Pharmacology Study Guide PDF

Pharmacology Study Guide for Final Exam Pharmacology – the study of the biological effects of chemicals. Drug Approval Process Preclinical Trials: Chemicals tested on laboratory animals. Phase I Studies: Chemicals tested on (healthy) human volunteers à Goal = Safety Phase II Studies:...

Pharmacology Study Guide for Final Exam Pharmacology – the study of the biological effects of chemicals. Drug Approval Process Preclinical Trials: Chemicals tested on laboratory animals. Phase I Studies: Chemicals tested on (healthy) human volunteers à Goal = Safety Phase II Studies: Drug tried on (100s) informed patients with the disease à Goal = Effectiveness Phase III Studies: Drug used in vast clinical market à Various populations, dosages and combinations FDA Approval: Drug evaluated by FDA; if approved, may be marketed. Phase IV Studies: Continual evaluation of the drug à Begins detecting adverse events Clinical Trials Are Limited in Time and Scope Many Serious Side-effects Cannot be Detected in Trials Dangerous to Include Pregnant Women, so no tetragons are detected Children and pregnant women aren’t tested Controlled Substances (5 Schedules determined by the DEA) I High Potential for Abuse and No Currently Accepted Medical Use (in the US) Ex. Heroin, Marijuana, LSD, Ecstasy Il High Potential for Abuse but is approved for Medical Use - Pain ADHD Ex. Cocaine, Methadone, Dilaudid, Oxycodone, Fentanyl, aAderall, & Ritalin. III Moderate to Low Potential for Physical and Psychological Dependence Ex. Tylenol w/Codeine, Anabolic Steroids, and Testosterone. IV Low Potential for Abuse - Mood and Sleep Ex. Xanax, Soma, Darvon, Valium, Ativan, Ambien, Tramadol V Lowest Potential for Abuse generally used for anti-diarrheal, antitussive, and analgesic purposes - Muscle Ache, Diarrhea Ex. Lomotil, lyrica Benefits of OTC meds à Easily accessible ; Therapeutic = works Drawbacks of OTC meds à Adverse interactions ; Overdose. ; Organ problems Nurses Responsibilities Administering drug (11 rights of medication administration) Assessing drug effects Intervening to make the drug regimen more tolerable Providing patient teachings about drugs and the drug regimen EX. giving food before motrin, teaching them when to take it, how to store it Monitoring the overall patient care plan to prevent medication errors The nurse's role as advocate… Last line of defense for the patient Ethically and legally unacceptable to administer a drug that is harmful to the patient, even though the medication has been prescribed by a licensed prescriber and dispensed by a licensed pharmacist Ideal Drug à Effective; Safe ; Reversible action ; Predictable ; Free of drug interactions ; Ease of administration ; Low cost ; chemically stable ; Selective → works only for a specific problem and not throughout the whole body ; Simple generic name Half life: the period of time it takes for the concentration / amount of drug in the body to be reduced by ½. Half-life is affected by absorption, distribution, metabolism, and excretion. Pharmacokinetics à How the body (ADME) effects the drugs Pharmacodynamics à How drugs effect the body Replace/Substitute missing chemicals.  o Insulin ; Synthroid (thyroid hormone) Increase/Stimulate cellular activities o Metformin (stimulate pancreas to make more insulin) Depress/Slow down cellular actives o Digoxin (slows and strengthens heart rate) Interfere with functioning of foreign cells o Chemotherapy Agonist (activate), Antagonist (inactivate), or Alternate intracellular enzymes Four Basic Forms Drug à Any chemical that can affect living processes EX. Oxygen Pharmacology à Study of drugs and their interactions with living systems Clinical pharmacology à Study of drugs in humans Therapeutics à The use of drugs to diagnose, prevent, or treat disease or to prevent pregnancy o EX. Baby Aspirin, Morning After Pill, Abortion Pill, Birth control, Therapeutic Objective à Provide maximum benefit with minimum harm! Medication Orders Must include … patient's full name , name of the medication (brand, generic), dose, route, frequency of administration, date, time, signature of the prescriber Medication Order Transcript Typed into computer (preferred method) Handwritten on an order sheet. Verbal orders → Signed by the transcriber, countersigned by the prescriber. Telephone orders → Signed by the transcriber, countersigned by the prescriber. Medications often associated with errors include. Insulin (diabetes), heparin (blood thinner), warfarin (tablet form of blood thinner), digoxin All high alert medications (contain a narrow therapeutic index) Drug Name Chemical Name à scientific name based on the compound's chemical structure. Generic Name à granted by USAN Council and commonly used to identify a drug. Naming Generic Name à same drug class will have similar endings and functions, written with lowercase. Trade / Brand Name à identifies the drug during the 17 years that the company has exclusive rights to make, sell, and use it under patent law. Naming Branded Medications à Memorable or catchy and start with a Capital letter. Key Points There is no such thing as a safe drug; all drugs can cause harm. There is no such thing as a selective drug; all drugs can cause side effects. The objective of drug therapy is to provide maximum benefit with minimum harm. Because all patients are unique, drug therapy must be tailored to each individual. Elderly and young people need low doses → pharmacokinetics (drugs stay longer in the body of older individuals because kidney function is decreased) FDA Pregnancy Risk Category AKA Pregnancy Category Safety During Pregnancy Category A à Not demonstrated a risk to the fetus in the 1st or later trimester of pregnancy Category B à Not demonstrated a risk to the fetus in the 1st or later trimester of pregnancy Category C à Animal studies have shown an adverse effect on the fetus, but there are no adequate studies in humans; o benefits of the drug in pregnant women may be acceptable despite its potential risks.  