NUR 2407 Pharm Study Guide Exam 2 Week 4 – Chapter 37-39, 32-33-

NUR 2407 Pharm Study Guide Exam 2 Week 4 – Chapter 37-39, 32-33 Chapter 37: Antineoplastic Agents • Cancer • Cancer (malignant, neoplastic) cells are characterized by unregulated growth, lack of differentiation and spread (metastasis) to other places in the body. • Anticancer Therapy: • Chemotherapy is the use of chemicals to kill cancer cells by inhibiting or preventing cell reproduction. Classes of Chemotherapy Drugs: - Alkylating Agents - Antimetabolites - Antitumor Agents - Mitotic Inhibitors - Hormonal Agents • Antimetabolites Folic Acid Antagonist - Methotrexate (Trexall) – Used to treat cancer, rheumatoid arthritis, psoriasis. INDUCES MISCARRIAGES in patients with ectopic pregnancy.  General side effects: Bone suppression leading to leukopenia, thrombocytopenia, and anemia. Can cause stomatitis, vomiting, alopecia, and hepatic/renal dysfunction. Patients should report any signs of bleeding and have platelet levels checked. • Alkylating Drugs Nitrogen Mustard - Cyclophosphamide (Cytoxan) is used to treat Hodgkin’s disease and many other types of cancer. - This drug can cause hemorrhagic cystitis as result of severe bladder inflammation - This drug should be taken with copious amounts of water and early in the day, so it does not accumulate in the bladder. Chapter 38: Targeted Therapies to treat cancer Targeted Therapy: - Drugs or other substances that block the growth and spread of cancer by interfering with specific molecules in tumor growth and progression. - Cancers that do not have sufficient quantities of the specific molecular target will not respond to targeted therapy. Chapter 39: Biological Response Modifiers Colony Stimulating Factors: - Erythropoietin (Epoetin Alpha) stimulates red blood cell production, and increases the risk of death when a patient’s hemoglobin is 12 Chapter 32: Anti-TB, Antifungal, Peptides, Metronidazole Tuberculosis is caused by a bacterium call mycobacterium tuberculosis. The bacteria usually attack the lungs, but TB bacteria can attack any part of the body, such as the kidney, spin, and brain. If not treated properly, TB disease can be fatal. - TB is one of the world’s top health challenges: More than 2 billion people, equal to a QUARTER of the world’s population are infected with TB. - Each year there is 9 million new cases and 1.5 million deaths - Each day there is 24,000 new cases, 4000 deaths and 8,000 missed. Latent TB Infection – TB bacteria can live in the body without making you sick. This is called Latent TB Infection. In most people who breathe in TB bacteria and become infected, the body is able to fight the bacteria to stop them from growing. People with this condition do no not feel sick and do not have any symptoms. People with this condition are not infectious and cannot spread TB bacteria to others. TB Disease – TB bacteria becomes active if the immune system can’t stop them from growing. When TB bacteria are active, multiplying in your body, this is called TB disease. People with TB disease are sick. They may also be able to spread the bacteria to people they spend time with every day. - Mycobacterium have a thick, way cell wall. It is very tough! Main Symptoms of Pulmonary Tuberculosis: - Appetite Loss - Fatigue - Chest Pain - Coughing up blood - Productive, prolonged cough - Night sweats, pallor Anti- Tuberculars • TB Treatment - To prevent drug resistance – Multidrug Therapy (The golden standard of treatment) - Drugs: Isoniazid, Rifampin, Ethambutol, and Pyrazinamide******* Rifampin - Antimycobacterial - Must be taken daily for several months with no break. - Can stain body fluids orange. - Can cause hepatotoxicity - Take on empty stomach or absorption reduced by 30%*** - First discovered in soil from the French Riviera Isoniazid - Antimycobacterial - BLACK BOX WARNING: Hepatoxicity - Drug to Drug Interactions: Acetaminophen due to increased risk of liver damage*** - Drug of choice for pregnant women with TB - Treats Latent and Active TB - Can cause peripheral neuropathy in patients with vitamin B6 deficiencies - First tested in the Navajo community Many Farms, AZ Ethambutol - Can cause vision problems, including optic neuritis and red green color blindness. - Ok to take while breast feeding - Antimycobacterial Pyrazinamide - Give in first months of combo therapy to reduce the total length of treatment (by months)****** - Can cause arthralgia (joint pain), peripheral neuropathy, and hepatoxicity *** - • Drug Resistance TB - TB drug resistance is a major public health problem that threatens progress made in TB care and control worldwide. This improper use is a result of a number of actions including, administration of improper treatment regimens and failure to ensure that patients complete the whole course of treatment. - Extensively drug-resistant TB. MDR TB is caused by an organism that is resistant to at least isoniazid and rifampin, the two most potent TB drugs. - “Totally Drug-Resistant” tuberculosis: a WHO consultation on the diagnostic definition and treatment options. • TB Vaccine - The Bacille Calmette-Guerin (BCG) vaccine has existed for 80 years and is one of the most widely used of all currect vaccines, reading 80% of neonates and infants in countries where it is part of the national childhood immunization programmer. BCG vaccine has a documented protective effect against meningitis and disseminated TB in children. - The World Health Organization recommends that in countries with a high rate of TB burden all infants should receive one dose of BCG attenuated live vaccine, as soon as possible after birth. Antifungal Drugs • Fungal Infections - Can be topical or systematic - Can be opportunistic or non-opportunistic - Can be mild to life-threatening - Can be caused by antibiotic or steroid use - In the mouth, it is called Thrush*** Nystatin (Myostatin) - Antifungal Drug - Action: Binds to fungal cell membranes, causing cell contents to leak out = death - Use: Topical treatment of fungal infections. Not absorbed in the GI system, so safe to give orally. - Elizabeth Lee Hazen and Rachel Fuller Brown discovered nystatin - Swish and Swallow!! Fluconazole (Diflucan) - Antifungal Drug - Used to treat candida infections and cryptocoal meningitis - Pregnancy Category C, give with caution Peptide Antibiotics Bacitracin - Effective against gram positive and some gram-negative bacteria - Available OTC as ointment for application to the skin - Peptide Antibiotic Metronidazole Metronidazole (Flagyl) - Impairs DNA function of susceptible bacteria - Used primarily to treat organism of the GI tract and to treat bacterial