Final Exam Review-SSRIs- Selective serotonin reuptake inhibitors-block the reuptake of serotonin into the nerve terminal of the CNS. More commonly used than TCAsless side effects. Used for major depressive disorders. -Fluoxetine (Prozac), Fluvoxamine (Luvox), Sertraline HCl (Zoloft)-most commonly used, Paroxetine (Paxil), Citalopram (Celexa), Escitalopram (Lexapro) An older client, who has been taking sertraline hydrochloride (Zoloft) for depression, is experiencing a sudden onset of nausea, vomiting, abdominal cramps, and diarrhea. The nurse suspects this client is experiencing: Adverse effect on the serum sodium level. Rational: Older clients are prone to developing hyponatremia as an adverse effect of sertraline hydrochloride (Zoloft). The symptoms of nausea, vomiting, abdominal cramps, and diarrhea are early manifestations of hyponatremia and need to be further evaluated in the client. -Many SSRIs interact with grapefruit juice. -SEs headache, nervousness, restlessness, insomnia, diarrhea, blurred vision, mydriasis, tremors, dry mouth, anorexia, nausea, weight loss, menstrual irregularities, sexual dysfunction. -AEs- seizures, hyponatremia, dehydration, bleeding, osteopenia, suicidal ideation. -Assess: Baseline VS and weight. Liver and renal function (BUN, creatinine, urine output, liver enzymes). Health history of episodes of depression. Drug history. Assess for tardive dyskinesia, and neuroleptic malignant syndrome (NMS). -Observe for s/s of depression. VS. Orthostatic hypotension. Monitor for suicidal tendencies. Observe for seizures. -Teaching: Compliance is important. Full effectiveness may take 1-2 weeks. No alcohol. No hazardous activities. Do not stop abruptly. Take with food for GI distress. Advise taking at night to avoid sedative effects. (Nausea, headaches, drowsiness and nervousness). -ACE inhibitors- angiotensin-converting enzyme inhibitors-block release of aldosterone, which promotes sodium retention. Primarily used to treat HTN. -Benazepril (Lotensin), Captopril (Capoten), enalapril maleate (Vasotec), fosinopril (Monopril), Lisinopril (Prinivil, Zestril), moexipril (Univasc), perindopril (Aceon), quinapril (Accupril), Ramipril (Altace), trandolapril (Mavik). -Usually given with a diuretic. Not during pregnancy. Dose reduction necessary for patients with renal insufficiency. -Most common SE: constant, irritating cough. Others include: nausea, vomiting, diarrhea, headache, dizziness, fatigue, insomnia, hyperkalemia, and tachycardia. -Should not be taken with potassium sparing diuretics. -Assessment: Drug and herbal history. Baseline VS. Labs: serum protein, albumin, BUN, creatinine, K+, and WBC. -Intervention: Monitor BP. Monitor labs r/t renal function. Watch for hypoglycemic reaction in DM patients. Report to HCP evidence of bruising, petechiae, and/or bleeding. -Teaching: Abruptly discontinuing captopril could cause rebound HTN. HCP before OTC. No salt substitute containing potassium. Warn about pregnancy and contraindication. Rise slowly to avoid orthostatic hypotension. How to take BP and report BP changes. -Beta blockers-used as antihypertensive drugs, sometimes in combination with a diuretic. Reduce HR, contractility and renin release. -propranolol (Inderal), carvedilol (Coreg), acebutolol (Sectral), atenolol (Tenormin), betaxolol (Kerlone), bisoprolol (Zebeta), metropolol (Lopressor). -Use with caution on patients with preexisting bronchospasm. -SE: increased pulse rate, markedly decreased BP, and in (noncardioselective blockers) bronchospasm, dizziness, insomnia, depression, fatigue, nightmares and sexual dysfunction. -Assessment: Medical and herbal history. VS. Renal and liver function values. -Intervention: VS. (BP and pulse). Labs: BUN, serum creatinine, AST, LDH. -Teaching: Compliance. No abrupt discontinuation. No OTC without HCP. Teach patient how to monitor BP, and radial pulse. Educate how to avoid orthostatic hypotension. Report dizziness, slow pulse rate, changes in BP, heart palpitations, confusion, or GI upset. May cause sexual dysfunction. Teach non-pharmacologic ways for lowering BP (low sodium diet, exercise, relaxation techniques, smoking cessation). -Do not abruptly discontinue as it could put the patient at risk for: rebound HTN, MI.