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NR 508: STUDY GUIDE EXAM OUTLINE
Sexually Transmitted Infections and Vaginitis Differential diagnosis of vaginal discharge: sex partners, douching, lack of vaginal lactobacilli Management of syphilis: PCN G. IF allergic tx w/ 14 days of doxycycline 100mg BID po or tetracycle 500mg QID x 14 days. gonorrhea & chlamydia: Ceftriaxone 250mg IM x 1 Chlamydia: Azithromycin 1g PO x 1 or doxy 100mg BID for 1 wk PID: Cefoxitin 2g IM x 1 + probenecid 1g PO + doxy 100mg BID po x 14 days
Metronidazole po 500mg BID x 14 days IF severe: Admit bacterial vaginosis: Metronidazole 500mg po BID x 7 days or applicator once daily x 5 days or Clindamycin cream 2% one applicator bedtime x 7 days IF pregnant use oral metro
vulvovaginal candidiasis: common w/ antibx/DM/pregnancy. Yeast infection. Tx: Azole class. Clotrimazole, butaconazole, miconazole. Fluconazole 150mg x
genital warts: podofilox 0.5% solution/gel, cryotherapy, or bicholoracetic acid trichomonas: Protozoa infection, yellow/green discharge, itchy Tx: metronidazole 2g po x 1 or 500mg BID po x 7 days AVOID alcohol on ZOLES bc of disulfiram rxn HSV: simplex 2 genital herpes. Tx: acyclovir 400 mg TID x 7-10 days or Famciclovir 300mg po TID 7-10 days. Valcyclovir 1g BID 7-10 days. Episodic tx: acyclovir 400mg TID for 5 days HPV: Cervical Genotypes 16 & 18 neoplasia. public lice: 1% permethrin topical scabies: Permethrin cream, lindane lotion, crotamiton, Ivermectin Recommended follow-up (test-of-cure) for patients who have chlamydia, gonorrhea or syphilis Treating infections during pregnancy – choice of drugs NO DOXY if preg Chapter 48: Women as Patients
Management of dysmenorrhea: NSAIDS reduce prostaglandins to decrease contractions, oral contraceptives HIV and women: Fastest growing population for HIV. 25% risk to baby if no therapy given. 2% risk if anti-retrovirals given. Cannot breastfeed. Chapter 1: The Role of the Advanced Practice Nurse as Prescriber Roles and responsibilities of APRN prescribers: Collaborate w/ physician on best drug to give patient, in depth knowledge of drugs, use pharma protocols, central role in educating nurses & patients on appropriate use of drugs Clinical judgement in Prescribing- Is a prescription the right tx? Goals of therapy, effective drugs for the disease? Monitoring goals met? Cost? Collaboration with other providers- different perspective on prescribing, critical for quality patient care Autonomy and Prescriptive authority- varies state to state. 21 states are independent prescribing, 26 are autonomous. Chapter 2: Review of Basic Principles of Pharmacology Metabolism: Biotransformation/ Chemical change of drug structure Enhance excretion, inactivate the drug, increase therapeutic action, activate pro-drug, increase/decrease toxicity Factors (Age, genetics, pregnancy, liver dz, time of day, environment, diet, alcohol, drug interactions)
Drug Dose Determined: a) Dose-response relationship b) Therapeutic index: ratio of lethal dose/therapeutic dose c) Plasma level profile: Onset of action time d) Half-life e) Bioavailability: % of drug absorbed & available. Effected by incomplete absorption & first-pass metabolism Tissue Distribution: Fats=lipid-soluble drugs (low blood flow), bone (tetracycline deposits in bone & teeth), Blood-brain barrier= impenetrable only lipid-soluble drugs cross (Levadopa), Placental barrier= low molecular weight drugs pass easier (ethanol) Receptors: agonist: drug bind to/stimulates cell causing a response Antagonists: drug binds to/occupies cell without stimulating a response Potency: lower drug concentration to require response Efficacy: max effect a drug can produce
- Biliary: drugs excreted in bile can be reabsorbed into intestine
- Lungs: Gases (eg for volatile drugs) First Pass Effect: Rapidly metabolized by liver & has little desired action left Chapter 3: Rational Drug Selection Process of rational drug prescribing: 6 Steps proposed by WHO: define the problem, specify the therapeutic objective, collaborate with the patient, choose the treatment, educate the patient, monitor effectiveness Patient education: Poor adherence, pt education @ 5 th-6th^ grade lvl, purpose of med, instructions for administration, & adverse drug reactions Monitor effectiveness: Passive: patient educated on outcome & instructed to contact provider. Active: Follow up lab tests & monitoring to measure therapeutic effectiveness
