NR-291 Pharmacology I Study Guide–Exam 2

1 NR-291 Pharmacology I Study Guide – Exam 2 Effects of the Peripheral Vascular System • Cholinergic – Parasympathetic Nervous System (feed and breed; rest and digest) oCholinergic effects (SLUD) ▪ Salivation, Lacrimation, Urination, Defecation oAnticholinergic effects (Mad as a Hatter) ▪ Hyperthermia, blindness, confused, dry mouth, urinary retention, shaking, grabbing invisible objects, tachycardia, absent bowel sounds, flushed skin, mydriasis • Adrenergic – Sympathetic Nervous System (fight or flight) oAlpha effects ▪ Vasoconstriction (treat hypotension), CNS stimulation, relaxation of GI smooth muscles (decreased motility), constriction of bladder sphincter, contraction of pupillary muscles of the eye (dilated pupils), contraction of uterus, male ejaculation oBeta 1 and Beta2 effects ▪ 1 – increased force of contraction (positive inotropic effect). Increased HR (positive chronotropic effect), increased conduction through AV node (positive dromotropic effect) ▪ 2 – bronchodilation (relaxation of the bronchi), glycogenolysis in the liver, increased renin secretion in the kidneys, relaxation of GI smooth muscles (decreased motility), uterine relaxation, inhibits histamine release from mast cells, increases intraocular pressure oDopaminergic effects ▪ Vasodilation (resulting in increased blood flow) to: renal (diuresis), mesenteric, coronary (increase CO and contractility without increasing HR), cerebral Chapter 36: Antihistamines, Decongestants, Antitussives, and Expectorants • Know and apply pharmacology treatment for the common cold oCombination use of: antihistamines, nasal decongestants, antitussives, expectorants oTreatment is symptomatic only, not curative oTreatment is empiric therapy • Antihistamines (-dine) (-iramine) (-tadine) oKnow and apply common uses of H 1 versus H2 blockers or antagonists ▪ H1 – relief of allergy symptoms, treat non-allergy conditions (insomnia, motion sickness, Parkinson-like reactions due to anticholinergic effects) ▪ H2 – reduce gastric acid , gastric and duodenal ulcer, GERD, acid indigestion, heartburn oNice to know: ▪ Adv Eff – dry mouth, difficulty urinating, constipation, mild drowsiness to deep sleep, changes in vision o Good to know: ▪ Due to Adv Eff, use with caution in pts with – HTN, angina, MI, Asthma or COPD, hyperthyroidism, peptic ulcer disease (antihistamines stimulate gastric acid secretion), BPH or urinary retention bound 2 ▪ Antihistamines appear on Beers List (geriatric clients at risk for orthostatic hypotension) o Got to know: ▪ Pt education: report excessive sedation, confusion or hypo/hypertension, avoid driving or operating heavy machinery, advise againse consuming alcohol or other CNS depressant ▪ Contraindicated in glaucoma (angle-closure) – due to anticholinergic properties ▪ Diphenhydramine has multiple uses and is often combined with many other OTC meds oDiphendydramine oCimetidine • Decongestants oVasoconstrict blood vessels of the nose, throat and paranasal sinus, decreases inflammation and mucous formation o Good to know: ▪ Oral (adrenergics) – prolonged decongestant effects but delayed onset, less potent than topical, no rebound congestion ▪ Pt education – avoid caffeine, report a fever, cough, or other symptoms lasting longer than a week o Got to know: ▪ Topical or nasal adrenergics – prompt onset, rapid absorption, rapid decline in therapeutic activity, potent, sustained use over several days causes re congestion making the condition worse (cause overuse and dependency) ▪ Avoid or consult with prescriber – HTN, palpitations, BPH oOral – pseudooephedrine oIntranasal – phenylephrine, fluticasone, ipratropium • Antitussives – only for nonproductive coughs oOpioid – codeine ▪ Suppress the cough reflex by direct action on the cough center in the medulla oNonopioids – benzonatate, dextromethorphan ▪ Suppress the cough reflex by