Pharm ati - ATI adaptive quizzes log notes. PDF

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ATI adaptive quizzes log notes....

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General tips 

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a food interaction grapefruit juice is common side effect of a medication o headache o GI upset which GI upset is super common with medications o do not choose something really serious like seizures or urinary retention = not common side effects end in s o n E o prednisone are o typically steroids o side-effects  weight gain fluid retention  hyperglycemia  hypokalemia  peptic ulcer disease  bone loss Herbal supplements o Garlic o Ginger o Gingko o Biloba end in ma BRNIB o typically immunosuppressants o used to treat certain types of cancer or autoimmune disorders  risk of infection just assume in general most medications are contraindicated for pregnancy in general patients should never discontinue their medications suddenly o if they miss a dose they should usually never double up on doses  few exceptions such as:  birth control pills  in general it's never a good idea to double up on doses antibiotics o complete the entire course o cultures should be taken prior to initiating antibiotic therapy patients should not chew our crush extended-release capsules

Chapter 1 

Four phases of pharmacokinetics o absorption  oral meds take longer to absorb bc of gi tract  depends on if they ate food  PH of gastric secretions also impact  Liquid vs. Extended release change in absorption obv.  Sublingual very fast o Wait until completely absorbed  Inhalation  Very quick  Travels to alveoli

Intradermal  Slow and gradual o Lidocaine patch o Cant leave on all day  Topical  SubQ or IM  Depends on solute or solubility of med  Depends on blood perfusion of site  IV  Immediately o distribution  med requires binding proteins for distribution o metabolism  med is inactivated to les active form by enzymes  Primarily liver  Kidneys, lungs, bowel and blood can be involved as well  Babies metabolism isn’t as effective  Risk for toxicity  Older adult*  Liver or kidney problems , impact metabolism  Risk for toxicity o Excretion First pass effect o Oral meds inactivated through first pass of liver o May need to give pt higher dose of med Maintain plasma levels o Maintain between MEC (minimum effective concentration) o Maintain toxic concentration Some meds have low therapeutic index o This means TI and toxic level are very close together*  Hit very specific range to avoid toxicity o Vancomycin  Blood draws to check trough levels and peak levels  Make sure you’re not hitting toxic range Half life o Period of time for meds to be reduced by 50% o Low HF- you eliminate it quickly o High HF- lingers in body longer*  Risk for toxicity goes up 

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Agonist Meds* o Produce action o Ex. Morphine  Opioid agonist  Bind to opioid receptors Antagonist meds* o Oppose action o Ex. Naloxone Routes of admin

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Oral med  Mix with applesauce maybe, helps swallowing  Do not mix with large amount of food may not finish  Sit upright, tilt chin to chest will help swallow  Don’t chew etheric coated or extended release caps  Sublingual make sure it’s absorbed before they eat or drink Transdermal  Wash pt’s skin with gentle soap and water, and dry thoroughly  Rotate sites, remove old patch obv.  Choose hairless area Eye meds  Surgical aseptic technique  Drop med into center of conjunctival sac  Gentle pressure for 30-60 seconds at nasolacrimal duct  Don’t touch tip of dropper to eye Ear drops  Lay on unaffected side, effected side up  Pull auricle up and back for adults  Down and back for kids NG tube or G tube  Flush tubing before and after each med  15mL of sterile water  One last 15mL flush after last med is given Suppositories  Position pt on left side  Insert past internal sphincter  Keep inside for 20-30 mins (gayyyyyyyyyyyyyyyyyyyyyyy) for bowel movements  60 mins for systemic absorption Inhalation  Metered dose inhaler (MDI)  Shake 5-6 times  Presse and take deep breath ~3-5 seconds  Hold breath for 10 seconds before exhaling  Dry powder inhaler (DPI)  Avoid shaking  Deep breath 5-10 seconds IM injections  Child under 2 years old use fastest site*  After 2 years old use vastus lateralis site or ventral gluteal  Can accommodate up to 2mL of fluid  Deltoid max should be 1mL of fluid  Longer needle than SubQ because of layers of skin  1-1.5 inches in length usuall  22-25 gauge usually  90 degrees angle  Some require Z track method  Iron preparations  Pull in the skin and release skin once injected Intradermal

Low volume of amount of solution  Under 0.1mL  Hold needle at 5-15 degree angle w/ bevel up SubQ injections  Needle 3/8-5/8  25-27 gauge needle  45 degree angle IV  20 gauge IV catheters- standard  Trauma patient  16 gauge or something bigger  Surgery pts  18 gauge  If child or older pt and requiring blood transfusion  Can go smaller size like 22-24 gauge 

