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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