Pharmacology for Nursing
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| What are the untoward effects of the "grand-daddy" anti-convulsant **Phenytoin (Dilantin) | • GI distress
• Gingival hyperplasia
• Hirsutism, coarse facial features
• Blood dyscrasias
• Hypersensitivity--rash
• Teratogenicity
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| T/F: Given that **Phenytoin (Dilantin) prevents the spread of neural activity through the brain, one will not experience an aura prior to seizure activity. | False: one taking **Phenytoin (Dilantin) may still experience an aura.
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| What are the signs of actual toxicity with **Phenytoin (Dilantin)? | CNS depression, ataxia, nystagmus
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| What kind of teaching would be important when administering **Phenytoin (Dilantin)? | Good oral care, take w/food, use folic acid (to prevent anemia), importance of birth control, report rash
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| How is **Phenytoin (Dilantin) taken? | PO--slow absorption
IM--unpredictable absorption (avoid IM)
IV--slow onset, irritates veins
(only soluble in Normal Saline)
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| What is **Fosphenytoin (Cerebyx)? | IV form alternative to Dilantin--more soluble, less irritation--Dosed differently!!! (for acute seizures)
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| What's the story w/**Carbamazepine (Tegretol)? | • Similar mechanism of action to Phenytoin--may effect GABA system
• Used for tonic-clonic and partial complex seizures
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| Why don't we see much use of **Phenobarbital--Barbiturate? | Major CNS depression--sleepiness; although tolerance can be built
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| Which anti-convulsant can be life threatening if one d/c's without tapering? | **Phenobarbital--Barbiturate
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| The second line drug used for tonic clonic seizures **Valproic Acid (Depakote, Depakene) has what common effects? | Anorexia, nausea, vomiting--20%
Sedation, tremor
Increased hepatic enzymes
Clotting problems
All dose related--lower doses helpful
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| What all is **Valproic Acid (Depakote, Depakene) used for? | Adjunct for tonic-clonic and complex partial seizures
Also for absence seizures
Also used -- bipolar illness
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| What is the drug of choice for childhood absence seizures? | **Ethosuximide (Zarontin)
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| What are some adverse effects of **Gabapentin (Neurontin)? | • CNS depression, ataxia
• Nausea
• No effect on blood counts
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| What is an advantage of prescribing **Gabapentin (Neurontin)? | Does not interfere with other antiepileptic drugs--can combine with phenytoin
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| What is the drug of choice for an acute seizure attack? | **Lorazepam (Ativan) IV; repeat until seizures stop, fast onset, short duration --> Follow with Phenytoin IV (If no response: Phenobarbital)
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| What are important things to monitor when administering IV Lorazepam (Ativan) for status epilepticus? | BP and respiration rate; watch for depression.
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| Jake is taking **Levodopa (precursor to dopamine) for his Parkinson's. What should we be watching for? | (DOSE RELATED): Anorexia, nausea, vomiting, somnolence, headache, dyskinesia, cardiac dysrhythmias, POSTURAL HYPOTENSION, psychological disturbance
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| Why take **Carbidopa with Levodopa to tx Prakinson's? | Called: **Sinemet: can use lower doses of Levodopa, reducing adverse effects
➢ More effective than Levodopa alone
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| What's too bad about Levodopa? | It's a life-long kinda drug. Unfortunately your body stops being able to store dopamine.
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| What sucks about ***Sinemet—Levodopa/Carbidopa? | ➢ “Wearing off” --effectiveness reduces over time (years); body loses ability to store dopamine—worse in younger clients
➢ Other motor fluctuations—dyskinesia, dystonia
➢ 50% of people after 5-10 years of treatment
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| What are the side effects of the anti-parkinson's medication **Bromcriptine (Parlodel)? | Same as dopamine: anorexia, N,V, somnolence, headache, dyskinesia, cardiac dysrhythmias, postural, etc. PRE-TREAT w/ANTI-EMETIC
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| What is the therapeutic effect of **Benztropine (Cogentin), and **Trihexiphenidyl (Artane)? | These are anticholinergics. All anti-parkinsonian's should:
--reduce tremor, balance gait
--reduce rigidity, improve smooth movement
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| What side effects can you expect to see when taking **Benztropine (Cogentin) for Parkinson's? | Anti-cholinergic effects: dry mouth, urinary retention, etc.
