Pharm 2 Exam 1 Exhaustive Study Guide

Core Nursing Principles and Drug Name Corrections

• Safest Nursing Actions:

  • Always assess the client first when an issue arises.
  • Hold the medication dose if toxicity is suspected based on signs and symptoms.
  • Notify the provider immediately after stabilization or identification of critical issues.
  • Protect the airway, breathing, and circulation (ABCs) as the highest priority.

• Critical Drug Name Clarifications for the Exam:

  • Phenelzine (sometimes misheard as phenolzine or phenylene): A Monoamine Oxidase Inhibitor (MAOI).
  • Zolpidem (brand name Ambien; misheard as zopadim): A nonbenzodiazepine hypnotic.
  • Levetiracetam (brand name Keppra; misheard as levoteractam): An antiepileptic.
  • Carbidopa-Levodopa (brand name Sinemet; misheard as carvidopa lepidopa / cinemet): Used for Parkinson's disease.
  • Amantadine (misheard as amantenine): Used for Parkinson's disease.
  • Livedo Reticularis (misheard as levidoreticularis): A serious skin/eye-related effect associated with amantadine.
  • Pancuronium (misheard as pancoronia or paceronium): A neuromuscular blocker.
  • Succinylcholine (misheard as saxina coley or succeedocoline): A depolarizing paralytic.
  • Donepezil (misheard as denezil or dinepazil): Used for Alzheimer's disease.
  • Ramelteon (misheard as remelta yarn, lumetzion, or romeltion): A melatonin agonist for sleep.
  • Chlorpromazine (misheard as chlorprimazine): A first-generation antipsychotic.
  • Aripiprazole (misheard as ariprazole): An atypical antipsychotic.

Antidepressants and Mood Stabilizers

• Selective Serotonin Reuptake Inhibitors (SSRIs): Fluoxetine (Prozac)

  • Prototype: Fluoxetine ($\text{Prozac}$).
  • Indication: Major Depressive Disorder (MDD).
  • Serious Adverse Effects:
    • Cardiac arrhythmias.
    • Prolonged $QTc$ interval.
    • Increased suicidality (especially early in treatment).
    • Skin rash: Per the transcript, a rash can be an early sign of Serotonin Syndrome.
  • Nursing Action for Serious Effects: Hold the medication and notify the provider immediately.
  • Common/Minor Side Effects:
    • Insomnia, nausea, decreased libido (low sex drive), and dry mouth.
    • Teaching: These effects usually diminish over time with continued use.
  • Timing: SSRIs take several weeks to reach full therapeutic effect; patients will not feel better immediately.

• Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs): Venlafaxine

  • Key Considerations: Monitor for hypertension and salt levels. Be aware of risks for angle-closure glaucoma and suicidal ideation.

• Serotonin Syndrome

  • Cause: Often associated with SSRIs (fluoxetine) and SNRIs (duloxetine, venlafaxine).
  • Memory Cue: "Everything goes up."
  • Signs/Symptoms:
    • High blood pressure (Hypertension).
    • Agitation and hyperreflexia.
    • Tachycardia (or bradycardia depending on $QTc$/cardiac rhythm).
    • Muscle rigidity, shaking, and tremors.
  • Nursing action: Intervene quickly, stop the causative medication, and notify the provider.

• Monoamine Oxidase Inhibitors (MAOIs): Phenelzine

  • Dietary Restrictions: No aged cheese or any tyramine-containing products (can cause hypertensive crisis).
  • Drug-Drug Interactions: MAOIs "mix with everything" dangerously. Do not combine with other antidepressants (SSRIs, TCAs, etc.) unless specifically managed by a specialist.

• Atypical Antidepressant: Bupropion

  • Mechanism Warning: Lowers the seizure threshold.
  • Contraindications: Question the order if the patient has a history of seizures or is taking other seizure medications such as phenytoin ($\text{Dilantin}$).

• Tricyclic Antidepressants (TCAs): Amitriptyline

  • Serious Adverse Effects: Irregular heart rhythms, syncope (fainting), and prolonged $QTc$ interval.
  • Other Effects: Dry mouth and bradycardia.
  • Nursing Action: Cardiac findings require immediate notification and intervention.

• Mood Stabilizer: Lithium

  • Indication: Bipolar Disorder.
  • Toxicity Warning Signs: Tremors, EKG changes, lethargy, and slurred speech.
  • Common GI Symptoms: Nausea and diarrhea (less urgent than tremors).
  • Nursing Action for Toxicity: Hold the next dose, notify the provider, and prepare to draw lithium levels and a BMP (specifically for sodium).
  • Patient Teaching: Maintain consistent sodium and fluid intake. Salt and water levels directly influence lithium levels.

Antiepileptic and Neurological Medications

• Valproic Acid

  • Indication: Seizures and Bipolar Disorder (adjunct).
  • Major Concern: Liver toxicity (Hepatotoxicity).
  • Warning Signs: Right upper quadrant (RUQ) abdominal pain, jaundice (yellowing of the skin), and yellow sclera of the eyes.
  • Action: Hold the dose and notify the provider to prevent liver failure.

• Lamotrigine

  • Indication: Bipolar Disorder and Seizure management.
  • Major Warning: Development of a rash, particularly on the torso. This may indicate Stevens-Johnson Syndrome ($SJS$), extrapyramidal effects, or a liver reaction.
  • Action: Notify the provider immediately; do not ignore the rash.

• Levetiracetam (Keppra)

  • Indication: Prevention of seizures (not for stopping an active seizure).
  • Teaching: Do not stop abruptly (risk of status epilepticus). Report severe mood changes or drowsiness.

