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Pharm Exam 1 Study Notes Review
Kinetics and Dynamics o Drug classifications: the way that it is used to treat a particular condition. Each drug can be classified into one or more drug classes. o Pharmacokinetics: movement of a drug through the body (what the body does to the drug) o Four processes: ▪ Absorption ▪ Distribution ▪ Metabolism (biotransformation) ▪ Excretion (elimination) o Absorption: getting into the bloodstream ▪ What effects absorption?
- Blood flow
- Pain
- Stress
- Hunger
- Fasting
- Food
- pH
- exercise
- mode of administration o Distribution: circulation (plasma) into the body tissues ▪ Blood flow ▪ Affinity of the drug to the tissue ▪ Protein binding
- Highly protein bound
- Weakly protein bound
- Free drugs ▪ Protein binding: drug competition for sites, higher protein bound drugs will displace lower protein bound drugs
- If you give 2 drugs at the same time, the higher protein bound drug will replace the lower protein bound drug
- The weak drug will be free bound
- Too much free drug can become toxic ▪ Blood brain barrier: endothelial lining the blood vessels of the brain
- Protects the brain from foreign substances – 98% of drugs on market
- Central acting drugs can cross: Benzodiazepines, illegal street drugs, mood altering drugs, alcohol, nicotine, caffeine
- Water soluble and free drugs cannot cross the BBB
- During pregnancy, the BBB is not well formed
▪ Pregnancy: during pregnancy, the placenta does not filter anything, it goes straight to the baby.
- Effects fetal growth and development and causes birth defects
- Breast feeding is another highway for substances o Metabolism: changing the drug for excretion ▪ The majority of metabolism is in the liver, then gets sent to kidneys to be delivered ▪ The first pass effect- the amount of drug that gets metabolized immediately in the liver, part is immediately gone.
- If you have a bad liver, the level of drug in system is going to be higher because it is not being metabolized as quickly.
- Patients with bad livers should get lower doses
- If patient has kidney problems, there can be excess metabolized drug if it is not being excreted.
- If patient has heart problems effects distribution o Excretion ▪ Kidneys ▪ What effects excretion in the kidneys? Urine pH, renal conditions o Pharmacodynamics: what the drug does to the body o Primary effect- why are you giving them the drug (what you are assessing) ▪ Example: Benadryl- to stop itching o Secondary effect- else the drug is doing to the body ▪ Example: Benadryl- to help them sleep o Dose-response relationship ▪ Potency- how the patient responds to a substance, different for every person ▪ Maximum efficacy- amount of medication you can give, nothing is changing. All the drug is going to do regardless of how much you give. Must give another drug to help out. o Onset, peak and duration ▪ Onset- when it starts working ▪ Peak- maximum amount (IV: 30-60 mins, PO: 2-3 hours, IM: 2-4 hours) ▪ Duration- how long it’s going to stay there ▪ Trough- how much drug is in the blood right before next dose ▪ Half-life- amount of time half the dose of meds is metabolized away (When the next dose is due). o Receptor therapy ▪ Receptor: antagonist vs agonist ▪ Agonist- activate the receptor ▪ Antagonist- block the receptor o Mechanisms of drug action: ▪ Stimulation ▪ Depression
adjusted, female patient becomes pregnant, OTC med or supplement is added
- Side effects- what to expect, what to report
- Diet
- Cultural considerations
- Self-administration- patients motor skills and abilities Legal and Ethical Issues in Medication Administration o US Food and Drug Administration (FDA) o Protecting the public health o Oversee research and approval of new meds o Monitor all meds on the market for efficacy and safety o Core ethical principles: o Respect for person ▪ Autonomy and informed consent o Beneficence ▪ Risk-benefit ratio o Justice o Nurses role in clinical research o Responsible for both the safety of the patient and integrity of the research protocol o Nursing process- patient centered collaborative care o Drug standards and legislation o US Pharmacopeia and the National Formulary o Drug names o Every drug has multiple names ▪ Chemical name- chemical structure of drug ▪ Generic name- official nonproprietary name