Drug, Patient, and Provider factors that influence drug selection:
- Drug Factors: pharmacokinetic, pharmacodynamics, therapeutic, safety, cost, patient factor, provider factor, alt. therapies
- Patient factors: Previous adverse rxns, health beliefs, current drug therapy, drug interactions, consult PharmD on complex drug regimens, patient age, pregnancy
- Provider factors: ease of prescribing/monitoring, formularies, personal list Influences on Rational Prescribing: Pharmaceutical Promotion, prescribing recommendations change, provider need reeducated on appropriate approach Chapter 4: Legal and Professional Issues in Prescribing New Drug Approval process including Clinical Phases U.S. FDA Regulatory Jurisdiction: official labelling vs off-label use of drugs Off label prescribing only legal if there is evidence to support use, not approved by FDA Controlled Substance Laws: Controlled Drug DEA schedules (Table 4-1) Schedule I: No accepted medical use, no legal use, research only Schedule II: No refills permitted, written only no tele unless emergent, expires in 72 hrs if not filled Schedule III & IV: Prescription rewritten after 6 mo or 5 refills, tele OK Schedule IV: Same as all prescription drugs
Type A: Predictable/Exaggerated Rx Effect (insulin=hypoglycemia, diarrhea= antibx, anticholinergic= antidepressants) Drugs Secondary Effect Type B: Allergy/Hypersensitivity I. Immediate Response, IgE--> Mast cells, FATAL II. Cytotoxic, Improves w/ removal of drug, Lupus, Anemias, “Penias” III. Arthus Rxn/Immune Complex RXN, 1-3 wks after drug exposure, sx: fever, arthralgia, lymph node swelling, splenomegaly IV. Cell Mediated/DELAYED, COMMON skin RXN, 24-48hrs of drug exposure Time-Related & Dose-Related: Type C, reduce dose or withdraw medication Type D: Teratogens (Cat. X, C, D pregnancy)/ Carcinogens (Immunomodulators, androgens, estrogens, ethanol) Risk Factors: Kids, Elderly, Renal Patients Chapter 6: Factors that Foster Positive Outcomes Overview of non-adherence: 50% of patients adhere to drug regimen at 6 mo, highest risk pt are asymptomatic diseases such as HTN, cognitive impairment, psych, & complex regimens
Keys to effective patient education: simple instruction, written handouts, instructions in native languages, colored bottles/calendars, health/cultural beliefs Find a factor that can be modified: resources for new insurance, low cost med programs, referrals for social needs Chapter 7: Cultural and Ethnic Influences in Pharmacotherapeutics Cultural Influences on Care: who is decision maker, pts view of health/illness, attitudes towards drug use Ethnic differences: Hepatic metabolism African americans- Salt deficiency systems Eastern Asians fast acetylators- require higher doses of drug Chapter 9: Nutrition and Nutraceuticals Warfarin: (Spinach/kiwi/leafy veggies/brussels/asparagus) limit Vit. K to avoid therapeutic failure. Influence of Diet on Pharmacokinetics of Drugs:
OTC Medication Sales: Regulated by U.S. Food & Drug Administration Center for Drug Evaluation & Research Drug Interactions: a) Antacids: Don’t take them while on tetracycline/quinolones because it decreases absorption b) Anticholinergics: Benadryl (diphenhydramine) c) CNS Depressants: sedatives/hypnotics d) NSAIDS and ASA Combat Methamphetamine Epidemic Act- Restricts the sales of drugs that contain methamphetamine precursors including a daily & 30 day limit on sales Patient Education Regarding OTC Medications
A) Safe/Labeled for appropriate use B) low potential for misuse/abuse C) taken reliably for something self-diagnosed Chapter 14: Drugs Affecting the Autonomic Nervous System Pharmacodynamics of Alpha2 Agonists (Clonidine & Methyldopa) Activates central Alpha2 in brain, decrease SNS fxn, slows HR & BP Pharmacodynamics of Beta Blockers: Occupy beta receptor sites, Beta mostly heart & kidney, decreases RAA to decrease BP. Beta 2 mostly in lungs causes upregulation of Beta1. Contraindications: Bronchospasm, AV block, decompensated HF Side Effects: fatigue, weakness, dry mouth, depression, insomnia, impotence, inc. cholesterol, worsened psoriasis What happens with abrupt withdrawal of Beta Blockers: hypertensive crisis, flood of epinephrine/norepi= tachy, MI, angina Pharmacokinetics: Beta blockers: Substrates of CYP450 metoprolol dependent on this Phamacotherapeutics: precautions and Contraindications of beta blockers Cardio Selective: Beta1: metoprolol, atenolol, acebutolol Nonselective: nadolol, propranolol,
