NURS 3210 Pharmacology and Nursing Active Learning Guide PDF

NURS 3210 Pharmacology and Nursing Active Learning Guide- Module 2- Drugs that Affect PSNS and SNS Purpos...

NURS 3210 Pharmacology and Nursing Active Learning Guide- Module 2- Drugs that Affect PSNS and SNS Purpose/Overview Active learning guides help students to focus their study time. They include knowledge level questions as well as those focusing on the application and analysis of information to provide greater context in relation to the course and career skills. Students should review the active learning guide before beginning to engage with the module content, then work to complete the guide during and after engaging with the content. An active learning guide is not the same as a study guide or a test blueprint. It serves as a guide to help the student navigate course or module content. Instructions Quickly review the active learning guide (ALG) before you begin reading and engaging with other content in the module. Looking at the questions beforehand will provide a preview of the information you should be alert to as your work through your reading or module resources. As you work through the module content, complete the active learning guide, topic-by-topic. You should use the resources provided and linked on the “Prepare” page in Canvas as the primary source for answering the questions in the active learning guide. 1. Fill in the table with the drug’s classification/s. The drugs in the table are those you will be asked about on quizzes and exams. Keep in mind your assigned reading may include information about individual agents not listed here. Some drugs have multiple classifications. You can check your work in the practice activity (flashcards) for each module. Common endings or other clues about the drug’s classification are italicized.  NURS 3210 Pharmacology and Nursing Agent Classification Agent Name Classification Agent Name Classification Name Bethanechol Cholinergic Atenolol Beta Blocker. Salmeterol long-acting or Selective beta-agonist Muscarinic beta-1 bronchodilat (direct- adrenergic or acting) receptor antagonist. Atropine Anticholinerg Scopolamine Anticholinerg Phenylephrine Selective ic ic alpha-1 adrenergic receptor agonist Donepezil Anticholinest Midodrine Alpha-1 Propranolol Non- erase adrenergic selective (indirect- agonist beta- acting) adrenergic receptor blocker Carvedilol Non- Pyridostigmine Anticholinest Dobutamine Beta-1 selective erase adrenergic beta- (indirect- agonist adrenergic acting) receptor blocker Dopamine Neurotransm Oxybutynin Anticholinerg Phentolamine Alpha- itter ic adrenergic blocker Albuterol Beta2- Clonidine Alpha-2 Norepinephrine Adrenergic adrenergic adrenergic agonist agonist agonist Epinephrine Adrenergic Tamsulosin Alpha-1 Pseudoephedrine First- agonist adrenergic generation blocker antihistamin e Tolterodine Anticholinerg Dicyclomine Anticholinerg Labetalol Non- ic ic selective beta- adrenergic blocker Memantine NMDA- Metoprolol Beta-blocker receptor antagonist  NURS 3210 Pharmacology and Nursing Readings: Chapters 20 & 21 (PSNS: Cholinergics and Cholinergic Blockers) 2. Complete the table describing the physiologic responses of parasympathetic nervous system stimulation and blockade. (These are usually opposites.) System PSNS Stimulation PSNS Blockade (cholinergic agonists) (anticholinergics) Pupils Contraction. Decrease in Pupil dilation pupil size. Heart Rate Bradycardia Tachycardia Bronchi Bronchoconstriction/ Bronchodilation Bronchodilation GI/Bowel Increased Motility Decreased Motility Bladder Bladder contraction Decreased bladder muscle activity Vasculature Vasodilation Vasoconstriction 3. What does acetylcholinesterase do? The enzyme responsible for the breakdown of acetylcholine. Also referred to as cholinesterase. There are two categories of cholinesterase inhibitors: reversible inhibitors and irreversible inhibitors. Reversible cholinesterase inhibitors bind to cholinesterase for a short period, whereas irreversible cholinesterase inhibitors have a long duration of activity, and the body must generate new cholinesterase enzymes to override the effects of the irreversible drugs. 4. What is the primary neurotransmitter of the parasympathetic nervous system (PSNS)? Acetylcholine is the neurotransmitter responsible for the transmission of nerve impulses to effector cells in the PNS. A cholinergic receptor is a receptor that binds acetylcholine and mediates its actions. There are two types of cholinergic receptors, as determined by their location and their action. What are the two receptor types it activates?  NURS 3210 Pharmacology and Nursing Nicotinic receptors are located in the ganglia of both the PNS and SNS. They are called nicotinic because they also can be stimulated by nicotine. The other type of cholinergic receptor is the muscarinic receptor. Muscarinic receptors are located postsynaptically in the effector organs (i.e., smooth muscle, cardiac muscle, and glands) supplied by the parasympathetic fibers. They are called muscarinic because they are stimulated by the alkaloid muscarine, a substance isolated from mushrooms. 