Hesi Instructions:The contents on this guide are intended to help you organize your preparation for the Evolve

Specialty Exam (ESE) for NR292. This is NOT intended to serve as a direct reflection of the exact questions which will be presented in the exam. As you review the topics listed below, be sure that you can 1. Apply Pharmacological Concepts (to the drugs/drug classes listed below) Pharmacokinetics, Pharmacodynamics, Pharmacotherapeutics Indications and Contraindications Adverse effects Patient variables: Pediatric, Gerontology, Pregnancy/Breast-feeding, Gender, and Cultural/Ethnic variations 2. Apply Nursing Considerations (to the drugs/drug classes listed below) Assessments to include vital signs, physical assessment, labs, & diagnostics Drug administration: safety, route considerations, med orders Drug toxicity (signs/symptoms) and antidote if applicable Patient teaching 3. Perform medication calculation: Oral, suspension, injectable, IV (ml/hr and gtt/min) Metric and household conversions Pharmacokinetics A drugs time to onset of action time to peak effect and duration of action are all characteristics defined by pharmacokinetics. It is the study of what happens to a drug from the time it is put into the body until the parent drug and all metabolites have left the body. Absorption into, distribution and metabolism within and excretion from the body are combined focus of pharmacokinetics. Pharmodynamics- what a drug does to the body, ( done after phase 11 pharmacokinetic phase absorption, distribution, metabolism and excretion) involves drug receptor interactions Pharmacotherapeutics (mechanism of action) focuses on the clinical use of drugs to prevent and treat diseases It defines the principles of drug action the cellular processes that change in response to the presence of drug molecules. Some drug mechanisms of action are more clearly understood than others. Pharmacologic Concepts: Synergistic effects 1+1= 2 combination of drugs with similar action is greater than the sum of the individual effects of the same drugs given alone. Agonistic works together with. A drug that binds to and stimulates the activity of one or more receptors in the body. Antagonistic effects Inhibit a drug that binds to and inhibits the activity of one or more receptors in the body. Tolerance reduced response to a drug after prolonged use Addiction dependence physiologic or psychologic need for a drug physical dependence is the physiologic need for a drug to avoid the withdrawal symptoms (diaphoresis and tachycardia) Anaphylaxis severe allergic reaction closing of the throat and cutting airway off Adverse effects undesirable effects of one or more drugs Side effects - is an effect, whether therapeutic or adverse, that is secondary to the one intended; although the term is predominantly employed to describe adverse

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effects, it can also apply to beneficial, but unintended, consequences of the use of a drug. DRUG Categories: CNS drugs Opioids/Pain Management: Oxycodone (Percocet) scheduled II drug Indication used to control postoperative and other types of pain (strong opioid) Contraindicated for people with drug allergy or severe asthma. Opioids release histamine which causes the itching, vein and arteries to dilate which then leads to flushing and orthostatic hypotension. Adverse effects respiratory depression, hypotension, flushing disorientation, bradycardia, N/V, constipation, urinary retention and pruritus. Antidote naloxone (narcan) Acetaminophen (Tylenol)- nonopioid analgesic Indication mild to moderate pain and reduce fever. Mechanism of action blocks peripheral pain impulses by inhibition of prostaglandin syntheses. Contraindications drug allergy, severe liver/ kidney disease and genetic disease. Adverse effects- rash, nausea and vomiting or severe effects of the blood are anemias and nephrotoxicitys and hepatotoxicity Antidote acetylcysteine maximum dose is 4000mg however 2000mg or less may be necessary for patients with risk factors such as advanced age or liver dysfunction. Liver dysfunction can occur if taking acetaminophen with alcohol in access. Fentanyl (Duragesic)- synthetic opioid schedule II Indication (cancer induced pain med) moderate to severe pain has a high abuse potential. Available in parenteral injections transdermal patches buccal lozenges and buccal lozenges on a stick lollipop or IV giving fentanyl patch to a non-opioid tolerant patient may result in severe respiratory depression. To be considered for opioid patch the patient should have been taking for a week or longer morphine daily oxycodone or hydromorphone. Patients should not use heating pads because it can increase circulation that results in increased absorption causing overdose. Patches should be folded with sticky sides together and flushed down the toilet. New patches can be applied after 72 hours . Know that it will take 6 to 12 hours to reach steady state pain control again. Contraindicated for people with drug allergy or severe asthma. Opioids release histamine which causes the itching, vein and arteries to dilate which then leads to flushing and orthostatic hypotension. Adverse effects respiratory depression, hypotension, flushing disorientation, bradycardia, N/V, constipation, urinary retention and pruritus. Antidote naloxone (narcan) Aspirin (do not give to children with flulike symptoms because it can cause ryes syndrome). It is given as prophylactic therapy for risk factors of coronary artery disease or stroke and given as 81mg or 325mg dose. Mechanism of action inhibit platelet aggregation known as antiplatelet activity. There used as a prophylactic for acute myocardial infarction and many other thromboembolic disorders. Other NSAIDS generally lack these antiplatelet. Contraindications patient at risk for bleeding, vitamin K deficiency and peptic ulcer disease and patient with aspirin drug allergy. NSAIDs can be given the first 2 trimesters but is contraindicated in the 3rd trimester and is not recommended for nursing mothers. NSAIDs should also be discontinued one week before any surgical procedures due to risk of bleeding. Adverse effects GI symptoms such as heartburn and gastrointestinal bleeding, noncardiogenic pulmonary edema. Symptoms of alicylate intoxication: Increased HR, tinnitus, hearing loss, dimness of vision, headache dizziness, mental confusion, Nausea and vomiting sweating thirst hyperventilation hypo/hyperglycemia. Antidote for toxicity- no antidote medication goals is to remove salicylate from the GI and or preventing its further absorption correcting fluid electrolyte and preventing its further absorption, and acid base disturbances and implement measure to enhance salicylate elimination including hemodialysis. NSAIDs are contraindicated for patients with cardiovascular disease due to the increased risk of

