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NURS 5334
Final Exam study
Prescribing basics - --Prescribing is regulated by state BON Proper RX - --Providers name and address, Telephone DEA Pt name/DOB/Addres Name of Drug, strength, SIG(directions) with indication/Route and frequency, Quantity and signature. Drug Schedules: Most addictive to least - --1: Heroin,LSD, MJ 2: hydrocodone, cocaine, Methamphetamine, methadone, oxycodone, meperidine, fentanyl, adderall, ritalin 3: codeine, ketamine, testosterone 4: xanax, valium, soma, ambient, tramadol 5: antidiarrheal, antitussives, lomotil, lyrica Pharmicodyamics - --The effects of drug on the body. Receptors are large molecules usually proteins, that interact and mediate the action of drugs agonist - --produce receptor stimulation and a conformational change every time they bind. Do not need all available receptors to produce a maximum response Partial agonist - --drugs that have properties in b/w those of full agonist and antagonist. They bind to receptors but when they occupy the receptor sites, they stimulate only some of the receptors. antagonist - --drugs with affinity for a receptor but with no intrinsic activity. Affinity allows the antagonist to bind to receptors, but lack of intrinsic activity prevents the bound antagonist from causing receptor activation. The block action of drugs (ex. Narcan) Bioavailabity - --% of administered dosage of the drug that survives the first pass through the liver and reaches the blood stream half life - --Time required for the amount of a drug in the body to decline by 50%, drugs with shorter half lives must be administer frequently. 4.5-5. times the half life to get steady state and to be limited from the body what the body does to the drug - --absorption, distribution, metabolism,
excretion Distribution - --movement of absorbed drug in bodily fluids throughout the body to target tissue. Properties affecting: lipid/water solubility, PH affects ionization of drug, protein binding, size of molecule (smaller molecules are more able to diffuse) Tissue: fat, bone, blood/brain barrier (only lipid soluble will pass), placental barrier (many drugs can pass) Protein binding - --unbound drug is free which is active, crosses membrane. Low plasma proteins result in more free drug. Competition: when 2 highly bound drugs are given it increases the level of both drugs Metabolism - --take place in the liver mostly. Chemical change of a drug structure to: Enhance excretion, inactivate the drug, increase therapeutic action, active a prodrug (inactive until metabolized in the body into the active compound, ex: levodopa), increase or decrease toxicity CYP450 - --enzymes constitutes the most important of the phase I metabolizing enzymes (account for about 75% of drug metabolism in the liver) Phase 2: conjugation reaction occur leading to large increases in hydrophilicity of the substrates rendering them more readily excretable Substrate - --an agent that is metabolized by an enzyme into a metabolite and product and eventually excreted Inhibitors - --compete with other drugs for a particular enzyme affecting the metabolism (decreased) of the substrate and decreases the excretion of the substrate and increasing the circulating drug inducer - --competes with other drugs for a particular enzyme affecting metabolism of the substrate (increases) decreasing the efficacy of the drug excretion - --renal: passive glomerular filtration, active tubular secretion, tubular reabsorption, gi tract, lung, sweat and salivary, mammary genomics - --study of the complete set of genetic information present in a cell, an organism, or species pharmacogenetics - --the study of the influence of hereditary factors on the response of individual organisms to drugs, and the study of variations of DNA and RNA characteristics as related to drug response
Which of the medications are used to treat OIC? - --Naloxegol, methylinaltrexone, lubiprostone Tolerance is defined as - --increased does of a med needed to obtain the same response Which medication is used for opioid abuse? - --Naltrexone Euphoria induced by morphine: - --An exaggerated sense of well-being caused by the activation of mu receptors Which medication is given nasally for migraines? - --Butorphanol Which of the following describes the mechanism of NSAIDs? - --Inhibition of the cyclo- oxygenase enzyme Second generation COX 2 inhibitors: - --Suppress inflammation and cause less risk for gastric ulceration than COX 1, increase risk for heart disease Which of the following