PHARM EXAM 5 Flashcards
Parkinson’s Disease
- Resting Tremors “pill rolling”
- Rigidity “cog wheel” (difficulty eating)
- Bradykinesia (difficulty initiating movement)
- Postural instability (stooped, fall risk)
- Flat affect
- Difficulity starting a movement
- difficult to stop movements
- imbalance of ACH & Dopamine ( not enough dopamine)
Cause of Parkinson’s Disease
- Imbalance of acetylcholine (stimulation of muscle) and -Dopamine (relaxation of muscle)
- Normally there is a balance of both neurotransmitters that allow for normal posture, muscle tone and prevent involuntary movements.
- Treatment : increase Dopamine & decrease Ach (CNS)
Medications to improve symptoms would increase dopamine or decrease acetylcholine.
Parkinson’s Drugs (too much ACH, too little dopamine)
- Levadopa-Carbidopa (is synthetic dopamine)
- Pramipexole (is a dopamine agonist, acts like dopamine)
- Benztropine (blocks acetylcholine in the central nervous system/ anticholinergic)
As a nurse you know when treatment is effective when: Pt is able to fx with less assistance and increased ability of ADLs
Levadopa-Carbidopa
too much ACH, too little dopamine
-Levodopa crosses the blood brain barrier and becomes dopamine
Carbidopa prevents the metabolism of Levodopa allowing more to cross the blood brain barrier.
Levadopa-Carbidopa Side effects & cautions
Main side effects are orthostatic hypotension and dizziness **so if pt has HTN –> pt is at risk for falls **
- Can also cause tardive dyskinesia (uncontrolled involuntary movements) - tongue movements . blinking MUST LET MD KNOW AND FIND ALTERNATIVE OTHERWISE MAY BECOME PERMANENT
- Med can take up to 3 weeks to work
Should be stopped gradually, to abrupt could lead to increase in Parkinson’s symptoms.
Caution when used with antihypertensive medications. Antacids increase absorption and increase risk of toxicity
Monitor Liver Function
*can not be taken with High protein diet will decrease med absorption / can not be taken with MAOI can cause HTN crisis
Benztropine- Anti Cholonergic in the CNS
decreases ACH
Divided doses or all before bedtime
Anticholinergic side effects and contraindications
Overdose is treated with Physostigmine
SIDE EFFECTS: (ANTI- SLUDGE)
- Pupils dilate
- Saliva is inhibited
- Heart accelerates/ Blood vessel constrict
- Bronchioles dilate
- Digestion is inhibited
- Liver glycogen breakdown promoted
- Adrenal gland releases epinephrine and norepinephrine
- Sex organs inhibited
AVOID PT w/ BPH- Tachy- increased BP- CHF- kidney problems
Drugs for Alzheimer’s
Cholinergics (in CNS)
Donepezil
Alzheimer’s : Scaring/ lost of brain vol.
-Donepezil- Cholinesterase Inhibitor (Cholinergic)
-Enhancing the effects of acetylcholine in the cerebral cortex can improve memory.
-Modest improvement in 1-4 weeks.
-Does not treat severe stages.
Interaction with cholinergic and anticholinergics
-Contraindicated with hx of peptic ulcer or GI bleed
-Can cause hepatotoxicity
** In early stage you want to increase ACH with cholonergic meds** Can not be used in later stage of Alzheimer’s
**Increased risk of bleeding if Pt has peptic ulcer- if pt states he/she has dark stools nurse should be worried.
SIDE EFFECTS:
- Nausea and other gastrointestinal symptoms
- CNS effects (insomnia, dizziness, headache)
- Bradycardia, syncope
Seizures
** Extra Nerve activity in the Brain that cause activation depolarazation/ repolar of the muscles in the Brain**
-Abnormal or uncontrolled neural impulse
-Different from convulsion-muscle spasms.
Types:
Partial (simple or complex), generalized (absent, tonic-clonic, atonic), special syndromes (fever)
** SEVERE SEIZURE: Status Epilepticus**
Seizures Medication Management
The key is to slow electrical activity. (Make the cell more negative, do not allow it to become positive.)
