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PHAR37900Pharmacology for Nurses II Final Examination Breakdown

1. NMBA- Maintaining controlled ventilation during surgery Moa- Depolarizing: bind to cholinergic receptors on muscles initially initial depolarization followed by blockage Moa- Non-depolarizing: block binding of acetylcholine at the muscle Monitor closely during and after anesthesia including vital signs, BP, HR, temperature and RR.*Malignant hyperthermia is disease passed down through families that causes a fast rise in body temperature
and severe muscle contractions when the affected person gets general anaesthesia

2. Opioid Opioid is a term used to describe a drug that acts like morphine, whether naturally occurring or synthetically derived. Opiates and opioid drugs produce analgesia. Moa- Drugs can be agonists, partial agonists, and antagonists Indications- Alleviate moderate to severe pain during surgery, Adjunct medications during anesthesia Cough suppression, Treatment of diarrhea NCs : Adequately assess patients pain, Check vital signs and route/time of administration of other analgesics, Check if patient is in addictive state, Document effects of intervention, Constipation is very common

3. Anesthetics General Anesthetics (GA): produce general anesthesia where CNS is altered to cause pain reduction, consciousness depression, skeletal muscle relaxation, and reflex reduction Local Anesthetics (LA): produce regional anesthesia in a specific part of the body without affecting CNS function Adjunctive Anesthetic drugs: combinations allow balanced anesthesia to minimize the dose of the actual anesthetic drug.

4. Benzos- Binding to receptor sites to increase transmission of GABA (receptor cells in brain), which is a major inhibitory neurotransmitter in the CNS. Indications: Relieve anxiety, Sedation, Light anesthesia, Amnesia of operative events, CNS disorders: ADHD and seizures. NCs: Risk for respiratory depression, Monitor respiratory status, Monitor CV function (BP and decreases in HR) 5. Safety 6. NSAID- Inhibit pain mediators (histamine, bradykinin, prostaglandins, etc.)
Take medication with food and fluids to avoid GI effects ASA not used in children (maybe cause Reyes syndrome) Long-term use of COX-1 increases GI bleeding COX-2 are preferred to avoid GI bleeding ADx: Nausea, Pyrosis, Abdominal pain, Gastrointestinal bleeding, Tinnitus

7. Diverticulitis TX Fluoroquinolones- Inhibition of bacterial enzymesstops DNA synthesis in the cell Clients must complete full course of treatment, Encourage fluids to produce a more urine output to avoid crystalluria (drug crystals in the urine), Avoid exposure to sunlight Warfarin use, Not to be used in children under the age of 18 Cephalosporin- Inhibition of cell wall synthesis, Very poor absorption if given PO Assess for history of allergy, Clients must complete full course of treatment, Used cautiously because immature kidney function slows elimination ADx: Rash, Pruritus, N/V/D, Allergic reaction Treatment: Bed rest Pain medications Limited diets Antibiotics (tetracyclines discussed below 16) Clinicians will advise patients to maintain high fibre diet and start antibiotics For severe systemic symptoms: hospitalize + IV aminoglycosides + metronidazole / cephalosporin 8. PPI- Drugs bind to and inhibit the proton pump that secretes HCl into the stomach leads to a reduction in gastric acid secretion. Long term use reduces vit B12 levels, must be taken 30 min before large meal ADx: gastric tumors Indications: Gastritis, Short term GERD, Confirmed gastric or duodenal ulcers, Erosive esophagitis. 9. Diuretics-

Thiazide Diuretics-Inhibit the re-absorption of sodium, potassium and chloride in the distal convoluted tubule- given for: Congestive Heart Failure, Mitral Regurgitation, Hypertension NCs: Thorough cardiovascular assessment prior to administration, Monitor potassium and sodium levels, decrease diet of sodium-rich foods.
ADx: Dizziness, N/V/D, Headache, Hypokalemia, Hyperglycemia, Muscle cramping, Dehydration, Urinary frequency