numbing the stretch receptors in the respiratory tract and preventing the cough reflex from being stimulated o Good to know: ▪ Report any of the following symptoms to the caregiver: cough that lasts more than a week (possible CHF), a persistent headache, fever, rash o Got to know: ▪ Antitussive drugs are for nonproductive coughs only! • Expectorants oIrritates GI tract which causes a loosening and thinning of respiratory tract secretions oGuaifensin o Good to know: ▪ Report a fever, cough, or other symptoms lasting longer than a week o Got to know: ▪ Pt education – encourage more fluids, if permitted, to help loosen and liquefy secretions Chapter 37: Respiratory Drugs 3 • Know Evidence-Based Practice Guideline from GINA (stepwise plan) • Know classifications and actions of respiratory drugs (Bronchodilators, etc…) oBronchodilators – relax smooth muscles that line airway oBeta-agonists – increase mucociliary clearance oAnticholinergics – prevent bronchospasm oCorticosteroids – block inflammation that narrows airway • Relievers oShort-acting beta 2-agonist (SABA) ▪ albuterol, epinephrine oShort-acting anticholinergics ▪ ipratropium bromide, oxitropium bromide • Controllers oInhaled corticosteroids (ICS) ▪ beclomethasone, budesonide, fluticasone: 1, 2, 3, 5, 11, 12 oICS / Long-acting beta2-agonist (LABA) ▪ Advair – fluticasone / salmeterol: 1, 2 ▪ Symbicort – budesonide / formoterol: 1, 2 • Leukotriene receptor antagonists (LTRAs) omontelukast, zileuton oCounteract substances that cause air passages to constrict and secrete mucus • Xanthine derivatives otheophylline, aminophylline oinhibit action of mast cells • Anti-IgE oomalizumab: 1, 2 • Long-acting anticholinergics otiotropium: 1, 2 • Know and apply asthma action plan, definition of control, questions asked, peak meter flow • Good to know: o Pt education ▪ Use inhaled bronchodilator (albuterol) first to open up airways, then use inhaled corticosteroid to better penetrate the lungs • Hold breathe for 10 seconds, then slowly exhales, if a second puff of the same medication is ordered wait 1-2 mins, wait 5 mins before another inhalant ▪ Inhaled medications • Prime (shake) the unit before using, discard the canister after 200 sprays, rinse their mouth with water and spit after each inhalation dose, and once a week clean the mouthpiece in warm, soapy water • Use a spacer if difficulty coordinating breathing with inhaler activation ▪ Corticosteroids • Inhaled forms reduce systemic effects and are the most consistently effective long-term control medication sat all steps in both children and adult asthma • Got to know: o Pt education 4 ▪ Epinephrine (EpiPen) inject directly through clothing, into outer thigh and hold in place for 10 seconds to deliver all of the drug ▪ Albuterol, if used too frequently, loses its beta2-specific actions at larger doses • As a result, beta 1 receptors are stimulated, causing nausea, increased anxiety, tremors, vascular headache, palpitations, angina, and increased HR ▪ If you need quick-relief medicine more than 4 times in 1 day to stop asthma attacks, you need help from a doctor today! o Theophylline therapeutic level (10-20 mcg/mL) ▪ Draw peak levels 15-20 mins after IV loading dose ▪ Benzodiazepine (diazepam) to treat seizures ▪ Multiple drug and food interactions (cigarette smoking enhances xanthine metabolism) ▪ Contraindications: history of PUD or GI disorders (stimulates gastric acid secretion) ▪ Cautious use: cardiac disease (sinus tach, extrasystoles, palpitations, ventricular dysrhythmias • Nicotine o Good to know: ▪ Cravings can continue for several weeks even after physical dependence stops o Got to know: ▪ Nicotine abuse – patients cannot smoke while wearing nicotine patch Chapter 41: Antitubercular Drugs • Common infection sites ▪ Lung (primary), brain, bone, liver, kidney • TB-Related Injections oPPD: 1, 12 oBCG: 1, 2, 3, 12 • Know and apply concepts