Allow chloride into the cell
Decrease amount of sodium in the cell
Decrease amount of calcium in the cell
Drugs that like GABA- Cell is more negative
Drugs that make the cell more negative (increase chloride in the cell)
Phenobarbital (Barbiturate)
“Peanutbutter-ball”
Phenobarbital (Barbiturate) GABA receptor agonist
IM preferred, rarely IV
Tissue irritant can lead to tissue necrosis
Respiratory depression, CNS depression
Pregnancy category D
Mainly used in Emergency - also used in animal
RARELY GIVE OUT ANYMORE
Drugs that like GABA-Cell is more negative
Drugs that make the cell more negative (increase chloride in the cell)
Diazepam (Benzodiazepine)
- *WHEN Pt is in Status Epilepticus **
- MORE COMMON MED*
Diazepam (Benzodiazepine) GABA receptor agonist
PO, IM, IV
If given IV should monitor RR every 5-15 minutes
Sedation and dependency
Pregnancy category D
BIGGEST worry is resp. depression - NEED to monitor every 5 min!!- worried about AIR-way and breathing.
Drugs that make the cell less positive (decrease sodium in the cell)
Phenytoin- (Dilantin)
IV : When someone comes in seizure
- Mixed with saline only. If mixes with dextrose will precipitate which can lead to embolus (always flush extra)
- -** Start a new line other arm or Start a new IV line**
- Use large vein or central line
- Can cause tissue necrosis
Can also be given PO
Pregnancy category D
ONLY GIVE WITH SALINE
Drugs that make the cell less positive (decrease sodium in the cell)
Phenytoin- (Dilantin)
Side Effects
*Narrow therapeutic window, requires close monitoring of phenytoin blood levels. Therapeutic Range: 10-20 microgram/mL** If test comes back @ 20micro/ml- leave it it is in good range- do not call MD JUST KEEP MONITORING
- Multiple side effects: dysrhythmia, hypotension(brady), hyperglycemia, confusion, slurred speech, agranulocytosis(low WBC), anemia
- Severe skin reactions like SJS
- Connective tissue disorders: lupus
- Gingival Hyperplasia
- Blood test*: CBC/ electrolyte/ BMP/ BS/ phenytoin
DO not stop med abruptly- even though pt has not have seizure for a long time - meds are usually used forever
Drugs that make the cell less positive (decrease sodium in the cell)
Valproic Acid
IV and PO
Rules for PO administration: Do not chew, do not take with carbonated beverages. *Could open capsules and sprinkle on food if cannot swallow.**
Pregnancy category D
Drugs that make the cell less positive (decrease sodium in the cell)
Valproic Acid
SIDE EFFECTS
- Sedation
- Drowsy- no driving
- Prolonged bleeding times- use soft tooth brush/ no razor
- Bone marrow suppression- platelets/ INR/ Infection
- Photosensitivity- sun burn wear long sleeves/ sun block
- Fatal Liver Toxicity- should not drink alcohol only water/ avoid Tylenol
- Have labs: Liver pannel/ PTT/ INR/ CBC/ Platelets
- Preg Cat D (DONT DO IT)*
Drugs that make the cell less positive (decrease calcium in the cell)
Ethosuximide
- Ethosuximide*
- Pregnancy category C
- Psychosis, behavior change, suicide ideation
- Bone marrow suppression
- Photosensitivity
- Fatal Hepatotoxicity
Anxiety
Apprehension, tension, uneasiness that stems from anticipation of danger. The source of danger is unknown.
Feelings are disproportionate to danger.
Types:
-Generalized Anxiety Disorder
-Panic Disorder
-Phobias
-Obsessive-Compulsive Disorder
-Post Traumatic Stress Disorder
Best treatment is anti-depressant - used to calm down the person
Anxiety Med
LorazepamGABA receptor agonist
(Atiran )
- PO or IV
- When given IV monitor RR every 5-15 minutes
- Drowsiness and sedation/ CNS depression/ Liver disease**
- With IV the effects are more severe, additionally can cause disorientation and amnesia, BP change and vision change
- Cannot use with glaucoma, impaired brain function, liver disease, misuse/dependence (pt will go through withdraws)
- *Best practice is to give to Pt & observe - pt may get bad SE like Decrease in RR and disoriented/ or more amped up**
- IV Dose of Lorazepam - have to monitor RR every 5 min for the amount of time pt is on meds
- AS A NURSE you will need to go through med list and make sure you order the med if you see it otherwise pt will go through withdraws**
Insomnia
Sleep allows for restoration/ body repair as well as allows time to process new information collected during the day.
