Pharm Final Exam

Question 1

Peak level

Answer 1

• Peak is taken when drug is at highest level in bloodstream – allows dr to make sure patient medication level is within safe ranges
  o With IV infusion, 30-60 mins after infusion given
  o Drawn 1-2 hour afterwards if medication given orally

Question 2

Trough level

Answer 2

• Trough level is lowest level of medication in bloodstream

o Drawn right before next administration of medication

Question 3

Drug half-life

Answer 3

• Length of time required for the plasma concentration to decrease by half after administration
• Drugs with short half-lives stay in the body for a shorter period of time, vice versa with longer half-lives

Question 4

Loading dose

Answer 4

• Loading dose – giving a higher dose of a drug to prime the bloodstream to more quickly reach the plateau

Question 5

Maintenance dose

Answer 5

• Maintenance dose – given before the plasma level drops (aka the normal dose)

Question 6

How to minimize drug-drug interactions

Answer 6

• The more drugs a patient receives – the greater the risk for interactions
  o Encourage nonpharm alternatives and avoid copious use of OTC and herbal preps
• Imperative to obtain thorough drug history
• When possible interactions – careful attention to dosage and timing
• Patients must be monitored for potential signs of interactions
  o Especially when taking a drug with narrow therapeutic range

Question 7

Potential results of drug-food interactions and what are the nursing implications

Answer 7

• Potential results of drug-food interactions – may decrease the rate or extent of absorption. Absorption of other drugs is increased in the presence of food. Some drugs must be taken with food in order to reach the therapeutic range (e.g., orange juice and iron).
  o Example – to avoid
   MAOI – no foods rich in tyramine
   Theophylline and caffeine
   Potassium sparing diuretics and salt subs
   Aluminum containing antacids and citrus beverages
   Vitamin K – warfarin (unless being used as antidote for warfarin)
• Nursing implications – Administration with food is with or shortly after a meal. Empty stomach – 1 hour before or 2 hours after meal

Question 8

What is the effect of grapejuice on some drugs?

Answer 8

• Effect of grapefruit juice on some drugs – inhibits metabolism of drugs, leading to increased peaks and possible toxicity
  o Patients need to avoid grapefruit juice or grapefruit ENTIRELY (they can’t have 1 hour after they take med, etc)

Question 9

Inotropic effects

Answer 9

• Force of contraction, not rate – all about strength and force
• Can be positive or negative

Question 10

Chronotropic effects

Answer 10

• Heart rate

- Can be positive or negative (positive increases, negative decreases)

Question 11

Examples of inotropic/chronotropic, because hey, why not?

Answer 11

• Calcium channel blockers – negative inotrope, negative chronotrope
• Beta blockers – negative inotrope, negative chronotrope
• Digoxin (cardiac glycosides) - positive inotrope, negative chronotrope
• Dopamine, dobutamine positive inotrope (dopamine also positive chronotrope)
• ACE inhibitors – negative inotrope, negative chronotrope

Question 12

First-dose effect

Answer 12

• Profound orthostatic hypotension with the first dose of an alpha adrenergic or diuretic
• Common, especially in patients: with hypertension, on diuretics, or volume-depleted, those taking ACE inhibitors
• Patients should be given assistance when getting up

Question 13

First-pass effect

Answer 13

• Many drugs pass through the hepatic system without incident, but some get completely metabolized before they can travel further in the body
• Larger doses may be needed, or avoiding oral route

Question 14

Black box warning

Answer 14

• Warning issued by the FDA and notifies health professionals and consumers of extremely dangerous (and possibly fatal) risks with medication
• Strongest warning a drug can have while allowed to be on the market still
• E.g., Celebrex is only Cox-2 inhibitor on market today

Question 15

Ototoxicity – what is it and what groups of drugs are most likely to cause this? What are early signs of ototoxicity?

Answer 15

• What is ototoxicity – rare but adverse effect that is usually (but not always) reversible – hearing loss can be transient or permanent
• Can occur when serum levels exceed therapeutic range – increased chance when other ototoxic drugs are given concurrently
• Drugs most likely to cause this – vancomycin, ferosemide, aminoglycosides
• Early signs – high-pitched tinnitus, vertigo, dizziness

Question 16

Stevens-Johnson syndrome - what is it?

Answer 16

• Complex hypersensitive reaction (rare medical emergency) that can occur following exposure to some drugs
  o Examples of drugs: penicillin, barbiturates, cocaine, dilantin, sulfonamides
• Also following exposure to infections: viral, bacterial, fungal; and malignancies
• Can take weeks or months to recover from
• Discontinue any medications that could be causing it

Question 17

Red man syndrome

Answer 17

• Anaphylactic-like adverse reaction from administration of vancomycin too quickly
• S/S: hypotension, flushing, tachycardia, redness (HENCE THE NAME), angioedema
• Usually appears within 5-10 min of infusion
• If it happens, slow the infusion rates (stop if severe)
• Can treat symptoms with antihistamines

Question 18

Extrapyramidal effects – what are they? What drug most likely to see them with?