5. In 2-3 sentences describe myasthenia gravis (MG), its pathology, and explain why cholinergic drugs are beneficial for patients with this condition. Myasthenia Gravis → is a chronic autoimmune disorder where antibodies destroy the communication between nerves and muscle. The result is weak skeletal muscle. Pathology: Autoimmune disorder that affects the neuromuscular junction, causing antibodies to destroy neuromuscular connections, resulting in imparired communication between nerves and muscle, leading to muscle weakness. Especially in the eyes. Muscle weakness improves with rest. cholinergic drugs that work to increase acetylcholine by inhibiting acetylcholinesterase. Pyridostigmine has been shown to improve muscle strength and is used to relieve the symptoms of myasthenia gravis; it is the most commonly used drug for symptomatic treatment of this disease. Edrophonium (Tensilon) is an indirect-acting cholinergic drug used to diagnose myasthenia gravis. It can also be used to differentiate between myasthenia gravis and cholinergic crisis. 6. Create or draw a table, chart, or Venn diagram comparing and contrasting myasthenic crisis with cholinergic crisis in terms of cause, presentation, and treatment. Cause Myasthenic Crisis  NURS 3210 Pharmacology and Nursing Caused by sudden exacerbation of myasthenia gravis. Significant decrease is functional acetylcholine receptors at eh neuromuscular junction. Cholinergic Crisis Caused by overstimulation of nicotinic and muscarinic receptors at the neuromuscular junction due to excessive accumulation acetycholine. Presentation Myasthenic Crisis Severe muscle weakness that affects different muscle groups. Cholinergic Crisis Excessive cholinergic stimulation, increased salivation, increased lacrimal fluid released, increased sweating. Treatment Myasthenic Crisis Supportive care to make sure adequate ventilation and oxygenation occurs. Possibly mechanical ventilation or IV immunoglobulins. Cholinergic Crisis Focused on impeding the over active cholinergic stimulation. This is the result of atropine administration, a muscarinic antagonist. 7. Complete the Alzheimer’s Case Study Questions located in Chapter 20, p. 320. 1. In her discussion with E. and her husband, the physician mentioned a drug called donepezil (Aricept) that can be used in the early stages of Alzheimer’s disease. It may be started after a few diagnostic tests are performed. After the physician leaves the room, E. asks the nurse, “What will this drug do for me? Will it stop the Alzheimer’s disease?” How will the nurse reply?  NURS 3210 Pharmacology and Nursing Donepezil treats memory loss and confusion in people with Alzheimer disease. It works by improving attention, memory and the ability to participate in adl’s. It does this by increasing acetylcholine, a neurotransmitter that is involved in memory and cognition. This medication will help with signs and symptoms, but is not a cure. 2. G. is not sure about the oral dissolving tablet. “Can’t she just swallow it?” What will the nurse teach them about taking this form of the drug? The nurse will teach the patient about the following: Ease of administration → Oral Dissolving Tablets dissolve quickly in the mouth without the need for water. This can make it easier for some patients, especially those who have difficulty swallowing pills. Absorption → This form of tablet allows the medication to start being absorbed directly through the mouth’s mucous membrane. This route can provide a faster onset of action. Convienience → Oral Dissolving Tablets can be more convienient for on the move dosing without the need for water. 3. After 6 weeks, G. brings E. back to the doctor’s office for a follow-up appointment. G. privately tells the physician that he is “upset” because he has noticed very little improvement. E. states that she feels “fine” and has not noticed any problems. What do you think will be the physician’s next order at this time? The physicians order will be to reevaluate the patient. The patient may need to be reassessed to verify the diagnosis was correct and that donepzil was the appropriate prescribed medication. The physician will review the prescribed dosage to ensure it is correct and optimal. The physician will take into account additional supportive therapies.  NURS 3210 Pharmacology and Nursing The physician will reiterate patient education and expectation of the medication prescribed. Is E.’s response to the donepezil typical? Explain your answer. E’s response to the medication is typical. Donepezil is designed to assist with managing signs and symptoms of Alzheimer’s disease. Significant improvement is not always observed. It is used to stablilize or may improve cognitive function. The response to the medication can vary from subject to subject. Some may have noticeable benefits and others not or minimal results. 8. Complete Critical Thinking Question #2 in Chapter 20, p. 322. 