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NR 508 Midterm Study Guide
1. first-line treatment for Heart Failure (CHF). ( pg 250-254, 273) ➢ **Ace inhibitors **- captopril (capoten), enalpril ( vasotec), lisinopril ( Prinivil or Zestril), ramipril ( altace), trandolapril ( mavik)should be prescribed to all patients with heart failure unless contraindicated ➢ ARB’s- candesartan ( atacand), valsartan( diovan) should be used if ACE inhibitors are intolerant to patient ➢ Beta blockers – bisoprolol ( zebeta), carvediol ( coreg), metroprolol (Lopressor), are the recommended agents ( all patients with stable mild severe HF ➢ Digoxin (lanoxin), hydralazine ➢ Lasix ( furosemide)- fluid overload ➢ Thiazide diuretics (NaCl inhibitors) – hydrochlorthiazide ( hydroDIURIL) ➢ Potassium sparing diuretic- Aldosterone antagonist -spironalctone 9 aldactone), eplerenone (inspra), ➢ It can be used for NYHA stage I or before any onset of HF symptoms. It regresses ventricular hypertrophy, modify cardiac remodeling, and useful for HFpEF and HFrEF. I also wanted to say diuretics based on several articles. Also depends on the co morbities 2. treatment of acute heart failure and pulmonary edema. ( pg 250-254, 25, 37, 249) ➢ Nitrates, diuretics, morphine: Nitroprusside- vasodilator Nesiritride- atrial peptide , vasodilator and diuretic L - loop M - morphine N - nitrates O - oxygen P - positioning IV loop diuretics - Cause venodilation and diuresis - Reduces pre-load IV opiates (e.g. morphine) - Reduce anxiety - Vasodilates, reducing preload - Reduces sympathetic drive - Not routinely offered IV, buccal or sublingual nitrates (Glyceryl trinitrates "GTN") - Reduce preload and afterload - vasodilates Oxygen >> maintains O2 sats (Positioning - keep patient upright)
➢ cardiogenic decreased preload, decrease afterload, inc o2 inc o CPAP, BiPAP dec preload nitroglycerin, loop diuretics (furosemide, bumetanide) dec afterload nitroprusside, ACEi/ARB noncardiogenic treat underlying cause, mechanical ventilation
3. side effects of ACE inhibitors and mechanism of action of ACE inhibitors. (pg. 279, 274-275) ➢ side effects- cough (change to an ARB) Angioedema, rash, diaphoresis, angioedema, cough, abdominal pain, leukopenia, myalgia, headache, renal insufficiency. INCREASES creatinine, hyperkalemia, hypotension. Teratogen (fetal renal malformations) ➢ MOA- inhibits angiotensin converting enzyme, interfering with conversion of angiotension I to angiotensin II. ACE inhibitors inhibit the breakdown of bradykinin a potent and naturally occurring vasodilator by blocking the enzyme kininase II. This is thought to be the cause of the cough commonly experienced by patients who take this class of drugs. ➢ Uses : HTN, Chronic HF, Prevention of renal failure in diabetes 4. which antihypertensive medication classes are contraindicated in patients with asthma. (pg. 261) ➢ Beta blockers- such as metoprolol (Toprol), carvedilol ( coreg), nadolol (corgard), penbutolol ( levatol), pindolol ( visken), atenolol ( tenormin), ➢ Propranolol (Non-selective beta blocker) 5. mechanism of action of Digoxin. ( pg 248-255, 274t) ➢ increases intracellular concentration of calcium which increases force of myocardial contraction ➢ decreases activation of sympathetic nervous system ➢ improved quality of life but no decrease in mortality ➢ directly inhibits the Na+/K+ ATPase location in the plasma membrane, which leads to indirect inhibition of Na+Ca2+, increase in cardiac contractility 6. uses and the mechanism of action of Penicillin. (pg. 672-673, 674) ➢ PCN’s inhibit bacterial cell wall synthesis ➢ Penicillins, which are bactericidal against susceptible organisms, disrupt synthesis of the bacterial cell wall and compete for and bind to specific enzyme proteins that catalyze transpeptidation and cross-linking. The enzymes to which they bind are called penicillin-binding proteins (PBPs). They consist of transpeptidases, transglycosylases, and D-alanine carboxykinase and are implicated in the final phases of building and reshaping of the bacterial cell wall while it is growing and dividing. ➢ This action interferes with the biosynthesis of mucopeptides and prevents linkage of structural components of the cell wall. After the penicillin molecules bind and inhibit the
teeth, Side effects: loss of appetite, jaundice, abdominal pain which could be possible hepatotoxicity. Change of mental status may be due to intracranial pressure. May also have anaphylaxis, periorbital edema, rashes or systemic lupus erythematous-like syndrome. May increase AST, ALT, BUN, amylase, bilirubin and serum alkaline phosphatase.
