NR-291 Pharmacology I Study Guide With answers – Exam 4

1 NR-291 Pharmacology I Study Guide – Exam 4 Chapter 10: Analgesic Drugs oKnow and apply basic pharmacology principles for pain management oKnow WHO Analgesic Ladder and apply to acute pain and chronic pain management oOpioid Drugs: 1, 5, 6, 11, 12, 13 (addicts and non-addicts) ▪Nice to know: •Nursing Considerations: oMedicate pts before the pain becomes severe (Around the Clock, ATC) oPharmacologic and nonpharmacologic approaches to pain oOral forms should be taken with food to minimize gastric upset oEnsure safety measures such as keeping side rails up, to prevent injury •Drug Interactions: oAlcohol, antihistamines, barbiturates, benzodiazepines, monoamine oxidase inhibitors •4 categories of opioids: oEndogenous – produced by the body oOpium alkaloids – morphine oSemi-synthetic opioids – oxycodone, hydrocodone, hydromorphone, heroin oFully synthetic opioids – propoxyphene, tramadol, pentazocine •Heroin, oxycontin, and hydrocodone/acetaminophen (Vicodin) have similar effects •Opioid ceiling effect – codeine, nalbuphine, pentazocine •Clonidine oAlpha-2 adrenergic agonist oCentral inhibition of the hyper-nonadrenergic state that occurs in opioid withdrawal oDecrease BP and stress in the first few days of withdrawal ▪Good to know: •Rapid-onset opioids (fentanyl) oDo not have to swallowed (injection, buccal lozenge, or stick/sucker) oApproved for treatment of cancer-related breakthrough pain oPatches change every 72 hours ▪Dispose by flushing down toilet or sharps container, avoid heat over patch because can increase absorption •Use with extreme caution in pts with: oRespiratory insufficiency, elevated intracranial pressure, morbid obesity and/or sleep apnea, paralytic ileus, pregnancy •Adv Eff: oCNS depression ▪Leads to respiratory depression, most serious adv eff ▪Decreased BP and HR This study source was downloaded by from CourseH on :40:44 GMT -05:00 2 o GI o GU oSkin oEyes ▪Sleepiness ▪Nausea and vomiting ▪Paralytic ileus ▪Constipation (Opioid Induced Constipation/ OIC) – adequate fluid and fiber intake to prevent •Methlnaltrexone bromide (Relistor) •Lubiprostone (Amitiza) ▪Urinary retention ▪Diaphoresis, flushing, and itching ▪Pupil constriction (miosis) •Hydromorphone o8 times more potent than morphine oEpidural route can lead to increased ICP ▪Got to know: •Opioid antagonist drug: naloxone oGiven IV push oReverse adv eff of opioid drugs ▪Withhold dose and contact physician if there is a decline in the pt’s condition or if vital signs are abnormal, especially if respiratory rate is less than 10-12 breaths/min ▪Regardless of symptoms, when a pt experiences severe respiratory depression (dyspnea, diminished breath sounds, or shallow/irregular breathing) give opioid antagonist oReversal agent for opioid addicts: naltrexone •Opioid withdrawal/opioid abstinence syndrome oPeak 1-3 days; duration 5-7 days oManifested as: increased BP and HR, anxiety, irritability, confusion, insomnia, chills, hot flashes, diaphoresis, joint pain (arthralgia), lacrimation, rhinorrhea, nausea, vomiting, abd cramps, diarrhea, mydriasis, piloerection •Medication treatment for withdrawal oClonidine (Alpha 2 Agonist) oMethadone ▪Long half-life, may lead to overdose/death ▪Opioid so fills the same receptors of abused opioid, but block the effects of street drugs and decreases cravings •Meperidine HCl oToxic CNS, may lead to seizures; not long-term therapy ▪ adjuvant drugs: know classifications; amitriptyline: 2; gabapentin: 2 oNonopioids: 1, 2, 3, 5 ▪Nice to know: This study source was downloaded by from CourseH on :40:44 GMT -05:00 3 •Acetaminophen content of all medications taken by the pt, both OTC (more than 600 drugs) and prescription oInadvertent excessive doses may occur when different combination drug products are taken together ▪Good to know: •Contraindications/interactions (Acetaminophen) oDrug allergy oLiver