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| What side effects can you expect to see when taking **Trihexiphenidyl (Artane) for EPS? | Anti-cholinergic effects: dry mouth, urinary retention, etc.
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| What are adverse effects of anti-parkinson drugs **Benztropine (Cogentin) and **Trihexiphenidyl (Artane) and EPS drugs in general? | Behavioral changes, postural hypotension (especially apparent in treating Parkinson's), among others.
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| T/F: There is no cure for MS | True; must treat/prevent symptoms/exacerbations, but cannot cure
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| Liz is taking a sub-Q injection of **Interferon Beta-1-b (Betaseron) every other day for prevention of an MS attack. What are common side effects? | ➢ Flu like symptoms, injection site reactions (OK)
➢ Elevations of hepatic enzymes—monitor levels
➢ Neutralizing antibodies—may develop, limiting effectiveness
➢ Responsiveness to Interferons varies among individuals
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| What are the side-effects to expect when recieving an injection of **Glatiramer Acetate (Copaxone)? | Transient chest pain, flushing, dyspnea, palpitations, anxiety: THESE ARE OK, TEACH YOUR CLIENT NOT TO FREAK...
➢ Also: injection site reactions
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| How do we diagnose Myasthenia Gravis? | **Tensilon Test: Edrophonium (acetylcholinesterase inhibitor); effectiveness on muscle weakness must be seen in 5-10 minutes (positive)
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| When administering the ACh acetylcholinesterase inhibitor **Pyridostigmine (Mestinon), what should be monitored? | Cholinergic effects:
➢ N/V/D cramps, salivation
➢ Sweating, bronchial secretions
➢ Muscle cramps, twitch, weakness (must monitor other symptoms to determine if this is from the MG)
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| When administering the ACh acetylcholinesterase inhibitor, is it common to encounter Cholinergic crisis—excessive cholinergic stimulation? | Nope: Rare—should assume weakness is worsening of Myasthenia Gravis
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| What is the dose limiting effect of **Azathioprine (Imuran)? | Low WBC
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| When taking the immunosuppressant **Azathioprine (Imuran), what adverse effects should we monitor for? | ➢ Flu like illness—fever, nausea, vomiting, malaise—10%
➢ Hematologic, GI or liver problems—less common
➢ Monitor CBC, hepatic enzymes
➢ Low WBC—dose limiting effect
➢ LongTerm use increases risk of non-Hodgkins Lymphoma
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| What are the adverse effects of benzodiazepines like **Diazepam (Valium)? | ➢ Lightheaded, drowsy, (may be intentional)
➢ Ataxia, motor incoordination
➢ Confusion, amnesia
➢ Nightmares, paradoxical reactions
(esp. Elderly)
➢ Hangover of effects
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| T/F: Benzodiazepines have a low incidence of abuse? | True; does have dependance issues though. Barbiturates are the ones with addiction problems.
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| Mixing benzodiazepines with _______ could cause profound CNS depression. | Alcohol (or any other CNS depressant, but know ETOH)
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| What's the short-acting benzodiazepine we use for procedural sedation? | **Midazolam (Versed)--Short Acting
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| What are nursing implications for Valium, and other benzodiazepines? |
Monitor for therapeutic effects
--anxiety, sleep
--teach about combo with drugs and alcohol
--teach about hangover (don’t drive)
--assess suicide potential, dependence
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| Narcan is to narcotics as ___________ is to benzodiazepines. | **Flumazenil (Romazicon)
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| What is the issue with using the benzodiazepine reversal agent **Flumazenil (Romazicon) to treat Valium toxicity? | While it has a quick onset, it has a much shorter duration; thus a rebound effect of the valium could occur (re-dose as needed)
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| What are the adverse effects of **Phenobarbital (Luminal)? | ➢ Hangover common--don’t take within 24 hours of flying or driving
➢ Paradoxical excitement--elderly
➢ Hypersensitivity--urticaria, Facial swelling
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| What do we use to reverse the effects of barbiturate toxicity? | There is no reversal agent: you could call this a downside in the case of OD.
