Exam (elaborations) HCO 3 ATI PHARMACOLOGY PROCTORED REVIEW QUESTIONS Important Lab Values

Exam (elaborations) HCO 3 ATI PHARMACOLOGY PROCTORED REVIEW QUESTIONS Important Lab Values - 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. Nursing evaluation of medication effectiveness: - Prevention and termination of acute anginal attacks - Long-term management of stable angina. - Control of perioperative blood pressure. - Control of heart failure following acute MI. - In chronic stable exertional angina, nitroglycerin dilates veins and decreases venous return (preload), which decreases cardiac oxygen demand. - Use this rapid-acting nitrate at the first indication of chest pain. Do not wait until pain is severe. - Use prior to activity that is known to cause chest pain, such as climbing a flight of stairs. - Place the tablet under the tongue and allow it to dissolve - Store tablets in original bottles, and in a cool, dark place. - Medications Affecting Cardiac Rhythm: Ventricular Dysrhythmia (Active Learning Template - Medication, RM Pharm RN 7.0 Ch. 23) 1) Antidysrhythmic meds class IB (Lidocaine) 2) Decrease electrical conduction, Decrease automaticity, Increase rate of repolarization 3) Short-term use only for ventricular dysrhythmias 4) Administer phenytoin to control seizure activity. 5) Use cautiously in clients who have liver and kidney dysfunction, second-degree heart block, sinus bradycardia, and heart failure. Medications Affecting Coagulation (Chapter 25 page 191) Administering Heparin (pg. 193) Laboratory values to report to the provider Self- Administration of Enoxaparin (pg. 193) Adverse effects of clopidogrel (pg. 197) Monitoring for adverse effects of Warfarin Adverse effects of Heparin Medication safety with Warfarin (pg. 194) Reviewing client data during heparin infusion (pg. 192) PROTOTYPE: Heparin Low Molecular Weight: PROTOTYPE: Enoxaparin Other: Dalteparin Activated factor (Xa) Inhibitors: PROTOTYPE Medication: Fondaparinux Adverse Effects: Hemorrhage secondary to heparin overdose: - Monitor vital signs. - Advise clients to observe for bleeding (increase heart rate, decreased blood pressure, bruising, petechiae, hematomas, black tarry stools). - In the case of overdose, stop heparin, administer protamine, and avoid aspirin. - Monitor activated partial thromboplastin time (aPTT). Keep value at 1.5 to 2 times the baseline. Heparin induced thrombocytopenia Interventions: - Evidenced by low platelet count and increased development of thrombi: mediated by antibody development (white clot syndrome) - Monitor platelet count periodically throughout treatment, especially in the first month. - Stop heparin if platelet count is less than 100,000/mm^3; Nonheparin anticoagulants, such as lepirudin or argatroban, can be used as a substitute if anticoagulation is still needed. Hypersensitivity reaction (chills, fever urticaria): - Administer a small test dose prior to the administration of heparin. Toxicity/overdose: - Administer protamine, which binds with heparin-protamine complex that has no anticoagulant properties. - Protamine should be administered slowly IV, no faster than 20mg/min or 50mg in 10 min. - Do not exceed 100 mg in a 2-hr period. Administer carefully to prevent overdose (anticoagulation). Enoxaparin: Hemorrhage: - Monitor vital sings - Advise clients to observe for bleeding (increased heart rate, decreased blood pressure, bruising, petechiae, hematomas, black tarry stools) - Monitor platelet count. Instruct clients to avoid aspirin. Neurologic damage from hematoma formed during spinal or epidural anesthesia: - In clients who have spinal or epidural anesthesia: Assess insertion site for sings of hematoma formation, such as redness or swelling; Monitor sensation and movement of lower extremities; Notify provider of abnormal findings. Thrombocytopenia Interventions: - Monitor platelets. Discontinue medication for platelet count less than 100,000/mm^3. Toxicity/ Overdose - Administer protamine (heparin antagonist) - Protamine should be administered slowly intravenously, no faster than 20 mg/min or 50 mg in 10 min. Fondaparinux: -Hemorrhage -Neurologic damage from hematoma formed during spinal or epidural anesthesia. -Thrombocytopenia, as evidenced by low platelet count. Contraindications/Precautions: -Parenteral anticoagulants are contraindicated