Pharmacology I Final Exam Study Guide Chapter 1 Understand what is involved in each step of the nursing process (Assessment, Diagnosis, Planning, Implementation, Evaluation) o Assessment o Human Needs Statements (Diagnosis) o Planning: Outcome Identification o Implementation o Evaluation Understand the 9 rights of medication administration and what is involved in each step. o Right drug o Right dose o Right time o Right route & form o Right client o Right documentation Last 3: o Right reason (appropriate) Confirm, by reviewing client’s history & asking client o Right response Document assessment findings, interventions, monitoring o Right to refuse First, determine the reason the client is refusing Make sure the client understands the medication Inform the prescriber Document refusal and continue to monitor Chapter 2 Know which routes undergo the first pass effect and which routes do not. o Enteral o Absorbed through mucosa of the stomach and/or small/large intestine o Oral – FIRST PASS! o Sublingual – NO FIRST PASS! o Buccal – NO FIRST PASS! o Rectal – NO (or mixed) FIRST PASS! Understand the concept of protein binding and the effects it has on medication. o A drug’s efficiency is affected by the degree to which it binds to proteins within the blood o UNBOUND = Pharmacologically ACTIVE o BOUND = Pharmacologically INACTIVE o LESS BOUND = MORE EFFICIENT o When 2 highly bound protein drugs are administered at the same time, there is more free, unbound (ACTIVE FORM) of drug available Occurs when the presence of one drug decreases or increases the actions of another drug that is administered concurrently Know the different types of adverse drug reactions. o Any reaction to a drug that is unexpected and undesirable and occurs at therapeutic drug dosages: o Pharmacologic Extension of the drug’s normal effects o Allergic (hypersensitivity) Involves immune response o Idiosyncratic Unexpected genetically determined abnormal response o Drug Interactions 2 drugs interact and produce unwanted effect BUT can be intentional and beneficial Review the 4 phases of pharmacokinetics (absorption, distribution, metabolism, excretion). o Absorption • Movement of a drug from site of administration into bloodstream for distribution to tissues • Affected by route of administration • Bioavailability = the extent of drug absorption (0%-100%) • First-Pass Effect = initial metabolism in the liver of a drug absorbed from the GI tract before the drug reaches the blood stream o Distribution • Transport of a drug by the bloodstream to its site of action o Metabolism • Biotransformation • One or more chemical reactions involving a parent drug and produces a metabolite that is either inactive or active • Occurs mainly in the liver o Excretion • Elimination of drugs from the body • Occurs mainly in the kidneys • Half-Life: time it takes for one half of the original amount of a drug to be removed from the body • Measure of the rate at which drugs are removed from the body Chapter 3, 4, 5, 6 Review lifespan considerations in regards to pregnancy, fetal gestational age, and the older adult. o Drugs primarily transfer across the placenta by diffusion o First trimester Greatest danger for drug-induced developmental defects Maternal self-treatment for minor illness is strongly discouraged o Last trimester Drug transfer is more likely The greatest % of maternally absorbed drug gets to fetus o Older Adult • Drug therapy is more likely to result in adverse effects and toxicity due to: • Polypharmacy • Greater Medication Errors • Physiologic Changes • Absorption is slowed • Distribution is decreased • Metabolism is decreased • Excretion is decreased Understand what a Black Box Warning is and why it is used. o The strictest warning from FDA o Indicates serious adverse effects have been reported Review cultural considerations in regards to pharmacology. o Drug polymorphism o The effect of a patient’s age, gender, size, body composition, and other characteristics on the pharmacokinetics of specific drugs o Adherence with therapy o Environmental and economic considerations o o o Pharmacokinetics and Pharmacodynamics Health beliefs and practices Barriers (language, poverty, access, pride, beliefs) Understand the use of zeros and decimal points when writing medication orders. (trailing zeros, leading zeros) 0.3 is correct. 