Study Guide for NUR 268 (Integrated Patho-Pharm I) Exam #1
Exam 1
Thursday
2/10/2022
1 math dosage calculation question
Intro to Pathophysiology
Ch. 1 (Intro)
Ch. 4 (Pharmacokinetics)
Ch. 5 Pharmacodynamics)
Ch. 8 (Patient Variations)
Ch. 12 (Cholinergics)
Ch. 13 (Adrenergics)
Ch. 15 (Seizures)
65 questions (MCQ, Multiple responses {select all that apply}, short answer)
Study Guide for Exam #1
Review the content from the Pathophysiology chapter posted on Bb.
Understand the different types of cellular/tissue adaptation: atrophy, hypertrophy, hyperplasia, dysplasia, and
metaplasia. The 3 types of cell injury (and causative factors): hypoxic injury, ROS injury, and chemical injury.
Differentiating apoptosis (genetically programmed cell death) from the other type of cell death, which results
from severe injury where the cell is incapable of regenerating or recovering the injurious event.
Understand the components/phases of pharmacokinetics when the drug enters the body.
The concept of pharmacodynamics and what are some of the factors that influence
pharmacokinetics/dynamics.
The concept and meaning of selectivity as a significant drug quality.
Know the difference between: Indication, precaution, relative indication, and absolute contraindication.
- An absolute contraindication refers to a pre-existing condition that precludes use of a particular drug
under all but the most desperate circumstances.
- An indication refers to the purpose for which a medication is given.
- A precaution is a pre-existing condition that significantly increases the risk of an adverse reaction to a
particular drug but not to a degree that makes it life-threatening.
- A relative indication refers to the most likely reason a medication is given.
Why patients with kidney disease are at high risk for toxicity of the medication.
Prioritizing nursing care should be based on the acuity of the patient health status. A patient with multiple
allergies who exhibits signs of allergic reaction to a new medication would be a priority among other patients
assigned to a particular nurse.
Assessment relevant to medications in use is imperative prior to medication administration to prevent
adverse effects like checking the PT/INR and assessing the patient’s for signs and symptoms of bleeding or
bruising prior to giving Coumadin, or checking blood pressure prior to giving antihypertensive medication.
The term off label indicates -------?
Nitroglycerin (NTG) given orally is subject to the first-pass effect because ….? First pass effect
The purpose of enteric coating is to prevent the acids of the stomach from destroying the medication before
it is effectively utilized by the body.
Know the different routes of medication administration, which route provides the fastest rate of drug
absorption …?
Understand the different categories of receptorless drugs. All other meds work through receptors …?
The half-life (t1/2) of a medication is ……?
What is the therapeutic range and what is the most significant implication for the nurse to consider in a
medication with a “narrow therapeutic range” ……? and understand why the drug blood level should be
monitored in this case …….?
Understand what happens to the drug binding to protein molecules……?
The role of albumin in binding with drug molecules and the effect of having excessive free drug molecules in
the bloodstream……?
Know the difference between the loading does and the maintenance dose, peak level vs. trough level …..?
Know the difference between these terms: iatrogenic drug response and teratogenic drug response
Differentiate between additive drug effect, synergistic drug effect, and antagonistic drug effect?
The concept of bioavailability of drugs ……?
Understand the difference between drug Tolerance, Dependence, and Withdrawal Syndrome to certain
drugs.
Identify some forms of teratogenic effects which may result during pregnancy …....?
Understand the following concepts: affinity/potency, intrinsic activity/maximal efficacy.
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The chapter then discusses the subtypes of both the cholinergic and adrenergic receptors and describes the
effects of each on body systems.
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The peripheral nervous system works through several different types of receptors. Understanding these
receptors is central to understanding peripheral nervous system pharmacology.
Two basic categories of receptors are associated with the peripheral nervous system: cholinergic receptors
and adrenergic receptors.
Cholinergic receptors are receptors that mediate responses to acetylcholine.
Adrenergic receptors are receptors that mediate responses to epinephrine (adrenaline) and norepinephrine.
Cholinergic receptors can be divided into three major subtypes: nicotinicN, nicotinicM, and muscarinic
receptors.
Adrenergic receptors can be divided into four major subtypes: alpha1, alpha2, beta1, and beta2 receptors.
Another type of adrenergic receptor, the dopamine receptor, does not respond to epinephrine or
norepinephrine. Rather, it responds only to dopamine, a neurotransmitter found primarily in the central nervous
system.
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Activation of alpha1 receptors in blood vessels produces vasoconstriction.
Activation of alpha1 receptors in the sexual apparatus of males causes ejaculation.
Activation of alpha1 receptors in smooth muscle of the bladder (trigone and sphincter) and prostatic capsule
causes contraction.
Activation of cardiac beta1 receptors increases the heart rate, force of myocardial contraction, and conduction
velocity through the atrioventricular node.
Activation of beta1 receptors in the kidneys causes release of renin into the blood.
Activation of beta2 receptors dilates the bronchi, relaxes uterine smooth muscle, increases glycogenolysis,
enhances contraction of skeletal muscle, and dilates arterioles (in the heart, lungs, and skeletal muscle).
Activation of dopamine receptors dilates blood vessels in the kidneys.
Review therapeutic uses and side effects of bethanechol.
