NUR 304: Study Guide for Unit 1 Test

Chapter 1:

Understand the following processes/terms:

First-pass effect

Process in which the drug passes to the liver FIRST (hepatic 1st pass)

Protein-binding Effect (distribution) primarily albumin

Drug dose is prescribed according to the percentage in which the drug binds to protein

Highly protein bound drugs (89% +)

Moderately protein bound drugs (61-89 %)
Low protein bound drugs (30 – 60 %)

Peak/trough; therapeutic range of drugs

Peak drug Level

Highest plasma concentration of drug at a specific time

Indicates the rate of absorption

Trough Drug Level

Lowest plasma concentration of a drug

Measures the rate at which a drug is eliminated

Therapeutic Range of Drugs (therapeutic window) ED50 & LD50 close to ratio 1 toxic

Concentration range in plasma should be between MINIMUM effective

concentration in plasma for obtaining desired drug action and the MINIMUM
TOXIC concentration ( protein bound & free)
Narrow range-monitor to avoid drug toxicity
Wide range- not considered highly toxic
Pharmacokinetics

Process of drug movement to achieve drug action.

Absorption
 Passive Absorption (Lipid soluble)
 Diffusion
o Lipid & nonionized faster than water absorption

 Active Absorption (water soluble)

o Need carrier

Distribution (protein binding effect)

 Volume of drug distribution is dependent on drug dose & its concentration
in body

Metabolism (biotransformation)
 Liver (primary site and GI tract)

Excretion
 Main route Kidney but also bile, feces, lungs, saliva, sweat, breast milk

Pharmacodynamics

The study of drug concentrations and its effects on the body

Primary effect response is desirable

Secondary effect response may be desirable or undesirable
 Ex. Benadryl: prim (symp of allergies)/Sec (drowsiness; bad id driving auto)

Onset of action- time to meet min. effective concentration

Peak Action- Highest plasma concentration
Duration of Action- length of pharmacological effect

Loading dose
When immediate drug response is desired, a large initial dose is given to achieve a
rapid minimum effective concentration in the plasma.
 Absorption of different drug preparations

Blood flow, pain, stress, hunger, fasting, food, & pH affect drug absorption
Pain, stress, & solid, hot, fatty, foods slow gastric emptying time
Exercise: decr bl flow to GI tract (more bl to peripheral muscle)
Drugs that lipid soluble and non-ionized are absorbed faster than water soluble &
ionized drugs

Onset, peak, duration of action

Onset of action- time to meet min. effective concentration

Peak Action- Highest plasma concentration
Duration of Action- length of pharmacological effect

Chapter 2:

How to develop educational goals; what constitutes a good goal

RUMBA stands for Relevance, Understandable , Measurable, Behavioral and

Attainable
Effective Goal setting Qualities
Client centered; Clearly states expected change
Acceptable to both Client & Nurse
Realistic & Measurable
Shared with other Health Care Providers
Realistic Deadlines
Identifies Components for Evaluation
Steps of the nursing process and how they relate to teaching about drug therapy

Assessment (incl Nursing Diagnosis)

Subjective Data
 Prescription, OTC, herbs, Vitamins

Objective data
 ROM, Fine Mtr Control, Visual impairment affect taking meds
 Identify High risk clients for Adverse Reactions
 Probs w/ compliance; cost, forgetfulness, trust, value systems

Includes Nursing Diagnosis

 Cultural/lamguage barriers
 Pain/fear of addiction
 Ineffective Health maintenance (not having preventive care)
 Ineffective regimen management
 Noncompliance related to forgetfulness/costs
 Risk for Injury/side effects

Planning/goals
Client centered; Clearly states expected change
Acceptable to both Client & Nurse
Realistic & Measurable
Shared with other Health Care Providers
Realistic Deadlines
Identifies Components for Evaluation
Examples
 Client will independently adm prescribed dose of Insulin by end of 4 th
session of instructions
 Client will prepare a medication recording sheet that correctly reflects
prescribed meds schedule within 3 days

Implementation
Client Ed & teaching very important in this stage.
In practice settings, adm of drugs assessment of drug effectiveness are
important nursing responsibilities.
Chapter 5:

Schedules of drugs

Schedule I (labeled C-I)

Drugs with high Abuse potential. NO ACCEPTED MEDICAL USE
 Heroin, Hallucinogenics (Lsd, Marijuana(except presc), mescaline,
peyote, psilocybin)