3.0 is not. Review ways to prevent medication errors. o Checks and balances o Prescribers must write legible o Consult drug references/pharmacist o Check the med order 3 times before giving drug o 9 rights of medication administration o 2 patient identifiers (name & DOB) o Do not administer if you did NOT draw up or prepare yourself o Minimize verbal or telephone orders o Avoid abbreviations, acronyms o Never assume anything! o Do not try to decipher illegibly written orders o No trailing zeros (Do not use 5.0 mg; use 5 mg instead) o ALWAYS use leading zeros (Do not use .25 mg; use 0.25 mg instead) o Use generic names o Check patient allergies o Always listen to and honor any concerns expressed by patients regarding medications o Safeguard meds the patient may have already taken (on admission or transfer) so double-dose is not administered o Mandatory recalculation of every drug dose for high-risk drugs or high risk-patients o Educate patients to know their medications Review best practices for patient education, especially in the older adult. o Discharge planning and teaching begins upon admission! o Assess verbal and non-verbal communication o Use open-ended questions o Identify patient’s level of understanding and develop teaching to meet their needs o Knowledge deficit with older adults/those with cognitive ability is a big problem: Lack of understanding about a medication, its action, side effects Don’t understand how to administer the medication Lacks motor skills needed to safely administer the medication Non adherence is a big problem due to cost and A/E o Chapter 7 Review advantages and disadvantages of OTC medications. o Advantages: Patient’s can conveniently and effectively self-treat many minor aliments Healthcare costs tend to decrease when drugs are re-classified as OTC o Disadvantages: Delays patients from seeking medical care until they are very ill (bc they are self-treating and only relieving symptoms) Insurance usually doesn’t pay for OTC medications Many are inexperienced in the interpretation of medication labels, which results in misuse and drug-to-drug interactions Can be hazardous for patients with various chronic illnesses Abuse or overuse can be potential hazard (think of overuse of Tylenol and liver toxicity) Review the criteria that determines whether a drug is considered OTC. o Do NOT require a HC provider's prescription o Bought off-the-shelf in stores o Regulated by FDA through OTC Drug monographs Chapter 8 Understand how genetics play a role in the administration of medications and how the nurse might assess for these genetic factors. o Genetic testing and counseling-most common BRCA…also prenatal testing for cystic fibrosis and Down syndrome. o Use of rDNA vectors in the laboratory to make recombinant forms of drugs Hormones, vaccines, antitoxins, and monoclonal antibodies Escherichia coli bacterial genome: used to manufacture a recombinant form of human insulin o Pharmacogenetics/genomics help differentiate between “poor” and ”rapid” metabolizers with medications such as warfarin, phenytoin, codeine, and quinidine. Rapid metabolizers may need higher doses of warfarin for the desired effect. o Nursing Implications: Take thorough client, family, and drug histories Recognize situations that may warrant further investigation through genetic testing Identify resources for clients Teaching Maintain confidentiality and privacy Ensure that informed consent is obtained Chapter 10 Review acetaminophen (Tylenol) Non-Opioid MOA: • Block pain impulses by inhibition of prostaglandin synthesis Indications: • Mild to moderate pain and fever Contraindications: • Drug allergy, severe liver disease, G6PD deficiency AE's: • N/V, hepatotoxicity, nephrotoxicity Interactions: • Alcohol (most dangerous); phenytoin, warfarin, rifampin, beta blockers • Maximum daily dose for healthy adults: • 3000 mg/day • 2000 mg/day for older adults & those with liver disease • Inadvertent excessive doses may occur when different combination drug products are taken together Review tramadol (Ultram) Non Opioid MOA: • Centrally acting analgesic- acts similar to opiods Indications: • Treatment of moderate to moderately severe pain Contraindications: • Drug allergy AE's: • Similar to opioids: dizziness, drowsiness, HA, constipation, respiratory,depression, very hard on the stomach, take with food. Interactions: • TCA's, SSRI's, MAOI's • Concurrent use with TCAs comes a risk of seizures and serotonin syndrome with SSRIs Review morphine o • Treats severe pain • High