Answer 18

• What are they – movement disorders from effects of antipsychotics on extrapyramidal motor system
• S/S: acute dystonia (spasms of tongue/face/neck), parkinsonism, akasthisia, tardive dyskinesia
• With which drugs most likely to see – antipsychotic drugs

Question 19

Stevens-Johnson syndrome - S/S?

Answer 19

o First symptoms – flu-like (fever, malaise, etc)
o Involves a rash that can develop into bullae that eventually rupture; the rupture of the bullae makes person susceptible to infection
o Can affect mucous membranes of eye, oral, GI, GU, and respiratory tracts
o Can lead to
 Necrosis of GI or respiratory
 Blindness if eyes involved
o Pt may be hypotensive, tachycardic, CNS changes (seizures, decreased LOC)

Question 20

Extrapyramidal effects – How are they treated?

Answer 20

o Acute dystonia
 Onset: few hours – 5 days
 Spasms of muscles of tongue, face, neck and back; opisthotonus (body arched into dorsiflexion)
 Mgmt: anticholinergic drugs (e.g., benzotropine) IM or IV
o Parkinsonism
 Onset: 5-30 days
 Bradykinesia, mask-like facies, tremor, rigidity, shuffling gait, drooling, cogwheeling, stooped posture
 Mgmt: Anticholinergics, amantadine, or both
• Severe symptoms: switch to 2nd gen antipsychotic
o Akathisia
 Onset: 5-60 days
 Compulsive, restless movement; symptoms of anxiety, agitation
 Mgmt: Reduce dosage or switch to low-potency antipsychotic.
• Treat with benzodiazepine, beta blocker, or anticholinergic
o Tardive dyskinesia
 Onset: Months to years
 Oral-facial dyskinesias, choreoathetoid movements
 Mgmt: best approach is prevention; no reliable treawtment
• Discontinue all anticholinergic drugs.
• Give benzodiazepines
• Reduce antipsychotic dosage
• For severe TD – switch to 2nd gen antipsychotic

Question 21

What are opioid effects?

Answer 21

o Respiratory depression, excessive sedation, nausea, vomiting, urinary retention, orthostatic hypotension, biliary colic, euphoria, myosis (pupillary constriction), itching, decreased GI motility, cough suppression

Question 22

Tolerance

Answer 22

o Tolerance – biological condition in which higher doses of drug are needed to achieve same effect
 Natural consequence of regular opioid use
 Patients do not develop a tolerance to myosis or constipation (might develop tolerance to respiratory depression etc)

Question 23

Physical dependence

Answer 23

o Physical dependence – Results in abstinence of symptoms if the drug is stopped abruptly
 Symptoms of physical withdrawal include sweating, tremors, irritability, rhinorrhea, sneezing, N/V, diarrhea, dilated pupils

Question 24

Addiction

Answer 24

o Addiction – psychological dependence
 The individual has strong craving or need for drug
 Continues to use despite possibly having issues at home, work, interpersonal relationships

Question 25

What are anticholinergic drugs used for?

Answer 25

o Used for overactive bladder, eye disorders (to dilate pupil), bradycardia, intestinal hyperactivity, muscarinic agonist muscle poisoning

Question 26

What are anticholinergic effects?

Answer 26

o Vasodilation, tachycardia, dilation of pupils, decreased secretions, decreased GI motility, urinary retention, increased sweating
o Can’t see, can’t shit, can’t pee, can’t spit

Question 27

What are beta-agonists used for?

Answer 27

o Used for bronchodilation (beta 2), heart failure, increased force of contractions seen in beta-1, used in shock to increase rate and contraction strength, AV block, cardiac arrest, asthma, delay of preterm labor, management of cardiac arrhythmias, MI, hypertension

Question 28

What are beta-blockers used for?

Answer 28

o Decreased contractility, decreased workload, slow down heart
o Hypertension, anxiety, tachycardia, angina pectoris, heart failure, myocardial infarction

Question 29

What are alpha-blockers used for?

Answer 29

o Prevent stimulation of adrenergic receptors
o Hypertension, vasodilation, treat BPH, reverse toxicity of alpha-1 agonists, Raynaud’s disease
o Biggest thing is decrease BP

Question 30

Digoxin

Answer 30

• Used for slowing heart rate
• Generates forceful contractions
• Assess apical pulse for 1 min, hold if less than 60

Question 31

Diuretics (loop, thiazide, potassium-sparing) – what are the major differences in these?