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Chapter 2  Safe med admin  Prescriptions o Physicians, NP, PA, Dentist APN, can write scripts o Types of scripts  Standard script  Given on regular schedule  Every day, once a day, twice a day  Single or one time script  Give med only 1 time  Stat script  Give med right away  Emergent situation  PRN script  Given as needed  Still need to specify dose and frequency and why it’s given etc o Ex. Zofran for NV  Standing script  Specific circumstances or specific units o Components of med are important to know  Name of pt  Date and time of script  Name of med  Dosage throughout  Frequency of admin  Signature of provider o Can take telephone order, recommended to have second RN on line  Important to read back after physician gives order  They still need to come and sign of script within 24hrs o Know 6 right’s  Pt has right to refuse med o Abbreviations*

IU- International units U- units Qod or QD  Should not be used  SubQ  SC or SQ are not recommended  When writing out dose  Don’t use trailing 0  Use leading 0 – 0.5 Never admin that has been prepped by someone else  If error occurs, report within 24 hrs  Report does not become part of the pt’s permanent record  Report should not be referenced in another part of pt record   

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Chapter 3  If you know how to do this question then you’re Gucci 20mg/kg per day divided in equal doses every 12 hours to a preschool child who weighs 44lb’s 44/2.2

2.2lb=1kg

Child weighs 20kg Script says 20mg/kg per day Amoxicillin med available is 250mg/5mL

20kg x 20mg= 400 mg This is for the entire day though according to script, but dosing ask for twice a day so this means every 12 hours. So we actually want 200mg per dose 200mg twice a day is 400mg daily dose of script

250mg

200mg

1000= 250x

x

250x 250x

5mL

x= 4

Answer: 4mL for this 44lb child according to dosing and script and med available

Heparin 15,000 units sub-q every 12 hours Amount available- 20,000 units/mL How many mL’s do we administer per dose? 20,000 units 1mL

15,000 units x

15,000 = 20,000x 20,000x 20,000x

x=0.75

.75mL rounds to 0.8, make sure to see if they want you round***** Answer: 0.8mL of heparin

Chapter 4 

IV therapy o Absorbed right away  Will feel probably within 5 mins o Feel faster than oral med that takes ~45-60 mins to kick in o Risk of IV therapy  If pt has heart failure, IV fluid may cause circulatory overload  If you admin wrong med in IV so fast that you can’t do shit about  Some meds can irritate the lining of veins  Ex. Vancomycin o Much better off being infused via PICC line or a central line as opposed to peripheral IV line  Failure to maintain surgical sepsis can result in local infection and can become sepsis in some cases o Pts often given large volume of IV infusions continuously  100mL/hr  Dr. can order IV bolus of normal saline 500mL/hr (idk wtf this has to do with anything) o Do’s and Don’t’s  Don’t  Put IV med through tube that is infusing blood or blood products  Put IV med through IV tubing that is infusing TPN  ^^^^ get their own lines  Avoid using back of hand, especially in old people. Thin skin lots of nerves. May hurt like a bitch  Fluids should not hang for more than 24 hrs unless closed system o Ex. Pressure bags used for hemodynamic monitoring  Do  Verify compatibility of meds that you will be running through the same line  IV for older pts , use BP cuff instead of tourniquet when doing insertion  Have pt hold hands below level of heart  Change peripheral IV sites on regular basis per facility policy, usually every 72 hours  Replace fluid bag and tubing every 24 hrs  Wipe all ports with alcohol before any admin  Proper needle gauges o 16 gauge for trauma pt o 18 gauge for surgical pt o 20 gauge is default , works for continuous fluid admin o 22-24 gauge works for older pt or children as long as they don’t need blood or fluid bolus  Start distally when inserting- distal veins o If you miss then work way up o If you miss twice get someone else o Document date and time of insertion, site, appearance (catheter size? Lol what?)

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 Flush IV every 8-12 hrs  If not continuous check every 8-12 hrs to keep patent  Monitor site and infusion rate every hour Complications associated with IV therapy  Infiltration  Non- Vesicant solution that ends up outside of the veins o Symptoms:  Pallor  Local swelling @ site  Decreased skin temperature  Stop infusion  Remove catheter  Elevate extremity to get fluid of out  Apply cold or warm compresses depending on type of solution that was infiltrated  Extravasation- vesicant type of med o Symptoms:  Tissue damaging  Pain  Burning  Redness  Swelling o Stop infusion and notify provider depending on med  May want to infuse antidote through catheter before to removal of catheter  Hematoma  Ecchymosis or bruising @ site  Apply warm compress  Elevate extremity  Catheter embolus – this shit serious  Missing catheter tip  When removing inspect to make sure everything is intact  Catheter embolus can travel to lungs and cause pulmonary embolism  Place tourniquet high on extremity  Prep pt for removal of embolus through x-ray or surgery  Phlebitis/ Rambo phlebitis  Edema  Throbbing  Burning  Increased temp @ site (this is what makes it different from infiltration)  Erythema  Possibly red line up the arm with palpable band at the vein site, feels hard  Discontinue the infusion and remove the catheter  Elevate extremity  Apply cold compress, minimizes flow of blood  After ^ apply warm compress to increase circulation  Cellulitis – not common  Pain  Warmth  Edema  Hardness