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| What happens in barbiturate toxicity? | Respiratory depression/cardiovascular collapse (no reversal agent)
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| What are important contraindications of barbiturates? | ➢ Porphyria--increase symptoms
➢ COPD--reduce CO2 sensitivity
➢ ABRUPT WITHDRAWAL (don't do it)
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| What happens when someone is in withdrawal from barbiturates? | **Abrupt withdrawal absolutely contraindicated!!
**Withdraw over 2-3 weeks
S/S--irritability, tremors, insomnia, HA, sweating, nausea, vomiting
Seizures--status epilepticus (THE BIG WORRY)
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| What distinguishes the anti-anxiety drug **Buspirone (Buspar) from barbiturates? | Slow onset (use long-term; despite what book says),
• No anticonvulsant or muscle relaxant
• Little sedative effects
• No evidence for abuse or diversion
(not a scheduled drug)
• Little evidence of tolerance
• No rebound on withdrawal
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| What are the adverse affects of unopposed estrogens | • Increase LDL, Lipids (CVD)
• Na+ & H2O Retention
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| Liz is partaking in a controversial estrogen replacement therapy. What is Liz at an increased risk for? | ➢ Endometrial cancer
➢ Breast cancer
➢ Thromboembolism--DVT/PE (estrogen increases fibrinongen)
➢ Heart disease
➢ Stroke
➢ Cholecystitis
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| What would a woman intolerant of estrogen replacement use an oral contraceptive? | Progesterone (yup, can be used w/or w/o estrogen as a contraceptive)
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| Why is it important to take BC at the same time? | Really, just to remember to take it. (You can get away with one day, but not two days).
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| What are the common side effects of oral contraceptives | Combo with progestins reduce some risks—lower dose decreases risks, smoking increases of clots, small increase in glucose in diabetics, Nausea, headache, breast tenderness, dizziness, Weight gain, edema (should decrease over time), maybe photosensitivity
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| Jake is concerned about spotting and breakthrough bleeding during the second month of being on oral contraceptives. How should we respond to Jake's concerns? | "Jake buddy," you should be taking oral contraceptives, as they are not appropriate for males. Instead, use the pull-out method." Note: bleeding/spotting is totally norm for first 3 months, as long as it's not longer than a week.
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| How do anabolic steroids effect one's masculinity? | ➢ Decreased spermatogenesis (infertility)
➢ Shrink testes
➢ Paradoxical feminization
➢ Acne, baldness, gynecomastia
➢ Increase risk of prostate cancer
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| What are some adverse effects of testosterone? | ➢ Early closure of epiphysis
➢ Edema—weight gain
➢ Increase LDL, decrease HDL
➢ Jaundice—(cholestatic hepatitis) depends on
➢ Hepatic cancer (high dose, long term) agent used
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| What are some adverse effects of testosterone in women? | ➢ Masculinization
➢ Male-pattern baldness
➢ Facial hair growth
➢ Suppress menstruation
➢ Enlarge clitoris
➢ Deepened voice
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| Why was Jason so sad when he stopped taking testosterone? | Depression is a common withdrawal effect.
Others psychological effects include:
➢ Aggression
➢ Mood swings, irritability
➢ Manic-like symptoms
➢ Impaired judgment
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| Describe the two types of transdermal forms of testosterone? | o Matrix type is applied to scrotum
o Reservoir-type applied to torso, arms, legs
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| Where is the gel form of testosterone applied? | Topically to arms, shoulders or abdomen
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| T/F: Oral forms of testosterone have significant first pass effects. | True.