9. usage of antiarrhythmics, their mechanisms of action, and side effects of antiarrhythmic agents. ➢ reduce electrical irregularity of the heart by altering the action potential of cardiac cells. ➢ Class IA drugs (quinidine, disopyramide, procainamide) depress rapid depolarization of the action potential ➢ Class IB drugs (lidocaine, mexiletine, tocainide) exert less effect on sodium channels at rest but are more prominent during depolarization. ➢ Class IC drugs (flecainide, propafenone) depress phase 0 markedly and profoundly slow conduction. ➢ Class II (beta-blockers) work by inhibiting sympathetic stimulation. ➢ Class III (amiodarone, dronedarone, ibutilide, dofetilide, sotalol) prolong phase 3 repolarization by blocking potassium channels. ➢ Class IV (verapimil, diltiazem) inhibit calcium ion influx through slow channels into conductile and contractile myocardial cells & vascular smooth muscle cells; also slow AV conduction & prolong effective refractory period w/in AV node. ➢ Uses: -paroxysmal SVT, a-fib, PVC’s ➢ Common side effects (N/V/D, abd pain, light-headedness, headache, palpitations) ➢ amiodarone (photosensitivity, skin discoloration) ➢ digoxin (yellow halo around objects, nausea, decreased appetite, fatigue) ➢ esmolol (bradycardia, reduced exercise capacity, HF, hypertension, AV block, bronchoconstriction, fatigue) ➢ procainamide (nausea, prolonged use may lead to lupus-like syndrome) ➢ disopyramide (dry mouth, blurred vision, constipation, urinary retention, acute angle-closure glaucoma (rare), may cause or worsen CHF, hypotension. 10.treatment of Parkinson’s disease ( 506-508, 506t) First line drugs. ➢ Levodopa - carbidopa goes with levodopa to avoid levodopa being broken down in the periphery ➢ dopamine agonists - apoomorohine (apokyn), pramipexole (Mirapex), ropinirole hydrochloride (requip), bromocriptine (parlodel), cabergoline (dostinex) ➢ Radagiline (azilect)- Monoamine oxidase B(MAO-B) inhibitor ➢ Nonpharmacologic trx ...optimize the pt's general health, nutrition, emotional and neuromuscular status. 11.first line treatment of depression. ( pg. 519) ➢ First-line drugs : SSRIs, fluoxetine ( prozac), Paroxetine (paxil)( result in higher weight gain. Most antidepressants studied beyond 3-6 months are associated with significant weight gain unrelated to response) (highest rate of sexual dysfunction than other SSRIs) ➢ , citalopram (celexa), escitalopram (lexapro) except fluvoxamine, SNRIs (venlafaxine)( has a higher incidence of nausea and vomiting than the SSRIs. May be associated with an increased risk of cardiovascular events)
➢ NDRIs (bupropion) (significantly lower rate of sexual adverse events than the SSRI) (may be associated with an increased risk of seizures) ➢ First line in certain conditions: TCAs- nortriptyline ( pamelor), mirtazapine (result in higher weight gain. Most antidepressants studied beyond 3-6 months are associated with significant weight gain unrelated to response) ➢ SSRIs are associated with an increased risk for nonfatal suicide attempts and may be associated with higher risk of side effects in older patients than older antidepressants. ➢ Establish diagnosis
- Assess suicide risk
- Institute counseling or psychotherapy (this is often ignored or ineffectively communicated)
- Enlist patient participation in nonpharmacologic treatment such as exercise
- Begin drug therapy as needed. Choose based on adverse effect profile, cost, and patient preference
