NURS 251 PHARMACOLOGY LATEST UPLOAD EXAM 2026

NURS 251 NURS 251 PHARMACOLOGY LATEST UPLOAD EXAM 2026 10 rights of medication administration 1. Right Medication 2. Right Dose 3. Right Time 4. Right Route 5. Right Client 6. Right Client Education 7. Right Documentation 8. Right to Refuse 9. Right Reason 10. Right Evaluation drug any chemical that affects the physiologic processes of a living organism Pharmacology study or science of drugs Pharmaceutics The science of preparing and dispensing drugs, including dosage form design. Enteral dosage forms Tablets, capsules, oral soluble wafers, pills, timed-release capsules, timed-release tablets, elixirs, suspensions, syrups, emulsions, lozenges or troches, rectal suppositories, sublingual or buccal tablets Parenteral Dosage Forms Injectable forms, solutions, suspensions, emulsions, powders for reconstitution Topical dosage forms NURS 251 NURS 251 Aerosols, ointments, creams, pastes, powders, solutions, foams, gels, transdermal patches, inhalers, rectal and vaginal suppositories Pharmacokinetics Study of what the body does to the drug and the study of ADME ADME absorption, distribution, metabolism, excretion Pharmacodynamics The study of the biochemical and physiological interactions of drugs at their sites of activity. Pharmacotherapeutics The treatment of pathologic conditions through the use of drugs Pharmacognosy The study of drugs that are obtained from natural plant and animal sources. Pharmacogenetics the study of the influence on genetic factors on drug response Toxicology The study of poisons, including toxic drug effects, and applicable treatments. Pharmacoeconomics The study of economic factors impacting the cost of drug therapy. 3 types of drug names chemical, generic, trade chemical drug name Describes the drug's chemical composition and molecular structure Generic drug name official, nonproprietary name for the drug Trade drug name also known as brand or proprietary name. This is the name under which a manufacturer markets the medication. Enteral route - absorption the drug is absorbed though the mucosa of the stomach, small intestine, or large intestine NURS 251 NURS 251 Parenteral Route any where other than the gastrointestinal tract - commonly refers to injection Topical Route application of drugs directly to body surfaces - skin, eyes, ears, nose, lungs, rectum, vagina Inhalation route inhaled drugs are delivered directly to the lungs as micrometre-sized drug particles Absorption the movement of a drug from its site of administration into the bloodstream for distribution to tissues Distribution transport of a drug by the blood stream to the drugs site of action Metabolism involves the biochemical alteration of a drug into any of the following: an inactive metabolite, a more soluble compound, a more potent metabolite, a less active metabolite Organ most responsible for metabolism of a drug the liver Excretion the elimination of drugs from the body Primary organ responsible for drug elimination the kidney Substrates targeted drugs for specific enzymes - any drug that binds to an enzyme Lipophilic fat loving Hydrophilic water loving drug-drug interaction when the presence of one drug increases or decreases the action of another drug administered concurrently NURS 251 NURS 251 "free drug" active - unbound portion of a drug bound to albumin "bound drug" part of the drug bound to the albumin - inactive Albumin most common blood protein and carries the majority of protein-bound drug molecules Bioavailability describes the extent of drug absorption Transdermal route drug delivery through adhesive drug patches Subcutaneous route injections into the fatty subcutaneous tissues under the dermal layer of the skin Intramuscular (IM) injections given into the muscle beneath the subcutaneous fatty tissue Intravenous (IV) delivers the drug directly into circulation where it is distributed by the bloodstream throughout the body Sublingual & Buccal route Under tongue, in cheek Therapeutic effect A positive/intended change in a faulty physiological system Pharmacodynamics the relationship between the drug concentrations and the pharmacological response (actions of the drug) Mechanism of Action Once the drug is at the site of action, it can modify (increase or decrease) the rate at which that cell or tissue functions, or it can modify the strength of function of that cell or tissue Receptor a reactive site on the surface or inside of a cell. most commonly a protein structure within the cell membrane. NURS 251 NURS 251 Pharmacological Response What happens when a drug binds to and interacts with a receptor Affinity the degree to which a drug attaches and binds with a receptor Enzymes substances that catalyze nearly every biochemical reaction in a cell Selective Interaction a drug may inhibit or enhance the action of a SPECIFIC enzyme Drug-enzyme interaction when the drug chemically binds to an enzyme molecule in such a way that it alters the enzyme's interaction with its normal target molecules in the body Nonselective Interactions instead of reacting with receptors or enzymes, their main targets are cell membranes and various cellular processes such as metabolic activities. Half-life The time required for one half of a given drug to be removed from the body during elimination phase Steady state amount of drug removed via elimination = amount absorbed with each dose Peak level The maximum concentration of a drug in the body/blood after administration Trough level The lowest concentration of drug reached in the body/blood after it falls from its peak level Toxicity occurs if the peak blood level of the drug is too high Therapeutic drug monitoring used to monitor peak/trough levels, adequate therapeutic effects, and minimize drug toxicity Onset time required for the drug to elicit a therapeutic