medications should not be given with ASA? - -- Glucocorticoids Which medication is given for acetaminophen overdose? - -- Acetylcysteine What are non endocrine therapeutic uses for glucocorticoids? - --RA, SLE, IBS, Bursitis, OA, Gout, disorders of the eye What is the danger of prolonged use of glucocorticoids? - --adrenal insufficiency Methotrexate can cause fatal toxicities of: - --Bone marrow, liver, kidneys, lungs. Hemorrhagic enteritis and GI perforation Jane is on etanercept for RA. The NP knows - --Jane should be checked for TB yearly What is first line treatment for gout? - --Colchicine, indomethacin When would you initiate a Uriosuric Medication? - --more than 3 gout attacks per year Antiinflammatories - --inhibition of COX 1: protects against MI and stroke inhibition COX 2: surpasses inflammation, pain and protects against colorectal cancer (less GI bleeding) first generation NSAIDS - --inhibit COX 1 and COX2: treatment is for relief of mild to moderate pain, relief of cramps r/t dysmenorrhea (risk GI bleed and renal impairment) generation 2 NSAIDS - --only suppresses COX2, decreased risk for GI bleeding but impose risk for increased heart disease Aspirin - --Non-selective inhibitor of COX, therapeutic use analgesic, fever, mensural cramps, anti-inflammatory, Alzheimer disease. Risk for bleeding is
too high. Increased secretion of acid and pepsin therefore ruins all the protective lining of the stomaching. Pt at risk: alcoholics, smoking, older people, or people who have had PUD. Risk of ASA is not advised in pt younger than 18 r/t Reyes syndrome, pregnancy because it cause ductus arteriosis, if given with Ibuprofen it can decrease effects of ASA. first generation non-ASA NSAIDS - --inhibit COX 1 and 2, given for RA and OA, no protection against MI or stroke. ex. Ibuprofen, alieve, diclophinac. Indicated for mild to moderate pain, antiinflammaroty and analgesic effects. risk of GI bleed Celebrex - --second generation non ASA nsaids, lower risk for GI but can still cause renal impairment. given for OA, RA, dysmenorrhea. S/E: abdominal pain, renal impairment, sulfa allergies. Drug interaction: warfarin, Decrease effects of furosemide, (increases)lithium, ACE inhibitors. Acetaminophen - --Analgesic and antipyretic. Hepatotoxicity risk. No more than 3 g in 24 hr period. for overdose: acetylesistine. Can blunt immune response of vaccines
tricyclic antidepressants - --Weigh gain, drowsiness, and terrible anticholinergic effects. beers list, Amitriptyline, nortriptyline, imipramine, desipramine, clomipramine, doxepin, amoxapine. SSRIs - --Fluoxetine, paroxetine, sertraline, citalopram. effects don't start for several weeks (4-6 weeks) can cause weight gain, vivid dreams, bruxism, bleeding disorders, ED/sexual dysfunction, hyponatriemia, most can cause n/v that might go away. need to taper off these meds. can be used for panic disorder, pms, anxiety, ptsd, post menopausal women SNRI - --serotonin norepinephrine reuptake inhibitors, opposite of SSRI (weight loss and increase in energy) Desvenlafaxine (Pristiq, Khedezla) Duloxetine (Cymbalta) ― also approved to treat anxiety and certain types of chronic pain Venlafaxine (Effexor XR) ― also approved to treat anxiety and panic disorder S/E:Nausea Dry mouth Dizziness Headache Excessive sweating Other possible side effects may include: Tiredness Constipation Insomnia Changes in sexual function, such as reduced sexual desire, difficulty reaching orgasm or the inability to maintain an erection (erectile dysfunction) Loss of appetite Brupropion (wellbutrin) - --stimulate, appetite suppressant, helps with sexual side effects of SSRIs, S/E: dry mouth, constipation and increase risk of seizure disorder St. John's Wart (Hypericum perforatum) - --don't want to give this to patients with SSRIs, a lot of drug reactions, dosed at 300mg TID, CYP
inducer lithium - --Excretion is reduced with sodium levels are low. S/E: GI disturbances, n/v/d, ataxia, thirst, tremor, high urine output, death. Very narrow therapeutic index Benzodiazepines - --drugs that lower anxiety and reduce stress: alprazolam, diazepam alcohol abuse - -- nicotine abuse - - - Prior to starting antidepressants, patients should have what lab testing to rule out - --hypothyroidism A 32 yo male is starting paroxetine for depression. He is complaining of not being able to obtain an erection. What can the NP do to help? - --add bupropion A 6 yo us being treated with ethosuximide. She should be monitored for: - -- Blood dycrasias which are uncommon but possible. Sandy is taking