Download NSG 6005 PHARM MIDTERM STUDY GUIDE VERIFIED FOR YOUR STUDIES and more Exams Nursing in PDF only on Docsity!
YOUR STUDIES
There will be 75 questions on the Midterm. Most will be multiple choice. There are a couple True/False and 5 matching questions. I suggest you review your PowerPoints and Textbook Assignments. I hope this study guide is helpful Make sure you know the following topics very well.
- When a medication is listed below, make sure you know all about it and how to apply it to different patient situations: What disease process it is used for?, how does it work?, when should it not be used?, adverse effects, pros/cons, interactions, patient education factors (should it be taken w/ food? At bedtime?), tapering, preliminary **and post treatment labs, black box warnings/CI, etc.
- If a disease process is mentioned below—know how to diagnose and** recommended treatment guidelines.
- General principles of pharmacokinetics and dynamics? PHARMACOKINETICS- What the body does to the drug” Absorption –Entry of drug to the blood stream. Usually depends on passive diffusion of drug through cell membranes.
- Absorption depends on: blood flow at site, drugs lipid soluability (> lipic, > soluabililty that directly penetrate the memebrane), local PH and drug ionization (non-ionized absorb better), pharmaceutical processing (coatings and additives.
- Blood brain barrier: allow lipid soluable only. May pump out any drug that it sees as foreign, hard to treat CNS infections.
- Placenta: allows lipid drugs so does not protect from lipid soluable drugs, which is why pregnant women are limited to drugs. Know gestation age. Distribution : fat ratio changes may alter distribution, especially a people age.
- Fat soluable drugs may be accumulated: weight loss will release these drugs.
- Water soluable drugs are affected by dehydration Biotransformation (Metabolism) : Drugs become more hydrophilic (water soluable) for excretion.
- Also referred to as the P450 system or cytochrome P450 system. (a group of enzymes in the liver identified for their ability to breakdown drugs.)
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- Hepatic “First Pass Effect” (parenteral (IV or IM) meds bypass this enzymatic effect)
- breaks PO meds down to some degree, some are protected with coating but they don’t always work
- Metabolites Usually less active, less toxic, easier
- to excrete
- Prodrugs - inactive in form given but metabolized to active drug (ex: enalapril)
- Liver function determined by liver enzymes
- Failing liver produces fewer enzymes, drugs available longer: caution
- Excretion: Process by which medications are eliminated from the body unchanged or as metabolites
- Kidneys are main organ of excretion
- If poor renal function, drug may accumulate, may wish to prescribe less of drug
- Also eliminated via respiration, breast milk, defecation. Tears, sweat, saliva not as significant.
- START LOW AND GO SLOW!!!!
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- Freedom from drug interactions: few drugs are without drug interaction
- Low cost: easy to afford; significant factor in adherence, esp. with elderly
- Chemical stability: drugs ability to be stored for long time without loss of effectiveness – variable between drugs
- Possession of simple generic name: easier to remember and less confusion amongst drugs
- SYNERGISTIC EFFECT: When two or more drugs are given together they can react with each other: An effect arising between two or more agents, entities, factors, or substances that produces an effect greater than the sum of their individual effects. It is opposite of antagonism.
o Can be positive (synergistic) • Morphine and Motrin
o Can be negative (compete with each other) • Asa and Coumadin
4) Therapeutic drug levels: (not sure if this is correct) Minimal Effective Concentration (MEC) – plasma drug level below which therapeutic effects will not occur. Therapeutic Index or Range - margin of safety
- • The wider or bigger it is, the safer the drug. o Example 1: Drug A: normal dose is 1 mg, toxic dose is 10 mg
- Acetaminophen’s therapeutic range is 30 times the MEC o Example 2: Drug B: normal dose is 9 mg, toxic dose is 10 mg o Lithium’s therapeutic range is 3 times the MEC. 5) WHAT IS MEANT BY A SIGNIFICANT FIRST-PASS EFFECT? Metabolism is the process of changing one chemical into another. The
YOUR STUDIES
liver is a major organ for drug metabolism because it contains high amounts of drug-metabolizing enzymes and because it is the first organ encountered by drugs once they are absorbed from the GI tract. Metabolism by the liver following oral administration is called FIRST-PASS METABOLISM and is important in determining whether a drug can be orally administered.