Loop Diuretics (lasix): Acts on loop of Henle to block chloride and sodium re-absorption (reduces fluid volume and removes fluid from the body), Help to decrease preload and central venous pressures. NCs: Thorough cardiovascular assessment prior to administration, Monitor potassium levels, decrease diet of sodium-rich foods. 10. Cirrhosis TX- liver scarring and poor liver function, Common cause: hepatitis B and C, Other common causes: alcohol abuse, liver autoimmune inflammation, and certain medications and, Portal hypertension is a common complication. Treatment options: Dietary changes (stopping alcohol) Influenza and hepatitis A and B vaccinations Diuretics (for excess abdominal fluids) done above Antibiotics for infections Coagulopathy (blood products) for bleeding varices 11. Ferrous Salts- Iron is used as a carrier in both hemoglobin and myoglobin: iron def. NCs: take 1-2 hours after meals, dont take with antacids or milk (interferes with absorption), Take with vitamin C juices (increases absorption), stools will turn black. 12. Vitamin B12- Aids in the production of DNA and RNA, Essential for erythropoiesis.
Vitamin B12 thru IM route for patients with pernicious anemia (they lack an intrinsic factor from the gastric parietal cells which permits oral absorption)

13. Hepatitis TX- Hepatitis virus identified: A, B, C, D, and E, Virus replicates and destroys liver cells, Hepatitis B and C are most common causes for chronic hepatitis, cirrhosis, and liver cancer, Hepatitis A is commonly encountered as an acute infection, Therapies available only for hepatitis B and C and include: Intereferon Antivirals: lamuvidine, adefovir, entecavir, and telbivudine Treatment of Alcoholic Hepatitis: Corticosteroids (prednisone) Treatment of Autoimmune Chronic Active Hepatitis: Corticosteroids (prednisone) and Antimetabolites (e.g. azathioprine) Biological Response Modifier- it is thought to interfere with the ability of the virus to infect cells. Used for Hepatitis B and C, Various cancers, Multiple Sclerosis

NCs: Be aware of dose-limiting toxicities: bone marrow suppression, autoimmune disorders, and rarely CV problems (e.g. CHF) Antivirals: lamuvidine, adefovir, entecavir, and telbivudine: NRTI (nucleoside or nucleotide reverse transcriptase inhibitor): resembles nucleotides that incorporate into DNA and prevent viral transcription Doses must be adjusted during renal insufficiency and failure Telbivudine can be administered with or without food After discontinuing entecavir , monitor carefully for hepatitis reoccurrence 14. Diuretics- check out answer 9 15. Ferrous salts- check out answer 10 16. Tetracycline- Inhibition of bacterial protein synthesis NCs: Avoid taking with antacids, dairy products, iron preparations, or antidiarrheal medications, Avoid exposure to sunlight, complete full course. 17. NSAID- Inhibit pain mediators (histamine, bradykinin, prostaglandins, etc.)
Take medication with food and fluids to avoid GI effects ASA not used in children (maybe cause Reyes syndrome) Long-term use of COX-1 increases GI bleeding COX-2 are preferred to avoid GI bleeding ADx: Nausea, Pyrosis, Abdominal pain, Gastrointestinal bleeding, Tinnitus

18. Thrombolytic- Promote firbinolysis by converting plasminogen to plasmin, Plasmin is an enzyme which digests fibrin and breaks down fibrinogen, prothrombin, and other clotting factors. ADx: Bleeding, Intracranial bleeding Monitor for bleeding, Perform regular neurological assessments Obtain baseline coagulation tests (aPTT, INR, and PT) and hemoglobin, Not used in children Indications: Venous Thrombosis, Pulmonary Embolism, MI, Stroke 19. Anticoagulant- Heparin, warfarin (Coumadin: Inhibits clotting factors- Bleeding, Nausea
Only have an effect as a prophylaxis (they do not work on clots that have already formed) Monitor blood work, values such as aPTT (heparin use) and INR (warfarin use) Check for bleeding especially in gums and stool Vitamin K is used to reverse effects of warfarin toxicity Heparin containing benzyl alcohol must not be given to neonates (fatal reactions have been reported) When warfarin is used, all care providers should be informed to avoid unnecessary physical trauma More likely to experience bleeding complications dalteparin and enoxaparin can cause renal failure

20. Benzos- Central MOA; Binding to the BZ receptor to increase transmission of GABA, which is a major inhibitory NT in the CNS. Antispasticity agent Indications: Relieve anxiety, Sedation, Light anesthesia, Amnesia of operative events, CNS disorders: ADHD and seizures.