of bactericidal and bacteriostatic therapy • Know and apply concepts of culture and sensitivity of TB sputum cultures • Know patient and family education regarding spread of infection • Know and apply concept of MDR-TB • Know first-line drug therapy (RIPE) for TB, including length of treatment orifampin: bactericidal oisoniazid (INH): bacteriostatic opyrazinamide (PZA): 1, 5, 12 oethambutol: 1, 5, 12 ostreptomycin: 1, 5, 12 o Good to know: ▪ Rifampin • Can cause reddish-orange discoloration of urine, sweat, tears, feces, urine, and skin • Should not wear soft contact lenses while taking drug (turn orange) • Another form of birth control will be needed ▪ Oral preparations may be given with meals to reduce GI upset, even though recommendations are to take them 1 hr before or 2 hrs after meals ▪ Monitor for therapeutic effects (start within 2 weeks) 5 • Decrease in symptoms of TB, such as cough and fever • Lab studies (culture and sensitivity tests) and chest x-ray should confirm clinical findings (4-6 weeks for culture and sensitivity results, 2 months or earlier expect sputum cultures negative of TB) • Lack of clinical response to therapy, indicating possible MRR-TB (usually seen in China, India, Pakistan, Russia, South Africa) o Got to know: ▪ Medication regimen is 6 months • First 2 months – bactericidal phase o 4 drugs (RIPE), intensive treatment to reduce chances of development of MDR-TB • Next 4 months – continuation phase o 2 drugs (RI) ▪ Pt education is critical • Therapy is 6 months, but could be longer • Take medications exactly as ordered, same time everyday • Remind pts they are contagious during the initial period of their illness – instruct in proper hygiene and prevention of the spread of infected droplets • Report findings of fatigue, nausea, vomiting, numbness and tingling of the extremities, fever, loss of appetite, depression, jaundice Chapter 18: Adrenergic Drugs • Know multiple names of this classification of drugs (vasopressors, etc…) • Vasoactive Adrenergics, Pressors, Inotropes, Cardioselective Sympathomimetics • Know effects of sympathetic nervous system (fight or flight), both alpha and beta receptors • Vasopressors (-ine) odopamine oepinephrine onorepinephrine ophenylephrine omidodrine o Good to know: ▪ Midodrine • Can cause systolic supine HTN • Should be given after the evening meal or no less than 4 hours before bedtime • Monitor the supine and standing BP regularly ▪ Adv Eff • CNS – headache, restlessness, excitement, insomnia, euphoria • Cardiovascular – palpitations (dysrhythmias), tachycardia, vasoconstriction, HTN, angina o Got to know: ▪ Norepinephrine • Administer into a large vein, such as an antecubital vein • Phentolamine (alpha blocker) may be added to IV solutions containing norepinephrine to reduce the risk of local necrosis ▪ Multiple drug interactions • Acute hypertensive crisis if pt also taking tricyclic antidepressants or MAOIs 6 Chapter 19: Adrenergic-Blocking Drugs • Know multiple names of this classification of drugs (adrenergic antagonists, etc…) • Adrenergic Antagonists, Alpha blockers, Alpha/Beta blockers, Beta blockers, Sympatholytics oAlpha blockers (-zosin): arterial and venous dilation, decreases resistance to urinary outflow ▪ Know and apply concept of first-dose phenomenon: severe and sudden drop in BP ▪ Examples: doxazosin, tamsulosin ▪ phentolamine: 1 ▪ Good to know: • Adv Eff: o CNS – dizziness, headache, anxiety, depression, weakness, numbness, fatigue o Cardiovascular – palpitations, orthostatic hypotension, tachycardia, edema, chest pain • Inform pts to report – constipation, development of urinary hesitancy or bladder distention ▪ Got to know: • Phentolamine o Quickly reverses the potent vasoconstrictive effects of extravasated vasopressors (such as norepinephrine, epinephrine, phenylephrine, or dopamine), restores blood flow and prevents tissue necrosis • COPD, hypotension, cardiac