Pharmacology Final Exam Road Map PDF

Pharmacology Final Road Map There will be 70 questions (multiple-choice, multi-select, T/F), and you will have 120 minutes to complete the exam. Make sure to bring a calculator to work on metrology. The metrology section will be at the end of the exam if you want to work on those first. Each page w...

Pharmacology Final Road Map There will be 70 questions (multiple-choice, multi-select, T/F), and you will have 120 minutes to complete the exam. Make sure to bring a calculator to work on metrology. The metrology section will be at the end of the exam if you want to work on those first. Each page will consist of specific sections (the label is at the top of the page) so you can be as strategic as you’d like in taking this exam. You will be allowed to move back to previous pages. Scratch sheets of paper will be provided if you’d like one. 55% of the Final will include content covered after the midterm, the rest will be content covered previously. Metrology: There will be 5 questions for you to answer. Review the following (answers on the last page): 1) Ordered: 20 mg/kg/dose of medication A. A patient weighing 90 kg should receive ___ mg per dose. 2) Ordered: 2 g of Cefazolin in 50 mL infused over 30 min. There are no IV pumps so you will have to figure out the drip rate. The tubing has a drip factor of 15 drops/mL. How many gtt/min will you set the tubing at? 3) Ordered: 1000 mL of NS to be transfused over 12 hours. What will you set the infusion rate at (mL/hr)? 4) Order: Metoprolol 45 mg PO BID. You have 30 mg tablets. How many tablets should the patient receive per dose? 5) The physician has ordered a bolus dose of 40 units/kg to be given before starting the infusion. The patient weighs 99lbs. How many units of heparin will you give for the bolus dose? Review the rounding rules for tablets, capsules, flow rates, drip rates. Pharmacodynamics and Pharmacokinetics: What organ oversees the excretion of medications? Metabolism of medications?: Excretion is kidneys. Metabolism is liver. Which route has the fastest absorption rate? IV! Define: Pharmacokinetic: movement of drug through the body Pharmacodynamic: The way the drug effects the body Drug half-life: Time it takes for med concentration in blood to reach half of initial concentration Peak drug level (and when is it drawn?): How much of the med was absorbed. Drawn 30 minutes post infusion and 60 minutes post pill  Trough drug level (and when is it drawn?): How well the body is metabolizing and excreting the med. Drawn 30 minutes before the next dose First-pass effect: Liver breaks down the meds by enzymes before the remaining amount of meds are absorbed in the body Bioavailability: Amount of drug available to act on the body after going through the first pass effect High protein-bound vs low protein-bound drug: High protein-bound is more attracted to albumin and low protein-bound is less attracted to albumin Pharmacokinetics across the lifespan: Review the physiological changes that occur in the following and how it could disrupt the normal absorption, metabolism, and excretion of drugs: - Pregnancy: GI tract’s transit time is decreased which increases absorption. Kidney’s receive increased blood flow which increases elimination. Liver metabolizes more effectively which results in decreased bioavailability of drugs - Infant: GI tract is slow and irregular. Skin is thinner. Liver metabolizes slower. Kidney has decreased blood flow. Brain has an immature blood brain barrier. Immature albumin means decreased protein binding=increased risk for toxicity - Elderly (out of all the changes, which is the most important?): Kidneys have a lowered GFR!!! GI tract has decreased blood flow and gastric acid. Lowered total body mass, water, protein, and increased fat. Liver has lowered metabolism