dysfunction, possible liver failure oG6PD deficiency (hemolytic anemia) oDangerous interactions may occur if taken with alcohol or other drugs that are hepatotoxic ▪Got to know – Acetaminophen •Maximum daily dose for healthy adults is being lowered to 3000mg/day o2000mg/day for elderly or those with liver disease •Acetaminophen Toxicity oLethal when overdosed: hepatic necrosis or hepatotoxicity oMay remain symptom-free for up to 24 hours; after this initial period, the following symptoms are common: ▪Nausea, vomiting, abdominal pain, malaise, anorexia, confusion oRecommended antidote: acetylcysteine regimen ▪10 hours within overdose, 17 doses every 4 hours ▪Oral (bad tasting, odor or rotten eggs) or IV Chapter 11: General and Local Anesthetics oNice to know: ▪General Nursing Considerations •During recovery, monitor for cardiovascular depression, respiratory depression, and complications of anesthesia •Implement safety measures during recovery, especially if motor or sensory loss occurs because of local anesthesia •Reorient pt to his or her surroundings ▪Balanced anesthesia •Administration of minimum doses of multiple anesthetic medications oGood to know: ▪General anesthesia •Sites primarily affected: oHeart, peripheral circulation, liver, kidneys, respiratory tract oMost common: myocardial and respiratory depression •Nystagmus can occur; other findings include skeletal muscle relaxation, hypotension, and increased ICP ▪Spinal headache may occur (40%) in spinal anesthesia •Dull, throbbing pain, varies in intensity from mild to incapacitating •Pain typically gets worse when pt sits up or stands and decreases or goes away when pt lies down •May also have dizziness, ringing in the ears (tinnitus), light sensitivity (photophobia), nausea This study source was downloaded by from CourseH on :40:44 GMT -05:00 4 ▪Local anesthetics with vasoconstrictors (epinephrine) •Why? oTo prevent systemic absorption of anesthetic oTo help confine local anesthetic to injected area oTo reduce local blood loss during procedure •Caution into highly vascular tissue oCaution: face; tips of nose, ears, and fingers ▪NMBDs adv eff •Hypo/hypertension; tachy/bradycardia •Bronchospasm, excessive secretions oGot to know: ▪Moderate sedation reversal agents •Opioid antagonist drug: naloxone •Benzodiazepine antagonist drug: flumazenil ▪NMBDs •Artificial mechanical ventilation is required •Paralyze respiratory and skeletal muscles •Does not cause sedation, pain relief, or anxiety relief oPropofol forsedation in mechanically ventilated pts •Pt may be paralyzed yet conscious oCannot move or communicate ▪Malignant Hyperthermia •Occurs during or after general anesthesia or use of some NMBDs •Sudden elevation in body temp (104) •Tachypnea, tachycardia, muscle rigidity •Life-threatening emergency •Treatment – cardiorespiratory supportive care, dantrolene (skeletal muscle relaxant) oGeneral Anesthesia: 1, 2, 5, 8, 12 ▪ Used during surgical procedures to produce – unconsciousness, skeletal muscular relaxation, and visceral smooth muscle relaxation ▪Pharmacology principles of balanced anesthesia ▪Inhaled: nitrous oxide: 1 ▪Parenteral-adjunctive: 1 •Sedative-hypnotics: barbiturates (-bital), benzodiazepines (-zepam) (- zolam) •Opioid analgesics: fentanyl, morphine •NMBDs(-ium) •Anticholinergics: atropine, scopolamine oModerate Sedation: 1, 2, 3, 11, 12 ▪ Called conscious sedation and procedural sedation ▪Opioid: fentanyl: 13 ▪Benzodiazepine (-pam): midazolam: 13 oLocal Anesthetics (-caine): 1, 2, 5, 8, 11, 12 ▪ Also called regional anesthetics ▪Types This study source was downloaded by from CourseH on :40:44 GMT -05:00 5 ▪Order of paralysis and recovery •Autonomic activity is lost •Pain and other sensory functions are lost •Motor activity is lost •Recovery occurs in reverse order as above ▪Common uses with different types • Spinal anesthesia o Control pain during surgical procedures and child birth • Infiltration