- HOW DO YOU KNOW HOW OFTEN TO PRESCRIBE A MEDICATION- 1/2 LIFE OF MEDICATIONS.
- Half-life- amount of time it takes to reduce the plasma concentration by 50%.
- In pharmacokinetics, steady state refers to the situation where the overall intake of a drug is fairly in dynamic equilibrium with its elimination. In practice, it is generally considered that steady state is reached when a time of 4 to 5 the half-life for a drug after regular dosing has started. 7) AGONISTS VERSUS ANTAGONISTS: AGONISTS: Drugs that produces a physiological response when combined with a receptor. ANTAGONISTS : a substance or drug that interferes with or inhibits the physiological action of another.
- SUSTAINED RELEASE MEDICATION CONSIDERATIONS- implies slow release over time. It is defined as the type of dosage in which a portion of the drug is released immediately, and then the remaining/maintenance dose) is then released slowly by achieving a therapeutic level which is prolonged. 9) SUBLINGUAL MEDICATION ADVANTAGES.
- Sublingual medication administration (under the tongue) and buccal (between the cheek and gum) allow drugs to have a more rapid onset of action and to avoid liver metabolism as they enter the blood stream.
- Nitroglycerin given under the tongue can act within minutes to treat an angina attack. 10) FIRST STEP IN THE PRESCRIBING PROCESS ACCORDING TO WHO? - The first step in the prescribing process is an accurate diagnosis and a determination of a therapeutic objective. (page 29)
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dosages must be tailored to their body weight, immature organ function.
- Elderly- polypharmacy, decreased renal and hepatic function 13) FACTORS AFFECTING PATIENTS ADHERANCE TO A DRUG REGIMEN:
- Highest risk is those patients with asymptomatic condition, chronic conditions. Cognitive impairment, psychiatric illness or disorders with significant lifestyle changes (smoker), and those with complex multiple daily dosing.
- Adherance implies a voluntary act of negotiation and joint acceptance of a treatment regimen.
- Patients harbor strong concerns about the need for their medication and the risk for taking it.
- Limited access to health care
- Restricted formularies
- High drug costs and co-payments 14) HOW DOES FOOD IN DIGESTIVE TRACT AFFECT ABSORPTION?
a) the presence of food in the GI tract can influence the rate and
extent of absorption
b) alteration of PH- food tends to increase stomach PH by acting as
a buffer.
c) gastric emptying –fats and some drugs tend to reduce
gastric emptying and delay onset of action of drugs.
d) stimulation of GI secretions- GI secretions produced in response
to food may result in degredation of drugs that are susceptible to enzymatic metabolism, reducing bioavailablity. Secretions may also increase bioavailability.
e) fats stimulate bile secretion- bile salts dissolute poorly
soluable drugs.
f) food induced changes in blood flow- blood flow to the GIT and liver
increases blood flow after a meal. The faster the rate of drug presentation to the liver: the larger the fraction of the drug that escapes first-pass
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metabolism.
g)competition of food components and drugs: possibility of
competitive inhibition of drug absorption, especially with drugs who have similar chemical structure of nutrients. 15) RECOMMENDATIONS REGARDING FIBER AND CV HEALTH. A) Dietary fiber may lower cholesterol
b) provide feeling of fullness, thus causing weight loss.