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thrombotic events MI and stroke. (Not for aspirin because aspirin as the antiplatelet effect as other NSAIDs do not. In patients with GI upset they can be given cytotec to prevent gastric ulcers and gastrointestinal bleeding that can occur in patients receiving NSAIDs. Ketorolac (Toradol) powerful analgesic effect and has an anti-inflammatory effect. Ketorolac lacks the addictive properties like opioids. Its indicated for orthopedic injuries or surgery. Can be given orally or injection. It is a short tem treatment not for minor or chronic pain. Adverse effects renal impairment, edema GI pain dyspepsia and nausea- this drug can only be used for 5 days because of its potential adverse effects. Muscle Relaxants: Baclofen Indications trauma inflammation anxiety and pain associate with acute muscle spasms. Mechanism of action depresses nerve transmission in the spinal cord. Contraindicated in patients with renal failure. Adverse effects euphoria, lightheadedness, dizziness, drowsiness, and fatigue and muscle weakness experienced early in treatment, generally short lived after growing tolerant to them over time. Toxicity and antidote - No specific antidote or reversal drug. Gastric lavage and close observation of the patient is recommended. Adequate airway should be maintained and electrocardiographic monitor should be instituted and large quantities of IV fluids to avoid crystalluria. Neuromuscular blockers/Anesthetics: Nalbuphine (Nubain) synthetic narcotic analgesic Indications relief of moderate to severe pain also preoperative sedation analgesia as a supplement to surgical anesthesia. Contraindicated drug allergy or pregnancy. Caution use in patient with emotional instability or drug abuse head injury increased ICP cardiac disease impaired respirations, COPD GI disorders impaired kidney or liver function MI and lactation. Nursing implications Withhold this drug if respiratory rate is below 12 watch for respiratory depression of newborn if given during labor and delivery avoid abrupt termination of drug following prolonged use may result in withdrawal symptoms. Cholinergics: Tensilon evaluation of treatment requirements of myasthenia gravis. Diagnose cholinergic crisis - Negative Tensilon test - makes client worse - Positive Tensilon test - client improves. Tensilon is injected intravenously, atropine sulfate is antidote for overdose, in order to diagnose MG most clients will see improvement in 30-60sec/lasts 4-5 min Antiepileptics: Depakote valproic acid unspecified antiepileptic Indications treatment for generalized seizures (absence, myoclonic and tonic clonic)also effective in partial seizures. Contraindicated in patients with liver impairment and urea cycle disorders. Adverse reactions drowsiness, nausea and vomiting along with other GI disturbances, tremor weight gain and hair loss. This drug has interactions to the following drugs: aspirin, cholestyramine, diazepain and warfarin, rifampin, tricyclic antidepressants and antimalarial medications. Advice patients to avoid alcohol, herbal products and to notify health care provider if any thoughts or suicide or dying /anxiety irritability or panic attacks.

CNS/Psychotherapeutic Drugs: Stimulants: Amphetamine (Adderall) releases norepinephrine from nerve endings to increase motor activity mental alertness and decreased fatigue in narcoleptic patients and ADHD patients Indications ADHD and narcolepsy Contraindicated in patients with hyperthyroidism, psychotic personalities suicidal or homicidal tendencies chemical dependence glaucoma or pregnant. Adverse effects/side effects hyperactivity insomnia restlessness tremor palpitations tachycardia anorexia erectile dysfunction growth inhibition and psychological dependence Interactions : MAOI will cause hypertensive crisis, beta blockers, digoxin or antidepressants Nursing implementations advise patients to take at least 6 hours before bed to prevent insomnia, monitor childrens height and weight frequently, teach the parents how to take summer vacations from the meds.