abuse potential • Oral, IV, and rectal dosage forms -used a lot in hospice • Extended release forms are also available • Watch use in patients with renal impairment! • Metabolites can accumulate in kidneys Chapter 11 Review the following prototypes: Succinylcholine What is a benefit of succinylcholine? o Quick onset of action and short duration = used most commonly to facilitate ET intubation neuromuscular blocking drug: succinylcholine (Anectine, Quelicin) o Depolarizing: acetylcholine competitive agonist Route: IV Uses:•Facilitate controlled ventilation during surgery •Induction of ET intubation Duration:•Short-acting: 4-6 minutes •Used as an adjunct to general anesthesia -seldom used over long periods of time because causes muscle fasciculations (twitching) Understand general anesthesia, local anesthesia, and moderate sedation. moderate sedation o -conscious sedation, anesthesia that does not cause complete loss of consciousness and no respiratory arrest -used for planned procedure, allows patient to be discharged soon after procedure -physician can monitor patient and perform procedure at the same time general anesthesia o -complete loss of consciousness and loss of body reflexes, includes loss of respiratory function and requires mechanical or manual ventilation support -controlled conditions (anesthesiologist or CRNA) -one or more drugs may be used, synergistic affects can mean smaller doses and better control of patient's state local anesthesia o eliminates pain in tissues innervated by peripheral or spinal nerve impulses, does not involve paralysis of respiratory function Review malignant hyperthermia. o uncommon, but potentially fatal, genetically linked adverse metabolic reaction •Rapid rise in body temperature •Tachycardia •Tachypnea •Muscular rigidity Chapter 12 Review the nursing implications in regard to the use of benzodiazepines. •Emphasize: should only be taken as prescribed. Do not double up on the dose unless directed. •Teach: Do not drive or perform activities that require mental alertness. •Do not abruptly discontinue these drugs (avoid rebound insomnia) •Sedative-hypnotics for sleep promotion are not intended for long-term use •Patients taking benzodiazepines should not eat grapefruit or drink grapefruit juice Review the following prototypes: Cyclobenzaprine •Uses: reduce spasms following musculoskeletal injuries •AE’s: marked sedation •Routes: Oral •Structurally and pharmacologically related to tricyclic antidepressants Chapter 13 Review priority nursing considerations for new Ritalin prescription ◦Assess: ◦Pot. contraindications and interactions ◦use of herbal therapies ◦Conditions such as abn. cardiac rhythms, seizures, palpitations, liver problems ◦For children, assess baseline ht/wt Important ◦Last daily dose should be given 4-6 hours before bedtime to ↓ insomnia. ◦Take on an empty stomach 30-45 minutes before meals. ◦Drug “holidays” may be ordered. ◦Instruct parents to keep a journal to monitor child’s response to therapy. ◦Monitor for continued phys. growth, including ht/wt. Review anti-migraine patient teaching ◦Provide specific teaching about correct medication administration. (ex: blow nose before nasal spray) ◦Instruct patients to keep a journal to monitor response to therapy. Chapter 14 Review nursing implications in regards to antiepileptic medications Routine monitoring of drug levels with phenytoin •Administer at the same time each day to maintain therapeutic levels •Do not skip doses or abruptly discontinue the drug •Contact prescriber immediately if one or more doses is missed •Report any suicidal thoughts immediately •Avoid intake of alcohol, smoking & caffeine •May be driving limitations •Therapeutic response = decreased or absent seizure activity -diazepam used to treat status epilepticus •Prevent or reduce the severity of epilepsy and different types of epileptic seizures, not just convulsive seizures •Goal = control or prevent seizures while maintaining a reasonable quality of life •Have many AE’s – often difficult to achieve seizure control while avoiding AE’s •Usually LIFELONG treatment •Do NOT abruptly stop taking = withdrawal seizures •Not recommended after a single isolated seizure event •Always start single-drug therapy first, then may add multidrug therapy •Serum drug concentrations must be measured •If seizure-free for 1-2 years, MAY be able to stop meds. Review the following prototypes: phenytoin, valproic acid