c) increased soluable fiber intake has been associated with
better glucose and improve blood lipid panels. 16) TETROGENIC VITAMINS- a) vitamin A- can effect embryonic development 17) ANEMIAS- KNOW CHARACTERISTICS AND HOW TO TREAT. See # 27
18. Warfarin - This medication is used to treat blood clots (such as in deep vein thrombosis-DVT or pulmonary embolus-PE) and/or to prevent new clots from forming in your body. Preventing harmful blood clots helps to reduce the risk of a stroke or heart attack. Conditions that increase your risk of developing blood clots include a certain type of irregular heart rhythm (atrial fibrillation), heartvalve replacement, recent heart attack, and certain surgeries (such as hip/knee replacement). Warfarin is commonly called a "blood thinner," but the more correct term is "anticoagulant." It helps to keep blood flowing smoothly in your body by decreasing the amount of certain substances (clotting proteins) in your blood. Pharmacotherapeutics Warfarin Pharmacokinetics Wellabsorbed when taken orally Metabolized by CYP 1A2 and 2C
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Then less frequently but at least every 6 week
19. ITAMIN K Vitamin K, is a critical component of blood clotting , is found in many foods and is synthesized by intestinal bacteria. Newborns are at risk for early vitamin K–deficiency bleeding American Academy of Pediatrics(AAP) recommends that all newborns receive vitamin K within the first 2 weeks of life. The dose of vitamin K (phytonadione) recommended 0.5 mg to 1.0 mg IM, ideally given within the first hour of life (AAP Committee on Fetus and Newborn, 2003). Oral vitamin K is used by some countries and by some providers in the United States. The AAP notes that vitamin K–deficiency bleeding in newborns who received oral vitamin K. The AAP recommends IM administration until further study of oral administration is conducted. Warfarin interferes with the vitamin K–dependent clotting factors (II, VII, IX, and X), leading to decreased formation of clots. Vitamin K(phytonadione) is prescribed for patients who develop critically high INRs while on warfarin. Patients with an INR greater than 10 with no evidence of bleeding can be administered oral vitamin K (5–10 mg): if high INR with bleeding occurs, vitamin K (5– 10 mg IV) is administered along with prothrombin complex (Guyatt et al, 2012). Foods high in vitamin K compete with warfarin. Therefore, drug–nutrient interactions must be considered to utilize drugs effectively in the prevention and treatment of disease. Patient education must be provided about drug–food interactions, especially if there is a potential for adverse patient outcomes. Patients who are taking warfarin should not ingest foods high in vitamin K, as the combination may lead to therapeutic failure. Vitamin K Content in Common Foods Food Serving Size Foods High in Vitamin K (more than or equal to 200% DV) Kale, fresh, boiled Eat No More Than 1 Serving per Day 1/2 cup Spinach, fresh, boiled 1/2 cup Turnip greens, frozen, boiled 1/2 cup Collards, fresh, boiled 1/2 cup Swiss chard, fresh, boiled 1/2 cup Parsley, raw 1/2 cup Mustard greens, fresh, boiled 1/2 cup Foods Moderately High in Vitamin K (60% to 199% DV) Eat No More Than 2 Servings per Day
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Brussels sprouts, frozen, boiled 1/2 cup Spinach, raw 1 cup Turnip greens, raw, chopped 1 cup Green leaf lettuce, chopped 1 cup Broccoli, raw, chopped 1 cup Endive lettuce, raw 1 cup Romaine lettuce, raw 1 cup Power point information (short and sweet..) Vitamin K A critical component of blood clotting Found in many foods Synthesized by intestinal bacteria Newborns need 0.5 mg to 1.0 mg, ideally within the first hour of life, to prevent vitamin K- deficiency bleeding. Vitamin K is used as an antidote to critically high international normalized ratio in patients taking warfarin.
20. Vitamin C (ASCORBIC ACID) Vitamin C, also known as ascorbic acid, is a water-soluble vitamin that humans do not have the ability to synthesize so they must get adequate amounts of it in their diet. Patients with inadequate vitamin C intake may develop scurvy , with symptoms of fatigue, malaise, and gum inflammation or bleeding. Smokers and persons who are heavily exposed to secondary smoke have decreased vitamin C levels; therefore, it is recommended they take 35 mg more vitamin C per day than nonsmokers. Other groups at risk of vitamin C deficiency are infants fed evaporated milk or boiled milk without additional supplementation of vitamin C, patients with malabsorption disorders, and patients with end-stage renal disease who are on hemodialysis (ODS, 2013b). Vitamin C therapy has been studied for its effects on health because of its antioxidant and immune function action. It has been touted as prevention or treatment of the common cold since the 1970s, when Linus Pauling published his landmark study. A Cochrane Review in 2007 of 30 trials did not find that vitamin C decreases the incidence of colds in the general population (Douglas, Hemiliä, Chalker, & Treacy, 2007). The role of antioxidants in reducing the risk of cardiovascular disease. The Nurses’ Health Study found an inverse relationship between coronary heart disease and vitamin C intake (Myint et al, 2008). A meta-analysis of 16 studies examining vitamin C intake, circulating vitamin C levels, and risk of stroke suggests lower stroke risk with higher vitamin C intake and levels (Chen, Lu, Pang, & Liu, 2013).