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Antidepressants: SSRIs: Fluoxetine (Prozac) newer generation antidepressant Mechanism of action inhibits serotonin reuptake and have weak effects on norepinephrine and dopamine reuptake. Indications depression, bipolar, panic attacks, obsessive compulsive disorder, post tramatic stress disorder. Contraindicated in patients who use MAOI in the past 14 days and certain antipsychotic drugs, cardiac disease or seizures. Bupropion (wellbutrin or zyban antidepressant) is also contraindicated in cases of eating disorder and seizure disorder because it can lower the seizure threshold. Adverse effects insomnia weight gain sexual dysfunction and serotonin syndrome (due to concurrent use of MAOI and SSRI) potential to cause hypertensive crisis when taken with tyramine (aged cheese, red wine, cured meats like pepperoni and jerky sauerkraut spam Vienna sausages corn beef bologna or beer on tap).Teach patient not to take with OTC medication unless consulting with physician like St. Johns Wart. Antipsychotics: Clozapine (Clozaril) newer generation of atypical antipsychotic drugs- Indication psychotic disorders and Parkinsons disease. Mechanism of action Have a very weak dopamine blocking ability and which it becomes associated with minor to no symptoms of extrapyramidal symptoms, which makes this drug the # 1 choice for treatment of psychotic disorders and Parkinsons. Adverse reactions agranulocytosis, leukocytopenia (monitor blood levels frequently and if it falls below 3000 then withhold medication until it rises about this value. Contraindicated in patients with drug allergy, myeloproliferative disorders, severe granulocytopenia, CNS depression or angle closure glaucoma and in comatose patients. Interacting drugs include alcohol and other CNS depressants /antihypertensive (risk of hypotension) Haloperidol (Haldol) Musculoskeletal Drugs Osteoporosis tx: Miacalcin (calcitonin nasal spray) there are three types of drugs that treat osteoporosis Bisphosphonates, selective estrogen receptor modulators and calcitonin. Indication treatment of osteoporosis mechanism of action directly inhibits osteoclastic bone reabsorption. Contraindicated in patients with drug allergy to salmon because the drug is salmon derived. Adverse effects flushing of the face nausea diarrhea and reduced appetite. Interactions may cause hypercalcemia monitor electrolytes carefully and avoid giving aspirin or NASIDs if they are taking bisphosphonates cause it can irritate the stomach. Respiratory drugs Leukotrienes (Singular) (Montelukast and zafirlukast) Leukotriene receptor antagonists mechanism of action modify or inhibit the activity of leukotrienes which decreases arachidonic acid induced inflammation and allergen induced bronchoconstriction. Indication prophylaxis and long term treatment of asthma in adults and children 12 years of age and older. Not meant for the management of acute asthmatic attacks, takes around 1 week to work. Contraindications drug allergy or allergy to povidone, lactose, titanium dioxide or cellulose derivatives because these ingredients are in this medication. Adverse effects headaches nausea and diarrhea. Anticongestants Decongestants Indication nasal decongestants to reduce the nasal congestion. Decongestants can be taken orally to produce a systemic effect can be inhaled or administered topically to the nose (pseudoephedrine and phenylephrine both OTC) Contraindicated in patients narrow angle glaucoma, cardiovascular disease hypertension diabetes hyperthyroidism and prostatitis. Adverse effects nervousness insomnia palpitations and tremors however they are usually very well tolerated. The most common adverse effect for intranasal steroids is irritation and dryness. Interactions sympathomimetic drugs and sympathomimetic nasal decongestants are more likely to cause drug toxicity when given together. MAOI may result in raising of the BP also medications with pH buffers. Nursing implication- encourage plenty of fluids if not contraindicated to loosen the secretions.

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Antitussives Although all opioid drugs have antitussive effects only codeine and its semisynthetic derivative hydrocodone are used as antitussive. Non opioid antitussive drugs are less effective than the other and are available either alone or in combination with other drugs of OTC cold and cough medications. Mechanism of action suppress the cough reflex through direct action on the cough center in the medulla. Indications stop cough reflex when the cough is nonproductive and or harmful for the patient. Contraindicated in patients with opioid dependency and high risk for respiratory depression, hyperthyroidism advanced cardiac and vessel disease hypertension glaucoma and the use of MAOI in the last 14 days. Nursing interventions - Antitussive medications may cause drowsiness or dizziness so inform patient not to drive or operate machinery while taking. It may also cause respiratory depression if giving with other antitussive medications, so the medication needs to be given in spaced intervals. Expectorant aid in the expectoration of excess mucus that has accumulated in the respiratory tract by breaking down and thinning out secretions. (guaifenesin mucinex) Mechanism of action loosen and thin secretions in response to an irritation of the GI tract produced by the drug and the direct stimulation of the secretory glands in the respiratory tract. Indication bronchitis laryngitis pharyngitis pertussis influenza and measles. Contraindicated for patients who are allergic to guaifenesin. Adverse effects minimal nausea vomiting and gastric irritation. Interactions NONE Bronchodilators- COPD patients! Help to relax bronchial smooth muscle bands to dilate the bronchi and bronchioles that are narrowed. Three types : beta2 agonists (albuterol, ephedrine and epinephrine fast acting), anticholinergic (ipratropium and tiotropium their actions are slow and prolonged and used for prevention of bronchospasms associated with chronic bronchitis and emphysema and not for acute symptoms.) and xanthine derivatives (plant alkaloids caffeine theobromine and theophylline) Inhaled corticosteroids reduce inflammation and enhance the activity of beta agonists to prevent the inflammatory process. Ex: inhaled - pulmicort, decadron phosphate respihaler, aerobid, Flonase, azmacort and the oral corticosteroids used for respiratory illness is prednisone and methylprednisolone (IV or oral). Nursing implementations for respiratory drugs Provide other measures such as humidified o2 etc. Caution about use of alcohol, narcotics and sedative hypnotics due to CNS depression (antitussive) Encourage cessation of smoking Monitor therapeutic response and adverse responses Show patient how to use the inhalers or nasal sprays with return demonstration Have patient rinse mouth with inhaled corticosteroids / do not use for acute respiratory attacks/ taper off the corticosteroids because it can affect your adrenals.

1. 2. 3. 4. 5. 6.