- Assess patient status, therapeutic response, and adverse effects of therapy on a regular basis; monitor for increased suicidal thoughts and behaviors. 12.preferred antidepressants used in the elderly (less anticholgenic effects) ( pg. 522) ➢ SSRI’s- Fluoxetine (Prozac), Praoxetine ( paxil), citalopram (celexa), escitalopram (lexapro) ➢ MAOI’S- phenelzine ( nardil), tranylcypromine (parnate) ➢ Bupropion- is an SSNRI- (other name Wellbutrin) ➢ Nefazodone- is an SARI & SSRI (serotonin 2 agonists/blockers/serotonin reuptake inhibitor ➢ SSNRI’s- venlafaxine (Effexor) ➢ Mirtazapine- (remeron)- α2- non adrenergic antagonist ➢ ** note Citalopram, fluoxetine, and fluvoxamine have weak cholinergic inhibition 13.adverse effects associated with SSRIs (pg. 519) ➢ anxiety, agitation ➢ anorexia, GI distress ➢ headache, hypotension, sexual dysfunction ➢ Serotonin syndrome: hyperactivity, tachycardia, hypertension, tremors, GI upset, sweating, AMS, fever agitation, myoclonus, hyperthermia (will occur within 24hrs, treated with supportive care) 14.medications used to treat depression: including SSRIs, SNRIs, DNRIs, etc. ( 517, 526-527, 517t, 530) ➢ all antidepressants act on neurotransmitter systems by affecting three distinct processes: neurotransmitter degradation, neurotransmitter reuptake, and neurotransmitter binding. ➢ SSRI’s (Selective Serotonin reuptake inhibitors): first line meds increase the amount of serotonin by blocking the presynaptic serotonin reuptake pump. -Fluoxetine (Prozac) -Paroxetine (Paxil) -Citalopram (Celexa) -Escitalopram (Lexapro) ➢ SNRI’s (Serotonin/Norepinephrine reuptake inhibitors ): increase the amount of ➢ Second-line drugs: SNRIs- fluoxetine (Prozac), duloxetine ( cymbalta) , NDRIs - bupropion ( Wellbutrin), TCAs- nortriptyline (pamerlor) ➢ Third-line drugs: SARIs – trazadone (desyrel), MAOIs- phenelzine ( nardil),
o Dizziness--drowsiness o Ataxia- -nausea and vomiting o Rash-- photosensitivity reaction o Toxic epidermal necrolysis- -Steven Johnson syndrome o Hypersensitivity ( e.g. fever, rash, eosinophilia) o Pulmonary hypersensitivity ( e.g. fever, dyspnea, pneumonitis )
19. which common drugs require serum level monitoring ( pg. 47) ➢ Theophylline ➢ phenytoin ➢ carbamazepine ➢ digoxin ➢ aminoglycoside antibiotics ➢ Coumadin ➢ Potassium ➢ Gentamycin 20.role of the NP in practice and what guides NP practice. ( pg. 10-12) ➢ for specified classifications of medication ➢ integrate care across continuum and collaborate and coordinate ➢ scope depends on legal allowances by the state practice act, provides standards for nursing practice ➢ nurse practice act authorizes the board of nursing to establish statutory authority in each state. ➢ The scope of practice specific legal scope determined by the state statue, board of nursing, education preparation and common practice with in the community ➢ Standard of practice authoritative statement by with the quality of practice, service, education can be judged. ➢ There is an increased need for professionals who can provide cost-effective healthcare. Healthcare needs to be accessible and available. Advanced practice nurses are fulfilling this role. 21.mechanism of action for oral contraceptives and contraindications of oral contraceptives. ( pg. 612, 609, 623) ➢ Hormonal contraceptive agents interfere with the hypothalamic-pituitary-ovarian negative feedback loop to inhibit ovulation. Constant, low levels of estrogen and/or progestin have suppressive effects at both the hypothalamus and the pituitary, inhibiting GnRH, FSH, and LH. Suppression of FSH and LH inhibits