MID TERM STUDY GUIDE

MIDTERM STUDY GUIDE ● When a patient refuses to take medicine what do we do? Do we notify the healthcare provider what we do? ○ Clients have the right to refuse medication. Determine the reason for refusal, provide information regarding the risk of refusal, notify appropriate health care personnel, and document the refusal and actions taken. ● Pharmacokinetics - understand what pharmacokinetics ○ study of the absorption, distribution, metabolism and excretion of drugs ■ What the body does to the drug ■ Study of drug movement throughout the body ○ Absorption - the movement of a drug into the bloodstream after administration ○ Distribution -movement of a drug from the circulation to body tissues ○ Metabolism -the process by which the body chemically changes drugs into a form that can be excreted ○ Excretion -elimination of drugs from the body through the kidneys, bile lungs, sweat and breast milk ● Review what a blackbox warning is - why some medications are classified as blackbox warning ○ intended to provide alert regarding high risks associated with drug ■ FDA mandate ■ Potential adverse events, drug interactions, dosing information, monitoring & administration requirements, and at-risk populations. ● What is the action of lantus and levemir (insulins) - (Commonly prescribed controlled basal rate control) - how often do we give these long acting insulins? ○ Long acting insulins ○ Subcutaneous - given once daily - given at the same time each day (lantus) or with evening meal or at bedtime (levemir) ○ Gradual onset Over 24 hours ○ Duration 10-24 hours ● What do we tell someone whose going to have surgery and is taking oral contraceptives - how do we tell them how soon do they need to stop taking contraceptives ○ Stop taking at least 4 weeks before any surgery that increases risk of thromboembolic events. ● If someone misses an oral contraceptive - what type of teaching do we tell them - Concept of missing 1 pill, 2 pills, 3 pills, what do we need them to do? (oral contraceptive) ○ Follow the manufacturer’s instructions for missed pills: ■ 1 missed pill: take one missed pill with the next pill ■ 2 missed pills: two pills for 2 consecutive days ■ 3 or more missed pills: start new cycle 7 days later ● Women that are 35 years old and smoke - why we shouldnt give them contraceptives ○ Cardiovascular effects (hypertension, myocardial infarction, hemorrhagic stroke, venous thrombosis) ○ Breast (mainly BRCA1 +), Hepatocellular, and Cervical Cancers

○ Endocrine and Metabolic effects ○ Should be avoided in woman that smoke over 35 years old/ or History of blood clot ● What do patient's need to avoid if they are getting/taking spironolactone (Aldactone) ○ Monitor possibility of hyperkalemia ○ Potassium - sparing diuretic ■ Educate patient to stay away from high potassium containing food ■ Avoid use of potassium-based salt substitutes ■ When in direct sunlight, use sunscreen ■ Avoid performing tasks that require mental alertness ■ Do not eat excess number of foods high in potassium ○ Spironolactone may decrease effectiveness of anticoagulants. ● Mannitol (osmotic diuretic) how does it produce diuresis and mechanism of action - where do it work? Do we use it for intracranial pressure? What other reasons do we use it ○ Mannitol decreases intracranial pressure ○ Quickly reduce plasma volume ○ Mannitol is used to reduce intracranial pressure due to cerebral edema ○ Mannitol is also used to maintain urine flow in prolonged surgery, acute renal failure, or severe renal hypoperfusion ○ Osmotic diuretics act on the proximal tubule of the loop of henle to create osmotic force that pulls water into the nephron and increases the excretion of nearly all electrolytes ● LASIX - loop diuretic - idea of ototoxic - can lead to hearing loss - what do we assess the patient for (what they didnt tell us) ○ Assess for circulatory collapse, dysrhythmias, hearing loss, renal failure, and anemia ○ Monitor blood urea nitrogen (BUN), serum creatinine, uric acid, and blood- glucose levels ○ Monitor urinary output and weight to determine body fluid gain or loss. ○ Monitor vital signs and note decrease in BP. ○ Administer IV furosemide slowly, hearing loss may occur if it is rapidly injected. ○ Observe for evidence of hypokalemia. ○ Monitor potassium levels, especially when a patient is taking digoxin. ○ Monitor for side effects—orthostatic hypotension, hypokalemia, hyponatremia, polyuria ● Thiazide - thiazide diuretics (work at the distal part of the nephron ) - they can increase uric acid levels and lead to hyperuricemia can be a problem in patient's who have gout ● Hyperglycemia - side effect of glucocorticoids - discussed glucocorticoids such as prednisone - what we need to take into account? Do we stop it abruptly or taper down slowly? ○ Because corticosteroid drugs cause adrenal atrophy with long term therapy, these drugs must be tapered down slowly when discontinuing therapy