- Example: ibuprofen ▪ Brand or trade name- proprietary name
- Example: Advil o OTC drugs o No prescription needed o Some are restricted o Nursing considerations: interactions with Rx o Herbal Hazards o Natural does not mean safe!! o Patients keep secrets about herbals o Drug-herb interactions o Herbal tips o NO to pregnant or nursing o NO infants or children o What is on the label may not be what is in the bottle o Five plus Five Rights
o The right patient (identify name, DOB, chart) o The right drug (check the drug in hand with what’s on order) o The right dose (check the correct dosage) o The right route (PO, IV, IM, SQ) o The right time (in the right window of time based on the facility) o The right assessment (must assess patient before medication) o The right documentation o The right to education (educated about all their drugs) o The right evaluation (assess the effectiveness of medication) o The right to refuse (educate them) o Medication errors o Wrong medication or IV fluid o Wrong dose o Wrong IV rate o Wrong patient o Wrong route o Wrong time interval o Omission of a dose o Allergy to medication o D/C a med without an order o 6 Nurses Rights o Right to a complete and clear order o Right to have the correct drug, route (form) and dose dispensed o Right to have access to information o Right to have policies around safe medication administration o Right to administer meds safely and identify problems in the system o Right to Stop, Think and be Vigilant o Culture of safety o The National Council for Medication Error Reporting- “any preventable event that may cause or lead to inappropriate medication use or harm to a patient.” o ANA- just culture o Drug reconciliation o Pt should carry a list of personal drug information in case of an emergency. o Update this list of drugs whenever a change occurs. o Bring a list of medications to each doctor appointment. o Medication disposal o Remove medications from the original packaging and mix them (do not crush tablets or capsules) with an unpalatable substance such as dirt, kitty litter, or used coffee grounds. This method is intended to make medications less attractive to people and animals. o Place the mixture in a container such as a sealed plastic bag.
▪ Assist patients into an appropriate position, depending on the route of administration. ▪ Compare labels on medications with the MAR prior to administering drugs to a patient. ▪ Explain each medication and its action to the patient. ▪ For patients who cannot hold medications, place the cup to their lips. Introduce one drug at a time, and do not rush the patient. ▪ Stay with the patient until all the medications have been taken. ▪ Dispose of used supplies and perform hand hygiene. ▪ Evaluate the patient’s response to the medications. ▪ Educate patients and family members o Recording/charting ▪ Report any drug errors immediately ▪ Record effectiveness and results of medication administered, especially medications administered as needed (prn). ▪ Record and report drugs that were refused ▪ Record the amount of fluid taken with medications on an input and output chart. Cultural considerations o Ethnomedicine- study of ways in which people in different cultures conceptualize health and illness. o Traditional healers, priests, herbalists, midwives o Ethnopharmacology- study of ethnic groups and their use of drugs o Culture- shared learned beliefs and behaviors by a group o Pharmacogenetics- study of inherited genetic differences affecting individual responses to drugs o Transcultural nursing: o Provides culturally competent care. o Nurses need to be sensitive to beliefs and practices of different cultural groups. o Complementary health practices o Alternative health practices o Pediatric Pharmacology o Limited research ▪ Research risk ▪ Obtaining informed consent ▪ Drug labeling and dosing instructions ▪ Pediatric Research Equity Act in 2012 o Pediatric- Absorption o Influencing factors: ▪ Child’s age, health status, weight, route of administration ▪ Nutritional habits, physical maturity, hormonal differences ▪ Hydration, underlying disease, GI disorders o Route of administration:
