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Transcript
PLAN FOR REVIEW AND FINAL EXAM
~80 questions:
Review:
LIFESPAN TOPICS: 64 slides
Main concepts about pregnancy, breastfeeding
Main concepts about pediatrics
Main concepts about elders
General questions r/t patient education, adherence
Key concepts - Drugs for Diabetes Mellitus
Diabetes Mellitus
• signs and symptoms;
• short & long term complications
• Type 1 versus Type 2 diabetes in terms of pathology and treatment goals
• For Type 2: what is the pathology behind insulin resistance (think pharmacodynamics)
• importance of education, self-monitoring of blood glucose
• tight glycemic control vs. conventional therapy; benefits/drawbacks
• symptoms of hypoglycemia, hyperglycemia
Role of glucagon in management of diabetes
Insulin – where synthesized (pancreas)
Stimulus for insulin release
Importance of proinsulin as a precursor
Function of insulin – primary targets of insulin, effect on metabolism, anabolic actions;
Use of insulin in hyperkalemia
Understand the clinical implications of onset of action, peak action, duration of action related to insulin
Insulin administration
•
routes and types of administration
•
insulin orders
•
preparing for injection; sites of injection; syringes to be used
•
reading labels
•
concentrations of insulin available
•
mixing insulins
Situations which increase or decrease the need for insulin
Patient teaching regarding hypoglycemia & hyperglycemia
DIABETES--Insulin implications and use of the various types of insulin:
• Rapid acting (lispro)
• Short acting (regular)
• Intermediate acting (NPH)
Long acting = Glargine insulin (Lantus) - what makes this type of insulin unique? (Once-daily subQ dosing to treat adults
and children with type 1 diabetes and adults with type 2 diabetes)
Use of oral antidiabetic agents AND various, basic mechanisms of action (Lehne, p 685) among the following families of drugs
• Biguanides
• Sulfonylureas, second generation (true “hypoglycemic” because SFU’s cause insulin secretion regardless of what BG is; not a
good choice for people who skip meals)
• Glinides (Meglitinides) ((true “hypoglycemic” because meglitinides cause insulin secretion regardless of what BG is; not a
good choice for people who skip meals)
• Gliptins (DPP-4 inhibitors)
• SGLT 2 inhibitorsNoninsulin injectable diabetic agents-mechanisms of action
• Amylin mimetics
• Incretin mimetics
Drugs to know for Diabetes
Regular insulin (know onset, peak, and duration & how this compares to other types of insulins; do not need to know the PK
profile for other insulins)
Biguanides: Metformin (Glucophage)- in detail
Sulfonylureas (SFU’s); Glyburide
DPP-4 Inhibitors (Gliptins): Sitagliptin (Januvia)
Types of Insulin:
rate of onset, peak & duration
Type of Insulin
(prototype)
Onset
Peak
Duration
Bolus insulins
Short duration: Rapid acting (Lispro)
15-30 min
0.5 -3h
3 – 6h
Short duration: Slower acting (Regular)
30-60 min
1- 5h
5 - 10h
60-120 min
4– 14h
12 – 24h
60+ min
None
24+h
Lispro should be injected 5-10 minutes before meals
*Regular insulin , aka “short acting.”
SubQ injection; subQ infusion, intramuscular (IM) injection (used rarely); oral inhalation (off market?)
Regular insulin [Humulin R, Novolin R] U-100 (100 units/mL)
Humulin-R is the only insulin available in U-500 (500 units/mL)- NEVER GIVE U-500 INTRAVENOUSLY
Basal Insulins
Intermediate duration (NPH)
Long duration (Glargine)
**Regular and NPH insulin do not require a prescription for purchase, per Lehne.
Intermediate-Duration Insulin
• NPH insulin [Humulin N, Novolin N]
• Drug is injected twice or three times daily to provide glycemic
control between meals and during the night
• NPH insulin is the only insulin suitable for mixing with shortacting insulins
• Allergic reactions are possible
• NPH insulins are cloudy suspensions that must be gently agitated
before administration
• Never shake insulin
• NPH insulins are administered by subQ injection only
• NPH, Neutral protamine Hagedorn.
5
Types of Insulin: rate of onset, peak & duration
“BASAL”
Continuous
infusion
“BOLUS”
rapid acting (lispro); short-acting (regular); intermediate duration (NPH); long-duration glargine
Goal of insulin replacement strategies is to administer
exogenous insulin in such a way that it duplicates
the normal patterns of insulin secretion
by the pancreas of a person who is nondiabetic.