response NURS 251 NURS 251 Peak effect the time required for a drug to reach its maximum therapeutic response in the body Duration of action The length of time the concentration of a drug in the blood or tissues is sufficient to elicit a therapeutic response. Acute therapy used for acute illness Maintenance therapy chronic disease maintenance therapy - does not cure, only prevent future damages Supplemental (replacement) therapy supplies the body with a substance needed to maintain normal body function palliative therapy comfort measure in disease end stages Supportive therapy maintain integrity of body functions Prophylactic therapy Vaccines or treatment with antibiotics to prevent an infection, as in intraabdominal surgery or after trauma Empirical Therapy The administration of antibiotics according to a patient's symptoms and one's understanding of infectious disease before the pathogen has been identified; uses a broad spectrum antibiotic What do we monitor when using drug therapy? Therapeutic action, Adverse effects, Toxic effects, therapeutic index, Drug concentration, patient condition Therapeutic action beneficial effects - what we want to happen Adverse effects predictable undesirable effects - usually negative Toxic effects undesirable effects due to an over abundance of drugs NURS 251 NURS 251 Therapeutic index ratio of toxic level to therapeutic level Low Therapeutic index we can give less of a drug for it to become toxic High therapeutic index we can give a higher dose of medication before its toxic Drug concentration amount of drug in the blood/body Tolerance the diminishing effect with regular use of the same dose of a drug, requiring the user to take larger and larger doses before experiencing the drug's effect Dependence physiological or psychological need for a drug Physical dependence Physiological need for a drug to avoid physical withdrawal symptoms Psychological dependence addiction; the obsessive desire for a drug Additive effects 2 medications are taken together and respond better together than on their own - total effect of both Synergistic effects 2 medications taken and greater effect for one of them; one drug enhances the other Antagonistic effects One medication blocks the other medication that is being taken at the same time incompatibility 2 drugs that cannot be taken together; chemical deterioration of one or both When can medication errors occur? prescribing, dispensing, administering, monitoring Adverse drug reaction any unexpected, unintended, undesired, or excessive response to a medication given at therapeutic dosages NURS 251 NURS 251 Allergic reaction hypersensitivity reaction Adverse drug withdrawal event withdrawal when we suddenly stop a medication Idiosyncratic reaction unexpected occurrence in patient and we don't know why it happens Drug interaction increased or decreased effect of one drug on another Teratogenic fetal defects Mutagenic permanent changes in genes (radiation) Carcinogenic Cancer causing (excessive hormone therapies) Bismuth subsalicylate (Pepto-Bismol) Adsorbent that coats the walls of the GI tract. It binds to causative bacteria/toxin and eliminates it through stool. Used on mild cases. Belladonna alkaloids Antimotility/anticholinergic that decreases intestinal muscle tone and peristalsis of the GI tract. This results in slow movement of the fecal matter. Side Effects: drying effect, decrease gastric secretions. Usually used in combination with adsorbents and opiates. Used on more severe cases. Codeine Phosphate, Loperamide hydrochloride, Diphenoxylate hydrochloride with atropine sulphate Antimobility/opiates. Decrease bowel motility and pain by relief of rectal spasms. Decreases transit time (slows) through the bowel. Allows more time for H2O and electrolytes to be absorbed. Used on antibiotic-induced diarrhea. Lactobacillus acidophilus Probiotics/Intestinal Flora modifiers/ bacterial replacement drugs. Supply missing bacteria in the GI tract, suppresses growth of diarrhea-causing bacteria NURS 251 NURS 251 Adverse Effects: Adsorbents Increased bleeding due to binding to vitamin K, constipation, dark stool, confusion, tinnitus, metalic taste, blue gums/black tongue Adverse Effects: Anticholinergic Suppreses CNS, urinary retention, dry skin, blurred vision, hypotension, brady-tachy cardia (abnormal), sexual dysfunction, headache, dizziness, confusion, anxiety, drowsiness, flushing Adverse Effects: Opiates Drowsy, lathargic, dizziness, nausea, vomiting, constipation, respiratory depression, hypotension, flushing, urinary retention Special Considerations: Adsorbents decrease absorption of any drugs (ex digoxin, quinidine sulphate and hypoglycemic drugs), toxic effects of methotrexate (increase with adsorbents) given with warfarin (anticoagulants) will increase bleeding time and bruising Special Considerations: Bismuth Subsalicylate Don't give to children/teens with chicken pox or influenza b/c it could cause Reye's Syndrome (inflammation of the liver and brain). or with aspirin Elderly: don't give with decresed bleeding time, clotting disorders, recent bowel surgery or confusion Special Consideration: Anticholinergics Don't give when there is a hx of narrow angle glaucoma, GI obstruction, myastheria gravis, paralytic ileus toxic mega colon Acute vs Chronic Diarrhea A: sudden change for a healthy person, 3-21 days, self limiting, resolves without sequelae ex: bacteria, viruses, fungi (protozoa), nutrition, drug induced C: reoccurring, more than 3-4 weeks (min), fever, loss of appetite, nausea, vomiting, weightloss, chronic weakness ex: tumors, diabetes, addison's, hyperthyroidism, acquired immunity (AIDS) Goals of Diarrhea treatment NURS 251 NURS 251 stop frequency, alleviating abdominal cramps, replenish fluids and electrolytes, prevent weight loss and nutritional deficits