▪ Gastric acidity, emptying, motility, surface area, enzyme levels, intestinal flora o IM/subQ ▪ Peripheral perfusion ▪ Effectiveness of circulation o Topical ▪ Children’s skin is thick and porous o Pediatric- Distribution o Influencing factors: ▪ Body fluid composition
- Neonates and infants have 75% water (adults 60%) ▪ Body tissue composition
- Neonates and infants have less body fat ▪ Protein-binding capability
- Neonates and infants have less albumin and fewer protein receptor sites ▪ Effectiveness of barriers
- Skin, blood-brain barrier o Pediatric- Metabolism o Influencing factors: ▪ Maturational level of child ▪ Liver metabolism ▪ Higher metabolic rate o Pediatric- Excretion o Kidneys ▪ Infants have decreased renal blood flow, glomerular filtration rate, and renal tubular function o Nursing Implications o Pediatric drug administration ▪ Teaching is directed to parents and child ▪ Age appropriate ▪ Basic rules o Adolescent considerations o Need individualized care specific to developmental stage ▪ Physical changes ▪ Cognitive level and abilities ▪ Social, reasoning, and decision-making skill development ▪ Emotional factors ▪ Independence from parents ▪ Self-care behaviors ▪ Impact of chronic illness ▪ Use of illegal drugs / Hx of drug use o Nursing considerations
o Encourage patient to report if the new drug is not improving the condition for which it was prescribed o Antidepressants o SSRI antidepressants o Prevent breakdown, it prolongs serotonin to work longer and remain in the receptor o End in -ine or - pram ▪ Paxil paroxetine ▪ Celexa citalopram ▪ Lexapro escitalopram ▪ Prozac fluoxetine ▪ Zoloft sertraline ▪ Luvox fluvoxamine ▪ Trintellixvoroxetine o Worsens glaucoma, prolongs bleeding, can cause hyponatremia o Serotonin- “happy” neurotransmitter ▪ Serotonin is a compound present in blood platelets and serum that constrict the blood vessels and acts as a neurotransmitter ▪ Centrally: keep serotonin in receptors ▪ Peripherally: anticholinergic effect
- Bottom right square, fight or flight o SSRI risks o Can take weeks, even months to achieve a therapeutic effect o Tremors, insomnia, suicidal thoughts can come before positive effects o Withdraw slowly: Agitation, headaches occur o Weight loss or gain are common – expect depression or SE o Sexual dysfunction can lead to noncompliance o Hypertension is a risk o Serotonin syndrome if overlapping with other antidepressant types – need a washout period o Serotonin syndrome o When you overlap 2 antidepressants together ▪ Unexplained fever, flushing, sweats ▪ Poor coordination, rigidity, tremors ▪ Rapid changes in blood pressure ▪ Agitation & restlessness ▪ Hallucinations & Confusion ▪ Hold Rx if toxic levels are expected ▪ Triptans, Tricyclics, Fentanyl, Tramadol, Lithium, Buspar, St John’s Wort can compound the risk o SNRI- Serotonin-norepinephrine re-uptake inhibitor o Effexor (Venlafaxine)
o Cymbalta (Duloxetine) ▪ These are used when depression and anxiety co-exist ▪ End in - ine ▪ Serotonin based drug o Side effects o Anxious symptoms sometimes escalate when taking this medication --panic, aggression, impulsivity, restlessness o Report confusion and unexplained changes in vital signs (serotonin syndrome) o Suicidal thoughts o Prolonged bleeding o Withdrawal symptoms (agitation) o Hepatotoxic o Anticholinergic effects / Ortho BP … Fall risk o HARD ON LIVER o SNDRI’s- Serotonin- Norepinephrine- Dopamine – Re-uptake Inhibitor o Keep serotonin, norepinephrine and dopamine in the receptor o End in - ion o Wellbutrin (Bupropion) o Used to combat addictions (aka ZYBAN for smoking cessation) o Linked to agitation, tremor & GI distress o Can contribute to suicidal thoughts o May lower seizure threshold o Can cause bone marrow depression ▪ Depresses WBC, can become anemic, at risk for bleeding o SRI’s- Serotonin reuptake inhibitor o End in - one o Trazodone (Desyrel) o Somnolence (drowsy) makes it less than ideal as an antidepressant – take at HS o Facilitates sleep & calming in agitated elders with dementia o Can cause nonsexual erections or impotence o Cause weight gain o Tricyclics o End in - ine ▪ Elavil amitriptyline ▪ Tofranil imipramine ▪ Anafranil clomipramine (good for OCD) ▪ Aventyl nortriptyline ▪ Asendin amoxapine (behavioral issues) o Very strong anticholinergic effects
