Pharmacology Review IChapters 1 - 28

All Materials in this presentation come from:Karch, A. (2008). Focus on: nursing pharmacology. New York, NY: Lippincott Williams & Wilkins.

Case Study # 1 AntibioticsMrs. Smith, a lively 78 yr old woman, successfully receiving Lasix (a diuretic) for hypertension comes in to the officecomplaining of UTI symptoms. She wants to know why the doctor did not prescribe Gentamicin. I used to always take Gentamicin..what do you explain to her?

Gentamicin is an aminoglycoside antibioticaminoglycosides and Lasix can cause severe ototoxicityMrs. Smith, are you listening to me?

Case Study # 2 AntibioticsSenator X receives a letter with a suspicious powder substance. What cephalosporin will he take for anthrax expsoure?

CeClor (cefaclor) 250 mg PO q8h

The Nurse warns Senator X not to go to Happy Hour, why?

CephalosporinsSenator X should not consume alcohol while taking cephalosporins because of a possible disulfiram-like reaction--Flushing, nuasea, vomiting, chest pain, palpitations, dyspnea, blurred vision, even consulsions!

Case Study # 3 AntibioticsSusan is ready to head to Florida for her Spring Break, too bad she has a UTI and is taking Cipro..

Why?

Photosensitvity!Cipro can cause a severe skin reaction when pt is exposed to sunlight or tanning beds.

Susans grandmother in the nursing home doesnt see much sunlight, she just needs to avoid using NSAIDs when taking Cipro !

Case Study # 4 AntibioticsUncle Larry seems confused latelyIts a good thing the doctor prescribed Zithromax for his upper respiratory infection..

Why?

Zithromax (Azithromycin)Half-life is 68 hours so patients only need to take it once a day.usefull for patients who have trouble remembering to take their pills.

Case Study # 5 AntibioticsLaTasha calls the nurse: my baby is allergic to the amoxicillinThe nurse will ask, what are her symptoms?

LaTasha says bad diarrheahow will you council her?

LaTasha and her babySometimes patients may confuse side effects with allergic reactions.Typical allergic reactions include:Hives, rashDifficulty breathing, respiratory arrestIncreased BP, dilated pupils, Increased heart rate, diaphoresis

Amoxicillin and other penicillinsCommon adverse effects include nausea, diarrhea and a furry tongue.A furry tongue! What are you talkin about? says LaTashaSuperinfections like yeast are very common

Case Study # 6 AntibioticsCarries husband has an abscessed tooth. The dentist prescribed Clindamycin (lincosamide)

Great wife that she is, she is bummed because she just cleaned her toiletswhat side effect is she thinking of?

Severe pseudomembranous colitisSo whats a little colitis?

Pseudomembranous colitis is actually another superinfection.

Clindamycin may allow Clostridium difficile (C. diff) to infect the colon.

Ancef (cefazolin)*Ancef is one of the cephalosporins.Toxic to the kidneysMonitor the patient BUN levelsNo alcohol while taking Ancef

If pt has an allergic rxn, give parenteral epinephrine to cause vasoconstriction and bronchodilation.

*(Material from ATI prep)

Case Study # 7 AntibioticsCheryl, a young nursing student, comes to the clinic with severe acne. The doctor has prescribed tetracycline.The nurse advises her to take the medicine on an empty stomach.

Most importantly of all, her nurse asks..Hint!

Antibiotics and Oral ContraceptivesAre you taking oral contraceptives?

Several antibiotics including tetracycline, are known to lead to failure of oral contraceptives.

Cheryl needs to know to use alternative methods for birth control.

Case Study # 8 Antimycobacterial Antibiotics

Michael volunteers at a health clinic for refugees from other countriesHe is surprised to see so many patients with T.B.He explains the treatment lasts from 6 months to two yearswhy?

Tuberculosis TreatmentThe slow growing bacteria form a mycolic acid outer coating. Isoniazid, rifampin and ethionamide are the first line of defense.

Michael also learns to say: Su pis hace naranja spanish for your pee will be orange for patients taking rifampin

Isoniazid (INH)Treatment for tuberculosisCan cause lupus and jaundice from liver toxicitySigns of jaundice:Yellow skinDiscolored sclerae

(material from ATI prep)

Case Study # 9 Antiviral Agents

Nathan says he feels like crap!

