): GI bleed (gastrointestinal bleeding), nephrotoxicity (kidney damage), tinnitus (salicylism) (ringing in the ears, often a sign of aspirin toxicity), Reye’s syndrome.

  • Ketorolac: opioid-level pain relief but \le5 days use only (provides strong pain relief similar to opioids, but should not be used for more than 5 days due to risk of renal/GI toxicity (kidney/gastrointestinal harm)).

  • Patient Ed (Patient Education): take with food/water, no ETOH (no alcohol), monitor for black tarry stools (a sign of internal bleeding), avoid crushing EC tabs (enteric-coated tablets, which have a special coating and should not be crushed), report tinnitus or severe dyspepsia (report ringing in the ears or severe indigestion).

Acetaminophen (APAP)

  • MOA: central COX inhibition (blocks enzymes mainly in the brain) \to analgesic & antipyretic (pain relief and fever reduction); no anti-inflammatory (does not reduce inflammation).

  • Max adult dose: \le3000 mg/day healthy; \le2000 mg/day if ETOH/liver dz (if consuming alcohol or have liver disease).

  • Contra: severe hepatic disease (severe liver disease), G6PD deficiency (a genetic blood disorder), chronic alcohol use.

  • Toxicity: hepatic necrosis (liver cell death) (N/V (nausea/vomiting), sweating, RUQ pain (pain in the upper right part of the abdomen)). Antidote = acetylcysteine (best within 10 h) (a specific medication to reverse acetaminophen overdose, most effective if given within 10 hours).

Other/Topicals

  • Tramadol: weak \mu-agonist (weakly activates opioid receptors) + SNRI (serotonin-norepinephrine reuptake inhibitor, a type of antidepressant); seizure risk.

  • Transdermal lidocaine 5\% patch: up to 3 patches x 12 h on, 12 h off (up to 3 patches of lidocaine applied to the skin for 12 hours, followed by 12 hours off).

Anti-Gout Pharmacotherapy

  • Patho (Pathophysiology, the mechanism of disease): hyperuricemia (high levels of uric acid in the blood) (over-production or under-excretion) (either too much uric acid is made or not enough is removed from the body) \to monosodium urate crystals in joints (sharp crystals forming in the joints, causing inflammation).

  • First-line acute pain (initial treatment for sudden pain): NSAIDs.

  • Maintenance (long-term management): Allopurinol (medication to lower uric acid) (xanthine oxidase inhibitor) (blocks an enzyme that produces uric acid) 200–600 mg/day; risk Stevens-Johnson syndrome (SJS, a severe skin reaction), agranulocytosis (a serious condition where the body does not make enough white blood cells) – push fluids \ge2000 mL/day (encourage patient to drink at least 2000 milliliters of fluids per day).

  • Acute flare (sudden, severe attack): Colchicine (medication for acute gout attacks) – loading (initial higher dose to quickly establish therapeutic levels) 0.6–1.2 mg then 0.6 mg q1 h (max 3 mg) (0.6 to 1.2 milligrams initially, then 0.6 milligrams every 1 hour, up to a maximum of 3 milligrams); GI upset common (stomach upset is a frequent side effect); avoid grapefruit, alcohol.

  • Uricosurics (class of drugs that increase uric acid excretion): probenecid, lesinurad (increase renal excretion) (increase the removal of uric acid by the kidneys).

Integrating It All – Quick Clinical Checklist Before Giving ANY Drug

  • Verify patient ID (check patient's identity), allergies, swallowing, VS (vital signs), labs (LFT (Liver Function Tests), KFT (Kidney Function Tests), drug levels (amount of drug in the body)).

  • Review purpose (why the drug is given): cure (heal), relieve symptom (ease discomfort), slow disease (manage progression), prophylaxis (prevent disease)?

  • Check therapy type (Acute, Maintenance, etc.).

  • Screen for contraindications (reasons not to give the drug) (pregnancy, organ dysfunction (poor organ function), culture/religion).

  • Educate patient (teach the patient): indication (reason for the drug), expected effects (what it should do), timing, potential AEs (possible side effects), when to call (when to contact a healthcare professional