from malnutrition Constipation infrequent, difficult passage, not illness but a symptom, disorder of movement through colon/rectum caused by diseases or drugs Constipation treatment surgical: stomas non-surgical: dietary (fibres, suppositories), pharmacological (not at night except Senokot), behavioral (increased activity) Bulk forming laxatives increase fibre, distend (swelling) bowel to initiate reflex bowel activity, absorb water to increase bulk indications: acute/chronic, IBS, diverticulitis adverse effects: electrolyte imbalance, impaction, fluid overload Psyllium (Metamucil) bulk forming laxative Emollient laxatives stool softener, lubricant laxative (lubricate fecal material and intestinal walls) increase H2O and fat in stool indications: acute/chronic, impaction, increase bowel movement in analrectal conditions adverse effects: lipid pneumonia Mineral Oil emollient (lubricant laxative) Docusate salts (Colace) emollient (stool softener) Hyperosmotic result in bowel distention, increase fecal H2O content, increase peristalsis and evacuation indications: chronic, diagnostic, procedure adverse effects: bloating, rectal irritation Polyethylene glycol, glycerin NURS 251 NURS 251 hyperosmotic laxative Lactulose hyperosmotic laxative, also used to decrease high serum amonia levels ammonia (result of protein breakdown) is toxic for the brain and results in swelling Saline Laxatives results in bowel distention, increased peristalsis and evacuation, increased osmotic pressure in the intestinal tract (H2O increasing in the intestines) indications: diagnosis/surgical adverse effects: magnesium toxicity, increase thirst Stimulant laxatives increase peristalsis via intestinal nerve stimulation indications: acute, diagnosis, procedure adverse effects: rash, discolored urine Senna (Senokot) stimulant laxative, at night as it takes 6-8 hours onset Bisacodyl (Dulcolax) stimulant laxative Magnesium hydroxide (Milk of Magnesia) saline laxative Magnesium citrate saline laxative Peripherally Acting Opioid Antagonists Treatment of constipation related to opioid use and bowel resection therapy Block entrance of opioid into bowel not approved by health Canada but accessible through Special Access Programme Allow bowel to function normally with continued opioid use Methylnaltrexone (Relistor) Peripherally Acting opioid antagonist Alvimopan (Entereg) peripherally acting opioid antagonist Nursing Implications for laxatives NURS 251 NURS 251 Assess bowel patterns. Do not take if you have unexplained abdominal pain Assess electrolytes Encourage a diet high in water (180-240mL) and fiber Long term use can result in dependency Do not chew or crush laxative tablets especially with enteric coating Take bulk laxative with 240mL of water Give bisacodyl with water (not milk or juice) Monitor for therapeutic effects IBS (irritable bowel syndrome) individualized, chronic intestial discomfort (cramps, diarrhea or constipation cope via food avoidance or OTC laxatives/antidiarrheal Parkinson's disease chronic, progressive, neurodegenerative disorder affect dopamine producing neurons in brain cause: imbalance of two neurotransmitters; dopamine and acetylcholine Goal of pharmacology for PD Block ACh or increase dopamine levels (antagonizing effects) Acetylcholine vs dopamine Contraction of smooth muscle inhibits movement Substantia Nigra An area of the midbrain that is involved in motor control and contains a large concentration of dopamine-producing neurons part of basal ganglia Symptoms of PD shows when 80% of neurons are lost/depleted partially controlled as long as there are functioning nerve terminals bradykinesia TRAP: tremor (pill rolling), rigidity (cogwheel), akinesia (facial, mask like), postural instability (leaning to one side, unsteadiness) NURS 251 NURS 251 On-off phenomenon rapid swings in response to levodopa (variable respose) worse when too little is present (dopamine) Wearing-off phenomenon A gradual worsening of parkinsonian symptoms as a patient's medications begin to lose their effectiveness, despite maximal dosing with a variety of medications. Dyskinesia difficulty in performing voluntary movements Chorea irregular, spasmodic, involuntary movement of limbs/face Dystonia abnormal muscle tone leading to impaired or abnormal movement (head/neck) Leodopa Therapy only effective for 5-10 years, more progressed is more difficult to manage symptoms, presynaptic for early PD when there are functioning nerve terminals are available precursor of dopamine (without can't make dopamine) bbb won't allow exogenously supplied dopamine to enter but Levodopa can taken up by dopaminergic terminal and converted to dopamine Direct Acting Dopamine Receptor- Agonists Nondopamine dopamine receptor agonists (NDDRAs) Ergot derivatives: bromocriptine Nonergot drugs: pramipexole (Mirapex), ropinirole (Requip) All of the NDDRAs work by direct stimulation of presynaptic and/or postsynaptic dopamine receptors in the brain or both Bromocriptine presynaptic (stimulate) inhibits the production of prolactin (used for increased lactation- glactorrhea or tumors) caution with pt with PVD Adverse: GI upset, dyskinesias, sleep disturbances drug interactions: erthromycin and adrenergic drugs NURS 251 NURS 251 Dopamine replacement presynaptic levodopa- increased levels needed= adverse effects carbidopa given with b/c less levodopa needed, can't cross bbb alone adverse effects: dizziness, synope Levodopa Therapy orally to activate, crosses bbb to become therapeutic adverse effects: hypotension (fall risk), confusion, involuntary movement, GI distress, cramps, cardiac dysrhythmias -IV as a pressor drug to increase BP and enhance kidney funcrion contraindicted: angle-closure glaucoma (cautiously) interactions: pryridoxine hydrochloride (vitamin B6), non selective MAOI, benzodiazepines, antipsychotics, dietary