Review therapeutic uses and side effects of Atropine
Review therapeutic uses and side effects of Cholinesterase inhibitors (ChEIs)
Cholinesterase Inhibitors (ChEIs) and Their Use in Myasthenia Gravis (MG): Pathophysiology of MG
Difference between Myasthenic Crisis and Cholinergic Crisis: ho w to differentiate between them How to
manage each type. Drug of choice for each type of these crisis.
 Neostigmine typifies the reversible cholinesterase inhibitors and is the prototype for the group. The
drug’s principal indication is myasthenia gravis.
 Neostigmine contains a quaternary nitrogen atom and therefore always carries a positive charge.
Because of this charge, neostigmine cannot readily cross membranes, including those of the
gastrointestinal (GI) tract, blood-brain barrier, and placenta. Consequently, it is poorly absorbed after
oral administration and has minimal effects on the brain and fetus.
 Neostigmine binds to the active center of acetylcholinesterase (ChE); the drug remains in place for a
relatively long time, preventing ChE from catalyzing the breakdown of ACh.
 By preventing inactivation of ACh, neostigmine and the other cholinesterase inhibitors can intensify
transmission at virtually all junctions where ACh is the transmitter. Cholinesterase inhibitors, therefore,
can cause bradycardia, bronchial constriction, urinary urgency, increased glandular secretions, increased
tone and motility of GI smooth muscle, miosis, and focusing of the lens for near vision.
The therapeutic applications and adverse effects of alpha1- and alpha2-adrenergic receptor activation.
The clinical consequences of activation of beta1 and beta2 receptors.
isoproterenol, dopamine, and albuterol.
The clinical consequences of dopamine receptor activation, multiple receptor activation (anaphylactic shock),
and properties of representative adrenergic agonists.
Review Alpha and Beta agonists, Antagonists (Blockers, Inhibitors): examples, therapeutic uses, side effects,
and contraindications.
Phentolamine is A nonselective alpha-adrenergic antagonist. It is used in the treatment of:
• hypertension and hypertensive emergencies,
• pheochromocytoma,
• vasospasm of Raynaud dise
ase and frostbite,
•
•
•
clonidine withdrawal syndrome,
impotence, and
peripheral vascular disease.
Phentolamine can cause orthostatic hypotension, reflex tachycardia, nasal congestion, and inhibition of
ejaculation. Overdose can produce profound hypotension. When this occurs, blood pressure can be elevated
with norepinephrine. Epinephrine should not be used because, in the presence of alpha 1 blockade, the ability of
epinephrine to promote vasodilation by activation of beta2 receptors may outweigh its ability to cause
vasoconstriction, causing further lowering of blood pressure. Norepinephrine does not activate beta 2 receptors.
Beta blockers may be used to treat severe reflex tachycardia.
The centrally acting alpha2 agents: methyldopa, clonidine (clinical applications/indications and side effects)
Antiseizure drugs (Antiepileptics AEDs): pathophysiology of seizures/epilepsy, classification of seizures,
classification of AEDs, example of effective meds, side effects, contraindications, nursing implications.
Phenytoin (Dilantin): Gingival hyperplasia occurs in about 20% of patients who take phenytoin. It can
be minimized with good oral hygiene, so patients should be encouraged to brush and floss regularly.
Patients should be cautioned against consuming alcohol while taking phenytoin. Rashes can be
serious and should be reported immediately.
Lamotrigine (Lamictal) can cause life-threatening rashes, such as Stevens-Johnson syndrome and
toxic epidermal necrolysis, and this risk increases with concurrent use of valproic acid.
Angioedema is an adverse effect associated with pregabalin (Lyrica).
Carbamazepine (Tegretol) induces hepatic drug-metabolizing enzymes and can increase the rate at
which lamotrigine and other drugs are metabolized; therefore, patients taking any of these drugs would
need an increased dose. Increasing the dose of carbamazepine may be necessary but only after
serum drug levels have been checked.
Valproic acid (Depakote) competes with phenobarbital for drug-metabolizing enzymes and can
increase plasma levels of phenobarbital by approximately 40%. When this combination is used, the
dose of phenobarbital should be reduced
Liver toxicity due to receiving large doses of valproic acid (not very common adverse effects) is marked
by symptoms of nausea, vomiting, malaise, and out of range (elevated) Liver Function Test results
(Bilirubin, ALT, AST, and Alkaline phosphatase).
Abnormal Serum Drug Levels:
The therapeutic serum level of carbamazepine (Tegretol), an anticonvulsant, is 5 to 12 µg/mL.
The therapeutic serum level of clonazepam (Klonopin), an anticonvulsant, is 20 to 80 ng/m.
The therapeutic serum level of phenytoin (Dilantin), an anticonvulsant, is 10 to 20 mg/mL.
The therapeutic serum level of ethosuximide (Zarontin), an anticonvulsant, is 40 to 100 µg/µL.
Grapefruit effect:
Calcium channel blockers (CCBs) and selective serotonin reuptake inhibitors (SSRIs) have been shown to reach
increased and/or toxic levels when taken with grapefruit juice.
Drugs administered on “Empty Stomach”: either 1 hour prior to or 2-hours after meals.
Older adults and risks for fall factors/meds: antiHTN meds.