Cardiovascular Drugs Antianginals: Nitrates/Nitroglycerin dilate all blood vessels used as prophylaxis and treatment for angina and other cardiac problems. Indications treat stable unstable and vasospastic angina rapid acting dosages are used to treat acute episodes. Contraindication- severe anemia closed angle glaucoma hypotension and head injury. Along with erectile dysfunction drugs such as Viagra. Adverse effects- headache, hypotension which can cause risk for falls, skin inflammation for topical nitrate forms. MAKE SURE TO PROTECT FROM HEAT AND LIGHT. Intravenous dosing is for emergency and the nurse needs to closely monitor BP and pulse and constant ECG monitoring, and the medication is only potent for 3-6 months. Patient should avoid alcohol hot environmental temperatures saunas hot

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tubs and excessive exertion. Sublingual: 1 tab under tongue at first sign of chest pain if pain not relieved after 1 dose call 911 may repeat up to 3 times Antidysrhythmics: Digoxin - Cardiac glycoside , Mechanism of action Increases force of myocardial contraction. Prolongs refractory period of AV node. Decreases conduction through SA and AV nodes, Indication - CHF, super ventricular tachydysrhythmias such as Aflutter, A fib Contraindications - V-Fib, V-Tach; Use with caution with acute MI Adverse effects Dysrhythmias, hypotension, AV block Nursing interventions- all electrolyte and drug levels should be checked to be sure they are within normal limits. The nurse should always measure the patients apical pulse rate for 1 full minute. If the pulse rate is below 60 or above 100 hold the medication and contact the doctor. Should a toxicity occur and digoxin rise to a life threatening level the antidote is digoxin immune Fab (digibind). Normal digoxin levels are 0.5-2 ng Low potassium levels can cause the potential for digoxin toxicity. Cordarone - one of the most effective antidysrhythmic drugs for controlling supraventricular and ventricular dysrhythmias and is considered a last resort drug. Mechanism of action - Blocks sodium channels at rapid pacing frequencies, exerts noncompetitive antisympathetic action, lengthens cardiac action potential, blocks potassium channels, slows conduction and prolongs refractoriness. Amiodorone is also vasodilator and decreases cardia workload and oxygen consumption Indications Ventricular fibrillation and V-tach. Precautions and contraindications sinus brady cardia, AV block and hypotension. Side effects visual halos and photophobia, hypotension, may precipitate with sodium bicarbonate and the half-life is very long and last up to 40 days Lidocaine is used for ventricular dysrhythmias Antihypertensives: Calcium Channel Blockers pines Calcuim plays an important role in the excitation contraction coupling process that occurs in the heart and vascular smooth muscle cells as well as in skeletal muscles. Preventing calcium from entering into this process therefore prevents muscle contraction and promotes muscle relaxation, which causes then to dilate. Increasing the blood flow to the ischemic heart which in turn increases the oxygen supply and helps shift the supply. Classification : benzothiazepines (diltiazem) dihydropyridines pines amiodipine, felodipine, isradipine, nicardipine ect.) and Phenylalkylamines (verapamil) Indication: Treatment of Prinzmentals angina, effort associated angina, chronic stable angina, also used to treat essential hypertension, paroxysmal supraventricular tachycardia Action: prevents the movement of calcium into the cardiac and smooth muscle cells when the cells are stimulated, interfering with their ability to contract. Leads to loss of smooth muscle tone, vasodilation, and decreased peripheral resistance; Decrease cardiac workload and oxygen consumption. Adverse effects: dizziness, light headedness, headache, asthenia, peripheral edema, bradycardia, atrioventricular block, flushing, rash, nausea Nursing Implications: Monitor blood pressure, cardiac rhythm, cardiac output Coagulation Modifiers: Antiplatelets Aspirin, clopidogrel (Plavix) eptifibatide (integrilin) Indications Aspirin MI prophylaxis, TIA prophylaxis Plavix Reduction of atherosclerotic events, acute coronary syndrome without ST segment elevation. Eptifibatide (integrilin) Unstable angina, MI percutaneous coronary procedures Contraindications thrombocytopenia, active bleeding, leukemia, traumatic injury, GI ulcer, Vitamin K deficiency and recent stroke. Adverse effects serious bleeding episodes