in clients who have low platelet counts (thrombocytopenia) or uncontrollable bleeding. -These medications should not be used during or following surgeries of the eyes, brain, or spinal cord; lumbar puncture; or regional anesthesia. -Use cautiously in clients who have hemophilia, increased capillary permeability, dissecting aneurysm, peptic ulcer disease, severe hypertension, hepatic or renal disease, or threatened abortion. Interactions: - Antiplatelet agents such as aspirin, NSAIDs, and other anticoagulants can increase the risk for bleeding. -Avoid concurrent use when possible -Monitor carefully for evidence of bleeding -Take precautionary measures to avoid injury (limit venipuncture and injections). Nursing Evaluation of Medication Effectiveness: - Heparin: aPTT levels of 60 to 80 seconds. - Heparin, enoxaparin, and fondaparinux sodium: No development or no further development of venous thrombi or emboli. Oral Anticoagulants PROTOTYPE: Warfarin Adverse Effects: Hemorrhage - Monitor VS. - Advise clients to observe for bleeding (increased heart rate, decreased blood pressure, bruising, petechiae, hematomas, black tarry stools). - Obtain baseline PT, and monitor PT levels of PT and INR periodically. - In the case of a warfarin overdose, discontinue administration of warfarin, and administer vitamin K. Hepatitis: - Monitor liver enzymes. Toxicity/ Overdose: - Administer Vitamin K, to promote synthesis of coagulation factors VII, IX, X, and prothrombin. - Administer IV vitamin K, slowly and in a diluted solution to prevent anaphylactoid-type reaction. - Administer small doses of vitamin K to prevent development of resistance to warfarin. - If Vitamin K, cannot control bleeding, administer fresh plasma or whole blood. Contraindications/ Precautions: - Classified as Pregnancy Risk Category X due to high risk of fetal hemorrhage, fetal death, and CNS defects. Advise clients to notify the provider if they become pregnant during warfarin therapy. If anticoagulation is needed during pregnancy, heparin can be safely used. - Contraindicated in clients who have low platelet counts (thrombocytopenia) or uncontrollable bleeding. - Contraindicated during or following surgeries of the eye(s), brain, or spinal cord; lumbar puncture; or regional anesthesia. - Contraindicated in clients who have vitamin K deficiencies, liver disorders, and alcohol use disorder due to the additive risk of bleeding. - Use cautiously in clients who have hemophilia, dissecting aneurysm, peptic ulcer disease, severe hypertension, or threatened abortion. Interactions: Concurrent use of heparin, aspirin, acetaminophen, glucocorticoids, sulfonamides, and parenteral cephalosporins increases effects of warfarin, which increases the risk for bleeding. - Avoid concurrent use if possible. - Instruct clients to observe for inclusion of aspirin in OTC medications. - If used concurrently, monitor carefully for indications of bleeding and increased PT, INR, and aPTT levels. - Medication dosage should be adjusted accordingly. Concurrent use of phenobarbital, carbamazepine, phenytoin, oral contraceptives, and vitamin K decreases anticoagulant effects. - Avoid concurrent use if possible. - If used concurrently, monitor carefully for reduced PT and INR levels. - Medication dosage should be adjusted accordingly. Foods high in vitamin K, such as dark green leafy vegetables (lettuce, cooked spinach), cabbage, broccoli, Brussels sprouts, mayonnaise, and canola and soybean oil, can decrease anticoagulant effects with excessive intake. - Provide clients with a list of foods high in vitamin K. - Instruct clients to maintain a consistent intake of vitamin K to avoid sudden fluctuations that could affect the action of warfarin. Multiple other medications interact with warfarin. - Take a complete medication history for clients taking warfarin, and advise clients to inform the provider if any new medication is started. Nursing Administer: Depending on therapeutic intent, effectiveness can be evidenced by the following. - PT 1.5 to 2 times control. - INR of 2 to 3 for treatment of acute myocardial infarction, atrial fibrillation, pulmonary embolism, venous thrombosis, or tissue heart valves. - INR of 3 to 4.5 for mechanical heart valve or recurrent systemic embolism. - No development or no further development of venous thrombi.