NURS 3247 ATI Pharmacology – Proctored 2 Assessment – University of Huston / NURS3247 ATI Pharmacology – Proctored 2 Assessment

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NURS 3247 ATI Pharmacology – Proctored 2 Assessment – University of Huston ATI Pharmacology IMPORTANT LAB VALUES • Sodium (Na): 136-145 mEq/L • Calcium: 9.0-10 mg/dL • Chloride: 98... -106 mEq/L • Bicarb HCO3: 21-28 mEq/L • Potassium: 3.5-5.0 mg/L • Phosphorus PO4 : 3.0-4.5 mg/dL • Magnesium: 1.3- 2.1 mEq/L • Cholesterol: o Total <200mg/dL o LDL ("bad") <100 o HDL ("good) >40 o Triglycerides <150mg/dL • Liver enzymes o ALT/SGPT 8-20 units/L o AST/SGOT 5-40 units/L o ALP 42-128 units/L o Total protein 6-8 gm/dL • Pancreatic enzymes o Amylase 56-90 IU/L o Lipase 0-110 units/L o Prothrombin time 0.8-1.2 • Glucose: Preprandial (fasting) 70-110 mg/dL Postprandial 70-140 mg/dL • RBC: Females 4.2-5.4 million/uL; Males 4.7-6.1 million /uL • WBC: 5000 -10,000 • Iron: Females 60-160 mcg/dL; Males 80-180 mcg/dL • Platelets: 150,000-450,000 • Hemoglobin (Hgb): Females 12-16 g/dL; Males 14-18 g/dL • Hematocrit (Hct): Females 37-47%;Males 42-52% • Prothrombin Time (PT): 11-14 seconds: therapeutic range 1.5-2x normal or control value • Urine specific gravity: 1.015-1.030 • Urine pH: average 6.0; range 4.6-8.0 • BUN: 10-20 mg/dL • Creatinine: female 0.5-1.1, males 0.6 - 1.2 mg/dL; • Creatinine phosphokinase MB (CK-MB): normal 30-170 units/L *increase 4-6 hrs after MI and remains elevated 24-72hrs • Troponin normal: <0.2 ng/dL *gold standard for MI - Safe Medication Administration and Error Reduction: Reviewing a Medication Administration Record (RN QSEN - Teamwork and Collaboration, Active Learning Template - Nursing Skill, RM Pharm RN 7.0 Ch. 2) 1) Report all errors, and implement corrective measures immediately 2) Complete an incident report within the time frame the facility specifies, usually 24 hr. 3) Do not reference or include this report in the client's medical record 4) Evaluate clients' responses to medications, and document and report them. 5) Identify side and adverse effects, and document and report them. Chapter 12 - Substance Use Disorders: Therapeutic effect of chlordiazepoxide (Ch. 12 pg.85) - Substance Use Disorders: Smoking cessation using bupropion (Ch. 12 pg. 87) - Substance Use Disorders: Treatment for Cocaine Toxicity (Active Learning Template - System Disorder, RM Pharm RN 7.0 Ch. 12) 1) First line treatment = Benzodiazepines (to reduce CNS & cardiovascular effects) 2) Chlordiazepoxide, diazepam, lorazepam, clorazepate, oxazepam 3) Provide seizure precautions 4) Manifestations include nausea; vomiting; tremors; restlessness and inability to sleep; depressed mood or irritability; increased heart rate, blood pressure, respiratory rate, and temperature; diaphoresis; and tonic‑clonic seizures. Illusions are also common 5) Monitor vitals and neurological status on a regular basis Chapter 13 - Chronic Neurologic Disorders: Adverse effects of neostigmine (Ch. 13 pg. 91) Adverse effects: Excessive muscarinic stimulation Cholinergic crisis - Chronic Neurologic Disorders: Medications that interact with Carbamazepine (Ch. 13 pg. 99) - Carbamazepine causes a decrease in the effects of oral contraceptives and warfarin due to stimulation of hepatic medication-metabolizing enzymes. - Grapefruit juice inhibits metabolism, and thus increases carbamazepine levels. - Phenytoin and phenobarbital decrease effects of carbamazepine. - Chronic Neurologic Disorders: Adverse Effects of Phenytoin (RN QSEN - Safety, Active Learning Template - Medication, RM Pharm RN 7.0 Ch. 13) 1) CNS effects: Nystagmus, sedation, ataxia, double vision, cognitive impairment 2) Gingival hyperplasia: Softening and overgrowth of gum tissue, tenderness, and bleeding gums (consider folic acid supplement) 3) Skin rash (stop medication if rash appears) 4) Cardiovascular effects: dysrhythmias, hypotension (administer slow; 50 mg/min and in dilute solution) 5) Endocrine and other effects: Coarsening of facial features, hirsutism, and interference with vitamin D metabolism (consume enough Vitamin D) 6) Interference with vitamin K‑dependent clotting factors causing bleeding in newborns. - Miscellaneous Central Nervous System Medications: Treating Malignant Hyperthermia (Active Learning Template - Medication, RM Pharm RN 7.0 Ch. 15) 1) Depolarizing neuromuscular blockers: Succinylcholine 2) Manifestations include muscle rigidity accompanied by increased temperature, as high as 43°C (109.4°) 3) Administer oxygen at 100%. 4) Initiate cooling measures including administration of iced 0.9% sodium chloride, applying a cooling blanket, and placing ice bags in groin and other areas 5) Administer dantrolene to decrease metabolic activity of skeletal muscle. - Airflow Disorders: Therapeutic Action of Montelukast (Active Learning Template - Medication, RM Pharm RN 7.0 Ch. 17) 1) Leukotriene modifiers: suppress the effects of leukotrienes, thereby reducing inflammation, bronchoconstriction, airway edema, and mucus production. 