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Nursing implementation patients should avoid taking aspirin or NSAIDs 5-7 days before a surgical procedure. Also avoid the concurrent use of other anticoagulants, antiplatelets and fibrinolytics should not be given together. Antilipemics: Statins hydroxymethylglutaryl-coenzyme a Reductase inhibitor (Lipitor, questran, Zetia) Mechanism of action decreases the rate of cholesterol production in the liver. Indications hypercholesterolemia especially elevated levels of LDL. Contraindicated in patients with liver disease or elevation of liver enzymes and pregnancy. Adverse effects headache dizziness blurred vision fatigue nightmares and insomnia, constipation diarrhea nausea changes in bowel function myalgias and skin rashes. Should ALT and AST levels increase it should be discontinued cultural differences should be assessed with a focus on the individuals beliefs about how to control diet and cholesterol levels. Diuretics: Loop: Furosemide (Lasix)- Prototype: Furosemide (Lasix) Indication: Treatment of edema associated with CHF, acute pulmonary edema, hypertension Action: Inhibits the reabsorption of sodium and chloride form the proximal and distal renal tubules and the loop of henle; leading to a sodium rich dieresis Adverse effects: Dizziness, vertigo, paresthesias, blurred vision, orthostatic hypotension, thrombophelebitis, photosensitivity, rash, uticaria, nausea, anorexia, vomiting, constipation, glycosuria, urinary bladder spasm, leucopenia, anemia, thrombocytopenia, muscle cramps, and spasms, ototoxicity Nursing Implications: This can be taken with food, maintain your usual fluid intake and try to avoid excessive intake of salt Eat foods that are high in potassium (orange juice, raisins, and bananas) Weigh yourself each day, at the same time of day and in the same clothing Change positions slowly Suck on sugarless lozenges and frequent mouth care. Report muscle cramps or pain Osmotics: Mannitol Indications treatment of patients in the early oliguric phase of acute renal failure, however renal blood flow and glomerular filtration must still remain to enable the drug to reach the renal tubules. It can also promote the excretion of toxic substances, reduce intracranial pressures and treat cerebral edema. Contraindicated in patients with known drug allergy sever renal disease pulmonary edema ( use loop diuretic instead) and active intracranial bleeding. Adverse effects convulsions thrombophlebitis pulmonary congestion, headaches chest pain tachycardia and blurred vision. Nursing interventions: Blood pressure, pulse rate, intake and output daily weights should be monitored and record during diuretic therapy. Changes from the initial assessment would alert the nurse to problems with the drug therapy. Anti-infectives Antibiotics: o Tetracycline- The tetracyclines were developed as semisynthetic antibiotics based on the structure of a common soil mold. They work by inhibiting protein synthesis in susceptible bacteria. They are composed of four rings, which is how they got their name. Researchers have developed new tetraclyclines to increase absorption and tissue penetration. Widespread resistance to the tetracyclines has limited their use in recent years. Vancomycin (vancoin, vancoled) is an antibiotic that interferes with cell wall synthesis is suspectible bacteria. It was developed as a result of a need for a drug that could be used both in patients how are intolerant to or allergic to penicillin and or cepalosporins and in the treatment of patients with staphylococcal infections that no longer respond to penicillin or cephalosporins. It

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can cause renal failure, ototoxicity, superinfections, and a condition known as red man syndrome o Cephalosporins- The cephalosporins were the first introduced in the 1960s. These drugs are similar to the penicillin in structure and in activity. Over time, four generations of cephalosporins have been introduced, each group with its own spectrum of activity, described in the following text: First generation cephalosporins are largerly effective against the same gram-positive bacteria that are affected by penicillin G, as well as the gram-negative bacteria Proteus mirabillis, E.coli, and Klebsiella pneumonia ( PEcK; use these letters as a mnemonic device to remember which bacteria are susceptible to the first-generation cephalasporins). Second generation cephalosporins are effective against those strains, as well as Haemophilus influenza, Enterobacter aerogenes, and Neisseria species. (Remember HENPeCK). The second generation drugs are less effective against gram-positive bacteria. Third- generation cephalosporins are relatively weak against grampositive bacteria but are more potent against the gram-negative bacilli as well, as Serratia marcescens (Remember HENeCKS) Fourth-generation cepahalosporins are in development. The first drug of this group, cefepime (Maxipime), is active against gram-negative and gram-positive organisms, including cephalosporin-resistant staphylococci and P. aeruginosa. o Metronidazole (Flagyl) Metronidazole (Flagyl) Also used to treat malaria, but for people who cannot take the -quines #1 drug of choice for Trichomoniasis Helps with many other bacteria that lives in the gut Not just an antibiotic but also an antiprotozoal no other antibiotics classify as an antiprotozoal Bactericidal, amebicidal, trichomonacidal Used for treatment of trichomoniasis, amebiasis, giardiasis, and antibioticassociated pseudomembranous colitis Also decreases anthelmintic (worms) activity #1 DO NOT drink alcohol projectile vomiting, headaches, and chest pain o Piperacillin + tazobactam (Zosyn) Penicillins cilin Bactericidal kills things Kills gram positives Natural penicillin regular penicillin G-#1 treatment for syphilis/strep/staph Aminopenicillins amoxicillin - #1 treatment for ear infections not that successful now we use Cephalosporins=2 nd drug of choice now is #1 Penicillinbeta-lactamase inhibitor combination drugs used to fight the beta-lactam ring. Ampicillin + sulbactam = Unasyn Amoxicillin + clavulanic acid = Augmentin Piperacillin + tazobactam = Zosyn Allergic reactions to penicillins hives or rash (Normal) its ok to try them with Cephalosporins Anaphylactic shock/reaction do NOT try Cephalosporins #1 thing people complain about=diarrhea/GI upset #1 have a problem with oral contraceptives use a different method while on it and a week after

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o Drotrecogin alfa (Xigris) Is a recombinant form of human activated protein C that has anti-thrombotic, antiinflammatory, and profibrinolytic properties. Drotrecogin alpha (activated) belongs to the class of serine proteases. Drotrecogin alfa has not been found to improve outcomes in people with severe sepsis. Drotrecogin alfa does not improve mortality in severe sepsis or septic shock but does increase bleeding risks therefore a 2011 Cochrane review recommended that clinicians and policy makers not recommend its use.[ NOT ON MARKET ANYMORE!!!!