protein (1.5 hours before or after) Carpidova (alone) adjunct to treat nausea (Sinemet) Sinemet CR: increase on time and decrease off time drug interactions: tricylic antidepressants and other leads to hypotension take on an empty stomach, minimize GI adverse effects take with food Selective Monoamine Oxidase Inhibitor MAO - breakdown catecholamines in CNS primarily-in the brain selegiline hydrochloride and rasagiline mesylate (Azilect) MAO-B inhibitor Selegiline hydrochloride and rasagiline mesylate (Azilect) MAOB-I, dopaminergic stimulation in CNS (don't breakdown dopamine) is not only selective on A so it does not cause a cheese effect (causing hypotension crisis) when 10mg is used or less. adjunct with levodopa contraindcations: allergy, concurrent use with Meridine (seritonin syndrome - high levels of seritonin) Adverse effects: dizziness, insomnia, hallucinations, hyper/hypo-tension Dopamine Modulator NURS 251 NURS 251 presynaptic indirect acting, release (causes) of dopamine and catecholamines from storage sites, blocks reuptake of dopamine into nerve fibres result: increase dopamine in synapses between nerves early, 6-12 months of effectiveness treats dyskinesia related to carbidova-levodopa adverse effects: mild-dizziness, insommia, nausea drug interaction: increase anticholinergic adverse effects when given with anticholinergic drugs Amantadine Hydrochloride antiviral (influenza), dopamine modulator Catechol Ortho-Methyltransferase (COMT) Inhibitors -Block COMT, the enzyme that catalyzes the breakdown of the body's catecholamines (hormones made by adrenal glands ie dopamine, epi, norepi) -Prolong the duration of action of levodopa; reduce wearing-off phenomenon adverse effects: urine discoloration (dark), GI upset, worsen dyskinesia that may be already present therapeutic effects within few days Entacapone (Comtan) COMT inhibitor (Catechol Ortho-Methyltransferase Inhibitors) Anticholinergic Therapy block effects of ACh (contractions of smooth muscle) used to treat muscle tremors and muscle rigidity associated with PD (b/c increased ACh) does not relieve bradykinesia (extremely slow movements) opposite effects of SLUDGE drying effects, decrease in saliva, costipation, dialated pupils, smooth muscle relaxation. taken at night to avoid taking with other meds, increase fluids and therapeutic effects take 2-3 weeks SLUDGE NURS 251 NURS 251 Symptoms of ACh saliva, lacrimination, urination, diarrhea, GI mobility, emesis (vomiting) Benztropine Anticholinergic (PD) other examples; trihexyphenidyl hydrochloride, Antihistamines dipenhydramine (Benadryl) Benztropine Mesylate anticholinergic drug used for PD and extra pyramidal symptoms from antipsychotic drugs Caution during hot weather or exercise because it may cause hyperthermia Adverse effects: tachycardia, confusion, disorientation, toxic psychosis, urinary retention, dry throat, constipation, nausea, vomiting Anticholinergic syndrome (exaggerated movement) Avoid alcohol Nursing implications for PD drugs perform assessments and hx in CNS, GI, GU, emotional and psycological status. S+S of PD (mask-like, speech problems, dysphagia, rigidity, shuffling gait) and conditions that may be contraindicators. Pt education on the importance of meds and taking them on time and to not stop suddenly, asst with walking (when starting dopaminergic drugs b/c of dizziness symptoms) 3000+mL of fluids unless contraindicated Taking levodopa with MAOIs may result in hypertensive crisis. Entacapone may darken the patient's urine and sweat. Therapeutic effects of COMT inhibitors may be noticed within a few days; it may take weeks with other drugs. Monitor response of drug therapy Insulin Lispro (Humalog) rapid acting insulin, onset 10-15 minutes, peak 1-2 hours, duration 3-5 hours. Important to eat AFTER injection of rapid acting insulin NURS 251 NURS 251 Regular insulin (humulin R, Novolin ge Toronto) short acting insulin, onset 30 mins, peak 2-3 hours, duration 6.5 hours Only insulin that can be given IV used to be made from bovine or porcipine resources insulin isophane (NPH) Intermediate acting insulin, onset 2-4 hours, peak 4-10 hours, duration up to 18 hours. Cloudy and often given with regular insulin to reduce amount of insulin injections per day NPH- neutral protamine hagedorn Insulin Detemir (Levemir) long acting insulin - onset 90 min, peak 16-24 hours, duration: dose dependant Insulin glargine (Lantus) Long-acting insulin. Onset: 2-4 hour. Peak: none. Duration 20 to 24 hours. Forms micro precipitates that are slowly absorbed over 24 hours - provided constant level of insulin in body. Usually dosed once per day or every 12 hours. Sometimes referred to as basal insulin. NOT interchangeable with insulin detemir (Levemir) Sliding Scale insulin Dosing Rapid or short acting insulins are adjusted according to plasma glucose test results DISADVANTAGE: Delays insulin administration until hyperglycaemia occurs Basal-Bolus Insulin Dosing Preferred method of treatment for hospitalized diabetic patients Mimics a healthy pancreas by delivering basal insulin constantly as a basal and then as needed as a bolus Basal insulin is a long-acting insulin (insulin glargine) Bolus insulin (rapid acting (insulin lispro or insulin aspart)) Bolus broken up into meal boluses and correction boluses Lab values for prediabetes type 1 diabetes mellitus sudden onset , auto immune response, diabetes caused by a total lack of insulin production or defective insulin made; usually develops in childhood, and patients require exogenous insulin replacement therapy to control the disorder, fewer: 10% NURS 251 NURS 251 Complications: DKA(diabetic ketoacidosis)- keytone bodies in urine, HHS (hyperosmolar hyperglycemic state) type 2 diabetes mellitus slow onset, diabetes in which either the body produces insufficient