lamotrigine for seizures and wants an rx for OCPs which can interact with lamotrigine and cause: - --reduced lamotrigine levels, requiring an increase in the dose of lamotrigine The tricyclic antidepressants should be prescribed cautiously in patients with - --CAD Atropine - --Cause pupil finalization in eye exam Bethanechol (Urecholine) - --GI/GU stimulation following surgery, parasympathomimetic Pyridostigmine (Mestinon) - --Category: Cholinergic, Anticholeristinase, Use: Myasthenia Gravis, Precautions: May cause cram,ps, increased peristalsis Doxazosin (Cardura) - --Hypertension, BPH Albuterol - --Asthma inhaler Scopolamine (Transderm Scop) - --Anticholinergic (drying effects) Used for motion sickness Can cause sedation, anticholinergic effects Phenylephrine - --Sudafed PE; sympathomimetics Propranolol (Inderal) - --Beta adrenergic blocker for hypertension Dobutamine (Dobutrex) - --sympathomimetic Indication: short term management of heart failure Action: Dobutamine has a positive inotropic effect (increases cardiac
A inotrope will increase contractility; a chronotrope will decrease HR; while a dromotrope will decrease conduction via the AV node? - -- positive, negative, negative Epinephrine is used in many emergency situations, such , Cardiac and hypo---------------anaphylaxis, cardia arrest, hypotension what "onset of actions symptoms" should be reviewed with patients who have been newly prescribed an SSRI? they can feel a bit of nausea but this resolves in about 1 week Jaycee has been on Escitalopram for a year and is willing to try tapering off the SSRI. What is the initial dosage adjustment when starting to taper off antidepressants? - --reduce the dose by 50% for 3-4 days One major drug used to treat bipolar disease is lithium. Because lithium has a narrow therapeutic range, it is important to recognize symptoms of toxicity, such as--------------------------------------------------------------------------------GI problems, drowsiness and nausea, seizures and coma are serious problems. monitoring of a patient on gabapentin to treat seizures includes ----------------------------------------------------------------------------------------Recording seizure frequency, duration and severity Sam, aged 65, is started on L-dopa for his Parkinson's disease (PD). He asks why this is necessary. You tell him the primary goal of therapy is to replace depleted stores of dopamine
A 55yo patient develops parkinson's disease characterized by unilateral tremors only. The NP will refer the patient to a neurologist and should expect initial treatment to be - --Ropinirole (lesser symptoms need lighter drug) Inattention and sleep-wake cycle disturbance are hallmark symptoms of:
- --delirium 3 types of information needed for neuropharmacologic drugs:
- --type or types of receptors through which the drug acts. Normal response to the activation of those receptors (Agonist vs antagonist) What the drug in question does to receptor function cholinergic receptors and adrenergic receptors are mediated each by? - -- Cholinergic by acetylcholine and adrenergic by epinephrine and norepinephrine what are the subtypes of cholinergic and adrenergic receptors? - -- cholinergic: nicotinic and mu Adrenergic: Alpha1, alpha2, beta1, beta 2 and dopamine what are the functions of alpha1 receptors? - --Vasoconstriction, ejaculation and contraction of bladder neck and prostate what are the functions of alpha 2 receptors? - --minimal clinical significance what are the functions of Beta 1 receptors? - --Heart: increases heart rate, force of contraction, velocity of conduction in AV node. Kidney: renin release what are the functions of beta 2 receptors? - --Bronchial dilation relaxation of uterine muscle vasodilation glycogenolysis what are the functions of Dopamine receptors? - --dilates renal blood vessels what are the functions of cholinergic drug receptors? - -- Blocks the action of acetylcholine. Cholinesterase inhibitors prevent the breakdown of acetylcholine Examples of anticholinergic drugs - --bethanechol, atropine, oxybutynin, scopolamine, ipratropium bromide They turn everything off and dry everything Side effects of anticholinergics - --dry mouth, blurred vision, constipation,