Category D à Evidence of human fetal risk, but the potential benefits from the use of the drug in pregnant women may be acceptable despite its potential risks. DON’T GIVE - only if you have absolutely no choice. Category X: Studies show fetal abnormalities or adverse reactions; reports indicate evidence of fetal risk. The risk of use in a pregnant woman clearly outweighs any possible benefit. THE WORST - DEF. DON’T GIVE Pharmacokinetics à How the body (ADME) effects the drugs Absorption Distribution Metabolism (biotransformation) Excretion of drugs (primarily occurs in the kidneys, but can also occur through the skin, lungs, bile, or feces) Critical Concentration à The amount of a drug that is needed to cause a therapeutic effect Loading Dose à A higher dose than that usually used for treatment Dynamic Equilibrium à The actual concentration that a drug reaches in the body ; affected by ADME Absorption What happens to a drug from the time it is introduced to the body until it reaches the circulating fluids and tissues. Routes of administration Affect drug absorption Oral route most common, but affected by presence of food in the stomach Absorption processes Passive diffusion Active transport Filtration Distribution The movement of a drug to the body's tissues affected by lipid solubility, ionization, perfusion of reactive tissue Protein binding Blood-brain barrier Placenta and breast milk Biotransformation (Metabolism) The liver is the single most important site for biotransformation (metabolism). Changes drugs into new, less active chemicals First pass effect: Phenomenon of drug metabolism whereby the concentration of a drug, specifically when administered orally, med is greatly reduced before it reaches the systemic circulation. Hepatic enzyme system: removal of a drug from the body; primarily occurs in the kidneys, but can also occur through the skin, lungs, bile, or feces. Excretion à Removal of drugs from the body Kidneys play the most important role in excretion of medication What is an action of a drug? A. To increase enzymatic reactions in the body B. To alter a missing chemical C. To depress or slow cellular activities D. To increase the effect of foreign substances Factors Influencing Drugs Effect Weight ; Age ; Gender. ; Physiological Factors ; Pathological Factors ; Genetic Factors ; Immunological Factors ; Psychological Factors ; Environmental Factors ; Tolerance ; Accumulation ; Interactions Drug-Drug Interactions Can occur any time two or more drugs are taken together (polypharmacy) Drug-Food Interactions Certain foods interact with drugs → shellfish allergies will prevent you from getting certain meds In most cases, drugs are best taken on an empty stomach (except NSAIDs) Drug-Laboratory Test Interactions Drugs may alter the results of lab testing. Laboratory test may be used to monitor the effects of other medications. Two patients are receiving injections of penicillin G. One patient is a male, 35 years old, weighing 165 pounds. The other patient is female, 18 years old, weighing 125 pounds. You know that you will see the effects of the drug first in the male patient. What is the rationale for this? A. Women have fewer fat cells than men B. Men have more vascular muscles than women C. Women have a smaller circulatory system than men D. Drugs are generally tested on healthy males Optimal Therapeutic Effect Incorporate basic history and physical assessment to spot and handle problems promptly Drug regimen can often be modified; rarely necessary to completely stop drug regimen due to adverse or intolerable effects Nurse may be in best position to assess problems and intervene early Pharmacokinetics (ADME) The study of absorption, distribution, metabolism (biotransformation), and excretion of drugs Onset of drug action - when the drug starts Drug half-life: the time it takes for the amount of drug in the body to decrease to one half of the peak level it previously achieved. Timing of the peak effect - when the drug is at its highest level rapid/regular insulin peaks 10-15 minutes Duration of drug effects - how long it has an effect in the body Metabolism or biotransformation of the drug - how it goes through the body Site of excretion: removal of a drug from the body; primarily occurs in the kidneys, but can also occur through the skin, lungs, bile, or feces Kayexalate - causes diarrhea to pull out potassium (given when potassium levels are high, to prevent cardiac arrest) Critical Concentration - The amount of a drug that is needed to cause a therapeutic effect Loading Dose - A higher dose than that usually used for treatment → Z-pack, Prednisone Dynamic Equilibrium - The actual concentration that a drug reaches in the body → depends on route Affected by ADME → Absorption, Distribution, Metabolism (Biotransformation), Excretion Optimal Therapeutic Effect (top notch drug for highest effect) Incorporate basic history and physical assessment to spot and handle problems promptly Drug regimen can often be modified; rarely necessary to completely stop drug regimen due to adverse or intolerable effects Nurse may be in best position to assess problems and intervene early When giving a pain reliever, give a drug with therapeutic effect (start small -ex. tylenol) unless patient has a chronic disease and constant pain (then you reach for the higher drugs - ex. morphine) Side Effect vs Adverse Effect Side effects occur when the medication is given at a therapeutic dose. o Discontinuation of the medication is usually not warranted. Manageable - Sore arm, tired, Adverse effects can occur at both therapeutic and higher-than-therapeutic doses. o Providers will discontinue the medication immediately. o Adverse effects are reported to the FDA  Deadly - Stroke ; Clot → STOP! Adverse Effects Undesired effects that may be unpleasant or even dangerous Reasons adverse effects occur The drug may have other effects on the body besides the therapeutic effect. The patient is sensitive to the drug being given. The drug's action on the body causes other responses that are undesired or unpleasant. The patient is taking too much or too little of the drug. Types of Adverse Effects Primary Actions - Overdose; extension of the desired effect Ex. taking too much aspirin can cause bleeding Ex. taking narcotic to get rid of toothache and not wake up the next morning Secondary Actions - Undesired effects produced in addition to the pharmacologic effect (Side Effect) Ex. oral antibiotic give education that it can cause NVD Ex. yeast infection bc of antibiotics Hypersensitivity Excessive response to primary or secondary effect of drug Drug Allergy Body forms antibodies to a drug, causing an immune response when re-exposed Anaphylactic – administer Epinephrine Cytotoxic – notify HCP and discontinue med Serum sickness – notify HCP and discontinue med Delayed reactions – notify HCP and discontinue med Types of Drug Allergies Hypersensitivity and allergy are terms used interchangeably. Occurs when an individual develops an immune response to a medication. The individual has been previously exposed to the medication and has developed antibodies. Hypersensitivity or allergies can result in a mild reaction (itching, rash, watery eyes, sneezing, rhinosinusitis) or a severe reaction resulting in anaphylaxis. Drug-Induced