precautions: Lowers Folate & Vit. B levels monitoring: hepatic enzymes adverse drug reactions: Dizziness/drowsy/nausea/drug interactions Black Box warnings: Toxic Epidermal Necrolysis (TEN) and Stevens-Johnson syndrome Serious/Fatal dermatologic reactions. Aplastic anemia/agranulocytosis What does Long Term monitoring consist of with Iminostilbenes? Baseline labs (CBCWD, CMP, LFT, TSH) Monitor carbamazepine lvls q3-4months. Looking for bone marrow suppression, aplastic anemia, agranulocytosis, hyponatremia Succinimides (Ethoxuximide/Zarontin): MOA: Antiepileptic drug, treats absence seizures in children Metabolized: LIVER Monitoring: LFTs & BMP, CBC, GI distress most common take w/ food No Alcohol Drugs That Affect GABA (Gabapentin/Neurontin): Anti-epileptic, partial seizures, treats neuropathic pain, RLS. Monitoring: Electrolytes & Renal fxn to adjust dosages bc it is not metabolized Preg Category C, Must taper off over 1-2 weeks. Watch for behavior changes/suicide Don’t use GENERIC
Topiramate/Topamax: Affects GABA, adjunctive w/ Lennox-Gasteau syndrome, partial seizures, generalized tonic-clonic, migraine prophylaxis. Causes hyperthermia, lack of sweat, confusion, elevated ammonia levels due to inhibiting carbonic anhydrase. Monitor ammonia, electrolytes, & bicarb levels Levetiracetam (Keppra): Adjunctive therapy to treat partial onset seizures. Does not use CYP450 enzyme system. Renal excretion so monitor kidney fxn. Somnolence is most freq side effect. VERY EXPENSIVE, WRITE GENERIC Lamotrigine/Lamictal: Extensively metabolized by LIVER. Monitor: CBC, LFT, Renal fxn, Black Box Warning for life threatening RASHES (SJS) risk increases w/ use of valproates (carbamazepine, phenytoin, phenobarbital). Taper if need to come off Note: Women on estrogen contraceptives will need 2x increase of lamotrigine dose Amitriptyline/Elavil (Tricyclic Antidepressants (TCA): Precautions and Contradictions: dry mouth, blurred vision, dizziness, drowsy/restless, palpitations, sweating. Do NOT take w/ MAOI, Zyvox (linezolid), Alcohol, or St. John’s wort
Bupropion (Wellbutrin): NRI antidepressant. Atypical. Used for smoking cessation. Atomoxetine (Strattera) over Adderall for ADHD. Patient Education: Do NOT stop abruptly, take at same time every day, takes up to 4 weeks before symptoms improve, take w/ or w/o food, Chapter 16: Drugs Affecting the Cardiovascular and Renal Systems ACE Inhibitors- inhibit angiotensin (which causes vasoconstriction) & aldosterone (which promotes Na & H20 retention). Increases bradykinin to VASODILATE. Use with DM, HF, MI pts. Lower dose for renal pts. Not first line w/ Afr. American. Precaution: Ace Inhibitors bioavailability reduced w/ food.Cough side effect is due to bradykinin. Contraindicated in Pregnancy, renal stenosis, angioedema. Blacks & Asians have 3-4x risk of angioedema. Angiotensin II Receptor Blocker (ARBS): prevent angiotensin II to bind to receptors, decreasing periph. Vasc. Resistance & BP. Use w/ kidney dz & HF. NO COUGH b.c. doesn’t affect bradykinins. NOT used in pregnancy. Excreted through FECES. So No renal dose adjustments needed. Ex: Losartan, metabolized in liver & P450 system, extensive first pass effect.
DECREASES lvl Losartan (induces P450 enzyme): Rifampin/barbituates. INCREASES lvl (inhibits P450 enzyme) Losartan: lovastatin, fluconazole, fluvoxamine, sertraline. Direct Renin Inhibitors (Alsikiren/Tekturna): Inhibit renin in RAAS, lowering BP. Contraindicated in Pregnancy, Renal Stenosis, Angioedema). Side Effects: Cough, ^K+, teratogenicity. CCBs: MOA: Block calcium through transmembrane channels into cardiac/smooth muscle tissues, prolonging relaxation. Type 1: Non-dihydropyridine CCB: Short/Acute. Tx: SVT. Ex: Dilitazem, Verapamil Type 2: Dihydropyridine CCB: Long/Chronic. Tx: BP control Ex: amlodipine,nifedipine ALL CCB metabolized by LIVER, CYP450. Adverse Rxn: hypotension, brady, constipation, dizzy/HA, edema, rash. Contraindicated: Pregnancy. AVOID NSAIDS b.c reduces CCB effects. Avoid Grapefruit juice bc creates toxic lvl of CCB. Avoid Statins bc elevates myopathy & lvls of statins Cardiac Glycosides (Digoxin): Highly selective inhibitor of ATPase system, inhibits pump which builds up Na & Ca inside cell therefore increases contractility of heart. For: Severe HF, or failed response to ACE Inhibitors/Beta blockers. Excreted unchanged by kidneys. Drug interacts w/ quinidine, amiodarone, verapamil,
