Professional Documents
Culture Documents
Instructions:The contents on this guide are intended to help you organize your
preparation for the Evolve Specialty Exam (ESE) for NR292. This is NOT intended
to serve as a direct reflection of the exact questions which will be presented in
the exam. As you review the topics listed below, be sure that you can
1. Apply Pharmacological Concepts (to the drugs/drug classes listed below)
Pharmacokinetics, Pharmacodynamics, Pharmacotherapeutics
Indications and Contraindications
Adverse effects
Patient variables: Pediatric, Gerontology, Pregnancy/Breast-feeding,
Gender, and Cultural/Ethnic variations
2. Apply Nursing Considerations (to the drugs/drug classes listed below)
Assessments to include vital signs, physical assessment, labs, &
diagnostics
Drug administration: safety, route considerations, med orders
Drug toxicity (signs/symptoms) and antidote if applicable
Patient teaching
3. Perform medication calculation:
Oral, suspension, injectable, IV (ml/hr and gtt/min)
Metric and household conversions
Pharmacokinetics A drugs time to onset of action time to peak effect and duration of
action are all characteristics defined by pharmacokinetics. It is the study of what happens to
a drug from the time it is put into the body until the parent drug and all metabolites have
left the body. Absorption into, distribution and metabolism within and excretion from the
body are combined focus of pharmacokinetics.
Pharmodynamics- what a drug does to the body, ( done after phase 11 pharmacokinetic
phase absorption, distribution, metabolism and excretion) involves drug receptor
interactions
Pharmacotherapeutics (mechanism of action) focuses on the clinical use of drugs to
prevent and treat diseases It defines the principles of drug action the cellular processes
that change in response to the presence of drug molecules. Some drug mechanisms of
action are more clearly understood than others.
Pharmacologic Concepts:
Synergistic effects 1+1= 2 combination of drugs with similar action is greater
than the sum of the individual effects of the same drugs given alone.
Agonistic works together with. A drug that binds to and stimulates the activity of
one or more receptors in the body.
Antagonistic effects Inhibit a drug that binds to and inhibits the activity of one
or more receptors in the body.
Tolerance reduced response to a drug after prolonged use
DRUG Categories:
CNS drugs
Opioids/Pain Management:
Oxycodone (Percocet) scheduled II drug Indication used to control
postoperative and other types of pain (strong opioid) Contraindicated for people with
drug allergy or severe asthma. Opioids release histamine which causes the itching,
vein and arteries to dilate which then leads to flushing and orthostatic hypotension.
Adverse effects respiratory depression, hypotension, flushing disorientation,
bradycardia, N/V, constipation, urinary retention and pruritus. Antidote naloxone
(narcan)
Acetaminophen (Tylenol)- nonopioid analgesic Indication mild to moderate pain
and reduce fever. Mechanism of action blocks peripheral pain impulses by inhibition
of prostaglandin syntheses. Contraindications drug allergy, severe liver/ kidney
disease and genetic disease. Adverse effects- rash, nausea and vomiting or severe
effects of the blood are anemias and nephrotoxicitys and hepatotoxicity Antidote
acetylcysteine maximum dose is 4000mg however 2000mg or less may be
necessary for patients with risk factors such as advanced age or liver dysfunction.
Liver dysfunction can occur if taking acetaminophen with alcohol in access.