Jennifer says, if its the flu and its been less than 2 days, you should try.

Tamiflu (oseltamivir)75 - 150 mg PO b.I.d. for 5 days

Also approved for use with children

Case Study # 10 Antiviral agentsRelenzaFor the FLuAldara for skin cancersAbreva forcold soresHepsera For Hep. B(liver damage)Retrovir(AZT)For HIVAcyclovirFor herpes

Review antiviral agentsFlu symptomsCold soresHepatitis BHIVHerpesSkin cancers(also genital warts)

HepseraAldaraAbrevaRelenzaAcyclovirRetrovir (AZT)

Case Study # 11AntifungalsThere is a fungus, among usWhat common antifungal is used topically for onychomycosis ?

AntifungalsLamisil is commonly used creamand is pretty safe howeverother antifungals are not used topically

Why would anyone need to take pills for fungus?

Case Study # 12 AntifungalsAnswer: Superinfections

Azoles are used to treat Candidiasis, systemic fungal infecitons and to prevent candidiasis in bone marrow transplants

Remember the furry tongue see case # 5

Antifungal Drug to Drug interactions Systemic antifungals like azoles may become toxic with:digoxinoral hypoglycemicswarfarin phenytoincyclosporine

Sounds like the average nursing home cocktail to me

Case Study # 13Antiprotozoal agentsMichael decides to take his clinic to AfricaWhat drug will he need to take to prevent malaria?

Should Michael and his wife plan to have kids while they are over there?

Antimalarial medicationChloroquine (Aralen) blocks the reproduction of the plasmodium organisms.Chloroquine has potential risk to pregancyAlso can cause serious eye damage and blindness

Case Study # 14 AntiprotozoalsCindy and Tara went backpacking in the Smoky Mtns. Cindy warned Tara not to drink the water, but she did.

Now Tara has pale, mucous filled stools and rotten egg smelling diarrheasounds like she needs---

Metroniadazole(Flagyl, MetroGel, Noritate)750 mg PO tid for 5-10 days for amebiasis and giardiasis2 g PO as one dose for Trichimoniasis

The Travelers Real Friend

Case Study # 15Anti-inflamatory agentsGrandpa believes if one is good, two is better when it comes to aspirin for his arthritis.

Lately, he complains about ringing in his earis there a connection?

TinnitusYes! Ringing in the ears is a classic sign of aspirin toxicity, called salicyclism.

Also sweating, headache and dizziness, Granpas liver may not be meatbolizing the aspirin as fast as it use to .

Case Study # 19Anti-inflammatory agents

Brenda, an alcoholic, has had a migraine for three days.Shes been taking Tylenol extra strength whenever it starts to ache.Yesterday, she started to have flu symptoms so shes been taking DayQuil (325 mg acetaminophen), a couple of swigs every few hours. She comes to ER with nausea, vomiting, and GI upset--

The doctor recognizes Acetaminophen Toxicity and prescribes:

Acetylcysteine

(Mucomyst) is 100% effective in preventing liver overdose

The LiverCant live Without it!

Gold SaltsGold Salts are available for treatment of rheumatoid arthritis

Monitor the patient for mouth sores, GI inflamation and allergic rxns. And anaphylatic shock

Anaphylactic shockAllergic rxn where body produces histmainesImmediate swelling and constricting of bronchiSymptoms include: urticaria (hives)Shortness of breathGive epinephrineUrticaria

Immunization scheduleHep BHibDtap 5 - dose series(Diptheria, Tetanus,Pertussis)IPVMMRPVCVaricella

Anxiolytics and Hypnotic AgentsXanax - anxiety, panicLibrium - anxiety, alcohol withdrawalKlonopin - restless leg syndrome, panicValium - muscle relaxant, antiepiletpticProSom - hypnotic, insomniaAtivan - anxiety, preanesthesiaSerax - preferred for elderly

Case Study # 20Benzodiazepines

Mr. Mason came into ER. He is a known drug abuser. He was admitted for possible stroke.Kim, his nurse asks when was the last time he had a beer? Mr. Mason says 3 days.Kim calls the doctor to request Ativan (STAT), why?