Answer 31

• Loop diuretic block reabsorption of potassium and they are potassium wasting
  o Have greatest potential to cause F&E imbalances because they act quickly and cause large amounts of fluids to be excreted in short time
  o Can potentially cause ototoxicity
• Thiazide block sodium absorption and increase water and potassium excretion – potassium wasting
  o First-line for hypertension
  o Don’t work as fast as loop
• Potassium-sparing – I have a feeling these spare potassium (!!), block aldosterone (which blocks the exchange of sodium and potassium)

Question 32

Calcium channel blockers

Answer 32

o What it does – block calcium channel entry ways (which would cause vasoconstriction)
 vasodilates, negative inotrope, negative chronotrope
o Primary uses – hypertension, angina, dysrhythmias (except drugs mentioned below)
o Adverse effects – headache, dizziness, potential for peripheral edema
o Can have reflex tachycardia and increased contractile force with lodapine, niphedipine, nicardipine (beta blocker to treat reflex tachycardia)
 Those 3 not useful in treating dysrhythmias

Question 33

ACE inhibitors

Answer 33

o What it does - Increase cardiac output by lowering BP, and decrease fluid volume
o Primary uses – hypertension, decreased symptoms and prolonged survival in heart failure, myocardial infarction, decreased risk of stroke in patients with hypertension or left ventricular hypertrophy
o Adverse effects
 Mainly hypotension
 Occasionally angioedema.
 Nonproductive hacking cough – 5-10% - common reason for discontinuing therapy
 Hyperkalemia (so don’t give with potassium sparing)
 First-dose effect – PROFOUND orthostatic hypotension

Question 34

Statins

Answer 34

o What it does – lower LDLs and total cholesterol, raise HDLs, reduction of triglyceride levels
 Also improve clinical outcomes – lower risk of heart failure, MI, sudden death
o Primary uses: hypercholesterolemia, primary and secondary prevention of CV events, primary prevention in people with normal LDL levels (rosuvastatin), post-MI therapy, diabetes
o Administered orally
 Only small dose reaches system as most is absorbed on first pass through liver
o Most effective when given in evening because cholesterol synthesis normally happens at night
o If statin therapy stopped – cholesterol will return to pretreatment levels within weeks-months
 Treatment should be lifelong, unless serious contraindications (esp pregnancy or muscle damage)
o Adverse effects:
 Myopathy/Rhabdomyolysis – muscle aches, tenderness, weakness localized to certain muscle groups
• Mild injury  myositis  rhabdomyolysis (fatal)
 Hepatotoxicity

Question 35

What is the baroreceptor reflex? (when is it activated and what are its effects?)

Answer 35

• What is it – feedback loop of autonomic nervous system
• When is it activated – when blood pressure goes up and heart rate decreases OR when BP decreases and HR increases
• What are its effects – causes vasodilation or constriction based on necessary response

Question 36

Anticoagulant and antiplatelet drugs

- If there are antidotes, what are they?

Answer 36

o Protamine sulfate antidote to heparin

o Vitamin K antidote to warfarin

Question 37

Anticoagulant and antiplatelet drugs

- If there are related lab tests, what are they?

Answer 37

o Heparin therapy measured by aPTT, normal value is 30-40 seconds
o Warfarin measured with PT – normal 10-15 seconds – with results expressed in INR
 INR 2-3 is best; used to adjust warfarin doses
 PT measures time to clot – so higher value means less likely to clot, more likely to bleed

Question 38

What is heparin-induced thrombocytopenia?

Answer 38

o Allergic reaction to heparin in which patient’s body reacts to heparin as if it’s foreign pathogen
o Symptoms: fever, fatigue, malaise
o Heparin immediately discontinued – patient should never receive again
o Unexpected drop in platelet count often an early sign

Question 39

Glucocorticoids

- When are they used? (In high doses? In low doses?)

Answer 39

o Low doses: to treat adrenocortical insufficiency
o High doses: used to treat inflammatory disorders (e.g., asthma, rheumatoid arthritis), certain cancers, and suppresses immune responses in organ transplant recipients

Question 40

Glucocorticoids

- What are glucocorticoid effects?

Answer 40

o Metabolism and electrolytes
 Elevation of blood glucose
 Suppress synthesis of proteins (can reduce muscle mass, decrease protein matrix of bone, thinning of skin)
 Fat redistribution (leading to potbelly, moon face, buffalo hump characteristic of Cushing’s) – long-term, high-dose therapy
 In rare cases, significant sodium retention or potassium loss
o Anti-inflammation
o Immunosuppression
o Adverse: adrenal insufficiency, osteoporosis, infection, glucose intolerance, myopathy, fluid and electrolyte disturbance, growth retardation (children), psychologic disturbances, cataracts, glaucoma, PUD, iatrogenic Cushing’s syndrome