Check BP before giving (hypotension) *Orthostatic Hypotension ARBS - --block access of angiotensin II cause dilation of arterioles and veins Prevent angiotensin II from inducing pathologic changes in cardiac structure Reduce excretion of potassium Decrease release of aldosterone Increase Renal excretion of sodium and water DO not inhibit Kinase II do not increase levels of bradykinin Aldosterone Antagonists - --selective blockade of aldosterone receptors in the kidney promotes excretion of sodium and water and thereby reduces blood volume (spiralonlatome) Calcium Channel Blockers do what to the heart - --have exact same effect on heart as beta blockers. They suppress calcium influx and reduce force of contraction and slow heart rate and suppress conduction through the AV node what are common side effects of CCBS are: - --constipation, LE edema, gingival hyperplasia what are the therapeutic uses for nifedipine? - --Migraines, angina, HTN beta blockers the adverse cardiac effects of nifedipine but can the adverse cardiac effects of verapamil and diltiazem - --decrease; intensify john is taking hydralazine for elevated BP. He comes in with arthralgia. What blood test might be elevated? - --ANA Untreated HTN can lead to what? - --angina, CHF, MI, kidney disease, stroke SYMPHATHOLYTICS are - --antiadrenergic drugs how is stage A CHF managed? - --Manage risks only true or false: virtually all dysrhythmias can also cause dysrhythmias - --TRUE Which medication is used to treat digoxin induced dysrhythmias? - -- Phenytoin bill is taking amiodarone for his atrial fibrillation. What diagnostics will need to be done?
- --TSH and chest x ray every 6 months recommended cholesterol screening is: - --every 5 years after 20 Lucy is taking gemfibrozil and warfarin. You know how to check INR and expect that - --INR might be Elevated (gemfibrozil displaces warfarin from plasma protein) Bill has prinzmetal's angina and it is wakening him at night. What will the NP prescribe?
- --CCB How do you prevent nitrate intolerance? - --Give smallest possible dose and have 8 free hours per day with long acting nitrates Mary has been admitted with unstable angina. You know she will be treated with? - --ASA Plavix Beta blocker Statin ACE What happens when clopidogrel is given with a PPI? - --the anti platelet effect is decreased What role does O2 play in STEMI? - --Although oxygen is recommended and using it seems to make sense, the practice is not evidence based What role does ASA play in STEMI? - --ASA caused a substantial reduction in mortality What role does morphine play in STEMI? - --in addition to relieving pain, morphine can improve hemodynamics by promoting ventilation, the drug reduces cardiac preload What role does Nitro play in STEMI? - --1. reduce preload and thereby reduce oxygen demand
- increase collateral blood flow in the ischemic region of the heart
- control hypertension caused by stemi-associated anxiety
- limit infract size and improve LV function however, despite these useful effects, nitroglycerin does not reduce mortality What role does BB play in STEMI? - --decreases myocardial oxygen demand; reduce cardiac pain, infract size, and short term mortality; recurrent ischemia and reinfarction are also decreased
Brad has HTN and is found to have enlarged prostate on exam. His BP has been running in the 150/90 range. Which of the following meds would offer treatment for both? - --terazosin Which best describes the action of ACE inhibitors on the failing heart? - -- Reduces preload Which of the following is the most accurate statement regarding digoxin? - -- Increases vagal tone and decreases AV node conduction Which of the following is a limiting adverse effect of ACE inhibitors? - -- hyperkalemia Which of the following medications can be used to treat gestational diabetes? - --Metformin and insulin What is the 4 step approach in the treatment of DM type 2? - --Step 1: lifestyle +metformin step 2: continue step 1 and add second drug step 3: step up to 3 drugs (including metformin) step 4: more complex insulin regimen John comes in with random glucose of 250? Does he need any further testing? - --NO Jane has type 1 diabetes and is taking a beta blocker. what does she need to be aware of? - --Beta blockers impair glycogenolysis and glycogenolysis is a means which the body can respond to and counteract a fall in blood glucose Gina is taking canagliflozin for her diabetes. The NP tells her this may increase her risk for? - --UTIs SGLT-2 inhibitors cannot be given if GFR <35. t or f? - --FALSE: can be given with GFR less than 35 opitmally at what interval should the TSH be reassessed after a levothyroxine dosage is adjusted? 6-8 weeks which of the following can induce thyroid dysfunction? Amiodarone Irma is an 80 yo with CAD. She has an elevated TSH with a low free T4. She weighs 80kg. What dosage of levothyroxine are you going to initiate? -------------------------------------------------------------------------------------12.5-25 mcg