Blood Glucose (mmols)
scale used in Canada
10864Physiologic
hypoglycemia not
depicted, so I scrawled
this blue line here
20
8am
noon
6pm
2am
4am
8am
Time
Red brown = glucose levels
www.diabetesclinic.ca
7
Key Concepts – Parkinson’s (Ch 21)
Pathophysiology; relationship of Dopamine, ACh, GABA
Dyskinesias – those that are observed in patients’ presenting symptoms, as well as those that result from drug therapy
Extrapyramidal system and relationship to dyskinesias
Goal of drug therapy from patient perspective & from a pharmacological perspective
Drugs to know for PD:
Basic pathophysiology, symptoms, epidemiology
Levodopa/Carbidopa (Sinemet)
Key Concepts – Alzheimer’s Disease (PD) (Lehne, Ch 22)
In general, presenting symptoms; overall progression of disease
Pathophysiology; as it relates to Acetylcholine
Treatment goals from a patient perspective & from a pharmacological perspective
Drugs to know for AD:
Donepezil (Aricept)
Donepezil improves the symptoms but does not slow the progression of AD
Treatment goals from a patient perspective & from a pharmacological perspective
Drug therapy Cholinesterase inhibitors
Key Concepts- Epilepsy (Ch 24)
Epilepsy – pathophysiology including initiation & propagation of seizures
Definition of seizure, convulsion, focus
In general, efficacy of treatment; types of seizures
General effects & specific MOA of AEDs (no need to memorize which ion of the action potential is affected, but just know that
the AP is affected)
Therapeutic goals of AED therapy
Guidelines for AED therapy (e.g. monitoring plasma drug levels, matching drug to seizure, maximizing patient adherence,
withdrawing AEDs etc.)
How newer AEDs differ from traditional AEDs in terms of efficacy, side effects, cost, drug interactions
Role of Phenobarbital as an antiepileptic drug; SEs of use
Drugs to know for epilepsy
Role of Phenobarbital as an antiepileptic drug; SEs of use
Phenytoin (Dilantin)
Carbamazepine (Tegretol)
Gabapentin (Neurontin)
GI
Goal of drug therapy in PUD;
Aggressive Factors vs Mucosal Defensive Factors; Various classes of antiulcer drugs used to treat PUD
Know the M of A:
• Histamine-2 receptor antagonists
• Proton pump inhibitors
• Ulcer binding / protective barrier drugs
Role of anticholinergic drugs in PUD
Role of prostaglandins in PUD
Drugs involved in treating PUD vs GERD
• MOA of antacids; implications of magnesium & aluminum compounds in antacids
Patient teaching implications of antacid administration
Overall reasons for using laxatives
Indications for using the particular classes of laxatives
Compare the various categories of laxatives in terms of M of A, indications for use, patient teaching, and nursing implications
Know the alternatives to laxative use!
General principles regarding antidiarrheals
Role of opioids in antidiarrheal therapy
In general, know the M of A, AND the indications for use of prokinetic drugs and antiemetic drugs
Drugs to know for GI
• Cimetidine (Tagamet)
• Omeprazole (Prilosec)
• Sucralfate (Carafate)
• Psyllium (Metamucil)
• Docusate sodium (Colace)
Key Concepts for Metabolism
Thyroid
Clinical importance of TSH
Levothyroxine (Synthroid)- especially know dosing considerations (when to take, drug interactions)
Methimazole (Tapazole)
Adrenocortical- Adrenocortical
Steroid hormones produced by the adrenal cortex & their principal actions (glucocorticoids, mineralocorticoids, androgens).
Glucocorticoids
Physiologic effects
Exogenous glucocorticoids: physiologic vs pharmacologic effects
Changing glucocorticoid needs in response to stress
Pharmacologic treatment that may be indicated for…
Cushing’s syndrome
Addison’s disease –
Hydrocortisone is the glucocorticoid/ drug of choice; as a hormone replacement, so-called “physiologic dose”, these doses are VERY LOW
Mineralocorticoids (fludrocortisone)
Feedback regulation of glucocorticoid synthesis and secretion; impact of stress, development of adrenal suppression.
Use of glucocorticoids in nonendocrine diseases: in order to achieve ANTI-IMMUNE OR ANTI-INFLAMMATORY effects, so-called “Pharmacologic doses,” glucocorticoid
doses need to be comparatively MUCH HIGHER than when used for hormone replacement for adrenal insufficiency (SEVERAL times the “physiologic dose”).
Adverse effects
Guidelines for withdrawing glucocorticoid therapy : WHY does pt need to taper off daily high dose glucocorticoid therapy?