Tissue and Organ Damage Dermatological Reactions Rashes, hives Assessment - Abnormalities in the skin, red area, blisters Interventions - May need to discontinue the medication in severe cases Stomatitis Assessment - Inflammation of the mucous membranes Interventions - Frequent mouth care Superinfections — Destruction of the body's normal flora Assessment - Fever, diarrhea, vaginal discharge Interventions - Supportive care (mouth and skin care), administer antifungal medications as needed, may also need to stop drug responsible for the superinfection Blood Dyscrasia — Bone marrow suppression Assessment - Fever, chills, weakness Interventions - Monitor blood counts, protective isolation Toxicity: An adverse medication effect that is considered severe and can be life-threatening. It can be caused by an excessive dose, but it also can occur at therapeutic dose levels Liver Injury Assessment - Fever, nausea, jaundice, change in color of urine or stool, elevated liver enzymes Interventions - Discontinue medication Renal Injury Assessment - Change in urinary pattern, elevated BUN and creatinine  If BUN is high, patient is DRY - dehydrate Intervention - Notify physician, may need to stop medication or decrease the dosage Poisoning Poisoning occurs when an overdose of a drug damages multiple body systems. Damage to multiple systems can lead to a fatal reaction. Treatment varies accordingly with drug Treatment = activated charcoal or stomach pumping for drugs Treatment for CO is an oxygen chambering Alterations in Glucose Metabolism Hypoglycemia Assessment: Fatigue, drowsiness, hunger, anxiety, headache, etc. Intervention: Restore glucose → sugar and then carbs Hyperglycemia Assessment: Fatigue, polyuria (peeing), polydipsia (thirsty), polyphagia (hunger), nausea, etc. Intervention: Administer insulin therapy to decrease glucose level Electrolyte Imbalance Hypokalemia Assessment: Low serum potassium levels Interventions: Replace serum potassium and monitor serum levels of potassium ; can cause muscle weakness and cardiac problems Hyperkalemia Assessment: High serum potassium level Interventions: Decrease the serum potassium concentration (sodium polystyrene sulfonate (SPS - to make patient poop and get potassium out), monitor serum levels of potassium (can cause muscle weakness and cardiac problems), and monitor cardiac rhythm (place EKG monitor Sensory Effects Ocular Damage Assessment: Visual changes Interventions: Monitor for any visual changes when giving any medication that is known to cause ocular damage; discontinue medication as appropriate. Auditory Damage Assessment: Dizziness, ringing in the ears (tinnitus), loss of balance, and loss of hearing Interventions: Monitor for hearing loss; discontinue medication as appropriate if a decrease in hearing is noted on assessment. Neurological Effects General Central Nervous System (CNS) Effects à Ex. Opioids Assessment: Confusion, delirium, insomnia, etc. Interventions: Prevent injury Atropine-like (Anticholinergic) Effects - give to patients before surgery to dry them up so that they don't get pneumonia and aspirate Assessment: Dry mouth, urinary retention, blurred vision Interventions: Sugarless lozenges to keep mouth moist; have the patient void before administration of the medication Parkinson-like Syndrome Assessment: Muscle tremors and changes in gait Interventions: Discontinue medication as appropriate Neuroleptic Malignant Syndrome Assessment: Neurological symptoms (dizzy, confused, changed in BP) Interventions: Discontinue medication as appropriate Teratogenicity Teratogenicity: Any drug that causes harm to the developing fetus or embryo Teaching to prevent teratogenicity Advise the pregnant woman that any medication may have possible effects on the baby. Weigh the actual benefits against the potential risks. Discuss with pregnant women that they should not take medications without checking with their health care provider first. Risk VS. Benefit Chemo, might not allow for family planning (having children), might want to get eggs harvested Therapeutic Actions Interfere with biosynthesis of the bacterial cell wall Prevent invading organism from using substances essential to their growth & development Interfere with steps involved in protein and DNA synthesis Alter the permeability of the cell membrane to allow essential cellular components to leak out (ex. Adding clavulanate to amoxicillin to be able to enter the cell) Narrow Therapeutic Index - small differences in drug dose may lead to serious adverse drug reactions that are life- threatening. Anti-infective Activity Anti-infectives vary in their effectiveness against invading organisms. Some are selective - only effective for a few number of organisms Bactericidal - kill the cell Bacteriostatic - prevent reproduction of the cell (make it stay still) Narrow Spectrum vs. Broad Spectrum Narrow Spectrum of Activity Effective against only a few microorganisms with a very specific metabolic pathway or enzyme Broad Spectrum of Activity Useful in treating a wide variety of infections Human Immune Response Goal of anti-infective therapy is reduction of the population of the invading organism. Drugs that would eliminate all traces of any invading pathogen might be toxic to the host as well. Example - chemo drugs Immune response is a complex process involving chemical mediators, leukocytes, lymphocytes, antibodies, and locally released enzymes and chemicals. Resistance Natural or acquired: Ability over time to adapt to an anti-infective drug and produce cells that are no longer affected by a particular drug. Occurs when drug is not taken for full course Antiinfectives act on specific enzyme system or biological process, many microorganisms that do not act on this system are not affected by this particular drug Acquiring Resistance Producing an enzyme that deactivates the antimicrobial drug Changing cellular permeability to prevent the drug from entering the cell Ex. Amoxicillin is strong enough to deactivate/breakthrough infection but when not taken for full course, the bacteria will form a hard shell that can’t be broken with regular amoxicillin and so Augmentin is needed to break through the shell and treat infection Altering transport systems to exclude the drug from active transport into the cell Altering binding sites on the membranes or ribosomes, which then no longer accept the drug Producing a chemical that acts as an antagonist to the drug Preventing Resistance Drug dosing: Doses should be high enough, and the duration of drug therapy should be long enough to eradicate even slightly resistant microorganisms. The duration of drug use is critical to ensure that the