vaginosis**** - To prevent a disulfiram reaction patients must avoid alcohol and all alcohol containing products during treatment and for 48 hours after treatment. Disulfiram Reaction - facial flushing - severe headache - abdomen cramping - slurred speech - tachycardia - palpitations - hypotension - dyspnea - sweating - nausea - vomiting ***Most common with metronidazole & cephalosporin antibiotics Chapter 33: Antivirals, Antimalarial, Anthelmintic • Viruses - Obligate intracellular infectious agents that must reside within a living host cell to replicate. - Uses their own DNA and RNA to generate new viruses within the host cell Common human viruses - Influenza - Herpes - Varicella Zoster (Chicken Pox & Shingles) - Epstein-Barr (Mononucleosis) - Hepatitis B - Human Papilloma Virus (causes cervical cancer) • Influenza - Osteltamivir (Tamiflu) – Shortens the course of flu symptoms by 2-3 days only if given within 48hrs of onset of symptoms. - Children and teenagers with the flu may be at a higher risk for seizures, confusion, or abnormal behavior early during their illness - An ounce of prevention (VACCINE) is better than a pound of cure (there is none) - Influenza viruses mutate quickly and often - The potential for a major pandemic is a constant threat - It is estimated that in the influenza pandemic; the global death toll was 30-50 million people. • Herpes - Acyclovir (Zovirax) is effective against the herpes virus!  Life threatening adverse reactions: neuropathy, seizures, nephrotoxicity (large doses), thrombocytopenia, leukopenia.  Comes in an oral medication, cream, and injection • Zika Virus - Zika virus is a mosquito born single stranded RNA virus related to dengue virus - Zika Virus infections have been confirmed in infants with microcephaly. - Because there is neither a vaccine nor prophylactic medications available to prevent Zika, virus infection, the CDC recommends that all pregnant women consider postposing travel to areas where Zika Virus Transmission is ongoing. - Women trying to become pregnant should consult with their healthcare provider before traveling to these areas. Pregnant Women with Any Lab Evidence of Zika Virus Infection**** • US States and DC: 195 • US Territories: 146 Anthelmintic Drugs - Helminths • Parasitic worms that fee on host tissue • Most common location is the intestine • Other sites include the lymphatic system, blood vessels, liver, and brain • Includes: Flukes, round worms, hook worms, and pin worms.  Can be acquired by poor handwashing, lack of access to clean drinking water, or eating undercooked pork. • Anthelmintic Drugs - Can cause GI distress, neurologic problems, or liver disease - Cysticercosis: Cysts on the brain caused by larval tapeworms. *** • Malaria - Caused by the protozoan parasites Plasmodium, carried by infected mosquitoes. - Once the human is infected with the parasite, it passes through two phases: • Tissue phase – No symptoms • Erythrocytic Phase – Invasion of RBCs, causing symptoms of chills, fever, and sweating. - Over one million people die from malaria each year, mostly children under five years of age, with 90% of malaria cases occurring in Sub-Saharan Africa Antimalarial Drugs - Chloroquine – Serious Adverse Reactions: ECG changes, hypotension, psychosis, seizures. - Scientists engineer mosquito with malaria-blocking genes: Scientists 'edit' mosquito DNA to resist malaria, with hopes to breed with species in wild, block disease transmission - EU regulator greenlights world's first malaria vaccine: Mosquirix is only about 30 percent effective, but EMA recommendation is likely to accelerate approval - New malaria drug could be introduced in 2016: Joshua Blumenfeld, the managing director of Malaria No More, discusses the new medicine and its prospect Week 5: Chap 35 & 36, 49 & 50 Chapter 35: HIV & AIDs related Drugs • HIV & AIDs • HIV is an RNA retrovirus. Retroviruses have an enzyme, called reverse transcriptase, that gives them the unique property of transcribing their RNA into DNA after entering a cell. The retroviral DNA can then integrate into the DNA of the host cell, to be expressed there. • HIV destroys CD4+ T helper lymphocyte cells, resulting in immune deficiencies, which can become fatal. • HIV Treatment: Combination Antiretroviral Therapy (ART) • Attaining viral suppression of HIV necessitates involves the use of at least two, preferably three, active drugs from two or more drug classes. • ART involves taking a combination of HIV medicines (called an HIV regimen) every day, EXACTLY as prescribed. • Zidovudine (AZT, Retrovir) – Nucleoside Reverse Transcriptase Inhibitor • Tenofovir (Viread) – Nucleoside Reverse Transcriptase Inhibitor • Efavirenz (Sustiva) – Nucleoside Reverse Transcriptase Inhibitor • Atazanavir (Reyatza) – Protease Inhibitor • HIV Lab Testing • Lab tests used to determine when to initiate medication therapy and to monitor efficacy of therapy and indications for changing therapy: • CD4 T-Cell count • HIV RNA quantitative assay (Viral Load) • HIV Resistance Testing • Here is what your T-cell count can tell you: - More than 500 cells/mm^3 = Your immune system is NORMAL - 200-500 cells/mm^3 = Your immune system is WEAKEND - Less than 200 cells/mm^3 = Your immune system is VERY WEAK. You are at high risk for getting an opportunistic infection - an infection that develops only when the immune system is weak. 1 Chapter 36: Vaccines • Active Immunity • Acquired Immunity: Occurs as part of the human immune response which is activated when a pathogen invades the body. The body recognizes this pathogen as foreign, and begins the production of antibodies. • The next time the body encounters the same pathogen, it recognizes it and mounts a target response. • Immunization can provoke acquired immunity • Artificial active immunity is a type of protection developed against illnesses that produce such serious side effects that total avoidance of the disease is most desirable (a vaccination) • Vaccination involves administration of a small amount of antigen, which although capable of initiating an immune response, does not typically produce disease. • Passive immunity occurs when antibodies against a specific antigen are in a person's body, but the person did not actively generate these antibodies. • Live attenuated (weakened) Vaccines • Contraindications: *** – currently ill – egg or flu vaccine allergy – under 2 or over 49 yrs – immune suppression or live with someone who is – pregnant – had or has Guillain Barre Syndrome – age 2-17 and taking aspirin – Ex. Flu Vaccine Nasal Spray** • Vaccines - Attenuated (Live): - BCG (Tuberculosis) - MMR (Measles, mumps, rubella) - Varicella (Chicken Pox) - Not Live (Inactivated): - Hep B (Hepatitis B) - Tetanus Toxoid ****Varicella (Varivax) – For varicella prophylaxis, outbreak control of local epidemics of wild-type virus in susceptible persons following varicella exposure. Adverse Reactions: anaphylaxis, thrombocytopenia, encephalitis, Stevens-Johnson syndrome. Chapter 49 & 50: Eye, Ear, and Dermatologic Medications Chapter 49: Eye and Ear Medications • Drugs for Disorders of the Eye • Diagnostic Stains • Topical Anesthetics*** • Anti-infective • Anti-inflammatories • Decongestants • Lubricants • Immunosuppressant • Anti-glaucoma Agents - Topical Anesthetics • Not for self-administration • Given only under strict medical supervision*** - Numbing of the eye could lead to serious injury of the eye by trauma, without the patient being aware of it. • Disorders of the Eye: Glaucoma*** • Optic nerve damage occurs as a result of increased intraocular pressure (IOP), due to a build-up of the fluid, aqueous humor. • Aqueous humor normally drains through the trabecular meshwork of the eye. - Open Angle Glaucoma = Trabecular network becomes gradually clogged - Narrow Angle Glaucoma = The iris bows and blocks the trabecular meshwork, narrowing the angle where the fluid normally exits the eye (often requires surgery) • Glaucoma Treatment 1. Prostaglandin Analogues 2. Beta-Adrenergic Blockers 3. Cholinergic Agents 4. Alpha Adrenergic Agonists 5. Alpha Adrenergic Agonists 6. Carbonic Anhydrase Inhibitors 7. Osmotic - Latanoprost (Xalatan) – Know this drug and its side effects!! • Prostaglandin Analogue* • Decreases IOP by increasing outflow* • Side Effects: Permeant darkening of the iris** • Increase in length, number, darkness, and thickness of eyelashes** • Adverse Effects: Up to 4% of patients report respiratory problems** • Disorders of the Ear: • Acute Otitis Media - Most common in children - Risk factors: under 2, day care, not immunized, exposure to tobacco smoke and air pollution - First choice treatment: Amoxicillin (PO) • Acute Otitis Externa (Swimmers Ear) - Infection of the external auditory canal, occurring when moisture is present with a break in the skin allowing bacterial or fungal infiltration. - Treatment: topical (drops) • Drugs for Disorders of the Ear: • Oral Antihistamines - diphenhydramine • Oral Decongestants - phenylephrine - pseudoephedrine ****Agency for Healthcare Research and Quality: “Outcomes showed NO BENEFIT for use of these medications…evidence of increased side effects and harms with use of these medications.” (Diphenhydramine, Phenylephrine, and Pseudoephedrine) • Cerumen Impaction • Cerumenolytics - Topical agents used to soften ear wax - Usually mineral oil with hydrogen peroxide (patients can use mineral oil alone • Irrigation - Body temperature water gently flushed into the ear canal - Can use 3% hydrogen peroxide 1:1 with water or vinegar 1:1 with water Chapter 50: Drugs for Dermatologic Disorders • Acne Vulgaris • Nonpharmalogic - diet, stress reduction, gentle cleansing • Topical - Keratolytic: benzoyl peroxide, salicylic acid, resorcinol, tretinoin • Systemic - oral antibiotics • Isotretinoin (Annesteem, Accutane) - For treatment of severe cystic acne - Decrease sebum formation, anti-inflammatory, antikeratinizing - Pregnancy Category X (Teratogenic)**** - Requires registry of patient, provider, pharmacist and wholesaler for use of medication, on iPLEDGE registry. • Psoriasis • Characterized by erythematous papules and plagues covered with silvery scales • Epidermal cell growth and epidermal turnover are accelerated to approximately 5x normal expected growth • Usually has periods of remission and exacerbation* • Topical Medications - Keratolytic - Glucocorticoids - Coal tar derivatives • Systemic Medications - Methotrexate (anticancer drug, can decrease cell growth) - UV light therapy - Biologic Agents • Sunscreens • Chemical Screens: Absorb UV radiation. Most absorb UVB, less than half absorb UVA. • Avobenzone absorbs UVA & UVB • Sunscreens protect against sunburn, premature aging of the skin, photosensitive to select drugs, but DO NOT protect against MELANOMA or Basal Cell Carcinoma • Burns • Minor burns should be treated with a cool water compress. • Minor burns can be treated with a cool water compress • Partial & Full thickness burns require more intense treatment • Silver Sulfadiazine (SSD) – Antibacterial, Topical, Used for cutaneous burns, Steven-Johnson Syndrome. - Works on cell wall to produce bactericidal effects - 1% or less of the silver is absorbed - Up to 10% of the sulfadiazine is absorbed - DO NOT use of the FACE or HANDs, tattooing (permanent staining) may occur** Week 6: Chap 29 & 30, 31 & 34 Chapter 29: Penicillin’s and Cephalosporins • Bacteria • Single celled organisms lacking a true nucleus or nuclear membrane • Can be classified by shape or ability of cell wall to hold gram stain • Produce toxins that cause host cell lysis • Antibacterial Drugs/ Antibiotics • Bacteriostatic- Slows the bacteria • Bactericidal-Kills the bacteria*** • 5 Mechanisms of Action (antibiotics): 1. Inhibition of bacterial cell wall synthesis 2. Alteration of membrane permeability 3. Inhibition of protein synthesis 4. Inhibition of the synthesis of RNA & DNA 5. Interference with metabolism within the cell - Alexander Fleming- the first to notice mold spores interfering with bacterial cultures. Leading to antibiotic development. - It’s not just the Drug! - Antibiotics & Your Immune system work together to subdue the invading micro-organism. • Antibiotic Resistance • Antibiotics are powerless against this new superbug: E.Coli • Researchers in China have discovered a strain of E. Coli bacteria resistant to all known antibiotics • Narrow Spectrum Antibiotics: • Primarily effective against one type of organism • More effective against the organism it is fighting than a broad-spectrum antibiotic • Broad Spectrum Antibiotics • Can be effective against gram negative and gram positive organisms • Often used when the organism causing the infection has not been identified. Ex. Sepsis. • Adverse Reactions to Antibiotics 1. Allergy or Hypersensitivity - Mild to fatal (anaphylaxis) – Itching and hives to angioedema 2. Superinfection - A secondary infection that occurs when the normal microbial flora of the body is disturbed - Often Fungal - More common with broad spectrum antibiotics - Ex. C.diff 3. Organ Toxicity - Hepatoxic - Nephrotoxic - Ototoxic • Anaphylaxis**** • A serious allergic reaction and should be treated as a medical emergency. It can occur within minutes of exposure, or take several hours. • Sign of Anaphylaxis: - Anxiety, Confusion - Lightheadedness, Loss of consciousness - Headache - Swelling of the lips, tongue, and/or throat - Runny nose **Think - Low blood pressure, fast or slow heart rate Airway** - Flushing of the skin, hives, and/or itchiness - Vomiting, diarrhea, and/or abdominal cramping - Cough, wheezing, shortness of breath - Hoarseness, pain when swallowing *Anyone with symptoms of anaphylaxis should seek medical attention immediately! Areas most commonly affected in anaphylaxis: - Skin, in 80-90% of cases - Respiratory, 70% - Gastrointestinal, 30-45% - Cardiovascular, 10-45% - Central Nervous System, 10-15% • Penicillins • Amoxicillin*** - Broad Spectrum - Primarily used to treat respiratory tract infections, Otis media, and sinusitis - Contraindicated with penicillin allergy - Give with caution in cephalosporin allergy - Other Penicillins include Penicillin, Ampicillin, and Bicillin • Beta Lactamase Inhibitor • Beta Lactamase: An enzyme produced by some bacteria that make them resistant to Penicillins. • Amoxicillin/ Clavulanic acid (Augmentin) • Combines - Broad Spectrum antibiotic - Beta Lactamase Inhibitor - Resulting in extended antimicrobial effect • Cephalosporins • Ceftriaxone (Rocephin) • Cephalexin (Keflex) - Active against gram positive and negative bacteria - Resistant to beta lactamase - Give with caution to patients with penicillin allergy, and monitor for signs of an allergic reaction - Cross allergy may not be as common as once thought - A fungus discovered near a sewer outlet in Mediterranean seawater at Sardinia. - REMEMBER: Potential Disulfiram Reaction when mixed with alcohol! Chapter 30: Macrolides, Tetracyclines, Aminoglycosides, and Fluoroquinolones • Macroslides – Antimicrobials • Erythromycin - Frequently prescribed if a patient has a hypersensitivity to Penicillins** - Allergic Reactions are rare - Hepatotoxicity can occur, especially when combined with other hepatotoxic drugs like acetaminophen - Excreted primarily in the bile by the liver, making it a good choice for patients with renal impairment.** • Azithromycin - Treats respiratory tract, sinus, GI tract, skin, and soft tissue infections, as well as impetigo and sexually transmitted infections (STIs) - Life Threatening Adverse Reactions: Hepatotoxicity, anaphylaxis, Steven Johnson syndrome. • Glycopeptide Antibiotics – Antimicrobials • Vancomycin - Used against drug resistant staphylococcus aureus - Ototoxicity can lead to permanent hearing loss by damaging CN VII*** - Too rapid administration can lead to Red Man Syndrome*** - Peak and trough levels must be checked to ensure safety and efficacy (metabolism and elimination). • Tetracyclines - Antimicrobials • Tetracycline* - Take on an empty stomach as milk or antacid products can prevent absorption. - Can stain teeth of fetus or young children** - Can decrease effectiveness of oral contraceptives** - Can result in photosensitivity reactions • Doxycycline - Take with food to enhance absorption, but AVOID milk containing products - Contraindicated in pregnancy - Diarrhea, Nausea, and vomiting are common side effects • Aminoglycoside Antibiotics • Gentamicin - Used to treat serious infections - Can cause nephrotoxicity and ototoxicity* - Assess hearing, balance, and urine output while on therapy • Fluoroquinolone Antibiotics • Levofloxacin (Levaquin) - Primarily used to treat respiratory infections, such as community acquired pneumonia, chronic bronchitis, acute sinusitis. Can also treat UTI and uncomplicated skin infections. • Ciprofloxacin (Cipro) - Broad spectrum antibiotic - Treats UTI, lower respiratory infections, skin, soft tissue, and bone infections - Used to treat anthrax** - Administer on an empty stomach. Products with magnesium, aluminum, iron, or zinc should be ingested 4 hours before or 2 hours after Cipro. - Do not take with antacids! **Fluoroquinolones can cause tendon rupture, especially if taken in combination with steroids Chapter 31: Sulfonamides • Sulfonamides • The first agent used against bacteria • Came into use in 1935 • Coal tar derivative** • 90% effective against E. coli infections • Clinical usefulness when not used in combination with other drugs has decreased over time. • Trimethoprim – Sulfamethoxazole (Bactrim)** - Treats UTIs, otitis media, and bronchitis - Photosensitivity: Patients should be advised to avoid sun exposure - Should be avoided in the 3rd trimester of pregnancy** - Increase fluid intake should be encouraged. • Sulfonamide Drug Allergies • If a patient reports an allergy to “Sulfa” drugs, they should be asked for more information about past reactions • While rare, it is possible that the patient could have an allergic reaction to the following medications: - Glucotrol (Glipizide), as sulfonurea - Celecoxib (Celebrex), a COX 2 inhibitor, contains a sulfonamide substitute - Furosemide (Lasix) Chapter 34: Drugs for Urinary Tract Disorders • Urinary Tract disorders • Urinary Tract Infections • Decreased Bladder Function • Urinary Tract Spasms • Urinary Tract Infections • Lower - Cystitis (Bladder Infection): More common in females due to shorter urethra, frequently caused by E. coli.*** - Urethritis - Prostatitis • Upper - Pyelonephritis (Kidney Infection): Symptoms include fever, chills, and flank pain (frequently severe)*** • Antibiotic Treatments for UTIs: • Nitrofurantoin (Macrodantin) - Bacteriostatic or -cidal, depending on the dose - Treats acute and chronic UTIs*** - Should be taken with food - Decrease absorption when taken with antacids • Trimethoprim/sulfamethoxazole • Fluoroquinolones • Norfloxacin • Ciprofloxacin • Urinary Analgesics • Phenazopyridine (Pyridum)** - Urinary Analgesic: Relieves urinary pain and burning - Turns urine orange, which can stain clothing*** (I believe contact lenses as well) - Can alter urine glucose - Take with food to avoid nausea • Urinary Antispasmodics/ Antimuscarinics • Treat Urinary tract spasms associated with infection or injury • Contraindicated if urinary or GI obstruction is present • Tolterodine Tartrate (Detrol, Detrol LA) • Cholinergic Receptor Blocker (Anticholinergic) • Decreases urinary frequency and urgency • Monitor for anticholinergic side effects Week 7: Chap 51 & 52, 56 & 57 Chapter 51: Endocrine System • Anterior Pituitary • Hormones of the posterior pituitary: • ACTH (Adrenocorticotropic hormone) • TSH (Thyroid Stimulating Hormone) • FSH (Follicle Stimulating Hormone) • LH (Luteinizing Hormone) • GH (Growth Hormone) • PL (Prolactin) • Posterior Pituitary • Hormones of the posterior pituitary: • ADH (antidiuretic hormone) • OT (oxytocin) • Thyroid Gland • Hormones of the thyroid gland: - Thyroxine (T4) - Triiodothyronine (T3) - These hormones affect nearly every tissue & organ in the body by controlling their metabolic rate & activity. - Stimulation by the thyroid hormones results in an increase in cardiac output, oxygen consumption, carbohydrate use, protein synthesis, and lipolysis. - Thyroid hormone levels in the blood are regulated by negative feedback • Parathyroid Glands • Secrete Parathyroid Hormone (PTH), which regulates calcium levels in the blood • Pancreas • Exocrine Section: - Secretes digestive enzymes into the small intestine. • Endocrine Section: - Has cell clusters (Islets of Langerhans)  Alpha cells: produce glucagon  Beta cells: produce insulin • Adrenal Glands • Medulla - Releases catecholamine epinephrine and norepinephrine • Cortex - Corticosteroids  Glucocorticoids – Cortisol  Mineralocorticoids – Aldosterone • Thyroid Disorders • Hyperthyroidism - Diagnosed by increased serum T4 & T3 levels and DECREASED TSH levels*** - Symptoms: tachycardia, palpitations, heat intolerance, nervousness, irritability, weight loss, exophthalmos (bulging eyes). - Treatment: symptom control, radiation, surgery, anti-thyroid drugs. • Hyperthyroidism - Diagnosed by decreased T4 serum levels and INCREASED TSH levels*** - Symptoms: Myxedema is severe or longstanding hypothyroidism and symptoms include- lethargy, weight gain, dry skin, cold intolerance, decreased heart rate, abnormal menses, periorbital edema, goiter. - Myxedema coma is a medical emergency. Symptoms: hypoventilation, hypotension, hypoglycemia, lactic acidosis, altered level of consciousness. • Treatment of Hypothyroidism • Levothyroxine (Synthroid) - Thyroid hormone replacement - Treatment of hypothyroidism - Adverse Reactions: tachycardia, hypertension, palpitations, osteoporosis, seizures, thyroid crisis (Thyroid STORM), angina, atrial fibrillation, cardiovascular collapse. • Treatment of Hyperthyroidism • Goal: Reduce the excessive secretion of T4 & T3 • Strong Iodide preparations such as potassium iodide can suppress thyroid function. • Thioamides: - Methimazole (Tapazole) - Propylthiouracil (PTU)  These drugs do not destroy thyroid tissue, but block thyroid hormone action.  Prolonged use may cause goiter due to increased TSH secretion & decreased T3 & T4 production. • Hypoparathyroidism • Calcitriol - Vitamin D analogue, promotes absorption of calcium in the GI tract & secretion of calcium from bone to blood stream. - Treats hypoparathyroidism & management of hypocalcemia in renal failure. • Adrenal Cortex Hormones – Corticosteroids • Mineralocorticoids – Aldosterone - An INCREASE in Corticosteroids: Adrenal Hypersecretion = Cushing Syndrome • Glucocorticoids – Cortisol - A DECREASE in Corticosteroids: Adrenal Hyposecretion (Adrenal Insufficiency) = Addison’s Disease • Corticosteroids: Glucocorticoids • Affect carbohydrate, protein & fat metabolism, & muscle & blood cell activity • Also have mineralocorticoid effects, so can cause water retention, potassium loss & increased blood pressure. • Cortisol the main glucocorticoid and has anti-inflammatory, antiallergic, & antistress effects. ** • Prednisone** - Can cause immune suppression** - When taken with NSAIDs, like aspirin, increased risk of GI bleeding - Discontinued dose should be tapered to allow adrenal glands to return to normal functioning (will have slowed production due to negative feedback loop), failure to do so can lead to adrenal insufficiency - Monitor Patient for signs of infection!** • Cortisone Drugs - Treat Inflammatory Condition, such as Multiple Sclerosis, Myasthenia Gravis, Ulcerative Colitis, Shock, Spinal Cord injury.. - Treat allergies, such as asthma, drug induced, contact dermatitis, anaphylaxis, etc. - Long term Side effects:  Moon face, acne, increased facial hair, flushing  Thinning hair, increased body hair  Increased weight, appetite, blood sugar**  Buffalo (fat) hump, bruising, fat pad, enlarge abdomen, stretch marks  Muscle atrophy  Thin skin, tears easily, slow wound healing* The symptoms you see with cortisone drugs, are the same signs and symptoms of Cushing’s Syndrome *Prednisone: The all the time eating, shaking, bone thinning, weight gaining, bitch making, so you can never sleep again medicine!  • Addison’s Disease – Adrenal Insufficiency/ Hyposecretion • Symptoms include: mood disturbances, weakness, fatigue, anorexia, weight loss, nausea, diarrhea, orthostatic hypotension, and hyperpigmentation associated with elevated ACTH levels. • Treatment: Will need to take corticosteroids for life. ** • Diabetes Insipidus • A disorder of salt and water metabolism marked by intense thirst and heavy urination. • Caused by a lack of antidiuretic hormone. • Can be caused by lithium use. • Can be caused by head injury. • Treatment: Desmopressin (DDVAP) - Antidiuretic Hormone (ADH), normally produced in the posterior pituitary - Reduces urine production - Adverse Effects: Can lead to hyponatremia - Normal sodium levels 135-145 - Monitor serum sodium levels***** Chapter 52: Antidiabetics • Insulin • Insulin is a hormone made naturally in the pancreas that helps move sugar into the cells of your body. Your cells use the sugar as fuel to make energy. Without enough insulin, sugar stays in your bloodstream, raising your blood sugar. Elevated blood sugar levels cause damage to capillaries and tissues. Without fuel, cells cannot perform life sustaining functions. • Diabetes Mellitus • Gestational: - May be treated with insulin or agents to decrease insulin resistance - Occurs during pregnancy • Type 1: - Autoimmune disease - Beta cells in the Islets of Langerhans in the pancreas have been damaged and can no longer produce insulin - Patient must be given insulin to survive • Type 2: - Body cells become resistant to the uptake of insulin - Initially the pancreas may increase the production of insulin - Over time, insulin production decreases - Most therapies are designed to decrease the cell’s resistance to insulin uptake - Insulin therapy may also be needed • Insulin Administration • Onset & Peak will affect administration times. • Rapid acting insulins should not be given more than 5 minutes prior to meals. • Short acting insulin can be given up to 30 minutes prior to meals. • Insulin bottle should not be shaken. This introduces air bubbles into the solution and could alter the dose in your syringe. • Treatment for Type II Diabetes: • Metformin (Glucophage) - Biguanide Class - Decreases hepatic glucose production - Decreases absorption of glucose from the small intestine - Increases insulin receptor sensitivity & cellular glucose uptake - Metformin Therapy SHOULD BE held for 48 hours before and after