-Afrin-oxymetazoline-long acting decongestant. Taken twice a day (morning and evening). -Oxymetazoline (Afrin) is an effective nasal decongestant, but overuse results in worsening or rebound congestion. It should not be used more than every 4 hours. To avoid future rebound congestion with nasal sprays, it is recommended that they be used for no more than 3-5 days.-Albuterol (Proventil) - a beta2-adrenergic agonist-To treat allergic reaction, anaphylaxis, asthma, bronchospasm, severe hypotension, severe hypotension, cardiac arrest. Promotes CNS and cardiac stimulation; strengthens cardiac contraction, increases cardiac rate and cardiac output. -SE- anorexia, nausea, vomiting, (nervousness, tremors, restlessness-most common), agitation, sweating, headache, pallor, insomnia, weakness, dizziness. -AR-Palpitations, tachycardia, hypertension, dyspnea, necrosis and gangrene of IV upon infiltration. Ventricular fibrillation, pulmonary edema. -Assess-baseline VS, drug history (contraindicated in narrow angle glaucoma and cardiac dysrhythmias). Baseline glucose level. -Interventions: VS (BP and HR). Monitor for dysrhythmias. Report SEs. Urinary output and bladder for distention. Food to avoid nausea. Evaluate BSLs in DM patients. -Teaching: HCP before OTC use. Compliance. Reporting side effects. Use of MDI. -Montelukast (Singulair) leukotriene inhibitor. (Chemicals that are released when you breathe in an allergen). For children, the nurse should instruct the parent to make sure the child chews the entire tablet and does not swallow it whole.-TB dugs- mycobacterium tuberculosis- prophylactic drug therapy or antitubercular drugs. Multi drug therapy is more effective against TB. Combinations can include the following: 1. Isoniazid and rifampin. 2. Isoniazid, rifampin and ethambutol. 3. Isoniazid, rifampin, and pyrazamide. -Prophylactic drug therapy is contraindicated in persons with liver disease. -Isoniazid (INH)-main antitubercular-prophylactic therapy. -SE: drowsiness, tremors, rash, blurred vision, photosensitivity, tinnitus, dizziness, nausea, vomiting, dry mouth, constipation. -AR: psychotic behavior, peripheral neuropathy (can be reversed with pyridoxine-vitamin B6), vitamin B6 deficiency, hyperglycemia, blood dycrasias, thrombocytopenia, agranulocytosis, hepatotoxicity. Not for patients with liver disorder; INH, rifampin and streptomycin all cause hepatotoxicity. Assessment: History of TB and TB tests. General medical history. Bilirubin, BUN and creatinine tests. Assess s/s of peripheral neuropathy. Intervention: Admin INH 1 hour before meals. Give vitamin B6 to prevent peripheral neuropathy. Serum liver enzyme levels. Collect sputum specimens. Encourage eye exams. Compliance. Teaching: Compliance is essential. No antacids or alcohol. Medical appointments for sputum testing. Talk to HCP if planning pregnancy. Report numbness, tingling, or burning of hands and feet (peripheral neuritis). Avoid sunlight. Body fluid may turn red-orange-normal. -Claritin-loratadine- Second generation antihistamine (also called non-sedating antihistamines). -For allergic rhinitis (stuffy nose) and urticarial (hives). Long acting H-1 blocking effect. Longer half-life (7-15 hours)can take less frequently. Dry up secretions, reduce sneezing. -Asthma and asthma medications: -Inflammation Blockers-address one