○ Bismuth subsalicylate- Pepto-Bismol (acts as an antacid as well) treats H. Pylori ● PPI - increase risk of osteopenia ○ Omeprazole ○ Long-term use associated with increased risk of gastric cancer ○ Increases the risk of Osteopenia/osteoporosis (low bone density) ○ Take 30 minutes prior to eating, usually before breakfast ○ May be administered at same time as antacids ○ Often administered in combination with clarithromycin (Biaxin)/PPI and antibiotics provides best outcomes as a combination therapy ○ If taken with NSAIDs it can help protect against NSAID-associated ulcers due to its long lasting inhibition of acid secretion by the stomach ● Hyponatremia - what happens? - sodium of less than 135 ○ Caused by excessive dilution of plasma ○ Excess antidiuretic hormone (ADH) secretion ○ Excessive administration of hypotonic intravenous solution ○ Vomiting, diarrhea, gastrointestinal suctioning, diuretic use (early signs) ○ Altered neurologic function such as confusion, lethargy, convulsions, coma, muscle twitching, tremors (later signs) ● Hyponatremia - can be caused of loss of sodium - how do we treat that? ○ Give fluids containing salt ○ Hypertonic solution ● How to treat hyperkalemia and hypokalemia, hypermagnesemia and hypomagnesemia and why is it important to treat these conditions? ○ Patient can go into cardiac arrest if they are hypokalemic ○ How to give these medications ○ Hyperkalemia ■ Hypotonic fluids ■ Restrict dietary sources ■ Decrease dose of potassium-sparing diuretics ■ Administer glucose and insulin IV ■ Administer calcium to counteract potassium toxicity on heart ■ Administer polystyrene sulfonate (Kayexalate) and sorbitol to decrease potassium levels ○ Hypokalemia ■ Potassium supplements ■ If Potassium supplementation is given as liquid form, make sure to dilute in water ■ Potassium should never be pushed IVP as it will lead into cardiac arrest ■ Crystalloid administration ● Short-term maintenance therapy ● Treat dehydration and electrolyte imbalance ● May be isotonic, hypotonic, hypertonic ○ Hypermagnesemia

■ Hypotonic fluid ○ Hypomagnesemia ■ Magnesium supplements ● Assess patient's for hypokalemia and hypotension - peripheral vasodilation - severe effects due to diuretic therapy needs to be treated ● Primary symptoms of cushing syndrome - what do we find ○ Upper body obesity (ecchymosis of the arms) ○ Patient's can have hypertension ○ Patient's can have hyperkalemia ○ Patient's can have delayed wound healing ○ Moon face ● Kidneys - primary organs that regulate fluid and electrolyte balance - also primary organs that regulate potassium balance ○ Do not affect serum oxygen levels ○ Do not have any impact on bacterial infections ● Renin - helps regulate blood pressure ● Potassium IV PUSH ( we never give ) ○ Leads to Cardiac arrest ○ Someone else has to co-sign ○ Never should be administered IV PUSH ● Protein and Glucose - if a patient has that this could be caused by renal impairment ● Nephron - functional unit of kidney ○ Millions and millions of nephrons in kidney ● Patient taking herbs (i.e. herbal preparations) - important patient must bring herbs to the hospital so we know what is it they are taking - herbs have large amounts of lead - some herbs can interfere with function of medication - leads to bleeding ● Patient is taking glucocorticoids for a long time - assess for any type of bleeding the patient has ● Bisphosphonates - fosamax - can be used to treat osteoporosis and paget's disease - do not heal fracture - can prevent fractures but do not heal ● Liver damage - what do they need to avoid? ○ Tylenol ● A drop of respiratory rate will be a side effect of what drug? ○ Morphine ● Wasting narcotics - another nurse needs to see that you are wasting the narcotics ● Enteric coated medications - should NEVER be crushed - enteric coated should work in the small intestine - bypass the first pass effect ● If a patient has some type of burns - the doctors orders for IM (intramuscular injections) ○ Ask the doctor if the medicine can be given IV instead of IM because it will cause delay on absorption if given IM ● Pain scale - assess the pain level - use pain scale ● Pain assessment - never alternate tylenol (the one given for adults to children) ○ Always go 10 mg of motrin / kilo for children ○ 15 mg of tylenol / kilo for children

● Important for the nurse - whenever giving medicine know why the medicine was prescribed, know how the medication works, know how the medication is supplied by the pharmacy, know the medications name ● If a patient has nephrotoxic problems - important for you and notify the doctor to know that the patient is nephrotoxic ● Medicines given orally - before we administer assess if the patient can swallow ● If a patient is taking aspirin - stop taking aspirin 1 week before surgery - Moa? ● If a patient is taking potassium (liquid form) - must be diluted - very irritating to the mucosal lining ● Prioritizing care - ABC’s - airway, breathing, circulation ● Fosamax (alendronate) has to be taken on empty stomach 30 minute before breakfast with a full glass of water - educate patient to sit out 30 mins after taking medicine ● Loop diuretics - inhibit the sodium chloride reabsorption in the loop of henle - ○ Increases urine output ○ Increases excretion of potassium ● Thiazide diuretics block sodium chloride in the distal tubule of the nephron ● Potassium sparing diuretics - block aldosterone - do not allow excretion of potassium - patient should stay away from potassium foods ● Reglan - gastrointestinal stimulant - used to relieve nausea, vomiting, heartburn, stomach pain, and bloating - promoting gastric emptying ● Levothyroxine - synthetic thyroid hormone - used in the treatment of hypothyroidism - instruct clients who have hypothyroidism to take levothyroxine (T4) ● Glucocorticoids - have the ability to suppress inflammation and mask symptoms of infection - do not give to patients who have infection ○ Glucocorticoids can lead to Cushing syndrome (can happen to long term use)