What trimester is the highest risk time for the teratogenic effects from medications?: First trimester How can we promote drug adherence in elderly patients? Assess reading level before giving written instructions, assess ability to get to meds, use large font on bottles, encourage use of pill counter or calendar, and choose appropriate administration forms. Cholinergics/Adrenergics: - Review the effects of cholinergic vs adrenergic activation (ex: what happens when an alpha 1 adrenergic agonist drug is given to a patient?) PAGE 55 Cholinergic: Adrenergic: - Review the side effects of Cholinergic agonists/muscarinic agonists (remember the acronym from lecture!) DUMBELLS. D: Diarrhea, U: Urination (dribbling), M: Miosis (small pupils), B: Bradycardia, E: Emesis, L: Lacrimation (tear production), L: Lethargy, S: Salivation- -Review the side effects of Anticholinergics/Antimuscarinics BUDCAT. B: Blurred vision (pupil dilation), U: Urinary retention, D: Dry mouth, C: Constipation, A: Anorexia/anxiety, T: Tachycardia and hypertension - What’s a reversal agent for Bethanechol overdose? Atropine! Anti-inflammatory: - What are the roles of COX 1 and 2? - If a medication is a COX 1 and 2 inhibitor, what are the therapeutic effects and the side effects? Medications: For each of the following medications, work through: - What is it commonly used for (why would someone be prescribed this medication?) - What are safety considerations (what will you monitor for? What should we teach the patient?) - Are dietary changes needed? (this usually corresponds with the side effects) - Any labs needed? (this also usually corresponds with the side effects) - What are the major side effects and most pertinent adverse effects? (stick to what was on your PPT slides and what was discussed in class) ✓ Furosemide: Loop diuretic, increases urination. Use: Diuretic in emergency or regular use Monitor for: I&O for dehydration, electrolytes, and hearing changes SE: Dizziness/lightheadedness, dehydration, hypotension, hyponatremia, hypokalemia, and rare cases of tinnitus ✓ Hydrochlorothiazide: Thiazide diuretic Use: HTN Monitor for: BP, glucose, and I&O SE: Hypotension, hyperglycemia, increased urination ✓ ACE inhibitors (Lisinopril, captopril, etc): Inhibits formation of angiotensin II which blocks release of aldosterone Use: HTN, HF, kidney dysfunction Monitor for: Swelling of face, mouth, tongue, epiglottis. Pulse, BP, and electrolytes SE: Nonproductive cough, insomnia, headache, dizziness, hyperkalemia, tachycardia, and hypotension ✓ ARBs (losartan, valsartan, etc): Prevent aldosterone release, lower BP, block Angiotensin II from Angiotensin I receptors Use: HTN, HF, CKD, and post-MI Monitor for: Angioedema and electrolytes SE: Dizziness, hypotension, headache, weakness, fatigue, hyperkalemia, and hyperglycemia ✓ Hydralazine: A1 blocker. Relaxes smooth muscles of arteries to cause vasodilation which decreases afterload, making it easier for the heart to pump Use: HTN Monitor for: Dehydration, BP, and swelling SE: Hypotension, reflex tachycardia, headache, dizziness, edema, congestion, anorexia, n/v, diarrhea ✓ Propranolol: Non-selective beta blocker. Blocks beta receptors in the heart to decrease pulse and lower blood pressure. No asthma patients!!!!! Use: HTN, migraines, HF  Monitor for: BP, HR, sensation, dehydration SE: Weakness, hypotension, bradycardia, paresthesia, depression, ED, n/v, constipation, bronchoconstriction ✓ Metoprolol (recognize the difference between cardio-selective and non-selective beta-blockers listed on slide #7 of Anti-hypertensives lecture): Cardio-selective beta 1 blocker. Limits calcium in SA node which decreases heart rate, also limits calcium in the myocardial cells which decreases contractility Use: HTN, MI, tachycardia Monitor for: pulse, BP, and ECG changes