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| Jake is taking ***Tamsulosin (Flomax) for low testosterone levels. When first starting this drug, what should the nurse be monitoring for? | Orthostatic hypotension.
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| Mark is presenting in the ER stating that he may have "gone overboard on the Sildenafil" What is Elizabeth (the ER nurse) likely to find during Mark's admission assessment? | Priapism; persistent erection...> 4 hours...ouch.
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| What is the most important nursing implication r/t administration of alkalyting agents like **Cyclophosphamide (Cytoxan)? | Encourage good hydration--may use IV pre-hydration; also watch for blood in the urine!!
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| The heavy metal agent _______________ is used just like an alkylating agent; as an anti-neoplastic. | ***Cisplantin (Platinol)
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| What is different about the adverse effects of alkalyting agents, and heavy metals as anti-neoplastics? | Very high incidence of vomiting—pre-treat with antiemetics and continue 2-3 days after each dose, pre-hydration common
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| What should be monitored on a client taking anti-metabolites? (e.g. folic acid analogs like ***Methotrexate, and pyrimadine antagonist **Fluorouracil (5FU)) | o Bone marrow suppression—WBC’s, platelets
o GI disturbances (nausea, vomiting, diarrhea)
o Neurotoxicity—coma, seizures
o Alopecia
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| What are some adverse effects of anti-mitotic drugs like ***Vincristine (Oncovin)? | Myelosuppression, Neurotoxicity—paresthesias, reduced reflexes, motor weakness, high doses—constipation or obstipation, rapid onset of action—risk of tumor lysis syndrome—high uric acid release ; “secondary gout” (pre-tx w/ Allopurinol)
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| What should an RN do before admistration of anticancer antibiotics? (e.g. **Doxirubicin (Adriamycin)) | Check cardiac function.
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| What is the number #1 adverse effect of the anticancer antibiotic **Doxirubicin (Adriamycin)? | o Cardiac toxicity—cardiomyopathy—long term toxicity--CHF
o monitor ECG’s
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| What are the adverse effects of the taxol drug **Paclitaxel (Taxol)? | o Bone marrow suppression
o Myalgias
o Peripheral neuropathy
o Mucositis
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| What is the anti-estrogen drug that causes menapausal-like symptoms? | Estrogen receptor blockers-- **Tamoxifen (Nolvadex)
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| What is a real important thing to monitor with Estrogen receptor blockers like **Tamoxifen (Nolvadex)? | S/S of DVTs; super common with ant-estrogen drugs.
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| Jake is taking o **Rituximab (Rituxan) for his non-hodgekins lymphoma. What side effects should we be concerned about? | o Fever, chills
o Nausea, dyspnea, rashes
o Neutropenia
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| What kind of PPE should be worn when handling antineoplastic medication? | Nitrile gloves when handling IV solutions,
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| What is the protocol of an IV site extravasation? | Written prior to administration
Stop drug
Try to aspirate residual and blood
Corticosteroids—Sub Q and topically
Ice packs
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| What is the Nadir with respect to cancer treatment, and when is it most likely to occur? | Nadir--lowest point in cell counts; often 1 week after treatment
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| What is an adequate neutrophil count (ANC)? | > 1500; less than 1500 is neutropenic
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| What are neutropenic precautions? | No fresh flowers from visitors
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| What should be monitored when administering Neupogen? | Monitor for edema, bone pain (may be managed with tylenol; warn client of these common reactions)
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| At what platelet count would one be considered for a platelet transfusion? | <50,000; If < 20,000 may have active bleeding that won't stop.
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| What is a normal hemoglobin? | 14-18 range (ballpark; from lecture)
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| What is important to teach a client about anemia r/t beginning cancer tx? | Teach—warn people before chemo about fatigue; planning day, etc.
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