Sulfa drugs: Bactrim (SMZ-TMP) Sulfonamides sulf Bacteriostatic- inhibits the growth or slows down the growth Sufamethoxazole (Bactrim only a pill) common drug - #1 drug for UTIs and staph infection (they kill e-coli and staph/especially MRSA) ----- UTIs are caused by e-coli -----Cellulitis and abscess are caused by staph --- in children it is (Septra a liquid)----also helps with pneumocystis pneumonia (HIV patients) Adverse effects hemolytic and aplastic anemia but you have to be on it for a long period of time people usually only stay on it for 3-7 days greater risk for HIV patients #1 thing people complain about=diarrhea/GI upset Sulfadiazine KNOW!(main drug in silvadene cream) used for burns if someone if allergic to sulfa drugs can they apply silvadene cream to their burns? No Drugs for treating UTI: o Nitrofurantoin (Macrodantin) nitrofurantoin (Macrodantin) dont get confused with seizure drugs. Treated for UTIs in pregnant women. o Pyridium Pyridium (used for UTI) teach pt ahead of time that it will change the color or they will come in complaining

Antivirals: HSV and hepatitis tx acyclovir (Zovirax) #1 drug of choice for herpatic conditions. #1 and #2 (all herpes) Cold sores, shingles, and genital There is a whole bunch of other virs but your body breaks it all down into acyclovir. The reason why our body breaks it all down. The reason we have all of it is because you have to take acyclovir 4-5 times a day. We found other drugs that last longer so you dont have to take it as often but they all break down into acyclovir. HIV Drugs: Protease inhibitors zidovudine (Retrovir) First anti-HIV medication in the word..retrovir..not going to ask you about this particular drug but it came out in 1981 Protease inhibitors (PIs) Work in the same situation but stop the replication part. Protease inhibitors (PIs) Inhibit the protease retroviral enzyme, preventing viral replication amprenavir (Agenerase) indinavir (Crixivan) nelfinavir (Viracept)

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ritonavir (Norvir)

# side affects of antiretroviral is nausea and vomiting. Antitufungals: Terbinafine (Lamisil) Terbinafine is used to treat fungal infections of the toenail and fingernail. Terbinafine is in a class of medications called antifungals. It works by stopping the growth of fungi. Antituberculars: Rifampin- (Rifadin, Rimactane), which alters DNA and RNA activity in the bacterium. No alcohol while taking this. Urine, Stool, Saliva, Sputum, Sweat, or Tears may become reddish-orange. Do NOT become pregnant while taking.

Antihelminthics: Vermox Drug of choice for worms. mebendazole (Vermox) Inhibits uptake of glucose and other nutrients, so the parasite cant eat anything, leading to autolysis and death of the parasitic worm We like it because it kills a lot of worms - roundworms, hookworms, and some tapeworms Adverse Effects GI most common Nausea / vomiting Diarrhea Headaches Nursing Interventions Some drugs may cause the urine to have an asparagus-like odor, or cause an unusual skin odor or a metallic taste; be sure to warn the patient ahead of time Vermox GI drugs GERD/PUD Tx: o Sucralfate (Carafate) Sucralfate is used to treat ulcers. It adheres to damaged ulcer tissue and protects against acid and enzymes so healing can occur. Shake well before you use. o Aluminum hydroxide (Amphojel) Aluminum hydroxide is used for the relief of heartburn, sour stomach, and peptic ulcer pain and to promote the healing of peptic ulcers. be aware that aluminum hydroxide may interfere with other medicines, making them less effective. Take your other medications 1 hour before or 2 hours after aluminum hydroxide. Antiemetics- Anti-nausea/vomiting drugs- Phenergan from phenothiazines. In low dose they are effective and at higher dosage they are used as antipsychotic. S/E drowsiness, muscle, dystonia (extra pyramidal). Zofran used for chemo- take 30 minutes before. Reglan is another drug. Laxatives: o Bulk-formingFiber!

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Causes gas Psyllium (Metamucil) Increases the consitancy in the stool and then helps absorb the water so the stool is looser and not as hard or compacted. Absorbs water to increase bulk o

Enulose (Lactulose) - Lactulose (Chronulac) is the alternative choice for patients with cardiovascular problems. This saltless osmotic laxatives pulls fluid out of the venous system and into the lumen of the small intestine. Vitamins & Mineral Supplements: o Iron 1st thing we try to do is? Diet What do they need to eat? Spinach, liver, organ meat, green leafy veggies, red meats Use with it? Encourage drink citrus (orange juice) to help break down the iron so our body can absorb it better. One thing grape-fruit juice is ok with. Avoid? KNOW! Tea it kilates (does not allow for it to be absorbed) iron do not drink tea within 30min to 1hr of taking iron When taking iron drink lots of fluid, increase fiber, take a stool softener, take before meals or eat with it. Kids higher potential of having iron deficiency make sure to tell parents to keep Flintstone/gummies vitamins in a secure area because kids think they taste like candy can become iron toxic and can die. Only give one. Oral liquid iron what do we tell our patients it will stain their teeth use a straw dilute it can dilute with orange juice KNOW! When someone is taking iron pills do we tell them to lay down and go to sleep? NO because of reflux it is very erosive to the esophagus o o o o Vitamin C Important in wound healing and prevention of bleeding. Vitamin D Sunlight