o Anxiolytics ▪ Avoid opiates, antihistamines, BP meds, caffeine, pseudo-ephedrine, inhalers, SSRIs (serotonin syndrome) o Rx: o Treat anxiety portion of depression o Can be prescribed together with antidepressant o Good for panic disorders/social phobia o End in - pam ▪ Have cholinergic effect ▪ Top right square ▪ Parasympathetic agonists ▪ Cause bronchioles to constrict o Alprazolam (Xanax) o Chlordiazepoxide (Librium) o Clonazepam (Klonopin) o Diazepam (Valium) o Lorazepam (Ativan) o Buspirone (Buspar) Only one safe for patients with respiratory disorders Anti-Psychotics: for agitation with delusions o Neuroleptics (typical) aka antipsychotics o End in -ine, -ole, - one ▪ Haldol (haloperidol) ▪ Stelazine (trifluoperazine) ▪ Navane (thiothixene) ▪ Prolixin (fluphenazine) ▪ Thorazine (chlorpromazine) ▪ Loxitane (loxipine) ▪ Moban (molindone) ▪ Abilify (Aripiprazole) ▪ Latuda (Lurasidone) o Side effects o Risk of dysphagia or seizures if toxic o Risk of impaired judgment o Risk of suicidal thoughts o Risk of dysphagia or seizures o Can cause neutropenia o Ortho BP, fall risk o Weight gain & dysplipidemia o Can have Anti-cholinergic effects o Haloperidol (Haldol) o Dopamine blocker, alters perception and behavior o low cost, works immediately, stops manic behavior
o Side effects: ▪ extrapyramidal symptoms (EPS): parkinsonian tremors and shuffling, stiff neck (dystonia), akathisia (restless movements), tardive dyskinesias (permanent) ▪ anticholinergic effects ▪ aspiration, cough suppressor ▪ profound sedation ▪ used for combative, aggressive, severe agitation ▪ EPS is treatable
- Wean them off med
- Give them congentin o Brings acetylcholine levels down to become equal with dopamine o Dyskinesia ID system vs. AIMS (assess involuntary movement): o Facial tics & grimaces o Blinking o Lip smacking, puckering o Odd tongue movements o Shoulder or hip torsion or arching o Odd writhing arm movements o Pill rolling with fingers o Toe tapping o Neuroleptic syndrome (reaction to neuroleptics) o When a patient is taking 2 neuroleptics at once ▪ Fever ▪ Rigidity (CPK rises) & dysphasia ▪ Labile BP ▪ Tachycardia ▪ Altered LOC (confusion to coma) & incontinence ▪ Hold Rx if toxic levels are expected – this is life threatening ▪ Notify the provider and get an order o Risk management o Extrapyramidal symptoms (EPS / dyskinesias) ▪ Rx with Cogentin (benztropine) an anti- cholinergic – less SE ▪ Must troubleshoot thirst, constipation, urine retention, & blurred vision o Must stop Rx if (mouth tremors) appear ▪ these tardive dyskinesias are permanent ▪ DISCUS & AIMS tools used to monitor EPS ▪ Seizures can appear during withdrawal o Benadryl used to Rx Dystonia (back arching) but this causes somnolence and drops BP o Some Anticholinergic S/S appear w/ antipsychotics alone
▪ Anticonvulsants ▪ Phenobarbital o Anticonvulsants: o Also used for BIPOLAR, Nerve pain, mood stabilization o End in -ine or - ate o Depakote (valproic acid) o Tegretol (carbamazepine) o Trileptal (oxcarbazepine) o Topamax (topiramate) o Lamictal (lamotrigine) o Neurontin (gabapentin) o Lyrica (pregabalin) o Benzodiazepines o Barbituates o Tegretol: alters Na+ transmit in CNS o Report bruising, petechiae, rash, chills, backache, dark urine, sore throat (SJS) o Report suicidal thoughts o Hepatotoxic - Watch for jaundice / watch liver enzymes o Safe level 4—12 mcg/ml o Photosensitivity- burn easily in the sun o Class D, makes birth control ineffective o Check for Rx compatibility o Don’t mix suspension with anything else (sludge results) o SLUDGE o s(alivation) o l(acrimation) o u(rination) o d(efecation) o g(gi symptoms) o e(mesis) o Dilantin (phenytoin): an Na+ blocker used just for seizures and arrhythmias o Watch WBC, renal & hepatic labs closely o Therapeutic range 10—20 mcg/ml … o Report bruising, petechiae, rash, chills, dark urine, sore throat, vision disturbances (SJS) o Report suicidal thoughts o IV use is very risky in elderly people o Check IV compatibilities list!!! o Give meticulous oral care (gingivitis risk) o Pregnancy class D, no lactation impairs hormonal birth control