• Phenytoin (Dilantin)

  • Drug Interaction: Significant interaction with Warfarin ($\text{Coumadin}$), which increases the risk of bleeding.
  • Adverse Effects: GI bleed (examine history for peptic ulcers) and dental problems (caries).
  • Teaching: Maintain meticulous oral hygiene and see a dentist regularly.

• Gabapentin

  • Indication: Primarily neuropathic pain (per transcript, not indicated for active seizures in this context).
  • Side Effect: Significant drowsiness.

Antipsychotic Medications

• General Class Concern: Extrapyramidal Symptoms (EPS)

  • Typical symptoms: Muscle stiffness, pseudoparkinsonism, dystonia (involuntary lower extremity movements), and tardive dyskinesia (involuntary upper extremity/facial movements).
  • Memory Cue: "APS" for antipsychotic meds leading to EPS.

• Chlorpromazine

  • Emergency Side Effect: Urinary retention/difficulty urinating. If a patient reports they cannot pee, the provider must be notified immediately.

• Risperidone

  • Unique Side Effect: Gynecomastia (breast development in men).
  • Cardiovascular: Causes orthostatic hypotension; patients must rise slowly from sitting or lying.
  • Weight Gain: Rapid weight gain of $2-5\text{ lb/week}$ is concerning. Weight gain of $5\text{ lb/month}$ is less urgent.

Sedative, Hypnotic, and Anxiety Medications

• Barbiturates: Phenobarbital

  • Indication: Seizure management and sedation.
  • Danger: Significant respiratory depression and drops in blood pressure and alertness. No alcohol.

• Benzodiazepines: Diazepam

  • Memory Cue: "Everything goes down" (respirations, BP, alertness).
  • Safety: No alcohol consumption.
  • Interactions: Ciprofloxacin ($\text{Cipro}$) may interact with diazepam to affect the $QTc$ interval; notify the pharmacist/provider.

• Nonbenzodiazepine Hypnotic: Zolpidem (Ambien)

  • Teaching: Take only at bedtime. Avoid driving or heavy machinery until alertness is confirmed. Avoid alcohol.
  • Absorption: Some guides suggest taking with a high-fat meal.
  • Warning: Morning grogginess/dizziness is common.

• Melatonin Agonist: Ramelteon

  • Contraindication: Obstructive Sleep Apnea ($OSA$). Sedative-hypnotics can be dangerous for patients who naturally stop breathing during sleep unless the patient is closely monitored.

Medications for Parkinson’s and Multiple Sclerosis

• Carbidopa-Levodopa (Sinemet)

  • Food Interaction: Avoid high-iron foods (red meat, shellfish) at the time of dosing, as iron binds the drug and reduces absorption.
  • Effectiveness: Monitor for return of Parkinson symptoms (rigidity, trembling, bradykinesia, shuffling gait) if absorption is compromised.

• Amantadine

  • Serious Effect: Livedo Reticularis (noted in transcript as an eye or skin disorder relative to the drug). Connect this term directly to amantadine for the exam.

• Baclofen

  • Indication: Muscle spasticity in Multiple Sclerosis ($MS$).
  • Warning: Causes CNS drowsiness. Do not combine with OTC sedating medications, such as antihistamines.

Myasthenia Gravis and Cholinergic Crisis

• Myasthenia Gravis (MG)

  • Presentation: Muscle weakness, limb weakness, facial drooping, and "fake ALS-like" symptoms.
  • Treatment: Neostigmine
    • Goal: Increase Acetylcholine ($ACh$) to improve muscle tonicity and limb movement.
    • Outcome: Improved ability to move limbs and walk suggests medication success.

• Cholinergic Crisis

  • Definition: Excess of Acetylcholine ($ACh$).
  • Symptoms: Muscle weakness, increased salivation, diarrhea, bradycardia, and hypotension.
  • Action: Stop neostigmine, notify the provider, and anticipate fluid support for low BP.

ICU, Paralytics, and Anesthesia

• Neuromuscular Blocker: Pancuronium

  • Function: Paralyzes respiratory muscles during mechanical ventilation.
  • Nursing Monitoring: Vital signs, oxygen saturation, cardiac rhythm, and breath sounds. The nurse must ensure the ventilator is adequately supporting the patient.

• Depolarizing Paralytic: Succinylcholine

  • Mechanism: Causes brief muscle contraction (depolarization) followed by fatigue/paralysis.
  • Electrolyte Warning: Causes Potassium ($K^+$) levels to rise as it shifts out of cells.
  • Risk: Hyperkalemia leading to cardiac arrhythmias or cardiac arrest.
  • Memory Cue: "Sucks in the choline / it sucks to have muscles (paralysis)."

• Direct Skeletal Muscle Relaxant: Dantrolene

  • Indication: Malignant Hyperthermia (often during surgery).
  • Malignant Hyperthermia Clues: Temperature $>104^\circ\text{F}$, muscle rigidity/spasms, and tachycardia.
  • Expected Result: Lowered body temperature and decreased muscle rigidity.

• Local Anesthetic Toxicity: Lidocaine

  • Toxicity Clues: Periorbital numbness (around eyes), mouth/tongue numbness, and tinnitus (ringing in ears).
  • Cardiac Clues: Bradycardia, tachycardia, or heart stoppage.
  • Key Distinction: Contrary to some assumptions, the transcript states lidocaine toxicity does not typically cause hypotension.

Alzheimer’s and General Medication Safety

• Donepezil

  • Indication: Alzheimer's disease.
  • Action: Increases acetylcholine levels to improve brain cognition, memory, and physical movement.

• Medication Errors

  • Priority: If a wrong medication is administered, assess the client first for safety and adverse reactions, then call the provider.