Red streaking Systemic symptoms: (these differentiate it from the others) o Fever o Chills o Malaise  Elevate extremity, apply warm compresses 3-4 times a day blah blah  Probably admin antibiotics, analgesics, and antipyretics o Bring temp down Fluid overload  Distended neck veins  Increased BP  Tachycardia  SOB  Crackles in lungs  Edema  Slow the IV rate , raise head of bead  Give diuretics  

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Chapter 5- these are all adverse effects that will be covered in other chapters anyways

Chapter 6 

Factors that affect med admin o Body weight  Someone bigger will need higher doses for it to work o Age  Kids  Liver and kidney function not fully matured, metabolism impaired  Require lower doses  Old people  Same as kids  Gender  Women more fat so respond different to meds compared to Men  Tolerance  IV drug users o Dilaudid at half mg  Aint gunna do shit  Accumulation  Not excreting med properly  Can lead to toxicity  Psychological factors  Placebo effect o Frame of mind- positive or negative can impact response to meds  Medical conditions  Inadequate gastric acid o Impairs absorption of med o Shitting everything out too fast

Vascular insufficiency o PAD  Not adequate blood flow  Meds wont get down there easily  Liver or kidney diseases o Impairs metabolism o Causes toxicity o Lower dosing needed Pediatric dosing  Based on body weight or body surface area Older clients  Increased gastric PH o More alkaline o Less effective at absorbing meds  Decreased GI motility  Decreased kidney function  Decreased protein binding sites o Insufficient albumin due to malnutrition etc  Impaired memory changes  Changes in vision and hearing  Decreased mobility and dexterity  Polypharmacy to many damn meds o Teaching required/ verbal and written o Use those little containers old people use to divide meds @ times  Difficulty swallowing  Admin liquid form of meds  Help pt setup daily calendar of meds of what to take and when Pregnant women  Most meds are considered harmful to fetus  Just assume it’s not ok to take meds if you’re preggers  Talk to provider  Avoid live virus vaccines o Measles o Mumps o Rubella o Polio o Etc.  Should get annual flu shot* o Inactivated influenza vaccine 

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Chapter 7 

Anxiety medications o Benzodiazepines � (-am)  Common benzos:  Diazepam  Lorazepam  Alprazolam

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 Chlordiazepoxide* (be familiar)  Treat anxiety  Treat seizures muscle spasms  Alcohol withdrawal  Induce or maintain anesthesia  Work by increasing the effects of GABA  GABA reduces activity of neurons  Side effects:  Sedation  Respiratory depression  Amnesia  Dependency  Withdrawal  Short term use, not long term  Don’t discontinue if you use for long period  Can cause withdrawal issues  Antidote: flumazenil  IMPORTANT- antidote is not naloxone * Buspirone  Treat anxiety  Treat panic disorder  Treat PTSD  Can be used long term  Sedation usually not a problem  Takes a few weeks to for full effects to be felt  Dependency is not likely  If pt experiences GI upset , don’t take with food  Side effects:  Dizziness  Nausea  Headache SSRI’s � (-ine)  Inhibit serotonin uptake  Treat anxiety  Treat depression  Treat OCD  Treat PTSD  Common meds:  Sertraline  Fluoxetine  Paroxetine  Side effects:  Nausea  Fatigue  Weight gain  Sexual side effects are common  Paroxetine can cause insomnia  Serotonin syndrome* - too much damn serotonin  Agitation

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 Hallucinations  Fever  Diaphoresis  Tremors Like buspirone won’t be felt immediately, takes like a month

Chapter 8 

Depression medications o Atypical  Bupropion  Quit smoking  Side effects: o Insomnia o Weight loss o GI distress o Agitation o Seizures  Trazodone o Side effect of sedation o (they make your libido go up or some shit, like when I took trazadone I was hard a fucking rock, not a true SSRI though, shares some shit though) o Tricyclic antidepressants (TCA)  Amitriptyline  Not only used for depression  Can be used for neuropathy  Fibromyalgia  Anxiety  Insomnia  Side effects: o Anticholinergic o Urinary retention o Constipation o Dry mouth o Blurry vision o Photophobia o Tachycardia o Sedation o Sweating o Seizures  How to counter side effects: o Chew gum o Wear sunglasses o Drink a lot of fluids o Eat high fiber diet  If they ask what the most serious side effect is go with answer like urinary retention (very dangerous side effect vs the others) o MAOI’s