ovulation. Additional contraceptive effects stem from actions on the cervical mucus (thickening, to prevent passage of sperm) and the endometrium (providing a lining that is hostile to implantation). Hormonal contraceptives are not abortifacients. An implanted pregnancy will not be disrupted by their administration. ➢ The primary contraceptive action of progestin in hormonal contraceptives is suppression of the LH surge, which inhibits ovulation. When given in supraphysiologic doses, progestins produce a decidualized endometrial bed with atrophied glands that is not receptive to implantation, as well as thick cervical mucus, which hampers sperm transport and may also impair ovum transport by slowing peristalsis and decreasing secretions in the fallopian tubes. ➢ The contraceptive action of estrogens in hormonal contraceptives is primarily the result of
suppression of FSH. Without FSH, no dominant follicle emerges and ovulation is inhibited. Estrogen contributes to endometrial stability and avoidance of irregular shedding and/or bleeding. Estrogen increases intracellular progesterone receptors, making the given dose of progestin more effective. ➢ Contraindications
abortion within 3 months, cervical neoplasia, untreated cervicitis/vaginitis, high STD risk woman, small/large uterus (<6 cm or >9 cm) - Paraguard contraindicated for anticogulants, bleeding disorders, copper allergy, or wilson's disease ➢ Yaz (ethinyl estrodiol and drospirenone) - CHECK POTASSIUM LEVEL caution with ACEI, ARB's, aldosterone antagonists, k-sparing diuretics, heparin, long-term NSAID's - Contrindicated with renal insufficiency, hepatic dysfunction, adrenal insufficiency, smoking over 35, thrombohemolytic disease, breast cancer, ovarian cancer, uterine bleeding - WARNING FOR HYPERKALEMIA ➢ transdermal patch and vaginal ring are HIGHER RISK FOR BLOOD CLOT than the COCP ➢ Progestrin only emergency contraception has few side effects and NO contraindications ➢ Progestin-only pills (mini pills), implants, depo shot, and IUD's - are SAFE for pts with breastfeeding and with contraindication to estrogen 25.treatment(s) for Generalized Anxiety Disorder ( pg 540) ➢ excessive worry regarding life circumstances that are difficult to control. ➢ Selection of medication depends on the side effect profile and cost ➢ Starting doses suggested to be 50% lower those for depression due to excitatory side effects ➢ Counsel patient that symptom relief may take 4-6 weeks ➢ Present on more days than not for a 6 mth period ➢ Treatment o Acute: Benzodiazepines – alprazolam (Xanax), diazepam (valium), lorazepam ( Ativan), clonazepam ( klonopin) o Long term: SSRI’S – fluoxetine ( Prozac), paroxetine ( paxil), citalopram ( celexa) , escitalopram ( Lexapro) fluvoxamine ( luvox), sertraline ( zoloft) , SNRIs (venlafaxine ( Effexor)) , buspirone ( buspar)
GAD: Cognitive-behavioral therapy; imipramine, paroxetine, sertraline, escitalopram,
venlafaxine, buspirone, hydroxyzine 26.treatment(s) for ADHD and its monitoring ( pg. 450-452) ➢ For children stimulants are not the initial treatment. Nonpharmacological treatments are attempted first, which include classes and counseling for parents in behavior modification (such as point systems that allow children to earn rewards), social skill training, cognitive-behavioral therapy, support groups, biofeedback, and mediation all go into a comprehensive, multidisciplinary management program. Guidelines recommend parents and teachers working together to assess efficacy of treatment plan.