tests using IV contrast dye, to prevent ACUTE RENAL FAILURE***** • Glipizide - Sulfonurea Class - Increases insulin production & insulin receptor sites on cell surfaces - Decreases glucose production in the liver - Should not be used in patients with liver or kidney disease - Alcohol may produce Disulfiram-like reaction - Green tea may potentiate hypoglycemia • Diabetic Complications • Hyperglycemia**** - Polyuria, polydipsia, polyphagia. - Diabetic Ketoacidosis (DKA), Type 1 diabetes, Blood glucose 250 - Hyperosmolar Hyperglycemic Nonketotic Syndrome (HHNKS), Type 2 diabetes, Blood glucose 600 (seen less commonly). • Hypoglycemia***** - Nervousness, trembling, lack of coordination, cold clammy skin, pallor, headache, agitation, incoherence - Can be caused by ill-timed or excess insulin dosing. • Diabetic Emergencies • Diabetic Ketoacidosis (Hyperglycemic Reaction) - blood sugar 250 (usually much higher 400+) - extreme thirst - fruity breath odor - Kussmaul breathing (rapid, labored, distressed) - rapid, thready pulse - dry mucous membranes, poor skin turgor - coma - death • Insulin Shock (Hypoglycemic Reaction) - blood sugar 60 - nervousness - perspiration, cold, clammy skin - slurred speech - tachycardia - confusion - seizures - coma - death • Treatment of Diabetic Emergencies • Diabetic Ketoacidosis - Fluid Resuscitation – Normal Saline - Check Potassium Level – Must be 3.3 before administering insulin - Administer Insulin *HHNKS Treatment: Very similar, may require more fluid and more electrolytes Insulin Shock - If patient is unconscious***  IV glucose (D50)  Glucagon (Subcu, IM, IV) – A hormone secreted by alpha cells of pancreas, increases blood sugar by breaking down glycogen in the liver. - If patient is conscious:  Able to swallow: Juice or oral glucose  Unable to swallow: IV glucose (D50) Chapter 56: Drugs for Women’s Reproductive Health and Menopause • Combined Hormone Contraception • Estrogen-Progestin Combination Products - Synthetic version of estrogen - Progestins (testosterone derivatives), natural or synthetic • The amount of estrogen & type of progestin determine bio-activity & side effects • The lowest effective dose should be used*** • Mechanism of Action: - Inhibits ovulation by preventing the formation of a dominant follicle, which prevents the stimulation of luteinizing hormone needed to induce ovulation. - Without ovulation, pregnancy cannot occur. • Routes of deliver: - Oral - NuvaRing - Ortho-Evra transdermal patch • Progestin Only Contraception • Pills • Depo-Provera - Injectable, long acting progestin, dosed every 11-13 weeks • Nexplanon- Implantable single rod device, lasts up to 3 years; It is a long-acting reversible contraceptive (LARC) and is place in the arm. - When discussing birth control with your patient, talk about whether she wants a non-intrauterine option. • Hormonal Contraception • Potential Side Effects & Adverse Reactions: - “It is accepted by health care providers that the risks associated with CHC (combined hormonal contraceptive) products and all other methods of hormonal contraception are much less than the risks associated with pregnancy” (Key, Hayes & McCuiston, 2015 p. 854). • Potentially severe Reactions: - hypertension - thrombo-embolism - carcinogenesis (may be due in part to less frequent use of condoms and transmission of HPV when taking hormonal contraception). • Absolute Contraindications (Know these!): - Pregnancy, venous thrombosis history or risk factors, liver disease, undiagnosed uterine bleeding or suspected uterine cancer, breast cancer, tobacco use of 15 cigarettes per day in a patient 35 years of age.***** • Emergency Contraception • Can prevent pregnancy after unprotected intercourse. • Most effective when used within 24 hours of unprotected intercourse. • The only contraindication is pre-existing pregnancy. • Works by preventing ovulation, fertilization or implantation • Available over the counter to all women of child bearing age. • Indicated and offered, along with STI treatment & prophylaxis in cases of sexual assault. • Menopause • Estrogen Replacement (Premarin) - Hormone Replacement Therapy:  Black Box Warning: should be used at the lowest dose possible, for the shortest duration possible, usually less than 5 years. ***  Potentially serious adverse reactions include increased cancer risk and cardiovascular events. • Menopause - Menopause - Cessation of ovarian function - Cessation of menstrual bleeding for one year - Still possible to become pregnant - Osteoporosis • Peri-menopause - Menstrual variations - Hot flashes - Vaginal dryness caused by reduced estrogen - Still possible to become pregnant • Osteoporosis • Progressive, debilitating, skeletal disease characterized by deterioration of the microstructure within the bone and a decrease in bone density. • Affects men & women • Women older than 50 are at greater risk since the loss of estrogen is directly related to loss in bone mineral density. • Treatments: - Estrogen no longer recommended - Selective Estrogen receptor modulators (SERMS)- act like estrogens in certain parts of the body while leaving others unaffected, ex: raloxifene (Evista) - bisphosphonates inhibit osteoclast action, ex: alendronate (Fosomax) - Raloxifene – Hormonal Oncologic 4; Antiestrogens; Osteoporosis; Adverse Effects: DVT, pulmonary embolism, retinal vein thrombosis, and stroke. - Alendronate: Used for calcium disorders. Adverse reactions: dysphagia, esophagitis, esophageal ulcer, esophageal erosion, esophageal perforation, hypocalcemia, gastric ulcers. Chapter 56: Drugs for Men’s Health and Reproductive Disorders • Androgens • Indications for use: hypogonadism, in which the testes fail to produce testosterone, sperm or both. • May also be used to treat refractory anemia in men & women, tissue wasting, & advanced carcinoma of the breast. • Testosterone - Adverse Reactions:  May cause hypercalcemia by stimulating bone reabsorption in patients with breast cancer or immobilized patients.  