Taper off! Especially if on high doses for greater than 10 days… although this guideline is somewhat subjective: many providers don’t taper until therapy
has been daily at high doses for 2-3 weeks
Mechanism (why are glucocorticoids employed for their potent anti-inflammatory and anti-immune effects?
Therapeutic uses
Dfc in systemic effects: topical/ intranasal, inhaled all have MUCH LESS OR NO SYSTEMIC EFFECTS compared to oral or iv doses
Drugs to know
Hydrocortisone
Fludrocortisone (Florinef)
Pain
Know mechanism of action and ways to decrease the impact of
the primary side effects of the opioid analgesics
Pharmacokinetics of Morphine
Know definitions and impact of the following on pain relief and
medication administration
Tolerance
Physical dependence
Abstinence syndrome
Abuse
Addiction
Meaning and clinical relevance of equianalgesia
Controlled substance actPatients requiring precautions re: opioid therapy
Opioid overdose; triad of symptoms and treatment
Consideration for dosing with opioids!!!! START LOW!!!!!!!!!!!!!!!
Mod-strong opioid analgesics
Agonist-antagonist analgesics
Opioid antagonists
Factors to consider in the clinical use of opioids
Barriers to opioid therapy (think about this one)
Non opioid analgesics – classification, uses, side effects
Cox 1 versus Cox 2 (stimulation vs inhibition)
Pain – definition (in general)
Factors affecting the pain experience
Nociceptive versus neuropathic pain; descriptions, response to
analgesics / adjuvant therapy
Adjuvant analgesics – definition; in general examples of the
classes of drugs used for adjuvant therapy
Factors involved in pain assessment
WHO analgesic ladder for pain management
Management of pain in special populations--- good to think
about
Drugs to know for Pain
Morphine
know equianalgesic dose between Morphine PO and Morphine IV;
know equianalgesic dose between Morphine PO and Codeine PO
Fentanyl
Methadone
Oxycodone (immediate and sustained release)
Codeine
Naloxone (Narcan)
Pentazocine (Talwin)
Acetaminophen (Tylenol)
Ibuprofen (Motrin)
Acetylsalicylic acid (Aspirin)
Drugs that affect clotting
Physiology & Pathophysiology of coagulation/ significance of coagulation
pathways (see Lehne 52-2)
very basic generalities
Definition
Anticoagulants
Antiplatelet drugs
Thrombolytic drugs
Pathways for activation of platelets -Mechanism of action of:
Aspirin
ADP receptor antagonists
GP IIb / IIIa inhibitors
Overall MOA:
Anticoagulants
Antiplatelet drugs (including usefulness in arterial thrombosis)
Thrombolytic drugs
Drugs to know
Heparin (including usefulness in venous thrombosis)
Warfarin (Coumadin)
Clopidogrel (Plavix)
Aspirin (in its role as an antiplatelet drug)
Anticoagulants--- heparin and warfarin
table in lecture handout compares HEPARIN vs WARFARIN.
It summarizes many essential need-to-know main ideas
***Comparison of Heparin and Warfarin***
M of A, uses, route of administration, onset of action, differences in
predictability, adverse effects, antidotes, lab values to monitor
In addition:
HIT (Heparin-induced thrombocytopenia)
Low-molecular weight Heparin; Uses, advantages
Compare unfractionated heparin vs LMW heparin
Know in general the new anticoagulants (Pradaxa, Xarelto); why they
were thought to be superior, issue with having no antidote
M of A of thrombolytic drugs; adverse effects
Key concepts to know - Respiratory Drugs
Asthma – symptoms; pathophysiology of immune-mediated asthma;
factors that trigger non-allergic asthma
Understand the difference between asthma and COPD
Classes of drugs used to treat asthma
Various methods of delivery of inhaled medications; efficacy; use of a
spacer; Inhaled versus systemic routes of administration
Mechanism of action, major SE & role in treatment of asthma (acute vs
long term control) for the following:
Bronchodilators
Beta2 adrenergic agonists (inhaled short acting, inhaled long
acting, and oral long acting)
Anticholinergics
Methylxanthines
Anti-inflammatory Drugs
Glucocorticoids – inhaled; systemic; effect on beta2
receptors
Mast cell stabilizers
Leukotriene modifiers
IgE blockers
In general, guidelines for management of asthma and COPD
Know management of acute exacerbation of asthma symptoms- what
medications would a person in severe asthmatic distress who was
brought by ambulance to the ER NEED?