microbes are completely, not partially, eliminated and are not given the chance to grow and develop resistant strains. PATIENT TEACHING REGARDING RESISTANCE Do not use this drug to treat other infections. This drug needs to be taken as prescribed—for the correct number of times each day and for the full number of days. Do not stop taking the drug if you start feeling better. You need to take the drug for the full number of treatment days to ensure that the infection has been destroyed. The Dose Should be enough to achieve minimum inhibitory concentration(MIC) MIC - Minimum effect of antibiotics require to suppress microorganism or to achieve therapeutic effect Route of administrations In order to achieve MIC and drug reaches the site of action Different routes has its own benefits Fast to Slow Intravenous à Intraosseous (in the bone) à Endotracheal (in the trachea) à Inhalation à Sublingual à Intramuscular (muscles move medications quickly) à Subcutaneous à Rectal à Ingestion (PO) à Transdermal (topical) Duration of therapy Depends of type of disease Acute - 5-10 days Subacute - 2-3 wks Chronic - several months Most drug → minimum 48 hours even after symptoms subsides Antibiotics → 3/5 -10 days Some chronic disease Tuberculosis 6-9 months Extra pul tuberculosis > 9-12-18 months... Leprosy > one 1yr Drug Therapy Mono drug therapy (just taking one med) Better tolerated Cost effective Chance of drug interaction less Combination drug therapy (taking multiple drugs) Eg. Tuberculosis Advantage Achieve synergism, less side effect, increase spectrum Change of Drug Therapy Frequent change is not good Need to provide enough time give so that it can be goodly absorbed, reach site of action and produce pharmacological effects Ex. antidepressant meds (can take 3-6 weeks to kick in) Failure of antimicrobial Therapy Improper selection of AMAs (anti-microbial agents), dose, route or duration of treatment. Treatment begun too late (infection already traveled throughout the body) Failure to take necessary adjuvant measures Poor host defense Trying to treat untreatable (viral) infections  Presence of dormant or altered organisms which later give risk to a relapse Ex. Pneumonia ; Herpes Types of Organisms Antibacterial: Penicillins, Aminoglycosides, Erythromycin, etc. Antiviral: Acyclovir, Amantadine B, Zidovudine, etc. Antifungal: Griseofulvin, Amphotericin B, Ketoconazole, etc. Antiprotozoal (treat infections caused by protozoa): Chloroquine, Pyrimethamine, Metronidazole, etc. Anthelmintic (treat parasitic worms): Mebendazole, Niclosamide, Diethyl carbamazine, etc. Treatment of Systemic Infections (ex. Sepsis) Identification of the infecting pathogen is done by culture Will be seen by Infectious Disease Sensitivity testing to determine which drugs are capable of controlling the particular microorganism Combination therapy Use of a smaller dosage of each drug Some drugs are synergistic In infections caused by more than one organism, each pathogen may react to a different anti-infective agent Sometimes, the combined effects of the different drugs delay the emergence of resistant strains Prophylaxis People traveling to an area where malaria is endemic Patients who are undergoing Gl or genitourinary surgery Patients with known cardiac valve disease, valve replacements, and other conditions requiring invasive procedures Adverse Reactions to Anti Infective Therapy Kidney Damage GI Toxicity Neurotoxicity Hypersensitivity Reactions Superinfections → can cause yeast infections Antibiotics Antibiotics are defined as: Chemicals that inhibit specific bacteria Made in three ways By living microorganisms By synthetic manufacture Through genetic engineering Types of Antibiotics Bacteriostatic - Those substances that prevent the growth of bacteria Bactericidal - Those that kill bacteria directly Signs of Infection Pain Fever Lethargy Slow-wave sleep induction Classic signs of inflammation (redness, swelling, heat, and pain) Goal of Antibiotics Therapy - Decrease the population of the invading bacteria to a point where the human immune system can effectively deal with the invader Selecting Treatment Identification of the causative organism  Based on the culture report, an antibiotic is chosen that has been known to be effective at treating the invading organism Bacteria Classification Gram-positive - The cell wall retains a stain or resists decolorization with alcohol Gram-negative - The cell wall loses a stain or is decolorized by alcohol Aerobic - Depend on oxygen for survival Anaerobic - Do not use oxygen (ex. fungi) Bacteria and Resistance to Antibiotics Adapt to their environment The longer in use, the greater the chance that the bacteria will develop into a resistant strain Principles of Antimicrobial Therapy Antimicrobial therapy is the use of medications to treat infections due to bacteria, viruses, or fungi. Antimicrobials use selective toxicity to kill or otherwise control microbes without destroying host cells. ANTI - INFECTIVE AGENTS Drugs designed to target foreign organisms that have invaded and infected the body of a human host. Do not possess total selective toxicity. No anti-infective drug has been developed that does not affect the host. Anti-infective Agents Across the lifespan Children Use with caution; early exposure can lead to early sensitivity and resistant strains (monitor hydration and nutritional status carefully). Adults Drug allergies and the emergence of resistant strains can be a big problem with this group. Extreme caution in pregnant and nursing women (affect the fetus and also cross into breast milk, leading to toxic effects in the neonate). Older Adults Culture and sensitivity tests to determine the type and extent of many infections. Susceptible to severe adverse GI, renal, and neurological effects and must be monitored for nutritional status and hydration during drug therapy. Anti-infective that adversely affect the liver and kidneys must be used with caution in older patients, who may have decreased organ function. Therapeutic Actions: Sulfonamides, antimycobacterial drugs, and trimethoprim-sulfamethoxazole (Sulfur Meds - Bactrim) prevent the cell of the invading organism from using substances essential to their growth and development, leading to an inability to divide and eventually to cell death Aminoglycosides and the macrolides (antibacterial med) interfere with protein synthesis, preventing cell division. Fluoroquinolones (Ex. Levaquin or Sipro) interfere with DNA synthesis in the cell, leading to inability to divide and cell death. Antifungals, and antiprotozoal drugs alter the permeability of the cell membrane to allow essential cellular components