Fentanyl (Duragesic)- synthetic opioid schedule II Indication (cancer induced
pain med) moderate to severe pain has a high abuse potential. Available in
parenteral injections transdermal patches buccal lozenges and buccal lozenges on a
stick lollipop or IV giving fentanyl patch to a non-opioid tolerant patient may
result in severe respiratory depression. To be considered for opioid patch the patient
should have been taking for a week or longer morphine daily oxycodone or
hydromorphone. Patients should not use heating pads because it can increase
circulation that results in increased absorption causing overdose. Patches should be
folded with sticky sides together and flushed down the toilet. New patches can be
applied after 72 hours . Know that it will take 6 to 12 hours to reach steady state pain
control again. Contraindicated for people with drug allergy or severe asthma. Opioids
release histamine which causes the itching, vein and arteries to dilate which then
leads to flushing and orthostatic hypotension. Adverse effects respiratory
depression, hypotension, flushing disorientation, bradycardia, N/V, constipation,
urinary retention and pruritus. Antidote naloxone (narcan)
Aspirin (do not give to children with flulike symptoms because it can cause
ryes syndrome). It is given as prophylactic therapy for risk factors of coronary
artery disease or stroke and given as 81mg or 325mg dose. Mechanism of action
inhibit platelet aggregation known as antiplatelet activity. There used as a
prophylactic for acute myocardial infarction and many other thromboembolic
disorders. Other NSAIDS generally lack these antiplatelet. Contraindications patient
at risk for bleeding, vitamin K deficiency and peptic ulcer disease and patient with
aspirin drug allergy. NSAIDs can be given the first 2 trimesters but is contraindicated
in the 3rd trimester and is not recommended for nursing mothers. NSAIDs should also
be discontinued one week before any surgical procedures due to risk of bleeding.
Adverse effects GI symptoms such as heartburn and gastrointestinal bleeding,
noncardiogenic pulmonary edema. Symptoms of alicylate intoxication: Increased
HR, tinnitus, hearing loss, dimness of vision, headache dizziness, mental confusion,
Nausea and vomiting sweating thirst hyperventilation hypo/hyperglycemia. Antidote
for toxicity- no antidote medication goals is to remove salicylate from the GI and or
preventing its further absorption correcting fluid electrolyte and preventing its further
absorption, and acid base disturbances and implement measure to enhance
salicylate elimination including hemodialysis. NSAIDs are contraindicated for
patients with cardiovascular disease due to the increased risk of
thrombotic events MI and stroke. (Not for aspirin because aspirin as the
antiplatelet effect as other NSAIDs do not. In patients with GI upset they can be
given cytotec to prevent gastric ulcers and gastrointestinal bleeding that can occur in
patients receiving NSAIDs. Ketorolac (Toradol) powerful analgesic effect and has
an anti-inflammatory effect. Ketorolac lacks the addictive properties like opioids. Its
indicated for orthopedic injuries or surgery. Can be given orally or injection. It is a
short tem treatment not for minor or chronic pain. Adverse effects renal
impairment, edema GI pain dyspepsia and nausea- this drug can only be used for 5
days because of its potential adverse effects.
Muscle Relaxants: Baclofen Indications trauma inflammation anxiety and pain
associate with acute muscle spasms. Mechanism of action depresses nerve
transmission in the spinal cord. Contraindicated in patients with renal failure. Adverse
effects euphoria, lightheadedness, dizziness, drowsiness, and fatigue and muscle
weakness experienced early in treatment, generally short lived after growing
tolerant to them over time. Toxicity and antidote - No specific antidote or reversal
drug. Gastric lavage and close observation of the patient is recommended. Adequate
airway should be maintained and electrocardiographic monitor should be instituted
and large quantities of IV fluids to avoid crystalluria.
Neuromuscular blockers/Anesthetics: Nalbuphine (Nubain) synthetic
narcotic analgesic Indications relief of moderate to severe pain also preoperative
sedation analgesia as a supplement to surgical anesthesia. Contraindicated drug
allergy or pregnancy. Caution use in patient with emotional instability or drug abuse
head injury increased ICP cardiac disease impaired respirations, COPD GI disorders
impaired kidney or liver function MI and lactation. Nursing implications Withhold
this drug if respiratory rate is below 12 watch for respiratory depression of newborn
if given during labor and delivery avoid abrupt termination of drug following
prolonged use may result in withdrawal symptoms.