2. A patient newly diagnosed with myasthenia gravis has received a dose of pyridostigmine (Mestinon) in the morning, just before breakfast. She says, “Oh, I know this won’t cure me, but I’m so glad that this drug makes me feel better. Will it last all day?” What is the priority when the nurse is teaching this patient about pyridostigmine? The priority patient education for pyridostigmine (Mestinon) is to emphasize the dosing schudule and the duration of action. Pyridostigmine (Mestinon) requires multiple doses throughout the day to keep muscle tone and strength and prevent symptoms of myathenia gravis from returning. The nurse will educate on the importance of medication adherence, dosage times and possible side effects. 9. Complete the Case Study about Transdermal Scopolamine in Chapter 21, p. 332. a. Before J. picks up the prescription, the nurse assesses for contraindications to scopolamine. What are the contraindications to the use of the scopolamine patch? How should the patient respond to the question?  NURS 3210 Pharmacology and Nursing Contraindications → Scopolamine can increase intraocular pressure, worsen urinary retention, may exacerbate conditions similar to paralytic ileus, can lead to difficulty urinating and can exacerbate signs and symptoms of myasthenia gravis. b. That evening, J. and L. go to dinner. J. is feeling somewhat drowsy, but thirsty. The waiter asks if they would like to have champagne as part of the celebration of the first night of the cruise celebration. How should J. respond? J. should decline the champagne. A non alcoholic beverage would be a better and safer choice. Alcohol may increase drowsiness and dizziness while a patient is taking scopolamine. c. The next morning, while out on the deck, L. and J. are taking pictures of the bright, snow-covered shoreline views. L. looks at J. and exclaims, “Look at your eyes! Is that a side effect of that patch?” What has L. noticed about J.’s blue eyes? What would you suggest for J. because of what L. has noticed? L. noticed that J’s. Eyes were dialated. J’s, pupil’s were larger than normal. d. Later that day, J. tells L., “I’m feeling great! I don’t think I need this patch. I’m going to take it off, but I’ll save it for later in case I get nauseated.” Is this a good idea? Explain your answer. That is not a good idea. The patch can possibly be contaminated during storage, reduced adhesion and reduced effectiveness. Patients should stick to the patient education, dosage, time and medication adherence.  NURS 3210 Pharmacology and Nursing Chapters 18 & 19 (SNS: Adrenergics and Adrenergic Blockers); selected pages from Ch. 23, 24 (Alpha-1 Blockers, Beta Blockers) & 37 (Beta Agonists) 3. Complete the table describing the physiologic responses of sympathetic nervous system stimulation and blockade. (These are usually opposites.) Notice that blockade of the SNS is similar to stimulation of the PSNS, and that stimulation of the SNS is similar to blockade of the PSNS. System SNS Stimulation (adrenergic SNS Blockade (adrenergic agonists) antagonists) Pupils Pupil dilation Pupil constriction Heart Rate Increased heart rate Decreased heart rate Bronchi Bronchodilation Bronchoconstriction GI/Bowel Increased Motility Decreased Motility Bladder Increased bladder capacity Decreased bladder capacity due to relaxation of due to increase in detrusor detrusor muscle. muscle contraction. Vasculature Vasoconstriction Vasodilation 4. Write the expected response for stimulation of each adrenergic receptor type. Although other receptor subtypes exist, and receptors can be found a variety of tissues, the tissues with the most significant response for pharmacotherapeutics are indicated: Receptor Primary Site of Action Expected Response Alpha-1 Vasculature (Blood Vessels) Vasoconstriction Alpha-2 Vasculature (Blood Vessels) Vasodilation Beta-1 Heart Increased heart rate and contractability Beta-2 Lungs Dilate airways. Easier to breathe. Dopaminergic (see Blood vessels to brain, Vasodilation. “dopamine” p. 294) kidneys, heart, mesentery Neurotransmitter release (Brain). Increased heart rate and contractability. Increase in renal perfusion pressure and an improvement in glomerular filtration rate(Kidneys). Vasodilation (Mesentery).  NURS 3210 Pharmacology and Nursing 5. What neurotransmitters activates adrenergic receptors like those in the table above? Catecholamines. The primary catecholamines that activate adrenergic receptors are Norepinephrine and Epinephrine. Norepinephrine (Levophed) acts predominantly by directly stimulating alpha-adrenergic receptors, which leads to vasoconstriction. It also has some direct-stimulating beta- adrenergic effects on the heart (beta1-adrenergic receptors) but none on the lung (beta2- adrenergic receptors). Epinephrine is an endogenous vasoactive catecholamine. It acts directly on both the alpha- and beta-adrenergic receptors of tissues innervated by the SNS. It is considered the prototypical nonselective adrenergic agonist. Epinephrine is administered in emergency situations and is one of the primary vasoactive drugs used in many advanced cardiac life support protocols. 