2) Long‑term therapy of asthma in adults and children, and to prevent exercise‑induced bronchospasm 3) Depending on therapeutic intent, effectiveness is evidenced by long‑term control of asthma 4) Advise clients to take montelukast once daily at bedtime. 5) For exercise‑induced bronchospasm, take 2 hr. before exercise. Instruct clients taking daily montelukast to not take an additional dose for exercise induced bronchospasm - Upper Respiratory Disorders: Client Teaching Prior to Allergy Testing (Active Learning Template - Medication, RM Pharm RN 7.0 Ch. 18) 1) Medications that can interfere with skin tests include: antihistamines, Tricyclic antidepressants, heartburn medications, asthma medication omalizumab (Xolair) 2) May need to discontinue certain meds 10 days prior 3) If you are running a fever or have an attack of hay fever or asthma, testing should be delayed 4) Do not change your diet before the test. - Medications Affecting Blood Pressure: Titrating Continuous Nitroprusside Infusion (RN QSEN - Safety, Active Learning Template - Medication, RM Pharm RN 7.0 Ch. 20) 1) Nitroprusside (centrally-acting vasodilator) 2) Direct vasodilation of arteries and veins resulting in rapid reduction of blood pressure (decreased preload and after load 3) Used for hypertensive crisis 4) Administer medication slowly because rapid administration will cause blood pressure to go down to rapidly 5) Prepare medication by adding to diluent for IV infusion. 6) Protect IV container and tubing from light & Discard medication after 24 hr. Angina Chapter 22 (pg. 169) Self-administration of nitroglycerine patch (pg. 170) Client teaching for a new prescription of sublingual nitroglycerin PROTOTYPE: Nitroglycerin (NTG) Oral extended-release capsules Sublingual tablet Translingual spray Topical ointment Transdermal patch Intravenous Isosorbide dinitrate (Sublingual) Isosorbide mononitrate (PO) Adverse Effects: Headache: - Instruct clients to use aspirin or acetaminophen to relieve pain - Clients should notify the provider if headache does not resolve in a few weeks. Dosage can be reduced. Orthostatic hypotension: - Advise clients to sit or lie down if experiencing dizziness or faintness. - Clients should avoid sudden changes of position/rise slowly. Reflex Tachycardia: - Monitor vitals. - Administer a beta-blocker such as metoprolol if needed. Tolerance: - Use lowest dose needed to achieve effect. - Take all long-acting forms of nitroglycerin with a medication-free period each day. This action reduces the risk of tolerance. Contraindications/ Precautions: - Pregnancy Risk Category C. - This medication is contraindicated in clients who have hypersensitivity to nitrates. - Nitroglycerin is contraindicated in clients who have severe anemia, closed-angle glaucoma and traumatic head injury because the medication can increase intracranial pressure. - Use cautiously in clients taking antihypertensive medications and clients who have hyperthyroidism or renal or liver dysfunction. - - - - - - - - - - - - - - - Give IM injections cautiously to avoid injecting into a nerve or an artery. - Advise clients to complete the entire course of therapy, even if symptoms resolve. - Advise client to use an additional contraceptive method when taking penicillins. Cephalosporins: PROTOTYPE: Cephalexin, first generation First generation: Cefazolin (IM/IV) Second generation: Cefaclor, cefotetan (PO) Third generation: Ceftriaxone, cefotaxime (IM/IV) Fourth generation: Cefepime (IM/IV) Adverse effects: - Allergy, hypersensitivity, anaphylaxis, possible cross‑sensitivity to penicillin. - If indications of allergy appear (urticaria, rash, hypotension, dyspnea), stop the cephalosporin immediately, and notify the provider. - Question clients carefully about a history of allergy to a penicillin or another cephalosporin, and notify the provider if present. - Bleeding tendencies from cefotetan and ceftriaxone - Avoid use for clients who have bleeding disorders and for clients taking anticoagulants. - Observe clients for bleeding. - Monitor prothrombin and bleeding times. Delays in clotting can require discontinuation of the - medication. - Administer parenteral vitamin K. - Thrombophlebitis with IV infusion - Rotate injection sites. - Administer as a dilute intermittent infusion or slowly over 3 to 5 min and in a dilute solution for bolus dosing. - Renal Insufficiency - Giver lower dosage of most cephalosporin to prevent accumulation to toxic levels. - Pain with IM injection - Administer IM injections deep into a large muscle mass such as into the ventrogluteal site. - Antibiotic‑associated pseudomembranous colitis - Observe for diarrhea, and notify the provider if