to leak out, causing cell death. With all antibiotics allergic reaction can include anaphylaxis. With antibiotics always assess GI and monitor CBC Antibiotics Classification Common Action / Route Interactions / Pregnancy Risk Metabolized / Adverse Effects / Nursing Medications Contraindications Eliminated Antidote Considerations / Client Education Aminoglycosides CIN endings Bactericidal (kill) Penicillin Crosses the placenta Eliminated Ototoxicity and Limited use of Cephalosporins and enter breast milk through Nephrotoxicity these drugs for its Amikacin (Amikin) Broad Spectrum Diuretics Kidney high kidney Gentamicin Nephro - (polyuria, ↑ toxicity and inner (Garamycin) Primarily effective against BUN and creatinine, ear toxicity. Neomycin gram-negative aerobic protein in urine) Tobramycin bacteria Oto - (early sign: Don't give to a (Nobcin, TOBI) tinnitus, vertigo, patient that is hard Streptomycin Best Route: IV or IM headache) for elevated of hearing or has Topical: conjunctivitis trough level kidney disease Oral: colorectal surgery (poor absorption in GI) Antidote - calcium gluconate Carbapenems PENEM endings Bactericidal (kill) Valproic acid Unknown if cross the Eliminated Pseudomembranous Don’t give to Meropenem placenta or enter the through colitis, C.diff diarrhea, pregnant women Doripenem Broad-spectrum - breast milk Kidney NVD, seizures Ertapenem Effective against Gram- Imipenem positive and Gram- Can lead to serious Meropenem negative dehydration and Meropenem electrolyte imbalances, Rapidly absorbed as IM superinfections Reach peak levels if IV Best drug of choice to kill pseudomonas infection Cephalosporins CEF/CEPH Bactericidal (kill) & Aminoglycosides, Crosses the placenta Metabolized Most significant - Gl Client Education **Extremely safe beginnings Bacteriostatic (prevent oral and enter breast milk in the liver, tract Avoid alcohol drug** 5 generations reproduction) anticoagulants, (can affect baby) excreted in Hypersensitivity/allergy while taking alcohol (ETOH) the urine : hive, itching, rash, medication and for First generation: Similar to penicillin in anaphylaxis 3 days after cefadroxil structure and activity (ask finishing the course cephalexin. (PO) about penicillin allergy) Bleeding: monitor PT, of medication INR, and platelet Report symptoms Second: cefaclor Well absorbed from the GI counts, etc for therapy of superinfection cefoxitin, cefprozil tract cefotetan and promptly. (eg. cefuroxime ceftriaxone only diarrhea)  New generations IM: rotate & large muscle Thrombophlebitis with Monitor bloody or are more advance mass (ex. Vastus lateralis) IV and pain with IM watery stools (rotation injection sites/ infusion slowly - with Monitor renal IV & IM) function, reduce dose for renal damage Fluoroquinolones / CIN endings Bactericidal (kill) Iron salts, Cross the placenta and Metabolized Mild CNS symptoms Check for renal Quinolones Broad-spectrum sucralfate, mineral enter breast milk in the liver, (dizziness, headache, dysfunction ( GFR, ciprofloxacin supplements, (careful with pregnant excreted in confusion) Creatinine, BUN) (Cipro), Oral-attractive & IV antacids, women) urine and levofloxacin quinidine, feces GI distress Wear protective (Levaquin) (1x Indications - UTI, theophylline, clothes and day) Respiratory and GI NSAIDs Achilles Tendon sunscreen Infections Rupture - happens Absorption can be especially in children, Infuse slowly over reduced by milk old adults 60 minutes (like (calcium), iron, and pt with Vanco) and antacids. glucocorticoid--report pain and stop Do not mix with other drugs (no Photosensitivity adjunct (sunburn-like reaction) drugs) Muscle weakness * Be cautious when administered to the SJS (rash) children < 18 due to risk of ATR Sulfonamides sulfadiazine Bacteriostatic (prevent Known allergy to Teratogenic (affect the Metabolized GI distress (could be Obtain blood (generic) reproduction) any sulfonamide, fetus) in the liver, severe) take with 8 oz samples for sulfasalazine thiazide diuretics, excreted in water or food baseline and (Azulfidine) Broad-spectrum and pregnancy the urine periodic CBC cotrimoxazole (kidney) Hypersensitivity (rash): counts to detect (Septra, Bactrim) Gram +: MRSA tolbutamide, Stevens-Johnson hematologic Gram - : Chlamydia tolazamide, syndrome disorders. trachomatis → UTI, STDs glyburide, glipizide, or If skin rash, stop Observe and Topical: high incidence of chlorpropamide immediately! instruct clients to hypersensitivity - not and cyclosporine Blood cell deficiency bc report bleeding, used. of blood dyscrasias sore throat, and EYE: treats conjunctivitis / (thrombocytopenia, pallor. corneal ulcer. anemia, leukopenia) Oral: treats Otitis  media (ear infections) Superinfection Well absorbed from the GI (infection on top of tract infection) Glycopeptides Vancomycin Bactericidal (kill) Can be used if Toxicity → Renal Give IV infusion Gram + patient is allergic failure (major) slowly over 1 hour Narrow spectrum to penicillin Infusion reactions red Monitor vital signs Potential toxic drug man syndrome ; If 50% increase in (hypotension, rash, serum creatinine Used to kill C-Diff, must flushing of the face and level, dose should be given as a PILL (PO) trunk - If symptoms, be reduced ; no IV slow the infusion, give antihistamine) ; Determine baseline Kills infections with Ototoxicity (rarely) - hearing acuity and MRSA reversible; monitor for hearing Nephrotoxicity (more loss (whisper test —-- common) CN VIII) Clostridium Difficile Disulfiram-like reaction Blood drawn one Infection when taken with alcohol hour before the Gram-positive next dose given Responsible for 15-25% (trough levels). of antibiotic-associated diarrhea and all cases of The trough levels colitis are more sensitive Txt: metronidazole & to the ototoxicity vancomycin and nephrotoxicity. Recommendations: Use antibiotic carefully Limit use of Isolate patients in a private aminoglycosides room less than 10 Wear gloves & gowns days/dose: once Wash hand with soap & per day water Use disposable rectal thermometers Penicillins and First antibiotic Bactericidal (kills) Tetracyclines, Enters breast milk excreted Most common reaction Penicillinase- introduced for Broad spectrum parenteral Use cautiously in unchanged in is GI (diarrhea) when Resistant clinical use, aminoglycosides patients who are the urine administered orally Antibiotics Derived from mold Indications: skin pregnant or lactating (kidney) (dangerous diarrhea: fungus infections, otitis media pseudomembranous (ear infection), sinusitis, colitis).  