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Iron is an essential mineral required for the regulation of cell growth and differentiation, as well as a component of oxygen transport. Patients with irondeficiency will develop microcytic-hypochromic anemia and have red blood cells that are small in size, pale, and low in hemoglobin. Iron-deficiency anemia (IDA) reduces the oxygen-carrying capacity of the blood, leading to fatigue and decreased immunity. Too much iron can lead to iron toxicity; therefore, patients should be advised to take only the recommended amount for their age and condition. POWERPOINT Needed for oxygen transport Patients with iron deficiency will develop microcytic-hypochromic anemia. Adequate intake is determined by age. All infants should be assessed for adequate iron in diet. Iron 0–6 mo 0.27 mg/d 7–12 mo 11mg/d 1–3 yr 4–8 yr 9–13 yr 14–18 yr male 14–18 yr female 19–50 yr male 8mg/d 19–50 yr female 18mg/d 19 to 50 yr pregnant 27mg/d 50+ yr 8mg/d Chicken liver, oysters, beef, clams, turkey dark meat. Legumes, dark green vegetables. Fortified breads and cereals. Iron-fortified infant formula. 22.VITAMIN A Vitamin A plays a critical role in vision, bone growth, reproduction, immune function, cell division and differentiation. There are two types of vitamin A: preformed vitamin A, which is derived from animal sources, and provitamin A carotenoid, which is derived from plant sources. Ahealthy diet should contain a variety of carotenoid-rich fruits and vegetables.
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Vitamin A deficiency can lead to night blindness and decreased immune function. Vitamin A may reduce the severity and duration of diarrheal episodes in malnourished children in developing countries but not in well-nourished children (Imdad et al, 2011; ODS, 2013a). Vitamin A supplementation has also been found to decrease bronchopulmonary dysplasia in extremely low-birth- weight infants with no increase in mortality or neurodevelopmental disorder. Chronic alcoholism may lower vitamin A levels , and patients with chronic alcoholism may require supplementation. Patients with cystic fibrosis (CF) are predisposed to malabsorption and fat-soluble vitamin deficiency, with 10% to 40% of CF patients being vitamin deficient and requiring supplementation. Caution should be used to avoid excessive vitamin A supplementation, as toxicity may occur. Levels above recommended amounts may be teratogenic in pregnant women ; vitamin A is labeled Pregnancy Category X if intake is greater than recommended amounts. Vitamin A(POWERPOINT) Critical role in vision, bone growth, reproduction, immune function, cell division and differentiation
26. Vitamin B Vitamin B 6 , also known as pyridoxine, is a water-soluble vitamin needed for protein and red blood cell metabolism, as well as glucose regulation. Vitamin B deficiency may lead to microcytic anemia, dermatitis with mouth sores and
Vitamin A Children:
1–3 yr
4–8 yr
Adolescents aged 9–13 yr
Adult males Adult females
Pregnancy
Liver, dairy products, fish, darkly colored fruits and leafy
mcg/d
mcg/d
mcg/d
mcg/d
mcg/d
770 mg/d
vegetable
s
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Pregnant women need 600 mcg/day of folic acid, a multivitamin/mineral supplement, 27 mg/day of iron (60 mg/day if patient is anemic ), and vitamin B 12 if the patient is vegan or lacto-ovo-vegetarian. Older adults over age 50 need 2.4 mcg/day of vitamin B and need to ensure 12 adequate intake of vitamin D and calcium.
- FOLIC ACID Folate Folate is a water-soluble vitamin that is critical to the production and maintenance of new cells. Folate is found in foods such as green leafy vegetables, citrus fruits, and dried legumes. Folic acid, the synthetic form of folate, is added to breads, flours, pastas, rice, and other grain products (ODS, 2012a). Folate deficiency occurs in times of increased demand, such as occurs in pregnancy and lactation, or when loss increases (malabsorption, alcohol abuse, dialysis, liver disease). Medications may interfere with folate utilization, leading to deficit. Folic acid supplementation is recommended for all women of childbearing age (400 mcg/d), with extra given when a woman is pregnant (600 mcg/d) to prevent neural tube defects in the fetus. Lactating women should take 500 mcg/day. Folate is necessary for the normal maturation and functioning of red blood cells. Folate deficiency produces a macrocytic-normochromic anemia. Patients with folic acid–deficiency anemia commonly complain of glossitis, stomatitis, nausea and anorexia, and diarrhea, and a systolic ejection murmur may be heard. Oral folic acid is well absorbed, and doses of 1 to 2 mg/day result in correction of the deficiency in 4 to 5 weeks. Hemoglobin (Hgb) levels begin to rise within the first week, and anemia is completely corrected in 1 to 2 months.