Nursing implications / patient education for maximizing drug delivery
and adherence to drug therapy
Allergic rhinitis – pathophysiology, symptoms
Use of the following classes of drugs (know M of A) used to treat
allergic rhinitis and cough:
Antihistamines; most common side effect of
first generation
Intranasal glucocorticoids
Decongestants; oral vs topical – impact on
side effects; rebound congestion with topicals
Antitussives – opioids; non-opioids
Expectorants
Mucolytics
what is meant by ‘selectivity is relative not absolute’ especially as it
relates to the use of beta2 agonists in the treatment regimen
for asthma?
Respiratory Drugs to know
Albuterol (Proventil)
Salmeterol (Serevent)
Beclomethasone dipropionate (Beclovent)
Cromolyn (Intal)
Diphenhydramine (Benadryl)
Fexofenadine (Allegra)
Diuretics!
Key concepts to know for Diuretics
Anatomy of the nephron; the 4 functionally distinct regions;
Figure 41-2 provides a visual depiction of the relative efficacy of loop diuretics vs. early distal convoluted tubule diuretics vs distal nehron/collecting duct diuretics
(Note that Figure 41-2 is an important graphic because it visually captures important information for a nurse to store in his/her long-term memory.)
Know:
• distribution of water in the body; how diuretics affect this distribution
• hydrostatic and oncotic pressure
• potassium and sodium in relation to intracellular and extracellular fluid; normal movement of these electrolytes in the loop of henle, early distal convoluted tubule, and late distal
convoluted tubule.
Three basic renal processes – filtration, reabsorption, active secretion
VERY IMPORTANT!! - Where in the nephron each of these processes occurs AND the amount of solutes exchanged at each of the functional sites within the nephron.
Know overall way in which diuretics work and the mechanism of action
The significance of the Cockcroft-Gault Equation in assessing renal function
Know normal Creatinine Clearance and normal serum creatinine
Therapeutic uses of diuretics and how they work in HTN & heart failure
Specific monitoring parameters to determine therapeutic outcomes and side effects of diuretic therapy
Electrolytes that are important to monitor in diuretic therapy
Monitoring parameters to assess side effects of diuretic therapy
Patient education regarding diuretic therapy including duration, timing, expected symptoms resulting from diuretic therapy, and education re: dietary implications
General concepts regarding drug-induced nephrotoxicity
Role of aldosterone in the nephron
Foods that will increase K+ in the diet
Mechanism / site of action in nephron, clinical uses, and side effects for the following 4 categories of diuretics:
Thiazides
Loop diuretics
Potassium-sparing diuretics
Osmotic diuretics
Drugs to know:
Furosemide (Lasix)
Hydrochlorothiazide (Hydrodiuril)
Spironolactone (Aldactone)
Mannitol (Osmitrol)
Key concepts to know for CV content
Physiology of the CV system
Starling’s Law and relationship to preload
Regulation of arterial pressure
Determinants of cardiac output – HR, SV
Determinants of stroke volume – preload, afterload, contractility
Factors that contribute to preload, afterload, contractility
Ejection fraction compared to SV
Implications of pulmonary resistance and peripheral resistance on CO and blood flow through the CV system Meaning of: inotropic, chronotropic
Classes of drugs that decrease and increase preload, afterload, and contractility; especially for the classes of drugs listed below--- look at front page of the lecture
handout
PART 1
The relationship of O2 demand and supply to the determinants of CO
Renin-angiotensin system (RAS) – actions of angiotensin II, effects of aldosterone release
Specifically where in the RAS beta blockers, ACE inhibitors, ARBs, and SARAs work
For the following classes of drugs, know mechanism of action, primary indications for use, primary side effects, & patient teaching implications:
ACE inhibitors
ARBs
In general, know interactions with other drugs:
1. effect of combining ACE inhibitors with diuretics;
2- effect of combining calcium channel blockers with beta blockers = increased hypotensive episodes
Sympathetic nervous system – effect of stimulating alpha and beta receptors on the heart and blood vessels
Understand the relationship of BP to CO and SVR (BP = CO x SVR) know this conceptually
Drug List – CV1
Captopril (Capoten)
Digoxin (Lanoxin)
Losartan (Cozaar
Key concepts to know for CV content Part 2
For the following classes of drugs, know mechanism of action, primary indications for use, primary side effects, &
patient teaching implications:
Aldosterone blockers
SARAs
Beta Blockers
Calcium Channel blockers
PART 2
Nonselective versus cardio-selective beta blockers
Effect of calcium & the role of calcium channel blockers on the heart and vascular smooth muscle
Differences in sites of action between dihydropyridines and other calcium channel blockers (such as verapamil &
diltiazem)
Various classes of drugs and why they are used to treat hypertension
Various classes of drugs and why they are used to treat heart failure
Role of platelets in acute coronary syndrome
Pathways for activation of platelets
Mechanism of action of GP IIb / IIIa inhibitors
Know normal cardiac conduction system- in general
PART 2 CONTINUED
Role of statins in drug therapy for dyslipidemias
treatment goals for total cholesterol: goal for good health is a LOW LDL and a HIGH HDL
Benefits of cholesterol lowering; cardiac and non-cardiac
Drug List – CV2
Spironolactone (Aldactone)
Propranolol (Inderal) (nonselective beta blocker)
Metoprolol (Lopressor) (cardioselective beta blocker)
Verapamil (Calan)Nifedipine (Procardia)Clopidogrel (Plavix)
Aspirin (in its role as an antiplatelet drug)
Amiodarone (Cardarone)
Key concepts - Drugs affecting Depression & Anxiety
Depression – definition
Clinical symptoms (in general); significance of distinguishing between grief / sadness and major depression
Pathogenesis of depression
Monoamine hypothesis of depression
In addition to drugs, other modalities for treating depression
Overview of drug treatment comparing TCAs, SSRIs, and MAOIs
Know M of A and major SE for the following categories of antidepressants:
Tricyclic antidepressants
MAO inhibitors (including interactions with other medications, food, significance of tyramine in diet etc.)