Penicillin G respiratory infections, benzathine (Bicillin meningitis prevention of Renal L.A., Permapen), bacterial endocarditis, impairment/hyperkalem penicillin G prior to dental work, ia with high doses potassium endoscopy exams Contraindications (Pfizerpen), - Allergies to Hypersensitivity: penicillin G Rapidly absorbed from the penicillin or Urticaria (rash), pruritus procaine, penicillin Gl tract cephalosporins, (itching), fever, life V (Penicillin-VA), renal disease, threatening anaphylaxis amoxicillin (laryngeal edema, (Amoxi) bronchoconstriction, severe hypotension) Treatment: epinephrine and respiratory support/ observe pt for 30 min following parenteral penicillin If allergy is mild, use cephalosporin, if severe, use vancomycin, erythromycin etc, because 1% cross allergy reaction Tetracyclines CYCLINE endings Bacteriostatic Penicillin G, oral Pregnancy risk Concentrated Most GI, but possible **Doxycycline and contraceptives, Category D in the liver, damage to the teeth and minocycline are Tetracycline Protein Synthesis Inhibitor Digoxin excreted bones. generally safe for demeclocycline Taking tetracyclines unchanged in Photosensitivity clients who have doxycycline Acne when penicillin is Do not given with after the fourth month the urine (intense sunburn) kidney disease, (Doryx, Acticlate) contraindicated (when calcium of pregnancy can stain Suprainfection - because the liver, minocycline allergic to penicillin) supplements, milk, the deciduous teeth, Pseudomembranous not the kidneys, (Arestin, Minocin) iron supplements, but they do not affect colitis (diarrhea), yeast eliminates these Adequately absorbed from magnesium- permanent teeth. infections of the mouth, two tetracyclines the Gl tract containing pharynx, vagina, bowels laxatives and most They do, however, **Tetracycline antacids (can stain the permanent should not be given cause antibiotic to teeth of children to patients with be less effective) between the ages of 4 renal failure months and 8 years who take them Administer on empty stomach  Use cautiously with liver and kidney disease Client Education: Wear protective clothing and use SPF ≥ 30 Notify if diarrhea or yeast infection occurs Report pregnancy-- change drug! Not for children vomiting, irritability, lethargy, hepatomegaly 25% progress to coma - - > death or permanent neurologic impairments Acetaminophen MOA: inhibit prostaglandins, which help to transmit pain signals and induce fever Equal to ASA (Aspirin) in analgesic and antipyretic effects Lacks anti-inflammatory activity Does not cause nausea, vomiting, GI bleeding, or interfere with blood clotting Metabolized in the liver; small amount remains in body as toxic metabolite Acute or chronic overdose can result in liver damage or fatal liver necrosis Usual therapeutic doses may cause/increase liver damage in those who abuse alcohol Available in tablet, liquid, rectal suppository Acetaminophen Toxicity Prevention: Maximum daily dose is 3 or 4 grams from all sources - tylenol, cough syrup, etc. More than 6-8 tablets of 500mg of Tylenol during the day = overdose Overdose causes hepatotoxicity Overdose may be accidental or intentional Signs/symptoms are nonspecific 24-48 hours after overdose, liver function tests begin to show increased levels Later manifestations may include jaundice, vomiting, CNS stimulation with excitement, and delirium followed by coma and death Acetaminophen Toxicity Treatment Gastric lavage and activated charcoal à If overdose detected within 4 hours after ingestion Antidote Acetylcysteine (Mucomyst) à Oral or IV Most beneficial if given 8-10 hours after ingestion, may be helpful within 36 hours Does NOT reverse damage already sustained - liver can heal itself Acetaminophen Interaction Alcohol It slows the metabolism of warfarin and increase the risk of bleeding. Healthy: Maximum daily dose of Acetaminophen 3-4gm. Malnourished: Maximum daily dose 3gm. Alcohol drinkers > 3 servings a day. Corticosteroid - ONE endings Prednisone; Hydrocortisone ; Prednisolone ; Betamethasone; Dexamethasone ; Triamcinolone Prednisone Taper (taper = lowering dose gradually ; need to do with steroids when taking it long term) Prednisone 10mg 6 tabs OD (once a day) with food x 2 days → 60mg for the first two days 5 tabs OD (once a day) with food x2 days → 50mg for the next two days 4 tabs OD (once a day) with food x2 days → 40mg for the next two days 3 tabs OD (once a day) with food x 2 days → 30mg for the next two days 2 tabs OD (once a day) with food x 2 days → 20mg for the next two days 1 tab OD (once a day) with food x 2 days → 10mg for the next two days DISP # 42 (tablets total) Selective Norepinephrine Reuptake Inhibitors (SNRIs) Selective norepinephrine reuptake inhibitors (SNRIs) are a class of antidepressant drugs used in pharmacologic pain management to treat chronic neuropathic painful conditions including fibromyalgia (pain without cause - mostly in women) → treated with Cymbalta (antidepressent) Other Medications Neurontin (Gabapentin) —post herpetic (after herpes) pain syndromes and diabetic neuropathy and seizures Lyrica - for neuropathic pain associated with diabetes (diabetic neuropathy), and spinal cord injury, and post herpetic pain syndromes Medication Goal & Considerations of Titration Goal of Medication Adjust the amount of medication to achieve a serum level that achieves maximum analgesia with minimal side effects Consider: Individual response Age - with elder, go with the lower dose Illness Hepatic function - lower dose depending on liver function Renal function - kidney disease /creatinine clearance Other variables Dosing Intermittent and Breakthrough Pain à Dose PRN Persistent Continuous Pain, Opioid Tolerant patients, and those who do not obtain relief from PRN Dose on a schedule with medication for breakthrough pain, not PRN Expect wide and variable individual responses Principles of Dosing & Interval Consider intensity of pain, medication used, effects of titration, individual variations Intervals are determined by half-life and duration of action of drug & patient condition Breakthrough Pain: Dosing "Rules of Thumb" With controlled released analgesics (PCA pump), evaluate patient for increase in maintenance dose of controlled release med if requiring > 2 breakthrough doses a day, for other than incident pain Dosing is based on current total 24-hour requirement à amount of times PCA pump was pressed i Rescue dose is 10-15% (1/10th to 1/6th) of total daily dose a 1-2 hours Rules of Thumb: Adjusting Maintenance Analgesics If pain remains mild → Increase dose by 25% If pain remains moderate → Increase by 50% If pain remains severe → Increase by 100% Monitor and document response to analgesia Universal Precautions in Pain Management 1. Diagnosis with appropriate differential 2. Psychological