Antiepileptic drugs (phenytoin, primidone) Metformin
Sulfasalazine Triamterene Methotrexate Barbiturates Trimethoprim Pyrimethamine Isoniazid
Oral contraceptives
BOX 9–1 MEDICATIONS INTERFERING WITH FOLATE UTILIZATION
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POWERPOINT
Folate
• Critical to the production and maintenance of new cells
• Found in foods such as green leafy vegetables, citrus fruits, and dried legumes
• Folic acid is the synthetic form of folate.
• Folate deficiency occurs during pregnancy and with increased losses.
• Folic acid supplementation is recommended for Childbearing
age teens and women: 400 mcg/day Pregnant women: 600 mcg/day Lactating women: 500 mcg/day Antacid therapy or potassium therapy can reduce absorption of folic acid, iron, and vitamin B .Phenytoin reduces the level of folic acid. 12
25. THIAMINE Vitamin B 1 (thiamine) is a water-soluble vitamin critical for many body functions and is widely available in fortified breads and cereals. Deficiency of thiamine can lead to beriberi or Wernicke’s encephalopathy. Alcoholic patients develop thiamine deficiency at 8 to 10 times the rate of the nonalcoholic population. Wernicke’s encephalopathy is a serious neurological illness in alcoholic patients and requires immediate high-dose levels of thiamine (500 mg IV TID for 2 days, then 500 mg/d IV or IM for 5 days). Patients should be given a daily 100 mg dose of oral thiamine until no longer considered at risk. Treatment for beriberi in children is IV thiamine 10 to 25 mg or 10 to 50 mg daily for 2 weeks, and in adults 50 mg IM/IV for several days or 5 to 30 mg/day for a month. POWERPOINT Vitamin B 1 (thiamine) Deficiency can lead to beriberi or Wernicke’s encephalopathy Alcoholics at high risk
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▪ 1.IRON DEFICIENCY ANEMIA
▪ Prevention
▪ Adequate intake via iron-rich diet
▪ Monitor in periods of rapid growth (infancy, adolescence, pregnancy).
▪ Replacement in infants 1 mg/kg/day starting at 4 months (2 mg/kg/day in preterm infants)
▪ Treatment
▪ Iron replacement based on age
▪ Divide dose in three doses per day.
▪ Monitoring
▪ Reticulocyte count 5 to 10 days after starting therapy
▪ Hgb, hematocrit (Hct), ferritin at 4 weeks, then at 3 months
and annually
▪ Outcome evaluation
▪ Return to normal Hgb, Hct, and ferritin levels
▪ If Hgb, Hct, and ferritin do not return to normal levels the patient should be
evaluated for a source of blood loss of other pathology.
▪ Patient education
▪ Importance of prevention with adequate iron intake in diet
▪ Administration
▪ Empty stomach if tolerated
▪ Three times per day is best
▪ Constipation (may need a stool softener)
▪ 2.FOLIC ACID DEFICENCY ANEMIA
▪ Risk groups
▪ Infants fed goat’s milk or powdered milk formula
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▪ Vegetarians and vegans
▪ Pregnancy increases daily requirement need.
▪ Patients with sprue, Crohn’s disease, giardial infections, and short bowel syndrome
▪ Patients taking drugs that affect folic acid absorption
▪ Prevention
▪ Adequate dietary intake
▪ Folic acid supplementation in pregnancy
▪ Drug therapy for deficiency
▪ Oral folic acid 1 to 2 mg/day for 4 to 5 weeks
▪ Hgb levels start to rise in a week
▪ Women of childbearing age and pregnant women should consume 0.4 to 0.8 mg/day.
▪ Monitoring
▪ Follow Hgb/Hct in 4 weeks and then regularly
▪ Education
▪ Need for folic acid
▪ Administration
▪ 3.PERNICIUS ANEMIA
▪ Pernicious anemia is caused by inadequate vitamin B12.
▪ Defective secretion of gastric intrinsic factor, which is necessary for vitamin B
absorption
▪ Vitamin B12 malabsorption occurs in 10% to 30% of adults over age 50 due to reduced
pepsin activity and gastric acid secretion.
▪ Prevention
▪ Eat foods high vitamin B12, such as mollusks (e.g., clams), fortified breakfast cereals,
liver, trout, salmon, milk, and eggs.