Phenytoin: •Uses: management of tonic-clonic and partial seizures •Contraindications: heart conditions that involve bradycardia •AE’s: A LOT! •Lethargy •Abnormal movement •Mental confusion/cognitive changes •Acne •Hirsutism •Osteoporosis •Dilantin facies •Gingival hyperplasia •Routes: Oral, IV •Therapeutic drug levels 10 to 20 mcg/mL •Toxic levels = nystagmus, ataxia, dysarthria, encephalopathy •Highly bound to albumin •Induces cytochrome P-450 enzymes • Long half life = twice or once daily dosage •Monitor CBC monthly for 1 year (thrombocytopenia, agranulocytosis) •Monitor liver enzymes to check for hepatitis (hepatotoxicity) •Very irritating! •Give slow IV push in large vein •Do not exceed 50 mg/min •Large gauge IV (20 or larger) •Monitor for bradycardia •Dilute only in NS •Use in-line filter Valproic Acid: •Uses: treatment of generalized seizures, bipolar disorder •Contraindications: liver impairment, urea cycle disorders •AE’s: •Hepatotoxicity, pancreatitis, drowsiness, n/v, tremor, weight gain, transient hair loss •Interactions: A LOT! (see table 14.5) •Routes: oral, IV •Do not take with carbonated beverages, take with 4-6 oz of water, take with food to minimize GI upset Chapter 15 Review nursing implications in regard to antiparkinson medications: •Take exactly as prescribed. •Delaying dose by even 30 min. may lead to "off" period & may last hours •Drugs are usually titrated to the patient's response and may take 3-4 weeks for therapeutic response Review the following prototypes: selegiline, carbidopa-levodopa Selegiline: •MOA: increases levels of dopaminergic stimulation in CNS by inhibiting monoamine oxidase •Routes: Oral (usually given BID), oral disintegrating (buccal) •Contraindications: meperidine (Demerol) •AE’s: mild (see table 15.3, page 234), postural hypotension •Interactions: tyramine-containing foods (aged cheese, sausages, beer), antidepressants (serotonin syndrome) carbidopa-levodopa: •Uses: directly restores dopaminergic activity in PD •Contraindications: angle-closure glaucoma, any undiagnosed skin condition (can activate malignant melanoma) •AE’s: cardiac dysrhythmias, hypotension, chorea, muscle cramps, GI distress (constipation) •Interactions: pyridoxine (vitamin B6) (reduces effectiveness) •Routes: Oral •Best taken on empty stomach, avoid high-protein diet, drink water Chapter 16 Review dosing considerations related to tricyclic antidepressants -Requires at least 6 weeks of therapy with adequate doses to be able to fully evaluate results -May require upward titration of dosages over several weeks -Should be used in conjunction with psychotherapy -Higher risk of suicide among both adult and pediatric population -OD can be lethal, prescribe 3-4 days initially and then only up to 30 -Adjunctive analgesics for chronic pain conditions, such as trigeminal neuralgia -Increased appetite is an effect of TCAs; therefore, TCAs are sometimes used to treat anorexia nervosa. -Sedation, Impotence, Orthostatic hypotension -Older patients (Dizziness, postural hypotension, constipation, delayed micturition, edema, muscle tremors) Review the following prototype: buspirone (Buspar) -Unknown mechanism of action -May have drug interaction with selective serotonin reuptake inhibitors (SSRIs) (serotonin syndrome) - Administered on a scheduled basis - Lacks sedative properties and dependency potential as other benzodiazepines - Adverse effects - Paradoxical anxiety, Blurred vision, Headache, Nausea - Do not administer with MAOIs Review fluoxetine (Prozac) -Prototypical SSRI -Indications: depression, bulimia, OCD, panic disorder, and premenstrual dysphoric disorder -Contraindications: known drug allergy and concurrent MAOI therapy -Adverse effects: anxiety, dizziness, drowsiness, insomnia, and others -highly protein bound, can lead to toxicity Chapter 18 Review the differences between inotropy, chronotropy, and dromotropy Inotropicincrease the force of contraction chronotropic increase heart rate dromotropic- increase conduction through the AV node Review epinephrine: Indications, adverse effects, contraindications Indications •Administered in emergencies, lethal dysrhythmias, ACLS, anaphylactic shock Contraindications -hypertension, hypothermia, pulmonary edema, myocardial ischemia, hypovolemic shock AEs -nervousness, restlessness, HA, tremor, pulmonary edema, dysrhythmias, chest pain, hypertension, tachycardia, N/V Review adrenergic agonists: indications and