assessment with risk assessment 3. Informed consent with Treatment agreement 4. Pre/post intervention assessment pain level and function 5. Trial of opioid therapy +/- adjunctive medication 6. Reassessment 7. Regular assessment of the 4 A's analgesia/activity/adverse effect/aberrant (not normal) behavior 8. Periodic review of pain diagnosis and comorbidities 9. Documentation Nursing Interventions Establish a trusting relationship Consider patient's ability and willingness to participate Use a variety of pain relief measures: pharmacologic and non-pharmacologic Provide pain relief before pain is severe Use pain relief measures the patient believe are effective  Align pain relief measures with report of pain severity Encourage patient to try ineffective measures again before abandoning Ex. if patient tells you the Tylenol never works, tell them to try again Maintain unbiased attitude about what may relieve pain, culturally responsive care Keep trying Prevent harm Educate patients, families and caregivers about pain RESTORATIVE THERAPIES Restorative therapies include treatments provided by PT / OT professionals, physiotherapy, therapeutic exercise, and other movement modalities that are provided as a component of interdisciplinary, multimodal pain care. Therapeutic exercise Transcutaneous electric nerve stimulation (TENS): postpartum, phantom limb pain and knee osteoarthritis. Massage therapy: effective in reducing pain, myofascial trigger points, with attention on the deeper layers of tissues. Traction: PT technique used to treat spinal pain Cold and heat: treatment of symptoms of a variety of acute and chronic pain conditions. Bracing: short periods of time, bracing (especially nonrigid bracing) may improve function and does not result in muscle dysfunction. Therapeutic ultrasound (TU): heat to deep tissues for improved injury healing. Physical Interventions Cutaneous stimulation Immobilization or therapeutic exercises Transcutaneous electrical nerve stimulation (TENS) Treats pain with minimally invasive interventions that can alleviate pain and minimize the use of oral medications. Most interventional therapies for acute and chronic pain conditions as part of a comprehensive treatment program. Intraspinal Epidural steroid injections: one of the most common procedures in pain management, deliver anti-inflammatory medication directly into the epidural space. they offer significant advantages; they may reduce health care costs, health care utilization, and the need for future surgical intervention. Invasive Therapies Surgical disruption of pain conduction cordotomy, rhizotomy, neurotomy Sympathectomy used for vasospasm to improve blood supply if pain is the result of peripheral ischemia Spinal cord stimulation electrode implanted next to spinal cord is attached to internal or external impulse generator Respiratory Medications Allergy An Overreaction By The Body's Immune System To A Normally Harmless Substance. Substances That Trigger An Allergic Reaction Are Called Allergens And Include Environmental Allergens, Such As: Dust Mites Pollen Mold Pet Dander One Problem Caused By Allergies Is Allergic Rhinitis (Clear Runny Nose). Allergic Rhinitis Is An Allergen-Induced Inflammation Of The Nasal Membranes That Results In Your Stereotypical Congestion, Itching, And Sneezing. Beta 2 - For The Lungs (2 Lungs) Beta 1 - For The Heart (One Heart) Trachea Splits Into Two Mainstem Bronchi, One Leading To The Left Lung And The Other Leading To The Right Lung. The Point Where The Trachea Divides Is Known As The Carina. Stress = Sympathetic Nerves = Beta 2 Adrenergic Receptors = Wide Airways Relaxed = Parasympathetic Nerves = Muscarinic Receptors = Narrow Airways Asthma Asthma Is Defined As Chronic Airway Inflammation, Resulting In Airway Swelling And Narrowing And Subsequent Recurring Episodes Of Coughing, Wheezing, Chest Tightness, And Breathlessness. It Can Be Brought Upon By, Not Surprisingly, An Allergen. Other Factors, Non-Allergic Causes Of Asthma: Exercise Respiratory Tract Infections Cold Or Dry Air Sensitivity To Medications Hormonal Changes (Such As Those During Pregnancy) Smoke Stress And Anxiety Asthma Triggered By An Allergic Reaction, To Things Like The Environmental Allergens Called Extrinsic Asthma. Intrinsic Asthma: Is Asthma Triggered By Non-Allergic Components = Cold Air, Exercise, Respiratory Infections. Asthma Characteristics Bronchoconstriction, Inflammation Hyperactivity To Stimuli Symptoms Dyspnea, (Inspiratory (Worse Can't Ge The Air In)/Expiratory /Wheezing, Chest Tightness Cough, Sputum Production Asthma Pathophysiology Bronchoconstriction Narrows Airways Sphincter Action Can Completely Occlude Airway Aggravated By Inflammation, Mucosal Edema, Excessive Mucus Mast Cells Release Substances In Response To Causative Stimuli → Bronchoconstriction And Inflammation Treating Asthma There Is No Cure For Asthma Drugs For Asthma Asthma Is Often Treated With Inhaled Forms Of Beta Agonists, Which Result In Bronchodilation. The Opening Up Of Constricted Airways Is Known As Bronchodilation. Two Main Pharmacologic Classes: Anti-Inflammatory Agents Glucocorticoids Cromolyn Montelukast (Singulair) Bronchodilators Beta, Agonists (Albuterol/Terbutaline) Theophylline/Aminophylline Inhaled Anticholinergics (Ipratropium) With Steroid Inhalers You Need To Rinse Out Your Mouth After Use Because It Can Cause Thrust (Very Sweet) Spacers used with → asthma pts, children, elderly ; meds stay in the spacer until they can inhale Client Teaching Take Medication As Directed. Do Not Discontinue Without Consulting Md When Using Corticosteroids And Bronchodilators Use Bronchodilators First And Follow 5 Minutes Later With Corticosteroids → cause vasodilation. Rinse And Spit After Inhalation Therapy Of Glucocorticoid To Prevent Oral Fungal Infections (thrush) Oral fungal infection = secondary infection Interval Of At Least 1 Minutes Between Puffs To Separate The Puff. Use A Tight Fitting Mask In Infant / Small Child Corticosteroids (Or Glucocorticoids) Are The Most Effective Drugs To Treat Asthma (First-Line Therapy For Asthma) Mechanisms: Suppressing Inflammation ↓ Synthesis And Release Of Inflammatory Mediators (Leukotrienes, Histamine, Prostaglandins) ↓ Infiltration And Activity Of Inflammatory Cells ↓ Edema Of The Airway Mucosa Usually Administered By Inhalation/Nasal, Also May Be Oral (ex. Singular) & IV Inhalation: All Patient With Moderate To Severe Asthma Should Use These Drugs Daily Oral And IV: Only Reserved For Severe Asthma pts Used For Preventive Therapy. They Are Not Used To Abort An Ongoing Attack. → not a rescue inhaler; must take everyday On A Regular Schedule Not