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Will interact with basically every other medication When in doubt MAOI will probably be the answer Phenelzine  Used for depression Side effects:  Agitation  Anxiety  Orthostatic hypotension  IMPORTANT- hypertensive crisis* (MUST KNOW ABSOLUTELY) o When you see phenelzine think hypertensive crisis as SE  Foods high in tyramine will trigger hypertensive crisis* o Salami o Aged Cheese o Avocado o Red wine o Chocolate Educate Pt not to eat foods high tyramine

Chapter 9 

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Bipolar disorder medications o Lithium  Side effects: important to know*  GI upset  Fine hand tremors (expected)  Coarse hand tremors (sign of toxicity)*  Polyuria  Electrolyte imbalance* o Important to monitor plasma levels frequently, bc they could end up in toxic range. Very very dangerous  Levels over 1.5= toxicity* important  Symptoms: o Coarse tremors o Confusion o Hypotension o Seizures o Tinnitus- ringing in ears o Coma o Death  Do not take diuretics if on lithium  Waste too much sodium  Give lots of fluids and sodium  2-3L a day  Do not give anticholinergic medications  Do not give NSAIDS  Hard on the kidneys o Issues present already r/t lithium Anti-epileptic drugs

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Carbamazepine  Also anti-convulsant  Side effects:  Blood dyscrasia  Anemia  Leukopenia  Thrombocytopenia  Monitor CBC  Vision issues  Double vision  Nystagmus  Stigmas  Hypo osmolarity  rash Valproic acid  ‘ ‘  Side effects:  Hepatic toxicity*  GI upset  Pancreatitis  Thrombocytopenia

Chapter 10 

Psychotic disorder medications o Schizophrenia  Conventional antipsychotic medications  Control positive schizophrenia symptoms  Control delusions and hallucinations  Chlorpromazine  Haloperidol  Extrapyramidal side effects- EPS o Dystonia- spasming of tongue, neck, face, or pack o Parkinson’s like symptoms  Shuffling gait  Drooling  Tremors  Rigidity  Cathesia- cant stand still  Tardive dyskinesia- involuntary movement of tongue and face  Neuroleptic malignant syndrome o Fever o Dysrhythmias o Muscle rigidity  If pt isn’t good about taking medications, they can receive IM injections every 2-4 weeks  Anticholinergic medications help control EPS  Atypical antipsychotic medications (-done)(-pine)  Risperidone

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Clozapine Control negative and positive schizophrenia symptoms Side effects: o Diabetes o Weight gain o Increased cholesterol o Orthostatic hypotension o Anticholinergic effects Can be given IM every 2 weeks o If pt is non compliant Avoid alcohol

Chapter 11 

Mental health issues in children o Methylphenidate o Amphetamine mixture o ^^^ used for ADHD or conduct disorders o Side effects: ^^  Insomnia  Decrease appetite, might lose weight o Do not administer at night, admin @ morning o Give immediately before or after meal  So it doesn’t affect appetite o Monitor child’s weight*

Chapter 12  Alcohol withdrawal o Starts 4-12 hours after last drink o Symptoms:  NV  Tremors  Increased HR  Increased RR  Increased BP  Possibly seizures o Medications for withdrawal  Benzo’s (covered previously)  Calm things down  Decrease VS  Prevent seizures  Antihypertensive medications  Clonidine  Propranolol  Anti-epileptics  Carbamazepine o Medications for abstinence  Disulfiram

If they drink with this, unpleasant side effects: o NV o Palpations o Sweating o Hypotension  Use these so they’re like fuuuuuck drinking with this makes me feel like booty  Naltrexone  Suppress craving of alcohol  Available monthly IM o For pt who is not compliant  Acamprosate  Decrease abstinence symptoms o Anxiety o Restlessness Opioid withdrawal  Methadone  Slowly decrease dose  Ween them off of it Nicotine withdrawal  Bupropion (covered in anti-depressants)  Can use gum, patch, or nasal spray  Ween them off  Varenicline tartrate (Chantix)  Reduce cravings and symptoms  Monitor closely, can cause depression and suicidal tendencies 

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Chapter 13  Chronic neurologic disorders o Myasthenia gravis – MG (2/3 meds have -stig)  Not enough acetylcholine  Cholinesterase inhibitors used to treat  So we don’t break don’t acetylcholine  Neostigmine  Pyridostigmine  Edrophonium  Used to diagnose MG  If conditions improves then it is MG  If worsens then you have cholinergic crisis o Give antidote – atropine  -Stig meds help improve strength a...