insulin or insulin resistance (a defective use of the insulin that is produced) occurs; the patient usually is not dependent on insulin for survival, diagnosed in adulthood, 90% of all cases Cormorbid Conditions of T2DM one or more: obesity, coronary heart disease, hypertension, dyslipidemia, microalbuminemia (protein in urine), increase risk for thrombotic events (blood clotting) Pancreas An organs in the abdominal cavity with two roles. The first is an exocrine role: to produce digestive enzymes and bicarbonate, which are delivered to the small intestine via the pancreatic duct. The second is an endocrine role: to secrete insulin (beta cells- increase blood glucose) and glucagon (alpha cells- decrease blood glucose) into the bloodstream to help regulate blood glucose levels. symptoms of diabetes mellitus elevated fasting blood glucose (7+mmol/L) or hemoglobin A1c level greater than or equal to 6.5% glycouria, weightloss, fatigue, blurred vision 3 polys: polyuria, polydipsia (thirst), polyphagia glycogenesis formation of glycogen from glucose stored in liver and muscle cells Gestational Diabetes Mellitus (GDM) any degree of glucose intolerance with onset or first recognition during pregnancy hyperglycemia during pregnacy, subside after delivery insulin given to prevent defects 30% may develop T2 within 10-15 years fetus is at risk for developing hyerglycemia if not caught Major longterm complications of DM (1&2) NURS 251 NURS 251 Macrovascular (atherosclerotic plaque) - coronary arteries, cerebral arteries, peripheral vessels Microvascular (capillary damage) - retinopathy, neuropathy, nephropathy DKA acute complication, diabetic ketoacidosis - keytones HHS acute complications, hyperosmolar hyperglycemic state - 30+ mmol/L Screening of DM pre diabetic- increase risk, HbA1c: 6.0-6.4%, fasting plasma glucose levels += 6.1mmol/L but less than 6.9mmol/L, impared glucose tolerance test (oral glucose drink) every 3 years for all pt 40+ years (recommended) Interventions of DM T1: insulin T2: weightloss, stop smoking, decrease alcohol consumpton, exercise, increase healthier dietary habits Glycemic Goal of Treatment HbA1c of less than 7% fasting glucose level of 4-7mmol/L (1st in the morning) after eating 5-10mmol/L (2hrs postprandial) Treatment of DM - Type 1: diet, exercise, must have insulin to survive - Type 2: diet, exercise; may need oral hypoglycemic or insulin to control blood glucose level if other options do not work Antidiabetic Drugs insulin and oral hypoglycemics or combination of antihypo with insulin new injectable hypoglycemic drugs with insulin or antidiabetic Insulin glucose transport, substitue of endogenous, same effcts as normal endogenous, restore diabetic pt's ability to : metabolize carbohydrates, fats and proteins, store glucose in liver and convert glycogrn to store fat NURS 251 NURS 251 Rapid acting (Insulin Lispro), Short acting (Regular Insulin), Intermediate (Insulin RPH) and long acting (Insulin Determir and glargine) Adverse Effects of Insulin hypoglycemia, tachycardia, palpitations, headache, lethargy, tremors, blurred vision, dry mouth, hunger *fight or flight Interactions with Insulin decrease insulin effects and increase blood glucose: B Blockers, corticol steroids, epi, furosemide, thyroid hormones increase insulin effects and decrease blood glucose: alcohol, anabolic steroids, ACE inhibitors, sulfa drugs, MAOI's, propanolol and salicylates (aspirin) Injectable Antidiabetic Drugs Amylin agonists -pramlintide (Symlin) Incretin mimetics -exenatide (Byetta) -liraglutide (Victoza) Amylin Agonist Pramlintide (Symlin) mimic natual hormone amylin, sub cutaneous injection, decreases the time of gastric emptying, supresses glucagon secreation, decreases hepatic glucose output *used when other options do not achieve adequate glucose control s+s: nausea, vomiting, anorexia and headache Incretin Mimetics Exenatide - injection pen device (Byetta), only if functioning beta cells (enhances) type 2, mimic incretin hormone liraglutide (Victoza) s+s: nausea, vomiting, diarrhea, rare- hemorragic or necrotizing pancreatitis, weightloss Oral Antihyperglycemic Drugs typically used for T2(insulin resistance, on going reduction of beta cells) target: lower A1c -7% NURS 251 NURS 251 pt recommended lifestyle mods combination therapy is recommended if A1c exceeds 9% (two drugs from two different classes) Oral Antidiabetic Drugs Used for type 2 DM Effective treatment involves several elements Careful monitoring of blood glucose levels Lifestyle changes: decrease BMI, diet (increase protein decrease carbs), stop smoking and drinking Therapy with one or more drugs Treatment of associated comorbid conditions such as high cholesterol and high blood pressure (control of) T2MD treatment life style treatments oral biguanide drug - metformin if 1st & 2nd (at max dose) do not achieve A1c goals after 3-6 months additional treatment with insulin or dipeptyl peptidase 4 (DDP-4) inhibitors and glucogonlike peptidal (GLP-1) receptor agonist Metformin (Biguanide) Does not increase insulin secretion from pancreas and therefore does not cause hypoglycemia Reduces glucose production/gluconeogenesis Reduced triglycerides & cholesterol Decreases intestinal absorption of glucose Improves glucose uptake by skeletal muscle, adipose, liver May be used in combination with sulfonylureas, thiazolidinediones or incretin mimetics when monotherapy & lifestyle measure are not successful AE: Abdominal bloating, nausea, cramping, a feeling of fullness, and diarrhea. Metallic taste, hypoglycemia, and a reduction in vitamin B12 levels after long-term use Lactic acidosis is a rare complication NURS 251 NURS 251 Concentrations increased when given with furosemide and nifedipine, cimetidine and digoxin IMPORTANT: Discontinue metformin the day of the test and 48hrs after