adverse effects Indications: •Respiratory •Bronchodilators •Topical Nasal Decongestant •Ophthalmic •Epinephrine •Overactive Bladder •Cardiovascular •Cardiac failure or shock Adverse effects: •Unwanted CNS effects •Other significant effects: •Sweating, nausea, vomiting, muscle cramps •Toxicity: •Extension of common adverse effects •Seizures •Hypotension or hypertension •Dysrhythmias, palpitations •Dizziness, nervousness •Fatigue Chapter 19 Review carvedilol (Coreg) for indications, contraindications, adverse effect Carvedilol (Coreg) •Nonselective beta blocker •Indications: heart failure, HTN, angina •Contraindications: uncompensated HF, asthma, cardiogenic shock, advanced heart blocks •AE’s: dizziness, HA, hypotension, bradycardia, edema, UTI, urinary retention Review metoprolol (Lopressor) for indications, expected therapeutic effects Metoprolol (Lopressor) •Indications: post-MI, HTN, stable heart failure •Has shown to increase survival in pts post-MI Review tamsulosin (Flomax) for indications, contraindications, adverse effects Flomax: treat BPH (men) or kidney stones (women) •Contraindications: known drug allergy; concurrent use of erectile dysfunction drugs •AE: headache, abnormal ejaculation, rhinitis Chapter 20 Review cholinergic agonists adverse effects Exaggeration of these effects: •Stimulate intestines and bladder •Increased gastric secretions, GI motility, and urinary frequency •Stimulate constriction of pupils •Decreases intraocular pressure •Increase salivation and sweating •CV effects •Reduced HR and vasodilation •Pulmonary effects •Bronchi constriction and airway narrowing Review the manifestations and early signs of cholinergic crisis: •Circulatory collapse, hypotension, bloody diarrhea, shock, & cardiac arrest. o •SLUDGE: • S: Salivation • L: Lacrimation • U: Urinary incontinence • D: Diarrhea • G: GI cramps • E: Emesis •Early signs: Abdominal cramps, salivation, flushing of the skin, nausea, and vomiting, transient syncope, transient complete heart block, dyspnea, orthostatic hypotension Review donepezil (Aricept) indications, nursing implications Indications: Mild to moderate Alzheimer’s disease These drugs will stimulate the PNS & mimic the action of acetylcholine. Assess: •Allergy, presence of GI or GU obstruction, asthma, peptic ulcer disease, & coronary artery disease •Baseline assessment of VS, systems overview Teach: •Take meds as ordered. Never stop abruptly. •Spread doses evenly apart to optimize the effects. •Overdosing can cause life-threatening problems. •Do not adjust dosages unless directed by prescriber. •When prescribed for -Alzheimer’s - drugs are for management of symptoms (not a cure). -Monitor for therapeutic effects. In clients with Alzheimer’s disease look for improvement in symptoms, mood and decrease in confusion -may not occur for up to 6 weeks. Chapter 21 Review atropine: indications, adverse effects •Indications: primarily for CV disorders ( cholinergic crisis) •Symptomatic second-degree atrioventricular block •ACLS – for sinus bradycardia and ventricular systole Contraindications: •Angle-closure glaucoma A/E: -blurred vision, dry mouth, constipation, urinary retention Chapter 38 Review Healthcare Acquired Infections (Nosocomial Infections) o Health care-associated (nosocomial) infections Contracted in hospital, institutional setting Infection was not present or incubating in the client on admission to the facility Occurs more than 48 hrs. after admission Difficult to treat. Often drug-resistant & virulent Review super infections o Occurs when antibiotics reduce or eliminate normal bacterial flora C. difficile infection Yeast infections Review amoxicillin (Amoxil) o MOA: inhibit bacterial cell wall synthesis o o o o o bactericidal (many G+ & some G-) Indications: streptococcus, and staphylococcus Contraindications: drug allergy AE/SE: allergic reactions occur in 0.7-4%. Most common: urticaria, pruritus, angioedema, N/V/D Interactions: aminoglycosides, NSAID’s, oral contraceptives, warfarin Review erythromycin o MOA: bacteriostatic but can be bactericidal with high concentrations inhibit protein synthesis o Indications: wide variety of infections Decreased GI motility (gastroparesis) o Contraindications: known drug allergy o AE/SE: GI related: N/V o Interactions: many drugs due to highly protein bound & metabolized in liver (P-450 complex) oral contraceptives o Nursing Considerations: Baseline CV function Baseline hearing