o Give apart from bolus tube feedings o Avoid taking with ETOH or sedatives o Benzodiazepines o Librium (chlordiazepoxide): given to prevent delirium tremens o Valium (diazepam): --first Rx for status epilepticus (works fast) --don’t mix Dilantin & Valium IV --Valium given IV push --Dilantin given IVPB drip (Never in D5W) o Klonopin (clonazepam): for head injury seizures o Ativan (lorazepam): For all of the above o Romazicon (flumazenil): rapid IV push antidote o Adverse effects of benzodiazepines and barbiturates o Drowsiness & Confusion o Hypotension & Unsteadiness – fall risk o Amplification of other sedatives o Psychological depression o Respiratory depression o Paradoxical agitation o Rx dependency o Tolerance (gateway effect) o Seizures if suddenly withdrawn o Status epilepticus o Constant seizure activity o Give diazepam (Valium)- benzodiazepine ▪ Rapid acting, stops the seizure ▪ May be administered by an RN o Must follow with long acting anti-convulsant to prevent future seizures Dementia: Alzheimer’s medications o Aricept (donezepil) o Slows progression of Alzheimer’s, does not cure it o Parasympathetic nervous system agonist o Keeps acetylcholine afloat o Insomnia, drowsiness, urgency incontinence & GI side effects. o Watch for weight loss & cholinergic effects o Razadyne (related rx) can cause bradycardia & tremors o Namenda (memantine) o Prevents glutamate (an excitatory transmitter) from bonding @ NMDA receptor sites
Stimulants o Medically approved uses o Attention-deficit/hyperactivity disorder (ADHD) o Narcolepsy o Reversal of respiratory distress o Categories o Amphetamines ▪ Act on cerebral cortex o Analeptics, caffeine ▪ Act on brainstem and medulla o Anorexiants ▪ Act on satiety center in hypothalamic and limbic areas o Amphetamines o Action ▪ Stimulate release of norepinephrine and dopamine ▪ Inhibit reuptake of norepinephrine and dopamine o Risks ▪ Insomnia, irritability agitation, seizures ▪ Palpitations ▪ Anorexia, weight loss ▪ Blurred vision ▪ Reliance ▪ Suicidal Thoughts ▪ Abrupt withdrawal may lead to seizures o Methylphenidate o Action ▪ Modulates serotonergic pathways by affecting changes in dopamine transport o Uses ▪ ADHD, narcolepsy, increase attention span o Risks ▪ Caffeine may increase effects ▪ Increases effects of oral anticoagulants, barbiturates, anticonvulsants, TCAs, MAOIs ▪ Decreased effects of antihypertensives ▪ May alter insulin effects ▪ Tachycardia, restlessness, blurred vision, dry mouth ▪ Anti-cholinergic effects o Anorexiants o Cause stimulant effect on hypothalamic and limbic areas of brain to suppress appetite o Should not be given to children under 12 o Risks
o Analeptics ▪ Nervousness, irritability, insomnia ▪ Tachycardia, hypertension ▪ Palpitations, seizures ▪ Risk of electrolyte disturbances o Caffeine, theophylline ▪ Used for neonatal apnea o Doxapram ▪ Used for postanesthesia respiratory depression o Risks ▪ Palpitations, tachycardia, dysrhythmias ▪ Insomnia, nervousness, restlessness ▪ Tremors, seizures o Activated charcoal o Used to counteract overdose of oral medications o Given PO or via NG tube o Binds with the drug in the stomach Opioids o Analgesics o Nonopioid analgesics ▪ Less potent than opioid analgesics ▪ Use- moderate to mild pain ▪ NSAIDs (aspirin, ibuprofen, naproxen) ▪ Analgesics (acetaminophen)-
- Acetaminophen (Tylenol) o Not an NSAID
- Uses- muscular aches and pain, fever
- Side effects: rash, headache, insomnia, hepatotoxicity, blood dysgracias o Opioid analgesics ▪ Use- moderate to severe pain
- Many opioids possess antidiarrheal effects
- Do not crush MS contin ▪ Drugs of abuse- controlled substances
- Must be locked at all times
- Important to maintain adequate count
- Keep eyes in your possession at all times
- Never leave Rx or keys lying around ▪ contraindication
- head injury ▪ side effects
- Respiratory Depression
- Euphoria