6. Stimulation of Beta-1 receptors results in a 3-fold response: 1. positive inotropy, 2. positive chronotropy, and 3. positive dromotropy. a. Write, in your own words, a definition for each of the following terms: i. Positive Inotropy → An increase in heart contractions, resulting in an increase in stroke volume and ejection fraction of blood from the left ventricle. ii. Positive Chronotropy → Chrono = Time. An increase in heart rate. iii. Positive Dromotropy → A shortening of the action potential duration. An increased rate of depolarization during the action potential in cardiac muscle cells. b. What is the expected response if Beta-1 receptors are blocked (beta-1 antagonism)? Heart response → Decrease in heart rate.  NURS 3210 Pharmacology and Nursing Contractility → Decrease in myocardial contractility, also known as decreased cardiac output. Blood Pressure → Decrease in blood pressure due to vasodilation and reduced systemic vascular resistance. Renin Release → Increased renin release from the kidneys. Causing an increase in angiotensin II and aldosterone, increased fluid retention and potential electrolyte imbalance. 7. At higher doses Dopamine causes stimulation of receptors other than dopaminergic receptors. This is called “dose-dependent” responses. What other receptors are affected by higher doses of dopamine, and what is the physiologic response that results? Adrenergic Receptors → Causing increased heart rate, vasoconstriction and increased blood pressure. Serotonergic Recetptors → Causing alterations in mood, behavior and cognition. Histaminergic Receptors → Causing vasodilation and regulation of wakefulness. Muscarinic Cholinergic Receptors → Causing changes in autonomic nervous system, leading to changes in heart rate and smooth muscle contraction. 8. Complete Critical Thinking Questions #1 & #2, Chapter 19, p. 313. a. A 46-year-old woman is now taking propranolol (Inderal) for the control of tachycardia and hypertension. What is the nurse’s priority in answering if the patient states, “Well, if it doesn’t work after a month or two, I’ll just quit taking it!? The priority for the nurse is to assess the patients understanding and knowledge of the medication, expectations and the need for medication adherence and consistency is needed to manage the diagnosed signs and symptoms.  NURS 3210 Pharmacology and Nursing b. A 73-year-old man is given a new prescription for tamsulosin (Flomax) for treatment of BPH. He lives at home with his wife and uses a cane to help him walk because of the effects of a stroke he had 5 years ago. During the patient education session, the nurse should emphasize which issue of highest priority? Fall prevention. Use of the alpha blocker tamsulosin in patients with BPH is quite common, and patients taking this drug need to inform all health care providers— including dentists—that this is part of their medical regimen, especially before any type of surgery. In addition, anything resulting in vasodilation needs to be avoided to prevent postural hypotension with resultant dizziness, lightheadedness, and syncope. This includes alcohol intake, excessive exercise, exposure to hot climates, and use of saunas, hot tubs, and heated showers or baths. See the box “Patient Centered Care: Patient Teaching” for more information. It is important to address fall prevention strategies. Tamsulosin is an alpha-blocker that can cause orthostatic hypotension as a side effect. Decreased blood volume, drop in blood pressure. 9. Complete the Dopamine Infusion Case Study questions 1, 2, and 4, in Chapter 18, p. 299. a. Explain how this dose of dopamine works to help treat Mr. P’s heart failure. Dopamine → vasoconstrictor, maintains blood pressure and prevents excessive blood pooling to prevent fluid overload. Stimulates release of endogenous catecholamines from adrenal glands, to improve cardiac output by improving heart rate and contractability. b. Do you think there is a concern at this time? Explain your reasoning and what should be done.  NURS 3210 Pharmacology and Nursing First a patient assessment should be completed to reevaluate the patient, verify the diagnosis is correct and the medication prescribed is correct. c. Later in the day, while making rounds, you check the insertion site of Mr. P’s dopamine infusion and find the area swollen and cool to the touch. What went wrong? The swelling is due to infiltration of the medication at the IV site. What is your priority action, and what treatment will you expect to be given? Priority action → Stop the infusion to stop the infiltration of the medication in the tissue. Elevate the affected limb to promote drainage of the infiltration. Place a warm compress to the area to improve circulation and increase comfort. Assess the area and monitor repeatedly. Consult the HCP about the infiltration and to receive management direction and document. 10. Complete Critical Thinking Question #1 in Chapter 18, p. 301. a. A patient is experiencing a severe anaphylactic reaction after a dose of an antibiotic, and the emergency team is present. The nurse is expecting to give what drug first? Explain your answer. Epinepherine → considered to be the cornerstone for treatment with anaphylaxis because of its rapid onset, vasoconstriction properties and bronchodilator effects. To reverse the symptoms of the anaphylactic reaction.