NCs: Risk for respiratory depression, Monitor respiratory status, Monitor CV function (BP and decreases in HR) 21. Atypical antipsychotics (haloperidol)- Block dopamine receptors, Newer agents block both dopamine and serotonin. Recall, dopamine and serotonin are used for behavior, cognition and movement. Blockage of dopamine results in an imbalance in Ach activity ADRs: Postural hypotension, Insomnia, agitation, Depression, headaches, Rash, CNS and GI effects, EPS PD symptoms. NCs: Tardive dyskinesia common in the elderly, Warn patient about ADRs and how to minimize their effects 22. Alz. TX23. Anti-spasticity agents1. Dantrolene- Acts directly on muscle to interfere with calcium release prevents muscle contractions- Management of chronic spasticity of skeletal muscle NCs: Fatal hepatitis has been observed in patients, Due to muscle weakening effects should be used in caution in patients with an MI, Can be used in children > 5 years, Drug crosses placenta and breast milk use with caution, Patient should be informed of various drug-drug interactions. 2. Baclofen- Muscle relaxant and antispastic agent. MOA not fully understood works at spinal cord level.- Management of spasticity due to SCI NCs: Patient should be aware of symptoms of abrupt drug withdrawal (seizure + hallucinations), Caution in patients with renal insufficiency, Safety not established during pregnancy and lactation, Not recommended for use in children, Regular liver screen tests must be performed 3. Tizanidine- Alpha (2) adrenergic agonist, Drug is extensively metabolized in liver; Management of spasticity (stroke, SCI, and cerebral palsy) ADx: Asthenia (weakness, fatigue and/or tiredness, Somnolence, Dry mouth, Increased spasm, Dizziness NCs: Clinical studies: use in geriatrics has less safety and efficacy, Patients should be informed that clinical trial information on tizanidine is limited, Can lower blood pressure and cause sedation in patients, Drug clearance reduced when taken with BCPs, There has been a risk of liver injury with tizanidine use (monitor liver function) 4. (benzodiazepine)- Central MOA; Binding to the BZ receptor to increase transmission of GABA, which is a major inhibitory NT in the CNS. Antispasticity agent Indications: Relieve anxiety, Sedation, Light anesthesia, Amnesia of operative events, CNS disorders: ADHD and seizures. NCs: Risk for respiratory depression, Monitor respiratory status, Monitor CV function (BP and decreases in HR)

24. Thrombolytic- Promote firbinolysis by converting plasminogen to plasmin, Plasmin is an enzyme which digests fibrin and breaks down fibrinogen, prothrombin, and other clotting factors. ADx: Bleeding, Intracranial bleeding Monitor for bleeding, Perform regular neurological assessments Obtain baseline coagulation tests (aPTT, INR, and PT) and hemoglobin, Not used in children 25. Anti-epileptic ethosuximide, clonazepam, and valproic acid (VPA): Increases GABA concentration (amnio acid which inhibits nerve transmission), Blocks sodium channels- Absence Seizures (petit mal seizures) NCs: Medications shouldnt be stopped abruptly, Extreme caution for patients with renal/ hepatic disease, There is risk of OCP failure in women, Extreme caution during pregnancy and lactation, VPA: highly teratogenic. Phenytoin: Works on the Na pump to decrease Na intracellularly doesnt allow neuron firing and therefore prevents seizure from spreading NCs: never be stop it abruptly, Many drug interactions can occur, Severe cardiotoxicity been reported with use, May impair mental and physical abilities. 26. Levodopa-carbidopa- Actively transported into CNS and converted into dopamine. Levodopa crosses BBB, but has many adverse effects when it dopamine in blood stream, so with carbidopa combo it doesnt convert into dopamine till its in brain. That dec. the side effects, but needs to administered in bigger doses this way. NCs: Usually given as Levodopa-Carbidopa-Entacapone combinations to enhance CNS entry, Young patients respond better, Long time periods of use lead to tolerance and drug wearing off ADx: Dyskinesias (involuntary body part movements), Nausea, vomiting, and anorexia, Anxiety, agitation, confusion, depression, psychosis, Hypotension, dizziness, syncope Contraindications: Abrupt discontinuation, Asthma or emphysema, Cardiac disease, hypotension, Active peptic ulcers, Diabetes, Renal / hepatic disease, Glaucoma and psychosis, Pregnancy and lactation 27. Anticholinergics- Block ACh (acetylcholine) receptors to prevent bronchoconstriction **RememeberACh comes from the PSNS and causes bronchial constriction** - Asthma, Bronchitis, COPD dont give to child under 12. ADx: Anticholinergic effects, Tachycardia, Restlessness, Dilated pupils, Decreased salivation, Urinary retention NCs: Do not use medication to terminate an acute attack, Hold breath for 5-10 seconds post inhalation, Use a spacer or Aero chamber for administration, Wait 2 minutes between inhalations, Rinse mouth after inhalation 28. NSAID29. Oxidase type B inhibitor- (Monoamine)- Helps to removed excitatory neurotransmitters, Typically used with levodopa when it starts to wear off.