Cholinergics: Tensilon evaluation of treatment requirements of
myasthenia gravis. Diagnose cholinergic crisis - Negative Tensilon test - makes
client worse - Positive Tensilon test - client improves. Tensilon is injected
intravenously, atropine sulfate is antidote for overdose, in order to diagnose MG most clients will see improvement in 30-60sec/lasts 4-5 min
Antiepileptics: Depakote valproic acid unspecified antiepileptic Indications
treatment for generalized seizures (absence, myoclonic and tonic clonic)also
effective in partial seizures. Contraindicated in patients with liver impairment and
urea cycle disorders. Adverse reactions drowsiness, nausea and vomiting along with
other GI disturbances, tremor weight gain and hair loss. This drug has interactions to
the following drugs: aspirin, cholestyramine, diazepain and warfarin, rifampin,
tricyclic antidepressants and antimalarial medications. Advice patients to avoid
alcohol, herbal products and to notify health care provider if any thoughts or suicide
or dying /anxiety irritability or panic attacks.
CNS/Psychotherapeutic Drugs:
Stimulants: Amphetamine (Adderall) releases norepinephrine from nerve
endings to increase motor activity mental alertness and decreased fatigue
in narcoleptic patients and ADHD patients Indications ADHD and narcolepsy
Contraindicated in patients with hyperthyroidism, psychotic personalities suicidal or
homicidal tendencies chemical dependence glaucoma or pregnant. Adverse
effects/side effects hyperactivity insomnia restlessness tremor palpitations
tachycardia anorexia erectile dysfunction growth inhibition and psychological
dependence Interactions : MAOI will cause hypertensive crisis, beta blockers, digoxin
or antidepressants Nursing implementations advise patients to take at least 6 hours
before bed to prevent insomnia, monitor childrens height and weight frequently,
teach the parents how to take summer vacations from the meds.
Antidepressants: SSRIs: Fluoxetine (Prozac) newer generation
antidepressant Mechanism of action inhibits serotonin reuptake and have weak
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antitussive drugs are less effective than the other and are available either alone or in
combination with other drugs of OTC cold and cough medications. Mechanism of
action suppress the cough reflex through direct action on the cough center in the
medulla. Indications stop cough reflex when the cough is nonproductive and or
harmful for the patient. Contraindicated in patients with opioid dependency and high
risk for respiratory depression, hyperthyroidism advanced cardiac and vessel disease
hypertension glaucoma and the use of MAOI in the last 14 days. Nursing
interventions - Antitussive medications may cause drowsiness or dizziness so inform
patient not to drive or operate machinery while taking. It may also cause respiratory
depression if giving with other antitussive medications, so the medication needs to
be given in spaced intervals.
Expectorant aid in the expectoration of excess mucus that has accumulated in the
respiratory tract by breaking down and thinning out secretions. (guaifenesin
mucinex) Mechanism of action loosen and thin secretions in response to an irritation
of the GI tract produced by the drug and the direct stimulation of the secretory
glands in the respiratory tract. Indication bronchitis laryngitis pharyngitis pertussis
influenza and measles. Contraindicated for patients who are allergic to guaifenesin.
Adverse effects minimal nausea vomiting and gastric irritation. Interactions NONE
Bronchodilators- COPD patients! Help to relax bronchial smooth muscle bands to
dilate the bronchi and bronchioles that are narrowed. Three types : beta2 agonists
(albuterol, ephedrine and epinephrine fast acting), anticholinergic (ipratropium and
tiotropium their actions are slow and prolonged and used for prevention of
bronchospasms associated with chronic bronchitis and emphysema and not for acute
symptoms.) and xanthine derivatives (plant alkaloids caffeine theobromine and
theophylline)
Inhaled corticosteroids reduce inflammation and enhance the activity of beta
agonists to prevent the inflammatory process. Ex: inhaled - pulmicort, decadron
phosphate respihaler, aerobid, Flonase, azmacort and the oral corticosteroids used
for respiratory illness is prednisone and methylprednisolone (IV or oral).
Nursing implementations for respiratory drugs
Provide other measures such as humidified o2 etc.
Caution about use of alcohol, narcotics and sedative hypnotics due to CNS depression
(antitussive)
Encourage cessation of smoking
Monitor therapeutic response and adverse responses
Show patient how to use the inhalers or nasal sprays with return demonstration
Have patient rinse mouth with inhaled corticosteroids / do not use for acute
respiratory attacks/ taper off the corticosteroids because it can affect your adrenals.
