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NUR292 NCLEX REVIEW Pharmacology Guidelines and Strategies Five Medication Rights • • • • • Right client Right medication Right dose Right time Right route Assessment Guidelines ALWAYS: • Assess for allergies or hypersensitivity • Assess for existing medical disorders that might cause med to be contraindicated • Assess for potential interactions • Check pertinent labs • Check vs, esp. if antihypertensive or cardiac med • Assess for intended effects, side effects, adverse effects, or toxic effects • Assess client’s response to med General Guidelines • Med absorption, distribution, metabolism & excretion affected by age – older & neonate at greater risk for toxicity • Many meds contraindicated during pregnancy & breastfeeding • Antacids not usually administered with meds – affect absorption • Grapefruit juice not usually administered – affects absorption & can cause toxicity • Enteric-coated & sustained release tabs should not be crushed; capsules should not be opened • Nursing interventions always include monitoring for intended, side, adverse or toxic effects & client education • Nurse or client should never adjust or change a med dose, abruptly stop taking or discontinue a med • Nurse may withhold a med if adverse or toxic effect is suspected; nurse must immediately contact the physician if either occur • Client should avoid OTC meds or herbal meds unless approved by health care provider • Client needs to know how to correctly administer meds • Client needs to be aware of side effects of meds & how to check own temp., pulse & BP • Client needs to take prescribed dose for prescribed length of therapy & understand need for compliance • Client needs to avoid smoking & consuming alcohol • Client should wear ID if taking anticoagulants, OHAs, insulin, certain cardiac meds, steriods, anti myasthenics, anticonvulsants & MAOs • Client needs to follow up with health care provider Medication Effects • • • • Intended Side Adverse Toxic Intended Effect • Desirable effect • Example – intended effect of morphine sulfate is pain relief Side Effect • Not a desired effect • Not usually life-threatening • Can usually be alleviated with specific measures • Example – side effect of antihistamine is drowsiness Adverse Effect • • • • More severe than a side effect Always an undesirable effect Always reported to the health care provider Example – adverse effect of sulfonamide is hypersensitivity evidenced by rash, fever, SOB • Can range from mild to severe (anaphylaxis) Toxic Effect • Medication level in the body exceeds the therapeutic level • Client will usually exhibit signs/symptoms that indicate toxicity. Nurse monitors for these s/s Medication Names • Both generic name & trade name will appear in NCLEX question • Identifying the med will help determine action or what med is used for • Try to break name of med into parts & use medical terminology to determine action of drug Medication Classifications • Learn meds by classification & be able to recognize common side effects, then relate appropriate nursing interventions to each side effects • Example – if side effect is hypertension then monitor BP. If side effect is hypokalemia, then monitor K+ blood level Identify Classification • -terone Androgens (testosterone) • -pril ACE inhibitor • -pressin antidiuretic hormones (desmopressin – DDAVP) • -statin antilipemics (atorvastatin – Lipitor) • -vir antivirals • -pam benzodiazepines or -lam • -lol beta-blockers • -pine Ca+ channel blockers – exceptions – diltiazem (cardizem) & verapamil (Calan) • -est estrogens • -sone glucocorticoids & corticosteroids • -dine histamine H2 receptor antagonists (cimetidine – Tagamet) • nitr nitrates (nitroglycerin) • -zine phenothiazines (chlorpromazine – Thorazine) • -zole proton pump inhibitors (lansoprazole – Prevacid) • sulf sulfonamides • -mide sulfonylureas (OHAs) • -zide thiazide diuretics • -ase thrombolytics (alteplase – Activase) • thy thyroid hormones • -line xanthine bronchodilators (aminophylline) Angiotensin II Receptor Antagonists (ARBS) • -sartan lowers BP , less K+ retention than ACE inhibitors • Losartan (Cozaar) • Olmesartan (Benicar) Antibiotics • cef cephalosporins • -cillin penicillins • -mycin macrolides (Biaxin, ERC, Zithromycin lincosamides (Vancomycin, clindamycin aminoglysides • -cycline tetracyclines • -xacin fluoroquinolones (Cipro, Levaquin) Common Herbal Remedies/Drug Interactions