Serious adverse events (serotonin syndrome) may occur if used in combination with other serotonergic drugs. Cheese syndrome (tyramine leads to HTN crisis r/t releasing of stored excitatory neurotransmitters. 30. Serotonin agonist- same as next one. 31. Triptan- Act as serotonin (5-HT) agonists on 1B receptors (on blood vessels) and 1D receptors (on neurons), Relaxes them, serotonin agonist.- Migraine treatments NCs: Clinical differences among the different triptans are small but may be meaningful for patients, Triptans should be used less than 10 days per month to avoid medication overuse, Various drug interactions (with other migraine esp treatments). ADx: Serious cardiac events, some fatal, can occur with use, Hypersensitivity, Serotonin syndrome (can be fatal). 32. MS TX Chronic neurologic disorder: targeted destruction of myelin and degeneration and loss of axons, genetic predisposition to mount an immune response to an environmental stimulus, Low exposure to Vit D and sunlight Treatment goals: Reduce the number, severity and duration of MS attacks Slow relapse-related disease progression and delay time to permanent disability Improve quality of life No treatment / cure but some disease-modifying therapies to reduce/delay disease progression: Short courses of high-dose corticosteroids, Interferons, Glatiramer and Mitoxantrone, Natalizumab and Fingolimod . Immunomodulators (glatiramer, mitoxantrone (off-label), natalizumab, fingolimod): Various

immune system effects involving T cell inhibition, NCs: Mitoxantrone reserved for patients with rapidly advancing disease who have failed other therapy options, Natalizumab: risk of PML may increase if used with other drugs, fingolimod used in patients who do not respond to or tolerate first-line therapies, Safety in elderly not established ADx: Glatiramer: well tolerated with few side effects (rare, postinjection reaction), Mitoxantrone: cardiotoxicity and leukemia, Natalizumab: hypersensitivity reactions and risk of PML, Fingolimod: generally well tolerated 33. Math 34. NSAID 35. Epilepsy TXSeizure Type First Choice Monotherapy

Generalized Tonic-clonic Absence Myoclonic and Atonic Partial (simple or complex)

Carbamazepine, Lamotrigine Phenytoin, Valproic acid/Divalproex Ethosuximide Valproic acid/Divalproex Carbamazepine, Lamotrigine Levetiracetam, Phenytoin

Some drugs are benzodiazepines and barbiturates Same as 25 36. NSAID 37. Bisphosphonate- Decrease function and number of osteoclasts (which normally breakdown bone) and increases lifespan of osteoblasts and osteocytes (help form bone)- Osteoporosis and various other diseases -1st, 2nd, and 3rd gen (differing potencies and administration methods) ADx: Generally well tolerated, GI effects (dyspepsia and nausea) most frequent, IV administration has most ADRs NCs: Must be taken after a prolonged fast (usually first thing in morning) with water only and nothing eaten for 30-60 min, Patient can sit in high fowlers to avoid GI side effects, Adequate intake of calcium and vitamin D needed 38. Bisphosphonate- same as above. 39. NSAID 40. NSAID 41. Math 42. Math 43. NSAID 44. NSAID 45. Estrogen replacement46. Estrogen replacement 47. Oral contraception 48. Erectile dysfunction TX. 49. Estrogen replacement 50. PPI 51. Oral contraception 52. HIV TX 53. HIV TX 54. Glaucoma TX 55. Cataract TX 56. Chemo 57. Chemo