Cardiovascular Drugs
Antianginals: Nitrates/Nitroglycerin dilate all blood vessels used as
prophylaxis and treatment for angina and other cardiac problems.
Indications treat stable unstable and vasospastic angina rapid acting dosages are
used to treat acute episodes. Contraindication- severe anemia closed angle glaucoma
hypotension and head injury. Along with erectile dysfunction drugs such as Viagra.
Adverse effects- headache, hypotension which can cause risk for falls, skin
inflammation for topical nitrate forms. MAKE SURE TO PROTECT FROM HEAT AND
LIGHT. Intravenous dosing is for emergency and the nurse needs to closely monitor
BP and pulse and constant ECG monitoring, and the medication is only potent for 3-6
months. Patient should avoid alcohol hot environmental temperatures saunas hot
tubs and excessive exertion. Sublingual: 1 tab under tongue at first sign of chest pain
if pain not relieved after 1 dose call 911 may repeat up to 3 times
Antidysrhythmics: Digoxin - Cardiac glycoside , Mechanism of action Increases force of myocardial contraction. Prolongs refractory period of AV node.
the class of serine proteases. Drotrecogin alfa has not been found to improve
outcomes in people with severe sepsis.
Drotrecogin alfa does not improve mortality in severe sepsis or septic shock but does
increase bleeding risks therefore a 2011 Cochrane review recommended that
clinicians and policy makers not recommend its use.[
NOT ON MARKET ANYMORE!!!!
amprenavir (Agenerase)
indinavir (Crixivan)
nelfinavir (Viracept)
ritonavir (Norvir)
# side affects of antiretroviral is nausea and vomiting.
Antihelminthics: Vermox
Drug of choice for worms.
mebendazole (Vermox)
Inhibits uptake of glucose and other nutrients, so the parasite cant eat anything, leading to
autolysis and death of the parasitic worm
We like it because it kills a lot of worms - roundworms, hookworms, and some tapeworms
Adverse Effects
GI most common
Nausea / vomiting
Diarrhea
Headaches
Nursing Interventions
Some drugs may cause the urine to have an asparagus-like odor, or cause an unusual
skin odor or a metallic taste; be sure to warn the patient ahead of time Vermox
GI drugs
GERD/PUD Tx:
o Sucralfate (Carafate)
Sucralfate is used to treat ulcers. It adheres to damaged ulcer tissue and protects
against acid and enzymes so healing can occur.
Shake well before you use.
Laxatives:
o Bulk-formingFiber!
Causes gas
Psyllium (Metamucil)
Increases the consitancy in the stool and then helps absorb the water so the stool is
looser and not as hard or compacted.
KNOW! When someone is taking iron pills do we tell them to lay down and go to sleep? NO
because of reflux it is very erosive to the esophagus
o
o
Vitamin C
Important in wound healing and prevention of bleeding.
o
o
Vitamin D
Sunlight
Endocrine Drugs
Antidiabetics:
o Insulin
Type 1 insulin dependent do not produce insulin at all - no point of taking oral
Type 2 oral / not insulin dependent producing insulin but your body is not utilizing
it
Rapid onset (15min) and duration (3-4) Lispro take when eating & NovoLog
Short onset (30min) and duration (3-6) Regular (Humulin R) four times a day
every meal and right before bedtime
Intermediate onset (2-4) and duration (10-16) NPH (cloudy) & Humulin give twice
a day morning and at dinner
Long onset (1-2) and duration (24) Lantus (clear) once a day give at night
does not peak
70NPH/30Regular Lantus & Levemir
Draw up clear first then draw up the cloudy
IV regular
How they work - They decreased production of glucose by the liver, decrease
intestinal absorption of glucose, increase uptake of glucose into the cells, and DO
NOT increase insulin secretion from the pancreas DOES NOT cause hypoglycemia
because it does not increase insulin secretion it just makes the insulin you have
more effective
KNOW! Metformin - #1 choice for all type 2 diabetes primarily effects the GI tract
most people will lose weight with this can cause gas and diarrhea but doesnt last
long - can cause lactic acidosis, dehydration makes it worse, KNOW! if someone is on
Metformin they have to stop it 24-48 hrs. before they get IV contrast and then after
they cant take it again for another 24-48 hrs.