undergoing radiological study that requires radioactive iodine based dye This may leads to acute kidney injury and lactic acidosis Sulfonylureas gliclazide early type 2 (not T1) b/c stimulate insulin secretion form beta cells (need functioning), enhance action of insulin in muscle, liver and adipose tissue prevents liver form breakingdown insulin as fast typically 2nd generation (b/c 1st gen did not work) AE: hypoglycemia, weight gain, skin rash, nausea, epigastric fullness and heartburn Gliclazide Interactions: Increased effect of hypoglycemia -Alcohol*, anabolic steroids, β blockers, chloramphenicol, MAOI's, oral anticoagulants, sulfonamides, garlic, ginseng Decreased effect -Adrenergics, corticosteroids, thiazides, thyroid drugs Contraindications: severe liver and kidney disease Active hypoglycemia Not used in pregnancy *Alcohol may cause a reaction similar to Antabuse (induced vomiting and hypertension) *Potential cross allergic reaction if allergic to sulfa drugs Thiazolidinediones (Glitazones) antidiabetic- Insulin sensitizing drugs; enhance receptor sensitivity; slow onset up to months (pioglitazone - Actos®) Glinides antidiabetic- Similar to sufonlyureas, increase insulin secretion in pancreas, much shorter duration of action (repaglinide - GlucoNorm®) NURS 251 NURS 251 Dipeptyl-Peptidase IV Inhibitor (DPP4) antidiabetic- Slow down incretin hormone breakdown; increase insulin secretion and lower glucagon secretion (sitagliptin - Januvia®) Sodium Glucose Co-Transporter-2 (SGLT2) Inhibitors A decrease in blood glucose caused by an increase in renal glucose excretion. This inhibitor is a new class (2014) of oral drugs for the treatment of type 2 diabetes. canaglifozin (Invokana®), dapaglifozin (Forxiga®) Action: work independently of insulin to prevent glucose reabsorption from the glomerular filtrate, resulting in a reduced renal threshold for glucose and glycosuria AE: vaginal yeast infections and urinary tract infections. Other effects: may increase insulin sensitivity and glucose uptake in the muscle cells and decrease gluconeogenesis Results: improved glycemic control, weight loss, and a low risk of hypoglycemia Hypoglycemia Abnormally low blood glucose level (below 4 mmol/L) Mild cases can be treated with diet—higher intake of protein and lower intake of carbohydrates—to prevent rebound postprandial hypoglycemia S+S:Adrenergic-Anxiety, tremors, sensation of hunger, palpitations, sweating Central nervous system-Difficulty concentrating, confusion, weakness, drowsiness, vision changes, difficulty speaking, dizziness and headache Later signs- Hypothermia, seizures Coma and death will occur if not treated Glucose Elevating Glucagon Used in the event of hypoglycemia Concentrated Glucose: Rapidly dissolving buccal tablets given and semisolid gels for oral use; better than regular sugar Intravenous glucose solutions up to 50% D50W Glucagon: a natural hormone given by injection Diazoxide: useful for long-term illness such as pancreatic cancer (oral) Example of hypoglycemic protocol Before giving drugs that alter glucose levels... NURS 251 NURS 251 obtain and document: A thorough history, Vital signs, Blood glucose levels, HbA1c level, Potential complications and drug interactions, Assess the patient's ability to consume food. Assess for nausea or vomiting. Hypoglycemia may be a problem if antidiabetic drugs are given and the patient does not eat. If a patient is to take nothing by mouth (NPO) for a test or procedure, consult the primary care provider to clarify orders for antidiabetic drug therapy Keep in mind that overall concerns for any patient with diabetes increase when the patient:Is under stress, Is pregnant or lactating, Has an infection llness or trauma Thorough patient education is essential regarding: Disease process, Diet and exercise recommendations Self-administration of insulin or oral drugs, Potential complications Insulin preparations double checked by two RN: Check blood glucose level before giving insulin. To mix suspensions, roll vials between hands instead of shaking them. Ensure correct storage of insulin vials. Only use insulin syringes, calibrated in units, to measure and give insulin. Ensure correct timing of insulin dose with meals When drawing up two types of insulin in one syringe, always withdraw the regular or rapid-acting (clear) insulin first. Provide thorough patient education regarding self-administration of insulin injections, including timing of doses, monitoring of blood glucose levels, and injection site rotations Oral antidiabetic drugs - Implications Always check blood glucose levels before administering. *Usually given 30 minutes before meals α-Glucosidase inhibitors are given with the first bite of each main meal. Metformin is taken with meals to reduce gastrointestinal effects. Metformin will need to be discontinued if the patient is to undergo studies with contrast dye, because of possible renal effects; check with the prescriber, Assess for signs of hypoglycemia. If hypoglycemia occurs: NURS 251 NURS 251 Administer oral form of glucose if the patient is conscious. Give the patient glucose tablets, liquid, or gel; corn syrup; honey; fruit juice or nondiet soft drink; or have the patient eat a small snack, such as crackers or a half sandwich. Deliver D50W or IV glucagon if the patient is unconscious. Monitor blood glucose levels Monitor therapeutic response. Decrease in blood glucose levels to the level prescribed by physician Measure HbA1c to monitor long-term compliance with diet and drug therapy. Watch for and monitor hypoglycemia and hyperglycemia. A1C test for diabetes by checking sugar on red blood cells to get an average glucose level over several months- check compliance with treatment hemoglobin life of 30 days Changes Across the Lifespan Age related changes have a dramatic effect