Prn. Side effects (of steroids) Oropharyngeal candidiasis Dysphonia (hoarseness, speaking difficulty) Adrenal suppression (Long-term use) Bone loss (particularly in premenopausal women) Slow growth in children (Long-term use) Peptic ulcer Infection Myopathy as evidenced by muscle weakness Potassium loss and sodium retention Weight gain - increases appetite and water retention Ways to ↓ S/E: ↓ the dose rinsing the mouth after use using a spacer device → bi-passes the mmuscal membranes and goes straight into the lungs Corticosteroids Inhalation: Beclomethasone Dipropionate (Qvar) Oral: Predisone Nursing Considerations Do not use these drugs for acute attack  Lowest possible dose or alternate day dosing Use at a regular schedule not PRN Supplemental dose as needed in time of stress (trauma, surgery, infection) Taper dose instead of stopping it suddenly → take less every day Inhalation/nasal: dry mouth: humidifier when sleeping, increase fluid, such on hard candy/tylenol for headache/spacer device, wash month Observe signs of infection (fever, sore throat), electrolyte imbalance (weight gain, edema, weakness) Interactions: NSAIDs increase Gl ulcer and bleeding → don’t take with NSAIDs ANTI-INFLAMMATORY DRUGS - CROMOLYN Mast cell stabilizer (long term txt for allergy related asthma) → mast tissues found in the lungs that produce/release histamine (making you congested and creating an allergic reaction to a trigger) - constricts airways and causes inflammation Used for prophylaxis, not quick relief Suppresses inflammation; not a bronchodilator Route - inhalation: Nebulizer Adverse effects Safest of all antiasthma medications Dry mouth/cough/bronchospasm/bitter aftertaste/headache Prophylaxis: exercise induced asthma---15 minutes before/ long term regular schedule daily It calms down your mast cells so that they don’t get a reaction ANTILEUKOTRIENE DRUGS Action: prevent the effects of leukotrienes, thereby suppressing inflammation, (helping with) bronchoconstriction, airway edema and mucus production. Indication: long term management of asthma Use cautiously in clients with liver dysfunction montelukast (singulair) Most commonly used leukotriene receptor blocker Can not be used for quick relief of an asthma attack PO S/E: headache, Monitor liver function → LFT, ALT, AST Bronchodilators Provide Symptomatic Relief But Do Not Alter The Underlying Disease Process (Inflammation) In Almost All Cases, Patient Taking A Bronchodilator Should Also Be Taking A Glucocorticoid For Long- Term Suppression Of Inflammation Principal Bronchodilators Are The Beta2 Adrenergic Agonists Functions Of Adrenergic Receptor Subtypes Beta1 Heart à Increases… Heart Rate Force Of Contraction And Conduction (AV Node) (Cardiac Arrest, Hf Shorck) Side Effects?(Altered Rhythm And Angina - chest pain) Kidney à Renin Release Beta2 Vasodilation Bronchial Dilation (Asthma) Relaxation Of Uterine Muscle (Delay Of Preterm Labor) Glycogenolysis (Breakdown Of Glycogen Into Glucose) Side Effects? (Hyperglycemia And Tremor) Dopamine Dilates Renal Blood Vessels Bronchodilators - Beta2-Adrenergic Agonists Most effective drugs for relief of acute bronchospasm and prevention of exercise-induced bronchospasm - exercise causes bronchoconstriction so take meds 15 minutes before Use in asthma: both quick relief and long-term control Adverse effects Inhaled preparations Systemic effects - tachycardia, angina (chest pain), and tremor Oral preparations Excessive dosage - angina pectoris, tachydysrhythmias Tremor ALBUTEROL (PROVENTIL) → EMERGENCY DRUG (SHORT ACTING BRONCHODILATOR) → SABA Therapeutic classification: bronchodilators Pharmacologic classification: adrenergic Indications: used as a bronchodilator in the management of reversible airway obstruction. Action: binds to beta 2-adrenergic receptors in airway smooth muscle. Adverse effects: Stimulant NS: nervousness, restlessness, tremor, headache, insomnia Cardiovascular: chest pain, palpitations, angina, hypertension, tachycardia (high dose) Nursing considerations: Avoid caffeine Bronchodilator before glucocorticoid Monitor tachycardia, angina, hypertension etc FORMOTEROL/SALMETEROL (LONG ACTING BRONCHODILATOR) → LABA LABA can increase the risk of asthma-related death. LABA should be used only by patients taking an inhaled glucocorticoid for long-term control, and only if the glucocorticoid has been inadequate by itself Regularly not PRN BRONCHODILATORS - THEOPHYLLINE (THEOLAIR, THEOCHRON) Benefits derive primarily from bronchodilation (relax smooth muscle in bronchi and lung) Narrow therapeutic index-plasma level 10 to 20 mcg/ml → STRONG DRUG CV toxicity is related to theophylline levels: mild (n/v, diarrhea, restless); severe (tachycardia, arrhythmia, convulsion → 30 mcg/ml) Nursing consideration--avoid coffee (coffee, may soft drinks)/monitor plasma level/monitor tachycardia/seizure BRONCHODILATORS - IPRATROPIUM (ATROVENT) Inhaled anticholinergics - drugs that block the action of acetylcholine Decreased stimulation of PNS: dry mouth, urinary retention, hoarseness, increased intraocular pressure (routine test for glaucoma - do not give if they have glaucoma) Do not use it as emergency rescue drug Beta2 agonist increase bronchodilation Do not give to clients who are allergic to peanuts FOUR CLASSES OF CHRONIC ASTHMA Intermittent Step 1: Rescue Drug Short acting inhaled B2 agonist prn Albuterol (proventil) Levalbuterol (хорепех) Mild persistent Step 2:  Short acting inhaled B2 agonist prn Albuterol (proventil) Levalbuterol (хорепех) Daily low dose inhaled corticosteroids Fluticasone (flovent) Mast cell stabilizers - keeping cells from over producing, prevents the production of histamine when coming across a trigger Cromolyn (intal) (particularly in children) Moderate persistent Step 3: Daily inhaled corticosteroids - LABAS Long-acting bronchodilator, e.G. Salmeterol (serevent)--may significantly worsen or deteriorate asthma Formoterol (foradil) SABA for suppressive breakthrough attack Add anti-leukotriene drugs, ex. Montelukast (singulair) Severe persistent - stuffy all day and it gets worse at night Step 4: High dose inhaled corticosteroids PO prednisone or If severe IV corticosteroids Oxygen Saba + ipratropium (reduce airflow obstruction) GLUCOCORTICOID/LABA COMBINATIONS Available combinations Fluticasone/salmeterol (advair) Budesonide /formoterol (symbicort) Indicated for long-term maintenance in adults and children Not recommended for initial therapy TREATING ALLERGIES MANY ALLERGIES ARE DIFFICULT TO CONTROL DRUGS FOR ALLERGIES ALLERGIES CAN BE TREATED WITH ANTIHISTAMINES, CORTICOSTEROIDS, AND ALLERGY SHOT Asthma can turn into a MI (heart attack) → causing death