Virilization in women and children  Increased serum cholesterol levels • Erectile Dysfunction • Causes of ED: - Diabetes - Hypertension - UTI - Vascular insufficiency - Neurologic disorders - Androgen deficiency - Diseases of the penis - Psycho-emotional problems • Treatment for Erectile Dysfunction • Phosphodiesterase (PDE) inhibitors facilitate erections by enhancing blood flow to the penis. • PDE-5 inhibitors are currently the most commonly used treatment for ED. • Sildenafil (Viagra) ***** - Sexual/Erectile Dysfunction - Caution in patients 50 yo - Adverse Reactions: MI, stoke, sudden death, ventricular arrhythmias, hypotension, pulmonary and renal hemorrhage, vision loss • Tadalafil (Cialis) - Benign Prostatic Hyperplasia (BPH); Sexual/Erectile Dysfunction - Adverse Reactions: Angina, MI, stroke, hypotension, HTN, syncope, neuropathy, tachycardia, vision and hearing loss • Vardenafil (Levitra/Staxyn) - Sexual/Erectile Dysfunction - Adverse Reactions: Anaphylaxis, angina, MI, HTN, hypotension, syncope, tachycardia, vision and hearing loss, glaucoma • Avanafil (Stendra) - Sexual/Erectile Dysfunction - Adverse Reactions: Hypersensitivity, hearing and vision loss, neuropathy, priapism • These medications are contraindicated in patients taking organic nitrates in any form. ** • When taken with nitrate medications can cause a significant decrease in blood pressure, possibly life threatening. • Includes: nitroglycerin, isosorbide dinitrate, isosorbide, isosorbide nitrate, etc. • Benign Prostatic Hyperplasia (BPH) • Enlargement of the prostate gland due to increase in the number of cells. • Cause is unknown. • Development is almost universal in older men. • Can lead to impairment or obstruction of urine outflow. • Treatment - 5-alpha reductase inhibitors  Finasteride (women of childbearing age should not handle, due to risk of harm to developing male fetus) ******* - Alpha adrenergic blockers  Tamsulosin (Flomax) – Adverse reactions: Orthostatic Hypotension, syncope, arrhythmias, hypersensitivity - PDE-5 inhibitors  Tadalafil Check-It! Questions 1. 1.In order to prevent injury to the eye, anesthetic eye drops should only be administered under what conditions?  With strict ___________________ Supervision 2. The Antimetabolic methotrexate is used to treat a variety of conditions including cancer, psoriasis, ectopic pregnancy, and rheumatoid arthritis. Regardless of the conditions it is treating, serious side effects include which of the following (select all that apply) ******* a) Bone marrow suppression b) Leukopenia c) Neutropenia d) Thrombocytopenia e) Stomatitis f) Alopecia 3. The medical term for bladder infection is __________________****** 4. The medical term for kidney infection is ____________________ ****** 5. A patient who is on corticosteroid therapy must be monitored for signs and symptoms of infection because steroids have what effect on the immune system? ___________________________ 6. You have a patient who reports menopausal symptoms that are causing her some distress. She has heard that women shouldn’t take hormone replacement for very long. You tell her that the black box waning on these products indicates:******  These products should be used at the _______________ dose as possible, for the ___________ duration as possible, usually less than __________ years. 7. You just gave your patient Lispro (Humalog) insulin and now they are refusing to eat. What should you do? 8. Glucagon should only be administered if the patient is _____________________ 9. Oral decongestants and antihistamines have been shown to have _______________ benefit in treating disorders of the ear. ****** 10. True or false: It is possible to die from chicken pox (varicella)? _________________ ****** 11. Cyclophosphamide (Cytoxan), an alkalizing agent, can cause hemorrhagic inflammation of which organ (s): a) Heart b) Liver c) Lungs d) Bladder 12. A Disulfiram reaction most commonly occurs with which two types of antibiotics: a) __________________________ b) __________________________ 13. The percentage of the world’s population that is infected with tuberculosis ________________ 14. The first agent used against bacterial infections, derived from coal tar: _____________________ 15. Tolterodine Tartrate (Detrol, Detrol LA) is contraindicated in which of the following conditions? a) Urinary Tract Infections b) Urinary Tract Spasms c) Diarrhea d) Bowel Obstruction 16. Peak and trough levels are ordered on the aminoglycoside antibiotic, vancomycin in order to ensure Safety, efficacy, ____________________ & _______________________ 17. Ciprofloxacin (Cipro) should not be taken with products containing which of the following (select all that apply): ***** a) Antacids b) Aluminum c) Iron d) Zinc 18. You are schedule to give aspart (Novolog) sliding scale insulin. The blood sugar reading is at 320. How many units will you give? a) If below 60, notify MD b) If 60-124, no coverage c) If 125-150, give 2 units d) IF 151-200, give 4 units e) If 201-250, give 6 units f) If 251-300, give 8 units g) If 301-350, give 10 units h) If 351-400, give 12 units i) If over 400, notify MD 19. Signs & symptoms of Hypoglycemia include which of the following (choose all that apply) a) Anxiety b) Tremor c) Lack of coordination d) Dry, warm, skin e) Pallor f) Headache g) Agitation 20. Your patient reports to you that she experienced unplanned and unwanted sexual intercourse. She asks you about rescue birth control. What key piece of information will you need to know? a) Who did it b) Where did it happen c) If alcohol was involved d) How long ago did the encounter occur 21. A patient on desmopressin need to have what serum lab value monitored closely? a) Potassium b) Calcium c) Sodium d) Magnesium 22. Potential side effects of corticosteroids include which of the following (select all that apply): a) Increased blood sugar levels b) Delayed wound healing c) Immune suppression d) Increased appetite e) Redistribution of body fat 23. Latanoprost (Xalantan) eye drops are used to decrease intraocular pressure in glaucoma patients. Potential side effects of this medication include: ******** a) Permanent darkening of the iris of the eye b) Increase in length, number, darkness, and thickness of eyelashes c) Respiratory problems d) Diabetes mellitus 24. Attaining viral suppression of HIV necessities, the use of at least __________ and preferably _________ Active drugs from ___________ or more drug classes ******** 25. Your 55-year-old patient tells you he knows he needs a flu vaccination, but he hates shots. He asks about the attenuated influenza nasal spray vaccine. You tell him that he doesn’t meet the criteria for the vaccine because: a) He’s a wimp b) He doesn’t need a flu shot c) He is too old for the nasal spray vaccine d) You don’t like his attitude 26. You are treating a patient who works as a guard in the county jail. She is currently being treated for tuberculosis infection acquired on the job. She explains to you that she has no energy for cooking and eats mostly packaged and easily prepared meals. She reports pain and tingling in her extremities. You suspect she has a deficiency of what vitamin? _____________ 27. How many people, mostly children in sub-Saharan Africa die of Malaria each year? a) One b) One thousand c) One hundred thousand d) One million 28. To prevent hemorrhagic inflammation of the bladder caused by Cytoxan, the patient should be encouraged to take the medication at what time of day? _______________ and accompanied by _________________. 