Insomnia is inability to fall or remain asleep.
Insomnia and anxiety are often associated with each other.
Types of Insomnia:
-Short term or behavioral insomnia
-Long term insomnia
-Rebound insomnia
Insomnia-Zolpidem (Short term insomnia)
Short term insomnia management (7-10) days
Rapid onset (give immediately before bed)
Neuropsychiatric effects BLACK BOX WARNING*
Sleep walk/ sleep drive
Help PT relax before bed:
- no electronics 30 min before bed
- relaxed environment/no caffine
- Med will work quickly
Depression
- Sad, despondant mood
- Five of the following symptoms for at least 2 weeks*
- Difficulty sleeping or sleeping too much.
- Tired, no energy
- Eating too much or too little
- Vague physical complaints.
- Inability to concentrate
- Feelings of despair, guilt, lack of self worth
- Obsessed with death
- Lack of interest in sex or personal appearance
- Delusions or hallucinations.
Depression- Imiprimide (TCA)
Blocks reuptake of serotonin and norepinephrine
(Happy/ motivation/ increased mood but decreased in ACH and anticholinergic)
Takes at least 2 weeks to work
*Can also cause anticholinergic side effects : HTN/increased HR/ dry mouth -urniation hesitation
-Can cause diaphoresis (diabetics)
Increased risk of suicidal ideation (when you first start med)
Contraindicated in MI, bundle branch block, glaucoma, kidney or liver impairement
**causes dangerous heart failure/ Cardiac SE)
Serotonin Reuptake Inhibitors
Depression Med
Focus on seratonin
Sertraline (SSRI)
-Oral
-As pill or liquid
-If liquid must be mixed with another liquid like water, white soda, or OJ
-Takes 2-4 weeks for onset of action (difficult to predict half life because is highly protein bound)
-Agitation, insomnia, headache, dizziness, somulene
Increased risk of suicide ideation
*risk of increased Weight- instruct healthy food for pt
risk of sexual dysfunction
Depression Med
Phenelzine (MAOi)
Phenelzine (Nardil)
Inhibits MAO leaving norepinephrine in the synapse
*Keeping NE & Seratonin & Dopamine linger in the synapse *
- Cannot be used in cardiovascular, cerebrovascular, -hepatic/renal impairment, or pheochromocytoma.
- Cannot use with TCA or SSRI as will cause severe temperature elevations and seizures.
MAOi Guidelines
Avoid caffeine
Avoid tyramine foods. (Tyramine in food is broken down by MAO in the intestine) Ingestion of tyramine foods will cause a rapid increase in NE leading to hypertensive crisis
HA, stiff neck, flushing, diaphoresis, and nausea
Tyramine foods: aged cheese, cured/smoked meats, beer, soy products, beer, wine, chocolate
OR PT WILL FALL INTO A HYPERTENSIVE CRISIS
Bipolar Disorder
Major Depression with periods of Mania (elevated psychomotor activity and irritability)
Mania
Grandiosity
Decreased need for sleep
Talkative
Flight of ideas
Distractible
Increased goal directed activity
Excessive involvement in pleasurable activities
Pt often have trouble compliance with meds
Bipolar-Lithium
Mood Stabilizer: Lithium
- Narrow therapeutic range: 0.6-1.5 mEq/ml REMEMBER
- Relationship with sodium
- Low sodium can cause lithium toxicity (can cause profound hypo htn & causes cardiac arrest)
- Toxicity: hypotension, circulatory collapse
- Also treats Bipolar: Anti-seizure medications: tegretol, lamictal, and valproic acid & Atypical antipsychotics
Attention Deficit Hyperactivity Disorder
ADHD
Easily distractible Failure to receive or follow commands Inability to focus on one task at a time Difficulty remembering Loss/misplacement of personal items. Excessive talking Inability to sit still Impulsiveness Sleep disturbance
KNOW med is effective when: pt is able to focus/ able to learn
ADHD-Methylphenidate (CNS Stimulant)
Heightens alertness Do not crush or break sustained release tablets Controlled substance, risk of dependence Should have drug holidays Nervousness, insomnia, hypertension Liver toxicity * Pt will need a HOLIDAY BREAK*
- can use as weight lost*
- Child needs to be measured height & weight to make sure they are in range before and during treatment*
Psychosis
Delusions-ideas/beliefs not founded in reality
Hallunciotions –seeing, hearing, feeling something that is not there
Illusions- distorted perceptions of stimuli.