Endocrine Drugs Antidiabetics: o Insulin Type 1 insulin dependent do not produce insulin at all - no point of taking oral Type 2 oral / not insulin dependent producing insulin but your body is not utilizing it Rapid onset (15min) and duration (3-4) Lispro take when eating & NovoLog Short onset (30min) and duration (3-6) Regular (Humulin R) four times a day every meal and right before bedtime Intermediate onset (2-4) and duration (10-16) NPH (cloudy) & Humulin give twice a day morning and at dinner Long onset (1-2) and duration (24) Lantus (clear) once a day give at night does not peak 70NPH/30Regular Lantus & Levemir Draw up clear first then draw up the cloudy IV regular

Oral Type 2 diabetes

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Biguanides- metformin(Glucophage) #1 drug of choice/ 1st line of treatment for diabetes - helps lose weight / wont be big anymore does not cause hypoglycemia does not stimulate - makes the insulin you have more effective How they work - They decreased production of glucose by the liver, decrease intestinal absorption of glucose, increase uptake of glucose into the cells, and DO NOT increase insulin secretion from the pancreas DOES NOT cause hypoglycemia because it does not increase insulin secretion it just makes the insulin you have more effective KNOW! Metformin - #1 choice for all type 2 diabetes primarily effects the GI tract most people will lose weight with this can cause gas and diarrhea but doesnt last long - can cause lactic acidosis, dehydration makes it worse, KNOW! if someone is on Metformin they have to stop it 24-48 hrs. before they get IV contrast and then after they cant take it again for another 24-48 hrs. If they dont feel right, clammy, and hands shaking what are we going to do? Give them juice, crackers, simple carb with a simple protein, cheese and crackers, cheese and peanut butter juice is quick put all 3 together juice, carb, and protein If they are laying there unconscious what are you going to do? D50 IV push what size IV? At least a 20g Why? It is a hypertonic solution and the tissue can become necrotic if IV site is not available give glucagon because it is an IM shot How long does glucagon work? less than 5 min o Glimepiride (Amaryl) Sulfonylureas First generation: chlorpropamide (Diabinese), tolazamide (Tolinase) Second generation: glimepiride (Amaryl), glipizide (Glucotrol), glyburide (DiaBeta, Micronase)

Sulfonylureas stimulates insulin secretion, better beta cell function, improve sensitivity of the insulin, result in lower glucose levels DO cause hypoglycemia because it stimulates insulin secretion KNOW! Pts have tendencies of hypoglycemia
Adrenal drugs: ACTH Oversecretion leads to cushings syndrome Cushings Syndrome - They have too much steroid. They will have trunkal obesity, fluffy and doughy, moon face. They have too much adipose tissue and too much third spacing

-tropin Anterior pituitary drugs o Cosyntropin o Somatotropin o Somatrem o Octreotide Posterior pituitary drugs o Vasopressin use in a code blue or someone has extreme hypotension very strong vasoconstrictor

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o Desmopressin Mimics sympathetic increase heart rate, bp, respirations Mechanism of action mimics the sympathetic nervous system if someone has a pituitary tumors, what are they going to have? You end up getting oversectretion of the productions of the hormones hypertensive crisis because you have the vasopressin is being released. Indication anti-inflammatory and promotes renal retention of sodium and results in edema and hypertension Thyroid drugs: o PTU- Propythiouracil (PTU) is the most frequently used thioamide; it is associated with severe GI effects. The other available thioamide is methimazole (Tapazole). Hematological adverse effects are more common in with methimazole, so the patient needs to have a complete blood count and differential monitored regularly. GI effects are somewhat led pronounced with methiamzole, so it may be the drug of choice for patients who are unable to tolerate PTU. o Radioactive Iodine If someone has thyroid cancer or graves disease will they have to be on thyroid placement forever? YES The thyroid could be destroyed by radioactive iodine, removed surgically, or can just have half of thyroid removed anytime someone has had any of these things done they will have to be on a thyroid replacement forever How do we treat it? Kill your thyroid we kill the thyroid then give you thyroid hormones that we can have control over we kill it with radioactive iodine, surgery, remove only half of thyroid, then after that need lifelong thyroid hormone replacement Give these drugs until they can get into surgery or get radioactive iodine: In the meantime methimazole (Tapazole) propylthiouracil (PTU) All they do is decrease the amount of thyroid hormone your body uptakes blocks they try to decrease your bp and heart rate All she cares about Some people who got the radioactive iodine and it didnt completely kill the thyroid put them on this Worry about Radioactive iodine treatment problem is that it causes liver and bone marrow toxicity Corticosteroids Glucocorticosteroids: There are multiple ways to use this. They care used for the respiratory system for asthma and COPD. Administration is inhaled. If you have sinus issues they are intranasal. The side effects: Inhaled: dry mouth and thrush Nasal spray: irritation, nosebleeds, headaches, and dry mucous membranes Oral: weight gain, high blood sugar, cushings (moon face) All cortocosteroids all end in -sone Mineralocorticoid fludrocortisone acetate Adrenal steroid inhibitor