present. - Stop the medication. Contraindications/Precautions: - Do not give cephalosporins to clients who have a history of severe allergic reactions to penicillins. - Use cautiously with clients who have renal impairment or bleeding tendencies. Interactions: - Disulfiram reaction (intolerance to alcohol) occurs with simultaneous use of alcohol and either cefotetan or cefazolin. Instruct clients not to consume alcohol while taking these cephalosporins. - Probenecid (gout) delays renal excretion. Monitor I&O. Nursing Administration: - Instruct clients to complete the entire course of therapy, even if symptoms resolve. - Advise clients to take oral cephalosporins with food. - Instruct clients to store oral cephalosporin suspensions in a refrigerator. Carbapenems: PROTOTYPE: Imipenenem-cilastaton (IM/IV), Meropenem (IV) Adverse Effects: - Allergy, hypersensitivity, possible cross‑sensitivity to penicillin or cephalosporins - Monitor for indications of allergic reactions, such as dyspnea, rashes, and pruritus. - Question clients carefully about their history of allergy to a penicillin or other cephalosporin, and notify the provider if present. - Gastrointestinal upset (nausea, vomiting, diarrhea) - Observe for manifestations, and notify the provider if they occur. - Monitor I&O. - Suprainfection - Monitor for indications of colitis (diarrhea), oral thrush, and vaginal yeast infection. Contraindications/ Precautions: - Imipenem‑cilastatin is a Pregnancy Risk Category C medication. - Use cautiously in clients who have renal impairment. Interactions: - Imipenem‑cilastatin can reduce blood levels of valproic acid. Breakthrough seizures are possible. - Avoid using together. If concurrent use is unavoidable, monitor for increased seizure activity. Nursing Administration: - Advise client to complete the entire course of therapy, even if symptoms resolve. Other inhibitors of cell wall synthesis: - Vancomycin (PO/IV) - Aztreonam, a monobactam, (IM/IV) - Fosfomycin (PO) Adverse Effects: Ototoxicity (rare and reversible) - Assess for indications of hearing loss. - Instruct clients to notify the provider if changes in hearing acuity develop. - Monitor vancomycin levels. Infusion reactions - Monitor for red man syndrome: rashes, flushing, tachycardia, and hypotension.) - Administer vancomycin slowly over 60 min. IM and IV injection‑site pain, thrombophlebitis - Rotate injection sites. - Monitor the infusion site for redness, swelling, and inflammation. Renal toxicity - Monitor I&O and kidney function tests. - Monitor vancomycin trough levels. Contraindications/ Precautions: - An allergy to corn or corn products and previous allergy to vancomycin are contraindications. - Use cautiously for older adults and with clients who have renal impairment or hearing loss. Interactions: - Increased risk for ototoxicity when taking vancomycin concurrently with another medication that causes ototoxicity (loop diuretics, aminoglycoside antibiotics). - Assess for hearing loss. Nursing Administration: - Monitor vancomycin trough levels routinely after blood levels have reached a steady state. - For clients who have renal insufficiency, creatinine clearance levels indicate IV dosage adjustments. Nursing Evaluation of Medication Effectiveness: Indications of effectiveness include the following. - Reduction of manifestations such as fever, pain, inflammation, and adventitious breath sounds - Resolution of infection. - Antibiotics Affecting Protein Synthesis: Dietary Supplement Interactions with Tetracycline (Active Learning Template - Medication, RM Pharm RN 7.0 Ch. 45) 1) Instruct clients to take tetracyclines (except for minocycline) on an empty stomach with 8 oz. water. It may be taken with food if gastric distress occurs. 2) Interaction with milk products, calcium and iron supplements, laxatives containing magnesium, and antacids causes formation of nonabsorbable chelates, thus reducing the absorption of tetracyclines. 3) Tell clients not to take tetracyclines just before lying down because it increases the risk of esophageal ulceration. 4) Instruct clients to maintain a 2‑hr interval between ingestion of chelating agents and tetracyclines. 5) Avoid milk products and antacids, or separate by 2 hr. - Urinary Tract Infections: Evaluating Client Response to an Analgesic (Active Learning Template - Medication, RM Pharm RN 7.0 Ch. 46) 1) Urinary tract analgesic (Phenazopyridine) 2) The medication is an azo dye that functions as a local anesthetic on the mucosa of the urinary tract 3) Relieves manifestations of burning with urination, pain, frequency, and urgency 4) Acute kidney injury and chronic kidney disease are contraindications 5) It changes urine to an orange‑red color (can stain clothing) 6) Instruct clients to take it with or after meals to minimize GI discomfort. 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