SE: Bradycardia, hypotension, HF, and AV block ✓ Statins (Simvastatin): HMG-COA reductase inhibitors. Hydroxymethylglutaryl coenzyme A is inhibited which decreases levels of LDLs, increases HDL levels, and decreases triglycerides levels Use: treat high cholesterol to reduce risk of heart disease and stroke. Take at night! Monitor for: Liver function, glucose levels SE: GI issues, hyperglycemia, muscle injury ✓ Pantoprazole: PPI. Blocks proton pump proteins to decrease gastric acid production Use: Prevents and treats gastric/duodenal ulcers and GERD Monitor for: Dehydration, C. Diff, magnesium, vitamin B12, hematocrit, hemaglobin SE: Headache, N/V, diarrhea, C. Diff, hypomagnesemia, vitamin B12 deficiency ✓ Heparin (what’s the reversal agent for this drug? What routes is this given?): Admin subQ in love handle area or IV, pushing slowly. Rapid acting anticoagulant by inactivating clotting factors thrombin and factor Xa. Reversed using protamine sulfate Use: PE, stroke, DVT, MI, DIC, open heart surgery, renal dialysis Monitor for: PTT changes SE: Bleeding and heparin induced thrombocytopenia ✓ Warfarin (what’s the reversal agent for this drug?): Anticoagulant by inhibiting vitamin K to prevent formation of new clots. Reversed using vitamin K. Use: Prevent DVT, PE, and for artificial (mechanical) valves. Reduces risk of stroke in patients with A-Fib Monitor for: PTT and INR SE: Bleeding and excessive bleeding ✓ Clopidogrel: Adenosine Diphosphate Receptor Antagonist. Blocks receptors on platelets to prevent clot formation Use: Prevent stroke or MI Monitor for: Bleeding SE: Bleeding ✓ Adenosine (how do we give this drug?): Class III: Blocks calcium influx in SA/AV node. First give 6mg, then 12mg Use: Paroxysmal supraventricular tachycardia (SVT) Monitor for: Pulse, respiration, chest pain SE: Bradycardia, dyspnea, CP ✓ Atropine: Cholinergic blocker. Muscarinic antagonist (turns off parasympathetic NS) Use: SYMPTOMATIC bradycardia Monitor for: Pulse, BP, I&O  SE: Tachycardia, CP, dry mouth, urinary retention, restlessness, anxiety, HTN ✓ Epinephrine: Sympathetic/Catecholamine. A1, B1, and B2 agonist Use: V-Tach/Fib, cardiac arrest, anaphylaxis Monitor for: Pulse, BP, glucose SE: Tachycardia, HTN, hyperglycemia ✓ Digoxin: Class V Variable Mechanism. Activates Vagus Nerve to decrease AV conduction, SA automaticity, and increases contractility of ventricles Use: A-Fib and SVT, congestive HF Monitor for: Dehydration, hallucinations, pulse, ECG changes ✓ SE: N/V, GI upset, depression, hallucinations, bradycardia, arrhythmias (V-Tach/Fib) ✓ Bethanechol: Muscarinic agonist. NO IV PUSH! (causes bradycardia), reversal agent is Atropine Use: urinary retention not related to obstruction. Beth can’t pee! Monitor for: BP, I&O, pupil size (small), dehydration, LOC SE: DUMBELLS ✓ Albuterol: Short-acting Beta 2 agonist to provide quick relief of SOB and wheezing Use: Acute bronchospasms, COPD, and asthma Monitor: Potassium, pulse, and BP SE: Headache, nervousness, tremors, insomnia, hypokalemia, bronchospasms, palpitations, tachycardia, and HTN ✓ Vancomycin (how is it given differently when used to treat C. Diff vs Sepsis?). Inhibits cell wall synthesis which weakens cell wall. No beta lactam ring. Use: Serious infections, drug of choice for MRSA and S. epidermidis, GIVE ORALLY FOR C. DIFF Monitor: Bun, GFR, creatinine, flushing, pulse, BP, hearing, and clotting SE: Renal failure, red-man syndrome, ototoxicity, and thrombophlebitis ✓ Penicillin. Bactericidal. Weakens cell walls->swelling->rupture->cell death Use: Gram positive organisms, skin infections, URIs, STIs, Endocarditis, and Otitis Media Monitor: C. Diff SE: Allergic reaction, C. Diff ✓ Ceftriaxone. Bactericidal. Cephalosporin. Broad spectrum. Weakens cell walls->swelling- >rupture->cell death Use: URIs, Intraabdominal