SSRIs
Atypical antidepressants (unique contribution of this group of medications)
Contribution / significance of SNRIs
Overall compliance issues with antidepressants; implications for patient teaching; time needed to see effects
Issues related to time frame of biochemical effects vs clinical effects
Suicide risk with antidepressant drugs
Definition: Anxiety
Overall treatment goals and classes of drugs used in treatment
Significance of distinguishing between situationally-appropriate anxiety and disabling anxiety
Know M of A, major SE and in general how benzodiazepines differ from barbiturates
Drugs to know for Anxiety & Depression
Fluoxetine (Prozac)
Bupropion (Wellbutrin)
Duloxetine (Cymbalta)
Alprazolam (Xanax)
Key concepts to know for Hormonal Therapy
Estrogens- effects
endogenous - where synthesized; major estrogen in humans
effects on primary and secondary sex characteristics in females
metabolic actions
exogenous therapy – therapeutic uses; adverse effects; routes of
administration
Adverse effects of estrogens, particularly risk of thromboembolic
events
Key take-home points from lecture:
Hormone Therapy
Metabolic actions of estrogen (slide 8)
Adverse effects of exogenous estrogen
Most concerning adverse risk of exogenous estrogen is
increased risk of thrombogenesis (CVA, MI, PE, etc)
When a nurse charts “Reviewed ACHES with pt”, what does
this mean?
Physiologic role of progestin
Efficacy/ failure rate of common birth control methods
Progestins –effect on the endometrium
Menopausal Hormone Therapy (HT) – overall take home message compare actual failure rate with theoretical failure rate see
p 752, Table 62-1
re: HT
LARCs = Long-acting Reversible Contraception are
recommended by WHO and others
Factors to consider when choosing a birth control method
Particularlry Nexplanon and IUD’s due to low actual failure
Combination Oral Contraceptives (OC)
rate of _________________% and _____________%
mechanism of action
respectively
effectiveness; what is meant by perfect versus typical use
where do OCs fall re: ‘effectiveness of birth control methods’ (see IUD’s- truths vs misconceptions as clarified by guest speaker
HRT – basic take-home message?
Table 62-1)
adverse effects
what factors make an individual a poor candidate for OCs
in general, drug interactions (think antibiotics)
Look over - contraceptives with novel delivery systems
Key concepts to know for CAM/ Herbs
What is CAM?
How are herbs regulated?
What are concerns about safety of herbs?
Side effects/AE
Herb-drug interactions (what may cause synergism/antagonism?)
Contaminants
What are concerns around efficacy of herbs?
What are the top-selling/most used herbs used for? (what conditions or health effects)
What are some resources for learning more about herbs?
KEY take-home points from lecture:
CAM% of people win US who use CAM; people often don’t tell PCP/ RN they use CAM unless specifically asked
Marketing is still permitted (2016) without proof of safety or efficacy
Range of ingredients from non-detectable to 20, 100 or even 1000-fold what is indicated on the label
Up to 26 pharmaceutically active ingredients have been found in dietary supplements, even though labelled for one ingredien
narrow therapeutic index meds: five were identified in class as being common; students should know these
Drug-Herb Interactions
Mechanisms
likelihood
St Johns Wort and Warfarin are the herb and med thought to have the most interactions with other meds/herbs
Efficacy concerns
Resources for more information