or more of the chemicals release upon exposure to a triggering event for asthma -Leukotriene receptor antagonists-effective in reducing the inflammatory symptoms of asthma caused by environmental and allergic stimuli (exercise induced asthma)not for treatment of acute asthmatic attack. -Only for prophylactic and maintenance drug therapy for chronic asthma. -Zafirlukast (Accolate) and montelukast (Singulair) - Maintenance therapy for chronic asthma. Reduce inflammation within bronchial tubes and airways. Assess: Baseline VS and med history. Assess decreased breath sounds, wheezing, cough and sputum production. Note confusion, and restlessness due to hypoxia. Determine hydration status. Intervention: Monitor respirations. Lung sounds. Cyanosis. Provide adequate nutrition. AST and ALT tests (may be elevated). Teach: s/s of allergic reaction. Liver function tests. Herb Alert: St. Johns wort, black or green tea, guarana. Stop smoking. Alleviate anxiety. Medic Alert tag. -Glucocorticoids-inhaledbeclomethasone (Beclovent)good for maintenance -Oral, for short term illness. -IV, for acute illness. -not for treatment of acute asthmatic attack (not for rescue) Mucolytics-acetylcysteine (Mucomyst) -Given by inhalation atleast 5 minutes after a bronchodilator. -Liquefy and loosen thick secretions in the airway so they can be coughed loose and eliminated. -Nausea, vomiting are common. -Fun Fact: antidote for Tylenol. Theophylline-low therapeutic index. Maintenance of chronic asthma and other COPDs. Declined use due to serious SEs (dysrhythmias, convulsions, cardiorespiratory collapse). Not for seizure, cardiac, renal or liver disease patients. Children & asthma: Cromolyn and nedocromil. Sometimes glucocorticoids for moderate to severe asthmatic state. Older adults & asthma: Must be closely consideredbeta2-adrenergic agonists and methylxanthines (theophylline) can cause tachycardia, nervousness and tremors. -Robitussin (guaifenesin)-expectorant-loosen bronchial secretions s they may be eliminated by coughing. Teach patient to: increase fluid intake to atleast 8 glasses a day to help loosen mucus. -Benylin DM-dextromethorphan Hydromorbide-antitussiveprovides temporary suppression of non-productive cough and loosens secretions. -non-narcoticwidely used in OTC cold remedies. -SE: nausea, drowsiness, fatigue, sedation. -Contraindication in COPD patients or patients with chronic productive cough. -Diabetes Mellitus I & II drugs (Type I-insulin dependent, Type II-non-insulin dependent) -Insulin:-administering: RN-Regular, then NPH. (clear before cloudy) -Rapid acting (clear)-insulin lispro (Humalog), insulin aspart (NovoLog), insulin glulisine (Apidra) -Onset of action (5-15 minutes), peak (30 minutes to 1 hour), duration (2-4 hours) -Short-acting insulin (clear)-Regular (Humulin R, Novolin R, regular insulin) -Onset of action (30-60 minutes), peak (2-3 hours), duration (3-4 hours) -Intermediate-acting (cloudy)-Insulin isophane NPH (Humulin N, Novolin N) -Onset of action (2-4 hours), peak (4-12 hours), duration (18-24 hours) -Long-actingInsulin glargine (Lantus) -Onset of action (1 hours), duration (24 hours), administered at bedtime. Keep at room temp b/c injecting cold insulin is painful -Combinations-composed of short and intermediate-acting or rapid and intermediate acting. (i.e.: Humulin 70/30 (isophane NPH 70%, regular 30%)-SE: Hypoglycemia, dizziness, confusion, slurred speech, nervousness, anxiety, agitation, tremors, uncoordination, sweating, tachycardia, seizures. -Hyperglycemia: extreme thirst, dry mucous membranes, poor skin turgor, polyuria, fruity breath, fatigue, tachycardia, Kussmaul respirations. -Interventions: Monitor VS and glucose levels. Teach s/s of hypo/hyperglycemia. Encourage compliance with diet, insulin, exercise. Teach