Herbal Remedies That Might Help • Astragalus – increases resistance to disease & restores immune function (oncology pts) • Echinacea – preventive & treatment for colds & flu. May interfere with immunosuppressive therapy • Feverfew – headaches – migraine. Minimal level of 0.2% parthenolide needed • Garlic – decrease cholesterol & lower BP, inhibits platelet aggregation, antiinfective • Ginger – stimulate digestion & relieve nausesa • Ginkgo – treatment of arterial insufficiency in brain & extremities, allergic responses & memory impairment • Ginseng root – acts on CNS, CV system & endocrine secretion. Promotes immune function & antistress activity. Those with hypertension should not use. • Green tea – act protectively CV disease & liver disorders. Has hypolipidemic, antioxidant, fibrinolytic effect • Milk thistle – prevent liver from damage by toxins (treat heptatis/cirrhosis • St. John’s Wort – treat mild to moderate depression • Shark Cartilage – antiinflammatory (arthritis), possible antineoplastic properties • Valerian – sleep problems & mild sedating & tranquilizing effect. No dependency risk Herb/Drug Interactions Increase Bleeding Potential Increased risk with concurrent use of aspirin, coumadin, heparin, NSAIDs • Feverfew • Garlic • Ginger • Ginkgo Decrease Action of Anticoagulants • Ginseng • Valerian Interact with MAO Inhibitors May cause hypertension or hypertensive crisis • Ephedra – weight loss, body building • Ginseng • Green tea • St. John’s Wort • SAMe – antioxidant, antidepressant, arthritis, fibromyalgia, migraines Inhibit Iron Absorption • Camomile (teas) – appetite stimulant, antispasmodic (also cause skin hypersensivity) • Feverfew • St. John’s Wort Potentiates sedation Used with barbiturates, BZDs, CNS depressants • Kava-Kava – anxiety, stress, insomnia, menstrual cramps, PMS • Valerian Increase hypoglycemic effects of OHAs & insulin • Ginseng • Garlic SHOCK • Physiologic state in which there is inadequate blood flow to tissues & cells of body Types of Shock Hypovolemic shock – decreased intravascular volume due to fluid loss Cardiogenic shock – results from impairment or failure of myocardium Circulatory or distributive shock – displacement of blood volume creating a relative hypovolemia & inadequate delivery of oxygen to cells – Anaphylactic shock – severe allergic reaction producing overwhelming systemic vasodilation & relative hypovolemia. Causes: medication or latex sensitivity, bee sting, transfusion reaction. Circulatory shock – Neurogenic shock – loss of sympathetic tone causing relative hypovolemia. Causes: spinal cord injury, spinal anesthesia, depressant actions of meds, glucose deficiency. – Septic shock – overwhelming shock causing relative hypovolemia. Causes: immunosuppression, extremes of age, malnourishment, chronic illness, invasive procedures. Treatment of shock • Fluid replacement to restore intravascular volume • Vasoactive meds to restore vasomotor tone & improve cardiac function • Nutritional support to address increased metabolic requirements increased in shock Vasoactive meds (Chart p. 303) Sympathomimetics • Amrinone (Inocor) • Dobutamine (Dobutrex) • Epinephrine (Adrenalin) • Milrinone (Primacor) Vasodilators • Nitroglycerine • Nitroprusside Vasoconstrictors • Norepinephrine (Levophed) • Phenylehrine (Neo-Synephrine) • Vasopressin (Pitressin) Multiple Organ Dysfunction Syndrome (MODS) • Organ dysfunction in acutely ill & compromised client occurs to extent that normal homeostasis is unable to be preserved without medical intervention. • Inadequate resuscitation accounts for about half of all MODS cases • MODS accounts for about 70-80% ICU fatalities • Septic shock – hemodynamic changes that occur may result in inadequate perfusion & development of MODS • Systemic inflammatory response syndrome (SIRS) may lead to MODS. • An initial event triggers – usually an event that results in low blood pressure. • Within 72 hrs may develop respiratory failure – ARDS – on vent • Develops hypermetabolic state – hyperglycemia • Liver failure • Renal failure Systemic Inflammatory Response Syndrome (SIRS) • May result from infectious & noninfectious trauma – burns, pancreatitis, ischemia, multitrauma. • SIRS – uncontrollable inflammatory response to different clinical insults • Defined by 2 of following: temp > 38° C or < 36° C, HR > 90 bpm, RR > 20/min, PaCO2 < 32, & WBC > 12,000 or < 4000 • Sepsis correct term when SIRS result of active infection