on pharmacokinetics Increased risk of adverse effects and toxicity at both ends of spectrum of life Drug Therapy for Pregnancy Drugs cross the placenta primarily by diffusion. Factors affecting safety: Drug properties Fetal gestational age Maternal factors US Food and Drug Administration (FDA) has implemented REVISED pregnancy safety categories. (see document on Blackboard: Drugs in Pregnancy and Lactation: Improved Benefit-Risk Information) Drug Therapy During Breast-Feeding Breastfed infants are at risk for exposure to drugs consumed by the mother Breast milk is not the primary route for maternal drug excretion Drug levels in breast milk are usually lower than in maternal circulation Exposure depends on volume of consumed milk Consider risk-benefit ratio Classification of Young Patients NURS 251 NURS 251 less than 38 weeks gestation- premature less than 1 month- neonate/new born 1m-1 year - infant 1-12 years - child 13-19 years - adolescent Neonatal and Pediatric Considerations: Absorption Gastric pH less acidic until 1 to 2 years of age Gastric emptying slowed *meds stay longer First-pass elimination reduced Reduced bile salt formation decreases bioavailability Intramuscular absorption faster and irregular Neonate and Pediatric Considerations: Distribution Total body water differences result in increased distribution and dilution of water-soluble drugs. Greater total body water means lower fat content. Decreased level of protein binding Immature blood-brain barrier means more drugs enter the brain Neonate and Pediatric Considerations: Matabolism Liver immature; does not produce enough microsomal enzymes Older children may have increased metabolism, requiring higher doses or more frequent administration than infants. Other factors: liver enzyme production, genetic differences, and substances to which the mother may have been exposed during pregnancy Neonate and Pediatric Considerations: Excretion Kidney immaturity affects glomerular filtration rate and tubular secretion. Decreased perfusion rate of the kidneys may reduce excretion of drugs Factors Affecting Pediatric Drug Dosages Skin is thin and permeable. Stomach lacks acid to kill bacteria. Lungs have weaker mucus barriers. NURS 251 NURS 251 Body temperatures are less well regulated, and dehydration occurs easily. Liver and kidneys are immature, impairing drug metabolism and excretion Methods of Dosage Calculation for Pediatric Patients Body surface area method Uses the West nomogram Always use weight in kilograms, not pounds. Always use height in centimeters, not inches. Body weight dosage calculations-Uses mg/kg Prepare all equipment and supplies first. Have caregivers stay as appropriate (Infants Toddlers, Preschoolers, School-age children) Assess for comfort methods before, during, and after drug administration. Adolescents - no peers may want care giver Considerations for Older Adult Patients Older adults: older than age 65 years High use of medications, Polypharmacy, Nonadherence Increased incidence of chronic illnesses,Sensory and motor deficits CV: decreased CO=decreased absorption & distribution=decreased blood flow GI: increased ph (alkaline)= decreased peristalsis, altered absorption = delayed emptying Liver: decrease enzyme production = decreased metabolism and blood flow Kidney: decrease blood flow, function and GFR =excretion Older Adult Considerations: Absorption Gastric pH less acidic Gastric emptying slowed Movement through gastrointestinal (GI) tract slowed because of decreased muscle tone and activity Blood flow to GI tract reduced Absorptive surface of GI tract reduced Older Adult Considerations: Distribution NURS 251 NURS 251 Lower total body water percentages Increased fat content Decreased production of proteins by the liver, resulting in decreased protein binding of drugs (and increased circulation of free drugs) Older Adult Considerations: Metabolism Aging liver produces fewer microsomal enzymes, affecting drug metabolism. Blood flow to the liver is reduced. Leads to a prolonged half-life of many drugs Potential for accumulation if not monitored Older Adult Considerations: Excretion Decreased glomerular filtration rate Decreased number of intact nephrons Older Adults: Beers Criteria for Prevention of Adverse Drug Events A listing of drug and drug classes to be avoided in older adults Identified disease states considered to be contraindications for some drugs Three categories: Potentially inappropriate drugs and classes in older adults Potentially inappropriate medications to avoid with certain diseases Medications to be used with caution in older adults Older Adults: Medications Requiring Special Considerations monitor b/c side effects/adverse effects (more likely) opiodes: confusion, constipation, urinary retention, nausea, vomiting, resp depression and falls NSAIDS: edema, nausea, bleeding, gastric ulcers, kindey toxicity anticholergents: blurred vision, constipation, urinary retention, dry mouth, confusion, sedation, tachycardia antidepressents: sedation and strong anticholergenic effects ethnocultural considerations Canada is a multiculturally diverse nation. Aboriginal populations are growing faster than the rest of the Canadian population. The 2016 census reported 21.9% of Canadians identify as landed or permanent NURS 251 NURS 251 immigrants Three in ten Canadians who are visible minorities are Canadian born Ethnopharmacology considerations Provides an expanding body of knowledge for understanding specific impact of cultural factors on patient drug response Hampered by lack of clarity in terms such as race, ethnicity (remember phenotype versus genotype?) Ethnocultural assessment needs to be part of the assessment phase of the nursing process. Not every patient from the same country shares the same culture Ethnocultural Influences and Genetics on