how to check BSLs. Teach how to administer insulin. (Insulin pumps, pen injectors, jet injectors) Oral antidiabetic drugs: to treat type II diabetes. First generation sulfonylureas -Short acting: tolbutamide (Orinase) -Intermediate-acting: tolazamide (Tolinase) -Long acting: chlorpropamide (Diabinese) -Second generation sulfonylureas -Glimepiride (Amaryl) -Glipizide (Glucotrol, Glucotrol XL) Nonsulfonylureas-biguanide: Metformin (Glucophage) Decreases hepatic production of glucose from stored glycogen. Alpha-Glucosidase Inhibitors: Acarbose (Precose), Miglitol (Glyset). Thiazolidinediones: Pioglitazone (Actose), Rosiglitazone (Avandia)-contraindicated in symptomatic heart disease and Class II and IV CHF. Meglitinides- Repaglinide (Prandin) and nateglinide (Starlix) Hyperglucemics- Glucagon- for insulin induced hypoglycemia. (SubQ, IM, IV)-DDAVP-desmopressin acetate- intranasal or by injection. To treat DI (diabetes insipidus) -DI- when there is a deficiency of ADH (antidiuretic hormone) and large amounts of water are --excreted by the kidneyscan lead to severe volume deficit. -Thyroid- secretes T4 and T3- metabolism. -Hypothyroidism-`decrease in thyroid hormone secretion. Myxedema- severe hypothyroidism. -lethargy, apathy, memory impairment, emotional changes, slow speech, edema in eyelids and face, dry skin, weight gain, constipation. -Drug therapy: -synthetic TRH preparations: Levothyroxine sodium (Synthroid) is drug of choice, Liothyronine (Cytomel), Liotrix (Thyrolar). -ADPIE: Obtain drug history. Record VS (temperature, HR, BP usually decrease). Monitor weight. Teach that certain food inhibit thyroid secretion. HCP before OTC. Teach s/s of hyperthyroidism (tachycardia, chest pain, palpitations). -Hyperthyroidism- increase in T4 and T3 levels-cause Graves disease or thyrotoxicosis. Surgery or drug therapy. -Drug therapy: Propylthiouracil (PTU) and methimazole (Tapazole)-useful for thyrotoxic crisis and in preparation for thyroidectomy. -ADPIE: Assess of s/s of thyroid crisis (thyroid storm). Teach to take with meals. Drug compliance. Teach SE of hypothyroidism. -Parathyroid- PTH regulates calcium levels in the blood. -Hypoparathyroidism-hypocalcemia (by PTH deficiency)-s/s of tetany (twitching of mouth, tingling and numbness of fingers, carpopedal spasm, spasmodic contraction, laryngeal spasm) -Calcitrol- a vitamin D analogue to treat hypoparathyroidism and manage hypocalcemia. -Hyperparathyroidim-can be caused by malignancies of the parathyroid glands or ectopic PTH secretion due to lung cancer, hyperthyroidism, or prolonged immobility. -Treated by synthetic calcitonin. Calcium levels: 4.5-5.5 mg/dL (ionized or free flowing calcium in the blood) or 8-10 mg/dL (total calcium)-Prednisone (Deltasone)- Adrenal hormone-a glucocorticoid- used to treat many diseases and health problems including: anti-inflammatory, allergic, and debilitating conditions. -Decreases inflammatory occurrence, an immunosuppressant, to treat dermatologic disorders by suppressing inflammation and adrenal function. -Assess: Baseline VS. Labs: serum electrolytes and BSLs. Weight and urine output. Medication history-can intensify-glaucoma, cataracts, peptic ulcers, psychiatric problems, or DM. -Interventions: Administer only as ordered. Weight. Labs (K+ decreases, BSLs increase). Watch s/s of hypokalemia (nausea, vomiting, muscle weakness, abdominal distention, paralytic ileus, irregular HR) -Teach: Importance of drug compliance. Do not abruptly stop. Teach drug tapering for short-term use. Avoid persons with respiratory infections (they suppress immune system). Advise eating food rich in potassium. -Levothyroxine Sodium (Synthroid) -To treat hypothyroidism, myxedema, and cretinism. -SE: nausea, vomiting, anorexia, diarrhea, cramps, tremors, nervousness, irritability, insomnia, headache, weightloss, diaphoresis, amenorrhea. -AR: tachycardia, HTN, palpitations, osteoporosis, seizures. -Contraindications: thyrotoxicosis, MI, severe renal disease, adrenal insufficiency. Caution with: Cardiovascular disease, HTN, angina pectoris, DM, osteoporosis. -Acthar-Repository Corticotrpin-adrenocorticotropic hormone (ACTH) -Used to diagnose adrenal gland disorders, to treat adrenal gland insufficiency, and as an anti-inflammatory drug in the treatment of allergic response. Also treats acute MS. -SE: N&V, diarrhea, constipation, mood swings, petechiae, water and sodium retention, hypokalemia, hypocalcemia, acne. -AR: edema, ecchymosis, osteoporosis, muscle atrophy, growth retardation, decreased wound healing, cataracts, glaucoma, seizures, menstrual irregularities, HTN. Life threatening: pancreatitis, ulcer perforation. -Antibiotics and antimicrobials inhibit bacterial growth or kill bacteria and other microorganisms. -narrow spectrum (usually effective against one type of organism) and broad spectrum (tetracycline and cephalosporins-effective against gram positive and gram negative organisms. -Adverse reactions to antibacterials- allergic reactions, superinfection or organ toxicity. -Overuse of penicillin lead to tolerance, requiring stronger antibiotics to be made. -Amoxicillin and dicloxacillin broad spectrum to treat respiratory tract infections, UTI, otitis media and sinusitis. ADPIE: Assess allergy to penicillin. Lab results (liver). Urine output. C&S. Epi available in case of allergic reaction. Teach s/s of allergic reaction. -Cephalosporins: fungus that acts as a broad spectrum antibacterial- large doses are nephrotoxic in patients with renal disorders.- cefazolin (Ancef) and cefaclor (Ceclor) ADPIE: Assess allergies to penicillin or cephalosporins. Lab results (especially liver enzymes). Urine output. C&S tests. Teach to report s/s of superinfections. Encourage use of ingesting probiotic yogurts, buttermilk and such. Comply with entire course of medication. Teach SE. -Antifungal therapy-fungal infections can be superficial/local, often opportunistic. -Oral candidiasis-Thrush-Mycostatin swish and swallow -Vaginal candidiasis-Monistat cream, suppository or oral Diflucan. -Prevention and treatment of GI fungal infection-IV Diflucan. -Prototypes: Nystatin (Mycostatin), Fluconazole (Diflucan) -Metronidazole (Flagyl)-used for treatment of a variety of GI conditions (H. Pylori, post-op GI surgery patients). For serious systemic fungal infections-Amphotericin B (Fungizone)- extremely toxic: nephrotoxic, thrombophlebitis. Fever, chills, nausea, vomiting, hypotension. -Pyridium-phenazopyridine hydrochloride -a urinary analgesic, works by relieving urinary pain, burning sensation, frequency and urgency that are symptomatic of lower UTIs. -SE: GI disturbances, hemolytic anemia, nephrotoxicity, and hepatotoxicity. Harmless reddish orange urine due to the dye. Alters glucose urine test. -UTI drugs-UTI: Microbial infection. Cause pain and inflammation, bladder spasm, urgency. -Urinary antiseptics/antiinfectives/antibiotics- nitrofurantoin (Macrodantin)take with food. Increase fluids. No antacids. Rinse mouth after taking because it stains teeth. Urine may appear brownish. - Bactrim and Cipro. -Urinary antispasmodics- oxybutynin (Ditropan)-do not use if patient has glaucoma. Do not use in cardia, renal, hepatic and prostate patients. -Urinary analgesicsphenazopyridine (Pyridium)- relieves pain, burning and frequency/urgency. Turns urine reddish-orange. Watch CBC, liver and renal function. Treatment: Nitrofurantoin (Macrodantin), Trimethoprim-sulfamethoxazole (Bactrim, Septra), Fluoroquinilones (Noroxin), Ciprofloxacin (Cipro), Fosfomycin tromethamine (Monurol)-single dose. Severe UTI- IV drug therapy followed by oral drug therapy. Preventing UTIs: Hydration, Cranberry juice, hygiene and toileting habits. Assess: history of UTI. Urine output and pH (5.5 is desired but alkalinization is nt recommended). Encourage to avoid antacids. Increase fluids. Report s/s of superinfection.