(based on a true story)

Ativan (lorazepam)Kim has seen this before.Mr. Mason is probably an alcoholic and will begin to have withdrawal symptoms if he stays any longer at the hospital.

Ativan will prevent wild behavior and lasts 12 - 24 hours------------> (that will cover her shift)

Ativan (lorazepam)Kim requests only 1 mg/day POfor Mr. MasonThe normal dosage is 2 -6 mg/day Why?

BenzodiazepinesMr. Mason is an African American.

Kim knows special care needs to be taken because he may have a genetic predisposition to delayed metabolism of benzodiazepines.She will closely monitor him for adverse effects like cardiovascular issues, urinary retention, sedation, confusion and blurred vision.Use lowest possible dose

BenzodiazepinesMr. Mason threatens to leave the hospital. You cant make me stay!Kim explains to him Ativan plus alcohol can cause serious CNS depression.She flips on the movie channel and Mr. Mason calms down.Just another day for Super Nurse!

BarbituatesAmytal sodium - convulsions, sedativeLuminal - preanesthetic, seizuresSeconal - preanesthetic, seizures

Selective Serotonin Reuptake Inhibitors (SSRIs)LuvoxPaxilZoloftCelexaCymbaltaProzacInform patients:May take 4 weeks To see improvementMay cause cystitis,Urgency sexual dysfunctionNeed alternative birth control(If using oral contraceptives)Do not combine with St. Johns Wort70 % experienceSexual dysfunctionThats depressing!

Case Study # 20Tricyclic AntidepressantsTCAs treat depressionClamipramine is for OCDsTCAs are anticholinergic so caution with:Cardiovascular disordersUrinary disordersImipramine also treats..?

Imipramine (Tofranil)25 mg/day 1 hr before bedFor bed wetting

Monitor for anticholinergic effects like dry mouth, constipation, rash, anxiety and bone marrow depressi

Case Study # 21Tricyclic antidepressants

Your patient is on Elavil (amitrptyline) (to elevate her mood obviously)

What side effectswill you monitor for?Im gonna push the upper button

Elavil (amitriptyline)

TCAs have anticholinergic effects

Monitor for dry mouth and urinary retention!

Anxiolytic and Hypnotic DrugsSonataAmbien (zolpidem) Lunesta

PhenerganBenadryl

Cause sedation and are used forShort-term treatmentinsomnia ofUsed preoperativelyMay cause thicksecretions I need Lunesta

Case Study # 22Antidepressant agentsTonya has been depressed for awhile, so the doctor prescribed Nardil (phenelzine). She was doing much better until her birthday: her nursing friends had a gala wine tasting event.(Caviar, aged cheeses, wines, sausage)She went to ER thinking she had a stroke..What happened?

MAOIsOccipital headache, palpitations, nausea, vomiting,sweating, tachycardia, chest pain, even stroke can result when MAOIs are combined with tyramine-containing foods (like wines and cheeses)

MAOIs can also cause hypoglycemia

No worries, Tonya sued her nursing friends for a fortune..

Case Study # 23 Antidepressant agents

Nicoles husband wants to quit smoking. The doctor prescribed Zyban (bupropion). The doctor forgot to mention a major side effect and Nicole is about ready to scream.

What is the side effect?

Bupropion (Wellbutrin, Zyban)

Major side effect: insomnia

Oh, well, says the doctor, at least he wont be depressed

Antipsychotics Treatment of:SchizophreniaPsychotic disordersCombative behaviorAgitation in elderlyHyperactivityAny adverse effects?

Adverse effects of Psychotherapeutic Agents

CNS depression, tremor, drowsinessCardiovascular effectsAnticholinergic effectsDry mouthConstipation, urinary retentionExtrapyramidal effectsPseudoparkinsonismDystonia,akathisia

Case Study # 24Psychotherapeutic agentsGranpas Alzheimers is getting worse. Yesterday, he slugged the nurse when she tried to give him a showerNow,he is taking Seroquel (quetiapine) 50 mg PO bid Grandma wants to know why he is droolinghe never did that before?

Atypical psychotherapeuticsTell grandma that since grandpa still needs to take his beta-blocker for his heart, he is having an increased response to the SeroquelThe nurse will also monitor for dyspnea and heart arrhythmias.