Drug Response Polymorphism: 2 different ind. who respond diff to a drug Medication response depends on the level of patient adherence (adherence is complex). Use of natural heath remedies that may alter a drug response Environmental and economic factors Awareness of ethnocultural differences is critical Ethnocultral Assessments Languages, Health practices and beliefs, Past uses of medicine, Use of herbal treatment, folk or home remedies, natural health products, Use of over-the-counter drugs, Usual response to illness, Responsiveness to medical treatment, Religious practices and beliefs, Support for patient's ethnocultural community, Dietary habits Ethnocultural Nursing Considerations and Drug Therapy Important to be knowledgeable about drugs that may elicit varied responses in culturally diverse patients Recognition that patterns of communication may differ A thorough ethnocultural assessment is needed. Maintaining, protecting, and restoring health 3 Types of Decongestants adrenergics, anticholinergics, corticosteroids antitussives NURS 251 NURS 251 suppress cough reflex through direct action on the cough centre in CNS (Medulla) Opioid and non-opioid Expectorants aid in coughing up and spitting out excessive mucuous in upper respiratory tract. used for relief of productive cough Histamine 1 receptors mediate smooth muscle contraction and dilation of capillaries histamine 2 receptors mediate acceleration of the heart rate and gastric acid secretion Physiologic symptoms associated with release of excessive amounts of histamines -constriction of smooth muscle -especially in lungs and stomach -increase in body secretions -vasodilation and increase permeability H1 receptor sites smooth muscle surrounding blood vessels and bronchioles each antihistamine has a varying degree of _______, __________, and __________ effects antihistaminic, anticholinergic, and sedating. indications of antihistamines nasal allergies, allergic rhinitis, typical symptoms of common cold, allergic reactions, motion sickness, parkinsons, disease, vertigo, sometimes as sleep aids. antihistamine mechanism of action Competes with circulating histamines for specific receptor sites. Antihistamines bind to the H1 receptors on mast cell and basophils which prevents further release of histamines and actions. anticholinergic actions on lacrimal, salivary, and respiratory mucous glands. Loratidine (Claritin, Alavert) NURS 251 NURS 251 antihistamine non-sedating acts peripherally and has very little effect on CNS Diphenhydramine (Benadryl) antihistamine traditional (sedating) works peripherally and centrally Pseudophedrine (Sudafed) Andrenergic decongestant (oral) Oxymetazoline Andrenergic decongestant nasal spray Adrenergic decongestants MOA Shrink engorged nasal mucous membranes and release nasal stuffiness. Accomplish this by constricting small arterioles in upper respiratory tract allowing swollen mucous membranes to drain. Corticosteroid decongestants Target inflammatory response elicited by invading organisms. Turn off inflammatory response anticholinergic decongestant Inhibits secretions of the serous and serous-mucuous membranes of the nasal passages Ipatropium Bromide (atrovent) nasal spray Anticholinergic decongestant Fluticasone Propionate (flonase) nasal spray Corticosteroid decongestant Beclomethasone Dipropionate (rivanase) nasal spray Corticosteroid decongestant Budenoside Corticosteroid decongestant codeine phosphate Opioid Antitussive NURS 251 NURS 251 Dextromethorphan non-opioid antitussive Guaifenesin expectorant 3 subtypes of B-agonists -selective B2 drugs -nonselective Beta adrenergic drugs -nonselective alpha and beta adrenergic drugs Anticholinergic Respiratory drugs MOA Binds to ACh receptors, preventing bronchoconstriction and causing airways to dilate. also helps to reduce secretions in patients with COPD. salmeterol long acting beta 2 agonist bronchodilator Salbutamol short acting beta 2 agonist - Bronchodilator Ipatropium (Atrovent) anticholinergic bronchodilator Theophylline xanthine derivative order of administrating bronchodilators and cotricosteroids Bronchodilators THEN corticosteroid 2-5 minutes in between 3 types of bronchodilators Beta agonists Xanthine Derivatives Anticholinergics Xanthine Derivative MOA Increases levels of cAMP by inhibiting phosphodiesterase (enzyme that breaks down cAMP). CAMP causes bronchial smooth muscles to relax and dilate. Leukotriene Receptor Antagonists MOA NURS 251 NURS 251 Leukotrienes receptor agonist prevents leukotrienes from attaching to receptors on circulating immune cells and immune cells in the lungs. Prevents inflammation of airways. Prodrugs Prodrugs are inactive its in administered form and must be metabolized to its active form by the liver or GI tract to be effective Blood pressure is determined by cardiac output x systemic vascular resistance primary hypertension Specific cause of hypertension is unknown. 90-95 % of all hypertension is primary secondary hypertension high blood pressure caused by the effects of another disease. 5-10% of all hypertension is secondary malignant hypertension Extremely high blood pressure usually above 180/120 and is considered a medical emergency 7 main categories of antihypertensives Diuretics, Adrenergic drugs, ACE inhibitors, ARBs, CCBs, Vasodilators, Direct renin inhibitors Rebound hypertension blood pressure that is controlled with medication and becomes uncontrolled (abnormally high) with the abrupt discontinuation of medication rebound congestion a process that occurs when the nasal passages become congested as the effect of a decongestant drug wears off; patients tend to use more drug to decrease the congestion, and a vicious circle of congestion, drug, and congestion develops, leading to abuse of the decongestant; also called rhinitis medicamentosa NURS 251