-Tetracyclines- bacteriostatic, broad spectrum. -Drug of choice for H. Pylori treatment (along with metronidazole and bismuth subsalicylate). -Continuous use has resulted in bacterial resistance to the drugs. -Prototype: doxycycline (Monodox)-avoid sun exposure, discoloration of developing permanent teeth. -ADPIE: Assess VS and urine output. Report abnormal findings. Labs-BUN, creatinine, aspartate aminotransferase, alanine aminotransferase, bilirubin. History if dietary intake. C&S. Administer 1-2 hours before meals for optimal absorption. Teach patient to store away from light and heat. Teach of photosensitive effect. Report s/s of superinfection. Teach effective oral hygiene. Avoid milk products, iron and antacids. -Any patient who breaks out in a massive rash, while on antibiotics, what do you do? Call HCP, make sure you have an airway. -Antivirals -HIV, Herpes (HSV 1-cold sores. 2-genital herpes, STD. 3-chicken pox and shingles. 4-Epstein-Barr virus. 5-CMV) -Herpes-acyclovir (Zovirax)-for cold sores and shingles (PO, IV, and topical) and valocyclovir (Valtrex) for shingles and genital herpes (PO) -Antiviral (non-HIV) drugs-inhibit viral replication. -Influenza- amantadine (Symmetrel)-for flu prevention and oseltamivir (Tamiflu)- for treatment of flu within 48 hours of symtoms. -Antivirals can have CNS effects and GI SEmonitor CBC and renal function. -Fentanyl (Duragesic)- transdermal opioid analgesic. Comes in various strengths. Short acting potent opioid analgesic. May be used with short-term surgery. Changed every 3 days.-Fentanyl citrate (Sublimaze)-used as a narcotic agonist for pain relief during labor. Watch for respiratory depression in neonates if drug is used during labor. IV drug-administer over 3-5 minutesto fast can cause muscle rigidity. -Atropine classic anticholinergic. Used primarily as preoperative medication to decrease salivary secretions. As an agent to increase HR when bradycardia is present. -SE: dry mouth, decreased perspiration, blurred vision, tachycardia, constipation and urinary retention, nausea, headache, dry skin, abdominal distention, hypotension or hypertension, impotence, photophobia. -Contraindicated in narrow angle glaucoma, obstructive GI disorders, MI, tachycardia, ulcerative colitis. -ADPIE: Baseline VS, urine output, medical history, drug history. Monitor BS during drug therapy. Fluid I&O. Assess bowel sounds. Mouth care in case of dryness. Direct patients to avoid hot environments. -Alprazolam (Zanax)-benzodiazepine-to treat anxiety and panic disorders. -ADPIE: Obtain drug history. Baseline VS. History of insomnia or anxiety disorders. Assess renal function. Monitor VS during drug therapy especially s/s of respiratory depression. Observe for adverse reactions. Teach: non-pharmacologic ways to induce sleep. Encourage to avoid alcohol, antidepressants, antipsychotic, and opioid drugs while on benzodiazepines.-Morphine-effective against acute pain from MI, cancer, and dyspnea resulting from pulmonary edema. May be used as preoperative medication. -Effective in relieving severe pain but can cause respiratory depression, orthostatic hypotension, miosis, urinary retention, rash, blurred vision, bradycardia, flushing, euphoria, pruritus. Hypotension, urticarial, seizures, ileus. Respiratory depression, increase intracranial pressure. -ADPIE: Obtain medical history, drug history, VS (especially respirations), urinary output, assess type of pain. Administer before pain reaches peak levels. Monitor VS at intervals (RR