58. Downs Syndrome TX 59. Celiac TX 60. Huntingtons TX 61. Huntingtons TX 62. Huntingtons TX 63. Tay Sach TX 64. Serotonin agonist- same as 30 65. Seizure TX 66. Anti-epileptic- same as 25 67. Eye infection TX 68. Seizure TX- same as 65 69. Ergot alkaloid- Act on serotonin receptors (very similar to the triptans), Also interact centrally with dopamine and adrenergic receptor, Not commonly used, used when other treatments are not working properly like Tylenol. ADx: Can cause serious cardiac events, Rhinitis, N/V/D, Taste disturbance, Dizziness NCs: Use is limit, May produce rebound headaches if used for 10 days. 70. NSAID 71. Corticosteroid-anti inflammatory Medications work in the same manner as naturally occurring steroid hormones, Gonadocorticoids: (androgens) contribute to onset of puberty, Mineralocorticoids: recall function of aldosterone , Glucocorticoids: (cortisol) 1. ADx: Increase blood glucose by inhibiting insulin secretion and promoting gluconeogenesis. Breakdown lipids and proteins, Suppress the inflammatory response, Influence CNS to affect mood, Impaired wound healing, Masking of infections, Hypokalemia. Peptic ulcers, Edema, Sodium/fluid retention, Nausea, Anxiety, Weight gain, Heart failure, Increased intraocular pressure, Fragile skin, Candidiasis (inhaler use) 2. NCs: Careful monitoring for adverse effects Long-term use may cause osteoporosis (decrease absorption & increase excretion of calcium) Long-term use may cause Cushings disease/syndrome Oral glucocorticoids should be given in the morning to decrease amount of adrenal suppression Oral glucocorticoids should be given with milk or food to decrease GI upset Growth retardation is possible. Thus, smaller doses should be considered and accurate weekly height and weight must be documented Indications: Corticosteroids often aggravate other conditions (i.e. hypertension, CHF, diabetes, infection), Addisons Disease, Asthma, Inflammatory Bowel Disease, Rhinitis, Pruritis, Chronic Obstructive Pulmonary Disease, Hodgkins Disease, Leukemias, Sinusitis 72. NSAID 73. Safety

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74. Safety 75. Math 76. Safety 77. Herpes TX 78. Analgesic 79. Analgesic 80. NSAID 81. Diuretic 82. Red eye TX 83. Math 84. Math 85. NSAID 86. NSAID 87. Local anesthetic 88. Diuretic 89. Chemo 90. Oral contraceptive 91. Parkinsons TX- Progressive disorder of the nervous system involving degeneration of inhibitory dopamine neurons in certain parts of the CNS PD treated by pharmaceuticals, exercise, and nutritional support. Aim of therapy: restore balance between dopamine (inhibitory neurotransmitter) and acetylcholine (excitatory neurotransmitter). Treatment drugs: 1. Dopamine aganists: Actively transported into CNS and converted into dopamine. NCs: Usually given as Levodopa-Carbidopa-Entacapone combinations to enhance CNS entry, Young patients respond better, Long time periods of use lead to tolerance and drug wearing off. ADx: Dyskinesias (involuntary body part movements), Nausea, vomiting, and anorexia, Anxiety, agitation, confusion, depression, psychosis, Hypotension, dizzines, syncope. Indications: Abrupt discontinuation, Astham or emphysema, Cardiac disease, hypotension, Active peptic ulcers, Diabetes, Renal / hepatic disease, Glaucoma and psychosis, Pregnancy and lactation 2. Oxidase type B inhibitor- (Monoamine)- Helps to removed excitatory neurotransmitters, Typically used with levodopa when it starts to wear off. Serious adverse events (serotonin syndrome) may occur if used in combination with other serotonergic drugs. Cheese syndrome (tyramine leads to HTN crisis r/t releasing of stored excitatory neurotransmitters.

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3. Antimuscuranic agents- Drugs are similar to atropine and block muscarine receptors (that respond to ACh) NCs: Care should be utilized in older patients, Many drug interactions, Caution with many side effects ADx: Dry mouth, Dizziness and drowsiness, Blurred vision, Constipation and urinary retention, Confusion and depression, Nausea, Tachycardia Contra. : Older patients due to risk of mental dysfunction, Urinary retention, esp in BPH patients 4. Antiviral (amantadine)- Not clearly understood possibly inhibition of NMDA receptors, (glutamate receptor, used for memory and learning; also helps to strengthen synapse between neurons in responses to disuse of transmission) NCs: Neuroleptic malignant syndrome associated with dose reduction or withdrawal (can be fatal), Abrupt discontinuation can lead to parkinsons crisis, Several drug interactions. ADx: CNS disturbances: depression, confusion, hallucinations, anxiety, irritability, nervousness, dizziness, Headache, weakness, and insomnia, CHF, edema, and hypotension, GI distress, constipation and urinary retention. 92. Oral contraceptive 93. Math 94. Math 95. Math 96. Math 97. Chemo 98. Chemo 99. Chemo 100. Safe admin.

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