anesthesia o Minor surgical and dental procedures • Nerve block anesthesia o Surgical, dental, and diagnostic procedures o Also used for therapeutic management of pain oNeuromuscular Blocking Drugs (NMDs) (-ium): 1, 2, 5, 11, 12 ▪ Main use: facilitating controlled ventilation during surgical procedures or in ICU setting ▪ Order of paralysis and level of consciousness • First sensation is muscle weakness, followed by total flaccid paralysis • Small, rapidly moving muscles affected first (fingers, eyes), then limbs, neck, trunk • Finally, intercostal muscles and diaphragm affected, resulting in cessation of respirations Chapter 12: CNS Depressants & Muscle Relaxants oCNS Depressants ▪Nice to know: •Midazolam causes amnesia without loss of consciousness: oEndoscopy and colonoscopy procedures •Short-acting benzodiazepines generally used for pts with sleep-onset insomnia without daytime anxiety •Pt teaching oCheck before taking any other meds, including OTC oAvoid alcohol and other CNS depressants oTake hypnotics 30-60 mins before bedtime for max effectiveness in inducing sleep (depends on drug’s onset) oRebound insomnia may occur for a few nights after a 3-4 week regimen has been discontinued •Herbal products: kava-kava, lemon verbena, valerian oUsed to relieve anxiety, stress, and restlessness and to promote sleep oKava may cause temporary yellow skin discoloration (with extended, continued intake) and visual disturbances oMany drug interactions ▪Good to know: •Flunitrazepam o“rophies”, “roofies”, “date rape” drug oNot manufactured or legally marketed in the US This study source was downloaded by from CourseH on :40:44 GMT -05:00 6 •Benzodiazepines – Interactions oCNS depressants(alcohol, opioids) oAntibiotics, rifampin oGrapefruit juice •Ramelteon (sedative – hypnotic) oDoes not cause CNS depression, mimic hormone melatonin oUse is to treat people who have difficulty falling asleep oNo potential for abuse, only hypnotic not a controlled substance •Monitor for therapeutic effects oIncreased ability to sleep at night oFewer awakenings oShorter sleep-induction time oFew adverse effects, such as “hangover” effects oImproved sense of well-being because of improved sleep ▪Got to know: •Benzodiazepines oAntidote – flumazenil oLong-acting benzos should not be used in the elderly since they are more sensitive to their effects and metabolize the drugs less efficiently oFall hazard and cognitive impairment for elderly persons ▪Ataxia, excessive sedation oMost benzos cause REM rebound and a tired feeling (“hangover” effect) the next day; use with caution in the elderly •Warning! Slight overdose of older barbiturates can: oFrequently leads to respiratory depression or arrest oOverdose may produce CNS depression (sleep to coma and death) ▪Supportive care, activated charcoal to prevent absorption •Overdose of benzos or newer non-benzo sedative-hypnotics typically produce: oAnesthesia without risk (unless combined with alcohol) ▪Benzodiazepines (-zepam) (-zolam): 1, 2, 3, 5, 6, 7, 8, 11, 12, 13 • Habit forming; low therapeutic index ▪Sedatives-hypnotics: 1, 2, 3, 5, 7, 8 •ramelteon: 2, 5 •herbal products: kava-kava, lemon verbena, valerian: 1, 6 ▪Barbiturates (-bital): 1, 5, 8, 12, 13 oMuscle relaxants: 1, 2, 3, 5 ▪Nice to know: •Monitor for therapeutic effects oDecreased spasticity, decreased rigidity •Baclofen can be administered in an implantable pump device (epidural) •Methocarbamol may cause urine to turn green-black in color. This effect is harmless and will go away once the med is stopped ▪Good to know: This study source was downloaded by from CourseH on :40:44 GMT -05:00 7 •Adv Eff on CNS and skeletal muscles oEuphoria, lightheadedness, dizziness, drowsiness, fatigue, muscle weakness, others ▪Got to know: •Dantrolene oTreat and prevent malignant hyperthermia ▪Since it is an inherited disorder, ask pt if any family members died suddenly during surgery •Carisoprodol oListed