dysrhythmias, bradycardia, heart failure, or other cardiovascular problems might be exacerbated by the use of these drugs oBeta blockers (-olol) – block neurotrasmitters (norepinephrine and epinephrine) ▪ Know effects of selective (cardioselective) and non-selective ▪ Examples: atenolol, metoprolol ▪ Good to know: • Used to “calm the brain” o Can be used to decrease palpitations during panic attacks, decrease essential tremors, decrease situational anxiety o May also decrease migraine headaches in some people o Nonselective beta blockers may interfere with normal responses to hypoglycemia (tremor, tachycardia, nervousness) – may mask signs and symptoms of hypoglycemia, use with caution in pts with diabetes ▪ Got to know: • Warning! Abrupt withdrawal can cause: severe exacerbation of angina, MI, sudden death, rebound HTN • Taper like steroids • Adv Eff – bradycardia, HF, wheezing, bronchospasm, impotence Chapter 22: Antihypertensive Drugs • Know multiple classifications of drugs (adrenergic, ACE-I, etc…) • Adrenergic Drugs oAlpha (Alpha 1 blockers, alpha2 agonists) (-zosin): oBeta blockers (-olol): o Good to know: o Alpha1 blockers – first dose syncope or hypotension side (dose bedtime) 7 • Got to know: o Adv Eff ▪ High incidence of orthostatic hypotension ▪ Bradycardia with reflex tachycardia, depression, hyperkalemia, hyperlipidemia, sexual dysfunction, decreased libido, exacerbate asthma, COPD, bronchospasms • ACE-Inhibitors (ACE-I) (-pril): • Good to know: o Adv Eff ▪ Can cause permanent dry, nonproductive cough, which reverses when therapy is stopped 30% ▪ First dose hypotensive effect may occur ▪ Possible hyperkalemia, hyponatremia ▪ Possible neutropenia (low neutrophils/WBCs) • Got to know: o Warning! These drugs can cause angioedema (swelling at the back of throat), a rare complication that can lead to cardiac arrest, can occur up to 1 year later (women, blacks) ▪ Angiotensin II Receptor Blockers (ARBs) (-sartan): slows progression of left ventricular hypertrophy after MI and increases survival rate after MI • Good to know: o ARBs are often used for people who cannot tolerate ACE-Inhibitors. They are not a substitute for ACE-I and do not prolong life the way ACE-I do (less likely to cause angioedema though) o Adv Eff – less likely to cause hypokalemia than ACE-I, upper respiratory infections • Got to know: o Women who are pregnant should not take ARBs because they cause birth defects (preg cat D in the 2nd and 3rd trimesters) • Calcium Channel Blockers (CCBs) (amlodipine, diltiazem, verapamil): • Good to know: o Younger people tend to have fewer problems when taking these drugs. Clients over age 60 should not take CCBs because of the risk of severe constipation • Got to know: o Warning! Educate pt about not eating grapefruit or drinking grapefruit juice when taking these medications. The combination causes a higher bioavailability of the drug and can be toxic • Diuretics – Thiazide (hydrocholorothiazide): • Good to know: o Adv Eff – hydrochlorothiazide (increases calcium, lipids, glucose and uric acid) • Got to know: o Hydrochlorothiazide is K wasting o Most diuretics are sulfa drugs – be sure to check for allergies prior to administration • Vasodilators (sodium nitroprusside): • Got to know: o Administer IV forms with extreme caution, and use an IV pump 8 Chapter 28: Diuretic Drugs • Know multiple classifications of drugs: • Know drugs effect on potassium, signs and symptoms of hypokalemia, diet considerations • Loop (furosemide): • Osmotic (mannitol): • Potassium-sparing (spironolactone): • Thiazide (hydrocholorothiazide): • Thiazide-like (metolazone): • Carbonic anhydrase inhibitor (acetazolamide) o Good to know ▪ Interactions • Diuretics and digitalis preparation – monitor for digitalis toxicity • Thiazide and/or loop diuretics and diabetic pts – monitor for elevated levels • NSAIDs may decrease effectiveness of diuretics ▪ Monitor serum K levels during therapy • Signs and symptoms of hypokalemia include muscle weakness, constipation, irregular pulse rate, and overall feeling of lethargy ▪ Pt education • Change positions slowly and rise slowly after sitting or lying to prevent dizziness and fainting related to orthostatic hypotension • Instruct pts to take the med in the morning if possible to avoid nocturia • Encourage pts to keep a log of their daily weight • Remind pts to return for follow-up visits and lab work o Got to know: ▪ Monitor for overall adverse effects • Drowsiness, lethargy, tachycardia, hypotension, leg cramps, restlessness, decreased mental alertness ▪ Adv Eff • Loop diuretics o Hypotension, hypokalemia, hyperglycemia, Stevens-Johnson syndrome, photosensitivity • Potassium-sparing diuretics o Hyperkalemia, gynecomastia, impotence, irregular menses, amenorrhea hirsutism, deepening of the voice • Thiazide diuretics o Hypokalemia, hyperglycemia, impotence, jaundice • Osmotic o Hypernatremia, convulsions, thrombophlebitis • Carbonic anhydrase inhibitors o Metabolic acidosis, hypokalemia, glycosuria in diabetics o Acidosis reduces diuretic effect in 2-4 days ▪ Most diuretics are sulfa drugs – check for allergies! ▪ Osmotic diuretics • Intravenous infusion only • May crystallize when exposed to low temps 9 • Use of a filter is required • NOT indicated for peripheral edema • Following IV administration, intracranial pressure falls within 60-90 mins • Extravasation (leakage) can cause edema and skin necrosis Chapter 23: Antianginal Drugs • Know multiple classifications of drugs: • Nitrates / nitrites (-nitro or -nitrate): oKnow and apply concepts: reliever versus controller, tolerance o Good to know: • Adv Eff – severe headaches (usually diminish in intensity and frequency with continued use), postural hypotension, dizziness, reflex tachycardia, tolerance may develop ▪ Got to know: • Tolerance may develop o Occurs when taking nitrates around the clock or with long-acting forms o Prevented by allowing a regular nitrate-free period to allow enzyme pathways to replenish o Transdermal forms: remove patch at bedtime for 8 hours, then apply a new patch in the morning • IV forms of nitroglycerin o Must be given with special tubing and bags o Discard parenteral solution that is blue, green, or dark red • Pt education – if anginal pain occurs: o Stop activity and sit or lie down, and take a sublingual tablet o If no relief in 5 mins, call 911 and take a second SL tablet o In no relief in 5 mins, take a third SL tab o Do not drive to the hospital • Warning! Clients should not take vardenafil, sildenafil, or tadalafil (Viagra) within 24-36 hrs of taking nitrates. The combo can cause a significant and dangerous drop in BP • Beta blockers (-olol): • Calcium channel blockers (CCBs): Chapter 24: Heart Failure Drugs • Know multiple classifications of drugs oKnow which type of drugs increase mortality or just relieve CHF symptoms • Increase Mortality – ACE-I, Beta blockers, ARBs, Aldosterone Antagonists • Relieve symptoms – loop diuretics, nitrates, positive inotropes (Digoxin) • Know concepts of preload and afterload, link with each classification • ACE-I (-pril) • ARBs (-sartan) • Diuretics oLoop (furosemide): oAldosterone antagonists (spironolactone) • Nitrates/vasodilators (nitrates, hydralazine): • Beta-blockers (-olol): 10 • Positive inotropes o Digoxin: odobutamine: • Got to know: • Digoxin Toxicity – hypersalivation, n/v/d, loss of appetite, fatigue, visual disturbances (halos) – give Digoxin Immune Fab (Digibind) o Pt education ▪ Pts should immediately report a weight gain of 2lbs or more in 1 day or 5lbs or more in 1 week o Digoxin ▪ Take apical pulse and hold if 60bpm ▪ Therapeutic digoxin levels ▪ Signs and symptoms of toxicity ▪ Antidote o Categories of drugs that decrease mortality after CHF (ACE-I, Beta blockers, ARBs, Aldosterone Antagonists)