infections, Otitis Media, STIs, UTIs Monitor: hematocrit, hemoglobin, clotting/clots SE: “A BATH” A: Allergic reaction, B: Bleeding, A: Alcohol intolerance, T: Thrombophlebitis, H: Hemolytic Anemia ✓ All 4 different types of insulins (be sure to cover patient education heavily) Rapid acting: insulin lispro and aspart. Take with meals! Onset: 5-15min, Peak: 30min-2hrs, Give SubQ or IV Short acting: “Regular insulin,” -R, onset: 30-60min, Peak: 1-5hrs. Give IV (100u/mL) Intermediate acting: NPH insulin, -N. Give between meals. Onset: 1-2hrs, Peak: 6-12hrs. GIVE SUBQ ONLY. Can be mixed with short acting Long duration: Insulin glargine. Prevents spikes throughout the day. Onset: 1hr, Duration: 24hrs. Give only 1/day at bedtime. DO NOT MIX. GIVE SUB! ONLY. Storage of insulin: Fridge: 3 months unopened. Out of fridge opened: 1month. NO COLD INJECTIONS  Administration of insulin: Best place: tummy. Thigh has slowest absorption rate. Rotate admin spots 1” apart! ✓ Metformin: Oral antidiabetic. Decreases production of glucose in the liver, reduces absorption of glucose, increases insulin sensitivity Use: Diabetes Type II Monitor: Glucose, Vitamin B12, folic acid, renal studies. DO NOT FIVE 48 HOURS BEFORE CT SE: GI disturbances, impaired vitamin B12 and folic acid absorption, Lactic acidosis ✓ Pioglitazone: Oral antidiabetic. Reduces insulin resistance and forces cells to respond, decreases glucose production. Use: Type II Diabetes in conjunction with calorie restriction and exercise Monitor: edema, liver function, bladder cancer, bone health, glucose SE: Fluid retention, impaired liver function, bladder cancer, fractures, hypoglycemia, ovulation ✓ Steroids (Prednisone/methylprednisolone) (which diseases do they treat, including endocrine?): Antiinflammatory Use: Autoimmune disorders, cortisol replacement in Addison’s Disease, organ transplants Monitor: Infections, bone health, glucose, BP, vision changes, cortisol levels SE: Infections, mood swings, osteoporosis, hyperglycemia, GI upset, Cushing’s Syndrome, HTN, glaucoma ✓ Levothyroxine: Replaces T4 Use: Hypothyroidism and Hoshimoto’s Thyroiditis Monitor: dehydration, weight, pulse, BP, seizures, glucose SE: N/V, nervousness, tremors, weight loss, tachycardia, HTN, seizures, decreased effects of insulin and oral antidiabetic meds ✓ Latanoprost: Patients with glaucoma should avoid anticholinergics due to drying effect which causes eye damage Use: Decreases pressure in the eye from glaucoma or hypertension of the eye Monitor: Eye pain, vision changes, dry eyes SE: Iris color and eye lash changes, eye pain, blurred vision, burning/stinging/itching/redness of the eye, watery eyes, dry eyes. ✓ Aspirin (should children take this?): Antiinflammatory, antiplatelet, antipyretic, CAUSES IRREVERSIBLE EFFECTS ON PLATELETS. STOP USE 7 DAYS BEFORE SURGERY. NO KIDS!!!! Use: Pain, inflammation, fever reduction, arthritis, prevention of MI, stroke, TIA, and thromboemboli Monitor: Hearing changes, ulcers, bleeding, seizures, lil red dots all over, PT, INR, uric acid, cholesterol, T3 and T4, potassium SE: Dizziness, drowsiness, headache, tinnitus, hearing loss, GI distress, ulcer formation, Reye syndrome. Risk for hypoglycemia with oral antidiabetics, increased gastric ulcer risk with glucocorticoids ✓ Ibuprofen (review the nursing considerations slide and drug interactions): Blocks COX1 and 2 (primarily 2) Use: Pain, arthritis, fever, inflammation Monitor: LOC, vision and hearing changes, bleeding, edema, BUN, creatinine, GFR SE: Drowsiness, dizziness, headache, confusion, insomnia, dreams, blurred vision, tinnitus, gastric distress and bleeding, edema, ACUTE KIDNEY INJURY  Drug interactions: Warfarin: Increased bleeding. Phenytoin, sulfonamides, warfarin, and cephalosporins: Increased effect. Aspirin: Decreased effect. Alcohol: Increased risk of