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aminoglutethimide

These are the adrenal corticosteroids but they are not used often because we dont like to mess around with peoples adrenal glands. Mechanism of action: Different drugs have different potencies, duration and action but they all do the same thing. The number one reason why we give glucocorticosteroids is for inflammation. That is the number one mechanism of action: it is an anti-inflammatory. Indications Adrenocortical deficiency Cerebral edema Collagen diseases Dermatologic diseases GI diseases Exacerbations of chronic respiratory illnesses, such as asthma and COPD We also give them to people who just had an organ transplant. THE BIGGEST THING THAT YOU HAVE TO UNDERSTAND ABOUT HAVING SYSTEMIC CORTICOSTEROIDS IS THAT IT WILL DECREASE YOUR IMMUNE SYSTEM. YOU TREAT PEOPLE WHO ARE ON LONG STANDING TREATMENT OF CORTICOSTEROIDS AS IF THEY ARE HIV POSTIVE, JUST WENT THROUGH CHEMO, ETC. BECAUSE THEIR IMMUNE SYSTEM IS JUST AS BAD. That is when it is systemic. When someone has a chronic inflammation from things like lupus, people who have RA, any type of autoimmune. Their immune system is going crazy so we give them something that will decrease their immune system and decrease inflammation. This is usually the drug of choice for autoimmune disorder. This is why people will only take steroids for a few days (immune system). Topical, creams and stuff is not such a big deal. Systemic steroids have to be tapered. Nursing Implications Know a baseline weight and height because the majority of the time they give people steroids based upon their weight Systemic forms may be given by oral, IM, IV, or rectal routes (not SC) never given subq because it is very toxic to the skin. Oral forms should be given with food or milk to minimize GI upset Topical is used for psoriasis or eczema you need to make sure that they put on sunblock also. The skin will become sensitive to the sun Immunologic Drugs Immunosuppressants: Cyclosporine Mix oral cyclosporine solution in a glass container because they will eat through the Styrofoam Oral immunosuppressants should be taken with food to minimize GI upset Grapefruit juice also interacts with some of these drugs iron is the only one we take with citrus o Primary drug used for the prevention of kidney, liver, heart, and bone marrow transplant rejection o May be used for other autoimmune disorders Biologic Response Modifiers (BRMS): Filgrastim (Neupogen) These substances arouse the body's response to an infection.

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Filgrastim is used to decrease the chance of infection in people who have certain types of cancer and are receiving chemotherapy medications that may decrease the number of neutrophils (a type of blood cell needed to fight infection), in people who are undergoing bone marrow transplants, and in people who have severe chronic neutropenia (condition in which there are a low number of neutrophils in the blood). Filgrastim is also used to prepare the blood for leukapheresis (a treatment in which certain blood cells are removed from the body and then returned to the body following chemotherapy). Filgrastim is in a class of medications called colonystimulating factors. It works by helping the body make more neutrophils.

Reproductive Drugs Steroids (anabolic) #1 illegal unless you have a prescription for it for a particular reason Schedule III does not require a triplicate (Ms. Martin can prescribe) Problem is most of the time it is misused for a number of reasons normally athletes because the biggest thing it does is muscle mass The reason why they made them illegal (Arnold Swartzinegar) all that muscle mass gets droopy because the skin got real big and the muscle underneath it is not there anymore - He has also had 4 open heart surgeries Heart disease is the #1 thing that anabolic steroids cause What she wants us to know It is illegal they only reason why they use it is for children with growth defects or who needs some secondary male characteristics that are not being developed for some reason Causes heart disease Causes testicular hypertrophy if you keep taking it (small testies and you will become infertile) Adverse Effects: Peliosis of the liver, other severe hepatic effects (they mess with your liver and your heart) Dermatologic Drugs Anti-Acne: Isotretinoin (Accutane) isotretinoin (Accutane) o Oral o Pregnancy category X!!!!!!!!!!!!!!!!!!!!!!! o You have to make a contract with whoever your prescriber is iPLEDGE which is a program for safety that tells them you will use two forms of birth control and you will not get pregnant when your taking the medication you will have to do monthly pregnancy tests o Biggest side effects with this drug is depression and suicidal thoughts while taking this drug you have to see your provider at least once a month do depression screening o Monitor liver and kidneys o If youre a boy and gets someone pregnant while he is on this he can still have chances of the baby having problems o Must wear sunscreen! Ophthalmic Drugs Beta-blockers Prototype: Metroprolol (Toprol) Indication: Treatment of hypertension, angina pectoris

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Action: These drugs block beta-adrenergic receptors and vasoconstriction (thereby stopping an increase in blood pressure) and prevent the increase in heart rate and increased intensity of myocardial contraction. These actions decrease the cardiac workload and the demand for oxygen. Used in combination with nitrates to increase exercise tolerance. Not for prinzmental angina The dose that is used to prevent angina is lower than doses used to treat hypertension. Adverse effects: dizziness, vetigo, CHF, arrhythmias, gastric pain, flatulence, diarrhea, vomiting, impotence, decreased exercise tolerance Nursing implications: Do not stop these drugs abruptly after chronic therapy but taper gradually over 2 weeks Miotics o Constrict the pupil Cholinergic Drugs slows things down and dilate Mimic the PSNS neurotransmitter ACh Also called miotics, cholinergics Direct-acting and indirect-acting drugs They lead to reduction of the interocular pressure by increasing the outflow of aqueous humor Adverse Effects Hypotension Bradycardia Nausea Vomiting

Yaaahhh all done..