If they dont feel right, clammy, and hands shaking what are we going to do? Give
them juice, crackers, simple carb with a simple protein, cheese and crackers, cheese
and peanut butter juice is quick put all 3 together juice, carb, and protein
If they are laying there unconscious what are you going to do?
D50 IV push what size IV? At least a 20g Why? It is a hypertonic solution and the
tissue can become necrotic if IV site is not available give glucagon because it is an
IM shot
How long does glucagon work? less than 5 min
o Glimepiride (Amaryl)
Sulfonylureas
First generation: chlorpropamide (Diabinese), tolazamide (Tolinase)
Second generation: glimepiride (Amaryl), glipizide (Glucotrol), glyburide (DiaBeta,
Micronase)
-tropin
Anterior pituitary drugs
o Cosyntropin
o Somatotropin
o Somatrem
o Octreotide
Posterior pituitary drugs
o Vasopressin use in a code blue or someone has extreme hypotension very
strong vasoconstrictor
o Desmopressin
Mimics sympathetic increase heart rate, bp, respirations
Mechanism of action mimics the sympathetic nervous system if someone has a pituitary
tumors, what are they going to have? You end up getting oversectretion of the productions
of the hormones hypertensive crisis because you have the vasopressin is being released.
Thyroid drugs:
o PTU- Propythiouracil (PTU) is the most frequently used thioamide; it is
associated with severe GI effects. The other available thioamide is
methimazole (Tapazole). Hematological adverse effects are more common in
with methimazole, so the patient needs to have a complete blood count and
differential monitored regularly. GI effects are somewhat led pronounced with
methiamzole, so it may be the drug of choice for patients who are unable to
tolerate PTU.
o Radioactive Iodine
If someone has thyroid cancer or graves disease will they have to be on thyroid
placement forever? YES
The thyroid could be destroyed by radioactive iodine, removed surgically, or can just
have half of thyroid removed anytime someone has had any of these things done
they will have to be on a thyroid replacement forever
How do we treat it? Kill your thyroid we kill the thyroid then give you thyroid
hormones that we can have control over we kill it with radioactive iodine, surgery,
remove only half of thyroid, then after that need lifelong thyroid hormone
replacement
Give these drugs until they can get into surgery or get radioactive iodine: In the
meantime
methimazole (Tapazole)
propylthiouracil (PTU)
All they do is decrease the amount of thyroid hormone your body uptakes blocks
they try to decrease your bp and heart rate All she cares about
Some people who got the radioactive iodine and it didnt completely kill the thyroid
put them on this
Worry about Radioactive iodine treatment problem is that it causes liver and bone
marrow toxicity
Corticosteroids
Glucocorticosteroids:
There are multiple ways to use this. They care used for the respiratory system for asthma
and COPD. Administration is inhaled. If you have sinus issues they are intranasal.
The side effects:
Inhaled: dry mouth and thrush
Nasal spray: irritation, nosebleeds, headaches, and dry mucous membranes
Oral: weight gain, high blood sugar, cushings (moon face)
All cortocosteroids all end in -sone
Mineralocorticoid
fludrocortisone acetate
Adrenal steroid inhibitor
aminoglutethimide
These are the adrenal corticosteroids but they are not used often because we dont like to
mess around with peoples adrenal glands.
Miotics
o Constrict the pupil
Cholinergic Drugs slows things down and dilate
Mimic the PSNS neurotransmitter ACh
Also called miotics, cholinergics
Direct-acting and indirect-acting drugs
They lead to reduction of the interocular pressure by increasing the outflow of
aqueous humor
Adverse Effects
Hypotension
Bradycardia
Nausea
Vomiting