as one of the most abused mood-altering substances in the US and some states classify it as a Schedule IV drug oIt is used to prolong the duration and increase the effects of alcohol or narcotics and to “take the edge off” the jittery feeling associated with cocaine abuse ▪cyclobenzaprine, dantrolene: 1 ▪baclofen: 5, 11, 12 ▪methocarbamol: 5, 11, 12 ▪carisoprodol: 1, 2 Chapter 44: Antiinflammatory & Antigout Drugs o NSAIDs: 1, 2, 5, 6, 7, 8, 11, 12, 13 ▪Nice to know: •Pt teaching oTherapeutic effects may not be seen for 3-4 weeks oLimit alcohol intake due to interaction with NSAIDs and risk of GI bleeding oNotify prescriber if adv eff become severe or if bleeding or GI pain occurs oInform to watch closely for the occurrence of any unusual bleeding, such as in the stool oEnteric-coated tablets should not be crushed or chewed •Ketorolac oPowerful analgesic, like an opioid, not addictive oShort-term (5 days) •Celecoxib oFirst and only remaining COX-2 inhibitor ▪Others taken off the market due to increased risk of: MI, stroke, and death ▪Diclofenac (combo COX-1 and 2 inhibitor) oContraindication in pts with known sulfa allergy •Herbals: Glucosamine and Chondroitin oTreat osteoarthritis pain; oral and injectable oDrug interactions ▪Enhance anticoagulant effects of warfarin This study source was downloaded by from CourseH on :40:44 GMT -05:00 ▪Good to know: 8 ▪Glucosamine may cause increase in insulin resistance •Take withy a full (6-8 oz.) glass of water oIf stomach upset occurs, take with food, milk, or an antacid •Conditions that may be contraindications to therapy: oGI lesions or PUD oBleeding disorders oMI or stroke •Salicylate (aspirin) Toxicity oCardiovascular – increased HR oCNS – tinnitus, hearing loss, dimness of vision, headache, dizziness, mental confusion, drowsiness oGI – n/v/d oMetabolic – sweating, thirst, hyperventilation, hypo/hyperglycemia ▪Got to know: Adv Eff •GI •Renal •CV oDyspepsia, heartburn, epigastric distress, nausea oGI bleeding, mucosal lesions (erosions or ulcerations) ▪Misoprostol can be used to reduce these dangerous effects oReductions in creatinine clearance oAcute tubular necrosis with renal failure oNoncardiogenic pulmonary edema •Integumentary oSteven-Johnson Syndrome ▪Got to know: •Reye’s Syndrome oDo not give salicylates (aspirin) to children and teenagers because of the risk of this syndrome oContraindicated in children with flulike symptoms oNeurological defricits, lead to coma and liver damage •Pt Teaching oCheck labels on all meds since many meds contain aspirin or other aspirin-like NSAIDs •Serious interactions can occur when given with: oAnticoagulants, aspirin, corticosteroids and other ulcerogenic drugs, diuretics, and ACE-I ▪4 properties (-profen) (-fenac) ▪acetylsalicylic acid (ASA): 1, 2, 5. 8, 11, 12 ▪celecoxib: 8 ▪indomethacin ▪ketorolac: 1, 2, 11, 12 ▪naproxen ▪Combination forms This study source was downloaded by from CourseH on :40:44 GMT -05:00 9 oHerbal products: glucosamine, chondroitin: 1, 6, 8 oAntihyperuricemics or Antigout Drugs (-case): 1, 2, 3, 5, 8, 11, 12 ▪Work either to correct overproduction or under excretion of uric acid ▪Nice to know: •May have an increase in gout flares when first start using these drugs ▪Good to know: •Clients with metabolic condition called glucose-6-phosphate dehydrogenase (G6PD) deficiency should not take these drugs oRisk severe damage to RBCs which could lead to anemia oHereditary abnormality in the activity of an erythrocyte (RBC) enzyme ▪Got to know: •Pegloticase oAnaphylaxis and infusion rxns have been reported during and after administration ▪Premediate pts with antihistamines and corticosteroids •Allopurinol oDevelopment of potentially life-threatening skin adv eff of exfoliative dermatitis, Stevens-Johnson Syndrome, and toxic epidermal necrolysis ▪allopurinol: 5 ▪pegloticase: 5, 12; rasburincase This study source was downloaded by from CourseH on :40:44 GMT -05:00