Stacy is 30 yo that has elevated TSH and low free T4. She weight is 100lbs. What does of levothyroxine will you give her? 75 mcg Jane is in her first trimester of pregnancy and has symptomatic hyperthyroidism. What is the endocrinologist going to prescribe? -----------------------------------------------------------Propylthiouracil Mary is postmenopausal is having severe vasomotor symptoms. She has a uterus. She would like to start on hormones. The NP Will start her on estrogen and progesterone Julie is wanting to start OCPs but would like to discontinue in 1 year to try for pregnancy. The NP will prescribe Beyaz due to having added folic acid A patient just call you and she missed a pill. She is on a 28 day cycle. you tell her: - --take the pill as soon as possible and continue the pack. Use another form of contraception for 7 days Lisa has migraines with aura. You are discussing contraception. You recommend: - --Mirena IUD One of the main reasons women stop progestin only pills break through bleeding Sally is post menopausal ands been having frequent UTIs. The NP ---------------------------------------------------------------------------------------------recommend vaginal estrace 1gm vaginally weekly David is prescribed sildenafil for ED. Side effects can be? Ischemic optic neuropathy, hearing loss and priapism What are possible side effects of testosterone? - --Disorders of the liver, prostate cancer, edema, abuse potential, elevated LDL and decreased HDL What is the MOA of alpha adrenergic agents? - --Blockade of alpha 1 receptors and relaxes smooth muscle in the bladder neck High FBG levels: - --NPH dose needs to be increased hyperglycemia after breakfast - --not enough SA insulin or too many carbs or calories at the meal
Antioxidant property and can help with iron as well Niacin - --Vitamin B3; deficiency can lead to dermatitis, which causes scaling and cracking of the skin, GI and central nervous system disturbances (ataxia) large dose can be used to treat low HDL- s/e of flushing (combative with ASA) Riboflavin (B2) - --essential for carbohydrate fat and protein metabolism. Necessary for tissue maintenance. And healthy eyes and good for MIGRAINE headaches and can take up to 3 months (400mg Daily) Thiamin - --Vitamin B1 needed in energy production. Alcoholism is the most common cause of deficiency Paradoxine (B6) - --coenzyme in AA metabolim, isoiazide interferes with B metabolism; deficiency is rare in US except in alcoholics Protein and starchy vegatables Black Cohosh uses - --menopause vasomotor symptoms; not to be given with selective estrogen modulators Co Q 10 - --Co Q-10 deficiency (statins), antioxidant, hypertension, heart failure, migraine prevention, Parkinson's cranberry juice - --helps prevent UTIs, may increase INR in patients taking warfarin Feverfew uses - --Bolded: Prevention of migraines S/e: platelet agreggations Extras: Rheumatoid arthritis flaxseed - --small brown seed of the flax plant; used in baking, cereals, or other foods. Valued in nutrition as a source of fatty acids, lignans, and fiber. Helps to lower LDL Garlic - --Decreases cholesterol and blood pressure Suppresses platelet aggregations.
Taken Raw 1-2 cloves daily with elision Ginger Root* - --Primary use to treat vertigo and N/V associated with Motion sickness. Helps patients with arthritis, lower blood sugar. At high dosages, possible interference with cardiac, antidiabetic, or anticoagulant drugs Ginko (Ginko biloba)* - --help increase pain free walking in patient with peripheral arterial disease Glucosamine* - --Made from shellfish. Can cause increased risk of bleeding and bronchospasm. a substance produced naturally in the body; often used as a supplement to maintain cartilage in the joints anyone over the age of 6 should get the flu vaccine: true or false. - --True out of the shingles (shingreks) it's a recombinate vaccine given in 2 dose. Started at the age of 50 but definitely by age l65. - --can get flu like symptoms and very sore after injections A good history of herb and supplement use in critical before prescribing because approximately % of patients in the us are using herbal products? - --38% A potential harmful effect on patients who take some herbal medication is? - --lead poisoning What black cohosh used for? - --Treating symptoms of menopause Herbs and supplements are regulated by the US food and Drug administration. True or False - --False