stomach ulcer formation ✓ Morphine (Heavily cover the safety implications of this drug- what should we monitor before and after giving): Binds to opiate receptors in CNS to decrease pain impulses. CNS depressant Use: Moderate and severe pain. Post-surgery slowly pushed IV. Antitussive and antidiarrheal Monitor: Dehydration, constipation, edema, BP, RESPIRATIONS SE: N/V, constipation, urinary retention, dizziness, anorexia, orthostatic hypotension, respiratory depression ✓ Narcan (When and how do we give this?): Given for opiate overdoses. Administered nasally, IV, IM, or SubQ ✓ Haloperidol: First Gen Antipsychotic, high potency Use: Schizophrenia, acute psychosis, Tourette’s Syndrome, administered for patients who present a risk for themselves or others Monitor: ECG, Parkinsonism, and muscle contractions SE: Extrapyramidal reactions, tardive dyskinesia, prolonged QT interval ✓ Benzodiazepines (Lorazepam): Beefs up action of GABA (calms nerves with limited sedation) Use: Short-term anxiety, insomnia, prolonged seizures Monitor: CNS depression, seizures if taking off cold turkey after long term use SE: Less CNS depression than barbiturates Patient education: Avoid other CNS depressants while taking, give at lowest dose possible for shortest time to reduce risk of dependency, discontinue slowly to prevent seizures after long term use ✓ Barbiturates (Phenobarbitol) (-barb-): Mimics GABA Use: Seizures, insomnia, sedation induction Monitor: CNS depression, cognitive changes, falls, BP, HR SE: CNS depression, dizziness, confusion, drowsiness, hypotension, bradycardia, agitation Patient education: Very easy to OD! No admin to patients with past suicidal ideation, only short- term use! (< 2weeks) ✓ SSRIs (Sertraline, Fluoxetine): Blocks serotonin reuptake to allow for more serotonin in the brain Use: Major depression Monitor: Suicidal thoughts, sexual dysfunction, serotonin syndrome SE: Suicidal thoughts/behaviors, sexual dysfunction, nausea, headache, CNS stimulation, weight gain, serotonin syndrome Serotonin Syndrome: Sudden onset of agitations, hallucinations, confusion, poor coordination, hyperreflexia, excessive sweating, fever ✓ Aripiprazole: Drug of choice for psych meds!!! 2nd gen. Blocks Alpha 1, dopamine, and serotonin receptors Use: Schizophrenia, acute bipolar mania, major depressive disorder Monitor: Dehydration SE: Headache, agitation, insomnia, N/V, nervousness ✓ Lithium: Unknown action. Some regulation with dopamine, glutamate, and GABA. Decreased excitability without sedation. Therapeutic range: 0.6-1.2 mEq/L Use: Acute manic episodes, recurrence of mania and depression  Monitor: Dehydration, seizures, cardiac arrest, sodium, change of cognitive function SE: N/V, diarrhea, polyuria, listlessness ➔ Toxic levels: Vomiting, weakness (early sign), drowsiness, seizures, cardiac arrest, seeming intoxicated ✓ Phenytoin: Seizure med. Lengthens time stimulus can cause effect by blocking sodium channels to slow nerves. NONSELECTIVE! DO NOT GIVE TO PREGNANT PEOPLE. Therapeutic range: 10- 20mg!!! Use: Prevention of seizures, epilepsy, brain surgery Monitor: Cognitive changes, painful swelling of gums, rash SE: Drowsiness, dizziness, weakness, gingival hyperplasia, rash ✓ Carbidopa-levodopa: Med for Parkinson’s Disease. Increases dopamine levels. Wait 2-3 months to determine efficacy. Avoid eating high protein meals when administrating. Carbidopa: Helps with N/V, decreases metabolism of levodopa to increase levodopa bioavailability Use: Parkinson’s Disease Monitor: Dehydration, ECG, sleep changes, BP SE: N/V, dyskinesia, dysrhythmias, postural hypotension, night terrors or hallucinations due to changes in dopamine levels (early sign of Parkinson’s) Metrology answers: 1) 1,800 mg/dose 2) 25 gtts/min 3) 83 mL/hr (rounded down from 83.3) 4) 1.5 tablets 5) 1,800 unit bolus