29. As the nurse caring for a patient who complains of urinary urgency and frequency and burning with urination, you anticipate she will be prescribed an antibiotic. What other medication will you suggest to the provider to be ordered? a) Physostigmine b) Phenazopyridine c) Phenobarbitol d) Phosphate Why would you prescribe this medication? ___________________________________________ 30. A macrolide antibiotic that is excreted primarily in the bile of the liver, making it a good choice for patients with renal impairment is: _________________________________ 31. A well-informed nurse knows that patients with a “sulfa” allergy may be at increased risk for allergies to which of the following medications? a) Glucotrol b) Celecoxib c) Furosemide d) Flomax 32. Fluoroquinolone antibiotics like ciprofloxacin (Cipro) can result in what connective tissue complication, especially when combined with steroids? __________________ _____________________ 33. Signs and symptoms of thyroid crisis or Thyroid storm include which of the following? a) Drowsiness b) Tachycardia c) Anxiety d) Hypertension 34. Your patient tells you he is interested in a prescription for sildenafil (Viagra). What important medication interaction will you assess for, prior to proceeding? _____________________________ 35. Combined hormonal contraceptives are absolutely contraindicated for women with which of the following? (Select all that apply) ****** a) History of blood clots b) Currently pregnant c) Suspected breast cancer d) Suspected colon cancer e) Over age 35 and smoke 15 cigarettes per day 36. The use of Silver Sulfadiazine (SSD) cream for burns should not be used on the ____________ or ______________ due to the risk of permanent dyeing (tattooing) of the skin. 37. Isotretinoin (Amnesteem, Accutane), a medication used to treat severe cystic acne is a pregnancy category: a) A b) B c) C d) D e) X 38. Which of the following in not an attenuated (live) vaccine? (select all that apply) a) BCG (Tuberculosis) b) Hepatitis B c) Varicella d) MMR e) Tetanus 39. A normal CD4 T-helper cell count is? a) 500 cells/mm (cubed) b) 500/mm (cubed) c) 500/mm (cubed) 40. Your patient is taking methotrexate and reports that she has numerous large bruises to her lower legs. Which actions should you take? a) Ask her about recent trauma b) Report the bruising to her prescribing provider c) Anticipate an order for a lab draw to check platelet levels d) Tell her to not be so clumsy Why do these actions apply? ________________________________________ 41. You know your patient needs further teaching about the treatment of her child’s thrush, when she makes which of the following statements? a) Nystatin is an antifungal medication b) If my child swallows the medicine, I need to call poison control c) I should not give my child anything to eat or drink right after giving the nystatin Why does this statement show she needs further teaching? ______________________________ 42. Your patient is starting a medication regimen for tuberculosis. You let him know that his bodily secretions may be stained orange by which medication? a) Ethambutol b) Isoniazid c) Pyrazinamide d) Rifampin 43. How many people are estimated to have died in the influenza pandemic of ? a) 1 million b) 10 million c) 20 million d) 30-50 million 44. Tetracycline antibiotics are associated with which of the following? (Choose all that apply) a) Take on empty stomach as milk or antacid products can prevent absorption b) Can stain teeth of fetus and young children c) Can decrease effectiveness of oral contraceptives d) Can result in photosensitivity reactions 45. Sulfonamides are _________ percent effective against E. coli bacteria, making them a good choice for UTIs. Because their clinical usefulness has decreased over time, sulfonamides are frequently given in _____________________ with other drugs. 46. If a patient has a mild allergic reaction, such as mild itching or minimal hives, to an antibiotic, they may be treated with an antihistamine (which might cause drowsiness), such as: a) Ibuprofen b) Acetaminophen c) Diphenhydramine d) Pseudoephedrine 47. If a patient is experiencing anaphylaxis, the nurse must always be most concerned with the patients: ____________________________ 48. A patient with hypothyroidism who takes levothyroxine may be expected to experience what effects? (Choose all that apply) a) Weight loss b) Increased energy levels c) Improved cold tolerance d) Sleepiness 49. Addison’s disease represents a condition with adrenal gland insufficiency. What medication if discontinued abruptly can cause the same problem? a) Calictrol b) Levothyroxine c) Prednisone d) Aldactone Insulin Onset Peak Duration Rapid Acting: Lispro (Humalog) Aspart (Novolog) Short – Acting: Regular ® Intermediate Act: NPH (N) Long – Acting: Glargine (Lantus) Long Acting: Detemir (Levemir) Answers: 1. Medical 2. All answers apply 3. Cystitis 4. Pyelonephritis 5. Immune suppression 6. Lowest, shortest, 5 7. Monitor glucose levels, monitor for hyperglycemia, Check repeatedly q3min for 2 hours 8. Unconscious 9. No 10. True 11. Bladder 12. Metronidazde, Cephalosporin 13. 25% 14. Sulfonamides 15. All answers apply 16. Metabolism & elimination 17. Antacids 18. If 301-350, give 10 units of insulin 19. Everything but D 20. How long ago did it occur 21. Sodium 22. All answers apply 23. A, B, C 24. 2, 3, 2 25. He Is too old 26. B6 27. One million 28. Early with water 29. Phenazopyridine, Relieves urinary pain and burning 30. Erythromycin 31. A, B, and C 32. Tendon Rupture 33. B, C, D 34. Nitrate medications 35. A, B, C, and E 36. Face, Hands 37. Category X 38. B and E 39. 500/mm (cubed) 40. A, B, and C, Thrombocytopenic is a general side effect of the medication. Accidents may cause bruises and her provider should be aware. 41. B and C, the medication is not poisonous and should be swallowed after swishing it around. You want to wait at least 15 minutes before eating or drinking, and Nystatin is an antifungal medication. 42. Rifampin 43. 30-50 million 44. All answers apply 45. 90, combination 46. Diphenhydramine 47. Airway 48. A, B, and C 49. Prednisone Insulin Onset Peak Duration Lispro (Humalog) Aspart (Novolog) 5 -15 minutes 30- 90 minutes 1 – 5 hours 2-5 hours 3 -5 hours Regular ® 30 minutes 2.5-5 hours 6-8 hours NPH (N) 1-2 hours 6-12 hours 18-24 hours Glargine (Lantus) 1 hour None 24 hours Detemir (Levemir) 3-4 hours 6-8 hours 24 hours