status Liver function & hx of liver disease Drug interactions: warfarin, digoxin, theophylline Use add’l form of contraception. Do not take w/fruit juices. Inform about drug interactions. Teach to report: CP, palpitations, dizziness, jaundice, rash, hearing loss. Take with meals or snacks. Chapter 39 Review fluoroquinolones o MOA: destroy by altering bacteria DNA Excellent oral absorption (comparable to IV) o Indications: Complicated UTI’s, resp, skin, GI, & bone & joint infections o Contraindications: drug allergy o Caution in: Prepubescent children o Black box warning: increased risk of tendon rupture o Interactions: antacids, calcium, magnesium, iron, zinc, sucralfate, enteral feedings amiodarone: prolonged QT interval (dangerous dysrhythmias) Review the prototypes: gentamicin, metronidazole (Flagyl), vancomycin (Vancocin) Gentamicin: o MOA: Prevent protein synthesis Often combined w/other antibiotics (i.e. penicillins) o o o o o o Indications: Serious G+ and G- infections Contraindications: not for pregnant women except in case of life-threatening infections when safer drugs are ineffective- can cause congenital deafness not for lactating women AE/SE: (serious toxicities): nephrotoxicity ototoxicity Interactions: other nephrotoxic drugs (i.e. vancomycin, cyclosporine, amphotericin B) Nursing Considerations: Baseline hearing, vestibular, & neuromuscular function Encourage ↑ fluid intake 3 L/day unless contraindicated. Inform hc provider if change in: hearing, tinnitus, ataxia, nystagmus, dizziness IV admin: solution may be slightly yellow but should be clear. Admin. diluted at corrected rate. metronidazole (Flagyl o MOA: Interferes w/microbial DNA synthesis (like quinolones) Antimicrobial activity against anaerobic organisms o Indications: Intraabd. & GYN infections Protozoal infections (amebiasis, trichomoniasis) Pseudomembranous colitis o AE/SE: dizziness, ha, GI discomfort, nasal congestion, reversible neutropenia & thrombocytopenia o Interactions: Alcohol intolerance! Lithium increased toxicity of lithium o Nursing considerations: Baseline neuro, GI & GU exams Avoid alcohol vancomycin (Vancocin) o MOA: Bactericidal antibiotic o Indications: IV: MRSA, bone/joint infections, sepsis PO: Clostridium difficile o Cautious use: pre-existing renal impairment hearing loss older adults & neonates o AE/SE: red man syndrome ototoxicity nephrotoxicity o Interactions: other nephrotoxic meds o Nursing considerations: Obtain trough: 15-20 mcg/mL Admin. over 1 hour or longer. Chapter 40 Review the prototype: acyclovir o MOA: Impairs viral replication by blocking enzymes o Indications: DOC for HSV-1 & HSV-2; herpes zoster (shingles) o Dosages: High dose: acute episodes Lower: viral suppression o Formulations: PO, topical, injectable o AE/SE: N/D, headache, burning (topical) o Interactions: CNS stimulants Antibiotics Probenecid Review post exposure prophylaxis (PeP) o Indications: after potentially exposed to HIV; to prevent infection o Dosing: Start within 72 hours after possible exposure. The sooner the better. Take it once or twice daily for 28 days. Chapter 41 & 42 Review nursing implications in regards to antitubercular medications o Drug therapy often last long time – up to 24 months o Important to adhere to drug regimen o Multiple drugs are often used o Important to take same time each day o Must complete all that is prescribed, even if feeling better o May need to be taken w/ food to minimize GI upset Review the following prototypes: isoniazid, rifampin, amphotericin B o isoniazid (INH) MOA: bactericidal = kills mycobacteria by disrupting cell wall synthesis and cellular functions Uses: prophylaxis & treat active TB Routes: Oral, injectable Contraindicated: acute liver disease Black Box Warning: possible hepatitis AE’s: pyridoxine (Vit B6) deficiency – often give B6 supplement, liver toxicity Interactions: See table 41.4, page 650 – antacids (reduces absorption) Slow acetylators – genetic deficiency of liver enzymes needed to metabolize drug o rifampin (Rifadin) MOA: bactericidal = kills bacteria by inhibiting protein synthesis Uses: prophylaxis & treat active TB Routes: Oral, IV AE’s: hepatitis, hematologic disorders SE’s: urine, saliva, tears, and sweat to be red-orange-brown colored Potent enzyme inducer = many drug interactions (see table 41.4), oral contraceptives, beta blockers, benzodiazepines, oral antidiabetics, anticoagulants o amphotericin B (Fungizone) Uses: treatment of severe systemic fungal infections Contraindications: bone marrow suppression, renal impairment AE’s: MANY! -- fever, chills, hypotension, tachycardia, malaise, muscle and joint pain, anorexia, n/v, headache Usually take antipyretics, antihistamines, antiemetics, and corticosteroids in addition to decrease severity of AE’s Interactions: see table 42.3, page 659 Routes: IV Review which types of clients antifungals are contraindicated o Those with liver/hepatic disease/disorders Chapter 44 Review ketorolac (Toradol) o Acetic acid derivative o Powerful analgesic effects o Some anti-inflammatory activity o Indications: short-term use (up to 5 days) to manage moderate to severe acute pain (good alternative to opioids) ( use short term due to kidney risk) o AE/SE: Renal impairment Edema GI pain, dyspepsia, nausea Review allopurinol (Zyloprim) o MOA: Inhibits xanthine oxidase to prevent production of uric acid o Indications: Gout caused by excessive production of uric acid (hyperuricemia) o Contraindications: Allergy o AE’s: Agranulocytosis, aplastic anemia, potentially fatal skin conditions o Interactions: Azathioprine and mercaptopurine Chapter 56 Review topical dermatologic drug formulations o Ointments have an oil base that makes them sticker than creams. These are better for smaller areas. Not removable with water. o Creams have a water base that makes them better for larger surfaces. o Gels tend to enhance penetration of the active ingredient. o Lotions are similar to creams but are lighter. Review age considerations with the use of dermatologic drugs o Systemic absorption is higher in very young and very old patients because their skin may be more permeable. Chapter 57 Review the different ophthalmic medications and their indications o Cholinergic (miotic): pilocarpine (Isopto Carpine) Indications: open-angle, angle-closure, convergent strabismus, & in ocular surgery o Sympathomimetic (mydriatic): dipivefrin (Propine) chronic open-angle glaucoma (initial or long-term therapy) & ocular hypertension o Beta-Adrenergic Blocker: timolol (Timoptic) reduce IOP in chronic open-angle glaucoma and ocular hypertension o Cholinesterase Inhibitor: echothiophate (Phospholine Iodide) Indications: open-angle and angle-closure; preoperatively to control IOP Review the prototype drug: latanoprost (Xalatan) o Newest class of drugs. o MOA: these drugs reduce intraocular pressure by increasing the outflow of aqueous humor between the uvea and sclera as well as via the usual exit through the trabecular meshwork. o Indications: these drugs are used in the treatment of glaucoma o o o o o o Contraindications: the only usual contraindication is drug allergy AE/SE: generally well tolerated. Adverse effects include foreign body sensation, dotted appearance of the cornea, stinging, bloodshot eyes, blurred vision, itching, and burning. Only available in eye drop form. About 3-10% of patients have increased iris pigmentation after 3-4.5 months of treatment In some people with hazel, green, or bluish-brown eye color, eye color will turn permanently brown, even after the medication is discontinued. Interactions: concurrent administration of these drugs with other eye drops that contain the preservative thimerosal may cause precipitation Nursing considerations: Same as the rest. Chapter 58 Review otic drugs nursing considerations: o Assess baseline hearing or auditory status. o Evaluate the patient’s symptoms. o Assess drug and food allergies. o Assess for contraindications. o Keep in mind that perforated eardrum(s) may be a contraindication to these drugs. o If necessary or if ordered, remove cerumen by irrigation before instilling eardrops. o Cleanse the outer ear thoroughly. o Warm eardrops to approximately body temperature before instillation. o Allow refrigerated solutions to warm to room temperature. o Keep in mind that cold eardrops may cause vomiting and dizziness. o Technique for administering: o Adults: Hold the pinna up and back. o Children younger than 3 years: Hold the pinna down and back. o Allow time for eardrops to flow down into the ear canal. o Have patients lie on the side opposite to the side of the affected ear for about 5 minutes after instilling eardrops. o A small cotton ball may be gently inserted into the ear canal to keep the drug in but do not force the cotton into the ear canal. o Gently massage the tragus of the ear to encourage flow of medication.