- All available stimulants appear to be equally effective. Methylphenidate (Ritalin, Ritalin SR, Metadate SR, Concerta, Metadate CD, Ritalin LA, Methylin, Daytrana Transdermal System) is usually first-line drug of choice for AD-HD
- When giving medication to children parents must give permission first.
- Although some parents chose not to tell the childrens teachers about placing their child on medication, teachers may be very helpful in evaluation response from therapy. The Connors Teacher’s Rating Scale, should be completed prior to initiation of therapy and 1 to 2 weeks after initiation.
- A once a day methylphenidate (Concerta) may be used to help children for whom multiple doses per day are difficult.
- If paradoxical aggravation of symptoms or other adverse effects occur, reduce dosage or, if necessary discontinue drug.
- If patients do not respond to methylphenidate, other medications from another class. Amphetamines are usually used such as Adderall, Vyvanse, Kapvay, Dexedrine.
- TCA antidepressants have been used as both primary and adjunctive therapy in children who fail to achieve positive response to stimulants. The specific agents used are desipramine and nortriptyline, primary because of their effects on norepinephrine reuptake. They should be avoided in patients with cardiac disease, specifically conduction abnormalities Monitor
- The American Heart Association recommends careful screening of all children and adolescents prior to initiating pharmacological therapy for ADHD, including a detailed patient and family history and physical examination. Ideally, a baseline electrocardiogram should be obtained and careful follow-up monitoring instituted.
- FDA recommends that clinicians periodically monitor heart rate or blood pressure on patients
- Monitor for exacerbation of preexisting psychiatric conditions, or new-onset episodes of psychosis, aggression, or mania
- Patients should be seen more frequently during dosage adjustment period. Once stable, they should be followed about once every 6-12 months. Blood pressure and weight should be monitored. Patient Variables
- Geriatric s: Methylphenidate has an unlabeled use in the elderly population. It may increase mental alertness and stimulate appetite.
- Pediatrics: Us in children younger than 6 years of age is off-label
- Pregnancy and Lactation: studies have not been adequate to determine safety; they are not recommended for women of childbearing age
- Gender: women who use modafinil (Brand name: Provigil. Short-acting psychostimulant) and oral contraceptives should take precaution to avoid pregnancy
- Use and Abuse : use with caution in emotionally unstable patients and in those with history of alcoholism or another drug dependence. Chronic abuse can lead to marked tolerance and psychologic dependence with varying degree of abnormal behaviors. Frank psychotic episodes can occur. 27.role of the Drug Enforcement Administration ( pg 7, 12-13, 17, 9, 112-113) ➢ if your state allows for substance control prescribing you must register with DEA and obtain a DEA number ➢ limited prescribing dispensing, manufacturing and distribution to those individuals who were registered with the DEA and Department of justice. ➢ Federal policy has established that only health care providers who are granted prescriptive authority to prescribe controlled substances by the state can be registered by the DEA to obtain DEA numbers. In response to the growing recognition that states were authorizing NPs to prescribe controlled substances, the DEA
issued a rule titled Definition and Registration of Mid-Level Practitioners
(MLPs) (21 CFR Parts 1301 and 1304 or 58 FR 31171).
➢ DEA will register individuals who may prescribe narcotics and other controlled substances. However registration depends on state authority to prescribe controlled substances. The DEA classifies narcotics and Other Drugs such as depressants and stimulants by their abuse potential with differing levels of control assigned to each class 28.treatment(s) for GERD ( pg 328-331) ➢ PPI’s (proton pump inhibitors) first line treatment- o potentially suppress gastric acid and secretion by inhibiting the hydrogen/potassium pump in gastric parietal o omeprazole ( Prilosec), lansoprazole (prevacid), raberprazole