Paranoia- extreme suspicion
Schizophrenia
Hallucinations, delusions, or paranoia
Strange behaviors
Rapid alteration between extremes in behavior
Detachment toward life
Strange or irrational actions and movements.
Deterioration of hygiene and job/school performance.
Withdrawal from social interaction.
Described as positive (add to normal) or negative (subract from normal) symptoms.
Hard to treat because they think they are not sick/ compliance issue
Anti-Psychosis
Phenothiazines-Chlorpromazine (dopamine receptor antagonist)
Phenothiazines
Chlorpromazine (dopamine receptor antagonist)
Controls mania and positive symptoms
SE: dizzy, drowsy, orthostatic hypotension
EPS
Neuroleptic Malignant Syndrome: hypertension and fever
med causes High fever & Increased BP
Adverse Effects of Antipscyhotics
Extrapyramidal Side Effects Dystonia- neck stuck Akathisia Parkinsonism Tardive Dyskinesia
Anti-Psychosis Nonphenothiazines Haloperidol (Haldol)
Haloperidol (Haldol)
Less sedation and hypotension but still has EPS symptoms
NMS is rare
* But still have all the parkinsons stuff & Risk Neuroleptic Malignant Syndrome: hypertension and fever
Risperidone (Risperdal)- Atypical
Weak dopamine receptor antagonist
Risperidone
Reduction of excitement, paranoia, negative behaviors associated with psychosis
EPS, fever, orthostatic hypotension
Weight gain and hyperglycemia (Teach about healthy diet & Risperidone
Reduction of excitement, paranoia, negative behaviors associated with psychosis
EPS, fever, orthostatic hypotension
Weight gain and hyperglycemia ( teach of healthy diet & √ BS)
- DO not have to worry about Risk Neuroleptic Malignant Syndrome*
Anti-Platelet Therapy
Inhibition of platelet adhesion at the site of injury.
- Inhibiting COX enzymes (ASA)
- Blocking ADP receptors (clopidogrel)
- Blocking Glycoprotein
Medications Affecting Platelets
Anti-Platelet Therapy- ASA
Inhibiting COX enzymes (ASA)
ASA- Salicylate - Bines to Platelets for 7 days
Prevents CVA/ MI but increases PUI & kidney diseases
- watch for PUI/ Kidney pt
- take with food/ milk
- avoid IBU- can cause blood clot
Medications Affecting Platelets
Blocking ADP receptors
Clopidogrel (Plavix)
- Stops platelets from binding sites from binding for 7 days*
- Given to prevent clots in patient with recent MI, CVA, or PAD.
- Prevention in unstable angina, those receiving PCI or stent
- Irreversibly binding the receptor for ADP, lasts the life of the platelet
Do not crush or split
Flulike syndrome, HA, dizziness, bruising, rash , prurutis
Bleeding
- when treatment is effective: no more CVA/ MI
- Eat with food/ milk
- Ideally hold Plavix for 7 days before SX
- AVOID Other NSAIDS*
Anticoagulation
Inhibition of the clotting factors or the clotting cascade
Warfarin (Coumadin)
Heparin
Low molecular weight heparins (lovenox) Held 1 day before SX
Rivaroxaban (Xarelto)
Dabigatran (Pradaxa)
Medications Affecting Clotting Factors
Heparin
Hold 12 hrs before SX/ works around factor Xa
- Binds to anti-thrombin III inactivating several clotting factors
- Works immediately when given IV. Works in an hour when given SQ.
- Weight based monogram based on use
- With SQ do not draw back on syringe or massage area
- Bleeding
- Heparin induced Thrombocytopenia (if platelets are already low- heparin will lower it even more)
- Epidurals
-Overdose: Protamine Sulfate, given IV, 1mg for every 100u of heparin
Medications Affecting Clotting Factors
Heparin
Extra Info
- Give deep into fat tissue SQ - put pressure for 1-2 min to decrease bruising *
- Heparin will also treat evolving clot - IV will prevent clot from getting bigger & body will try to get rid of clot*
Warfarin (Coumadin)
- works around factor Xa*
- √ PT / INR
- Vitamin K antagonist, cannot synthesize several clotting factors
- Can take up to a week to work. Protein bound, clotting factors that are already produced need to be used up.
Bleeding
Avoid in HTN, endocarditis, hepatic/renal impairment
Dietary interactions
Overdose: PO or IV administration of vitamin K. (salads/ Spinach - watch diet)
- √ freq- INR NL: 1-2
- 2-3–> Needs to be on forever therapeutic range
- > 4 : risk of spontaneous bleeding
Thrombolytic Medication
ATPase
- Converts plasminogen to plasmin which dissolves fibrin clots.
- Off label use to dissolve clots in central venous catheters
-Within 12 hours of MI, Within 3 hours of CVA - otherwise you will op risk of bleeding if given after 3 hours*
- Protection of patient after infusion
- Contraindications: internal bleeding, history of head injury or stroke within the past 3 months. Hx of trauma or surgery, severe incontrolled HTN, intracranial cancer or AV malformation - recent SX = bleeding
- No overdose treatment. (duration of action is 3 hours)
Thrombolytic Medication
ATPase
Extra info
- Do everything before you give med- ex: foley/ draw blood then 3 hours of nothing otherwise pt will bleed
- Need CT scan before TPA because it has to be a clot stroke not a heme stroke
- Before test no Neuro change & no bleeding *
Colony Stimulating Factors
Epoetin Alfa
- Stimulates production of RBC
- Chronic anemia, kidney failure
- Given SQ three times per week
- Do not shake vial, will inactivate medication
*Side effects: elevated blood pressure, HA, fever, nausea, diarrhea, and edema
Risk of clot
Colony Stimulating Factors
Filgrastim
- Increase number of neutropils, make the circulating neutrophils work better.
- Often used during chemotherapy
- Do not given within 24 hours before or after chemotherapy as this will decrease effectiveness
*Side effects: fatigue, rash, epistaxis, decreased platelets, fever, nausea and vomiting. Most common is bone pain
If WBC gets too high then can lead to serious adverse events respiratory failure, MI, intracranial hemorrhage, splenic rupture
Colony Stimulating Factors
Eltrombopag
Increase number of platelets
Common side effects: arthralgia, myalgia, paresthesia, HA, and flulike symptoms
Severe adverse events: bone marrow fibrosis, thromboembolism, hepatotoxicity, cataract formation
Lab Values:
RBC
WBC
Platelets
RBC: 3.2 – 5.2
WBC: 5000 – 10,000
Platelets: 150,000 – 450,000
Anemias
Blood loss
Erythrocytes destruction
Erythrocyte production
Anti-Anemic Medications
Cyanocobalamin
Vitamin Supplements
Cyanocobalamin (Nascobal) PO, intranasal, IM or deep SQ *
Folic Acid PO, IM, SQ, IV
Treatment for anemia related to B12 deficiency
Uncommon adverse events
Hypokalemia, arthralgia, dizziness, HA
Anti-Anemic Medications
Ferrous Sulfate
Iron Salts
Ferrous Sulfate PO *
Iron Sucrose (Venofer) IV
-If IV is highly irritating to tissue with infiltration
-Ztrack (deep muscle) for IM
-Do not crush or empty capsules
-Should be given 1 hour before or 2 hours after a meaql
Common side effect: Constipation, dark stools