Sch II thru Sch V have accepted med use (dep decr as you move down)

Schedule II (labeled C-II)

High potential for abuse. ACCEPTED MEDICAL USE. Can lead to strong physical
dependence & Psychological dependence
 Demerol, Morphine, Hydrocodone, Hydromorphine, Methadone,
Oxycodone, Codeine, Amphetamines, Secobarbital, Pentobarbital

Schedule III (labeled C-III)

Medically accepted Drugs. Potential for abuse is less than I or II. May cause
dependence
 Codeine preparations, Paregoric, nonnarcotic drugs-Pentazocine,
Propoxyphene

Schedule IV (Labeled C-IV)

Medically Accepted Drugs. May cause dependence
 Phenobarbital, Benzodiazepines (diazepam, oxazepam, lorazepam,
chlordiazepoxide), Chloral Hydrate, Meprobamate

Schedule V (labeled C-V)

Opioid-controlled substances for diarrhea & cough (eg codeine in cough
preparations)

Example: Codeine is a sch II drug but when added to acetaminophen, it becomes a sch III drug and
when in combination with cough preparations, it becomes a sch V drug
 Pregnancy categories

FDA developed a classification system related to the effects of drugs on the unborn
child (fetus). A preg category is indicated on most drugs

Pregnancy Categories:

CATEGORIES A & B are considered to be within SAFE LIMITS, esp. during 1 st Tri-semester
 A- No risk to Fetus (studies have shown no evidence)
 B- No risk in Animal Studies and well controlled studies in pregnant
women are not available. It is ASSUMED there is little or no risk
 C- Animal Studies indicate a risk to the Fetus. Control studies on
pregnant women are not available. Risk VS Benefit of the drug must
be determined.
 D- A Risk to the Human Fetus has been Proved. Risk VS Benefit of the
drug must be determined. It could be used in LIFE THREATENING
CONDITIONS
 X- A Risk to the Human Fetus has been Proved. Risk outweighs the
Benefit and drug should be avoided during pregnancy

Chapter 7:

General guidelines as to the use of OTC drug preparations

Category I
Drugs judged to be both safe & effective

Category II
Drugs judged to be either unsafe or ineffective; these drugs should not be
included in nonprescription products
 FDA recommends drugs in CAT II be reformulated to be incl. in CAT I or
removed from the market

Category III
Drugs for which there insufficient data to judge safety or efficacy
Chapter 9:

General guidelines as to the use of herbal medications/preparations

Do not take if pregnant or attempting
Do not take if nursing
Do not take a lge quantity of any one herbal preparation
Buy only preparations that have the plant & their quantities listed; no
guarantee of safety
Contact HCP before stopping use of prescription med
Store in a cool dry dark place; dark glass containers preferred
Use only herbs that are bought currently and are fresh
Do not delay seeking care for severe or persisting symptoms
Advise against belief in unsubstantiated claims of miracle cures

Consumers need to think of herbs as medicine MORE IS NOT BETTER

Herbs are not placebos
Most less potent than conventional meds
Conventional meds faster
Labeling of herbal products important
Scientific name & parts of plant
Mfg name & address
Batch & Lot #
Dates og mfg & exp; many have short shelf life
Chapter 11: p 199

General nursing implications for medication use in the elderly client

The # of drugs taken, drug interactions & physical health are factors assoc with drug
effects
 Hypnotics- Benzodiazepines (low doses w/short term therapy suggested)
 Anthypertensives- Start low/grad incr as per needs
 Anticoagulents-ck PT, INR
 Antibacterial- reduced doses/reduced clearance/prolonged t ½
 Antidepressants- reduce 30-50 % & incr as per need

Absorption
Decr gastric acidity alters absorp of weak acids such as aspirin
Decr Bl flow in GI tract (40-50%less) is caused by decr cardiac output
and absorp is slowed
Reduction in GI motility rate (peristalsis) may delay onset of action
Reduction in Gastric emptying time occurs
Amt of oral dose that is absorp is not affected by age (just longer)

Distribution
Because of decr body H2O, water soluble drugs are concentrated
Because if incr Fat to water ratio, fat- soluble drugs are stored &
accumulate
Decr in circ serum protein (fewer protein binding sites) there is more
free drug available to body tissue at receptor sites
Metabolism
Decr in Hepatic Enzyme production, hepatic Bl flow, Total Liver Function
cause a reduction in drug metabolism
o With reduction in metabolic rate, t ½ life INCREASES and drug
accumulation can result
Excretion
Decr in RENAL BL FLOW/GLOM FILTR at 40 t0 50 %
Decr renal function causes decr drug excretions and accumulation can
result. Poss. drug toxicity
Chapter 14:

Nursing implications of your prototypes

Vitamins
Assessment
o Ck client for Vit deficiencies before start & regularly thereafter
o Obtain 24 & 48 hr diet history analysis
Nursing interventions
o Adm vitamins w/ food to promote absorption
o If drop form, use the calibrated dropper for accurate dosing
o Adm IM to clients unable to take PO(GLmalabsorptionsyndrome)

o Vit A-To avoid risk for hemolytic anemia recognize need for Vit E
supplements for infants receiving Vit A
o Vit A-Monitor Vit A serum levels (80-300 int’l units/ml)

o Vit C Abrupt withdrawal can result in rebound deficiency

o Vit C decr effects of oral anticoagulants
o Vit C-smoking & Oral contraceptives decr levels
o Vit C- megadoses taken w/aspirin or sulfamides may cause
crystal formation in urine (crystalluria)

o Iron-incr amt needed during 1st trimester

o Iron-Megadoses cause teratogenic effect on fetus
o Iron-iron Toxicity serious cause of poisoning in children
o Iron-hemorrhage due to ulcerogenic effects of unbound iron
leads to shock
When is vitamin/mineral replacement indicated
Iron
To correct or control iron-deficiency anemia
Copper
Anemia (not corrected by iron supps)
Abnormal blood & skin chges; decr WBC count; skin & hair
pigmentation; glucose intolerance; Mental retardation in young
Zinc
Clients on Long term PTN

Vitamin A
Early sign of Hypovitaminosis A-night blindness/may progress to
dryness & ulceration of cornea & to blindness

Vitamin K
Hypoprothrombinemia
Spontaneous hemorrhage due to lack of bile salts

Vitamin B1 (thiamine)
Treatment of thiamine deficiencies (beriberi) & polyneuritis
Prevention of Wernicke's encephalopathy.
Dietary supplement in patients with GI disease, alcoholism, or cirrhosis.

Vitamin B6 (Riboflavin)
associated with poor nutritional status or chronic debilitating illnesses.
o Scaly Dermatitis
o Cracked corners of mouth
o Inflam of skin & tongue

Vitamin B3 (Niacin)
Pellegra
Hyperlipidemia

Vitamin B6 (Pyridoxine)
pyridoxine deficiency (may be associated with poor nutritional status or
chronic debilitating illnesses).
 B12
Deficiency uncommon unless there is a disturbance in the intrinsic
factor & intestinal absorption
Pernicious Anemia (lack of intrinsic factor) major cause of deficiency

Vitamin C
Scurvy

Know the purpose of all vitamins/minerals that have a significant impact on

illness/disease processes

Vitamin A

Purpose
o Essential for bone growth & the maintenance of epithelial
tissues, skin, eyes & hair
Used For:
o Treats Vitamin Deficiencies
 Biliary tract or pancreatic disease, colitis, cirrhosis, celiac
dis., sprue
 Skin disorders (acne)
 Night Blindness

Vitamin D

Purpose
o Major role(calcitriol) in regulating calcium & phosphorus
metabolism and needed for calcium absorption from small
intestines (if Ca levels low, more Vit D activated, when Ca
normal, Vit D is decr)
Used For:
Vitamin E

Purpose
o Antioxidant properties that protect cellular components (fatty
acids, RBCs from hemolysis). Promotes functioning of RBCs,
muscles & tissues
Used For:
o 400-800 Int’l units per day reduces # of Myocardial Infarctions
(MI)
o 200 Int’l units a day reduce CAD
o Prolongs PT; monitor

Vitamin K

Purpose
o Needed for synthesis of Prothrombin and clotting factors VII, IX,
X
Used For:
o Antidote for oral anticoagulant overdose
o To prevent & treat hypoprothombinemia of Vit K deficiency
o Newborns Vit K deficiency

Vitamin B1 Thiamine

Purpose
o It functions as a coenzyme during carbohydrate metabolism. It is
essential for the functioning of heart, muscles and nerves
Used For:
o Treatment of Wernicke-Korsakoff Syndrome

Vitamin B2 Riboflavin

Purpose
o It promotes carbohydrate and protein metabolism. Riboflavin is
necessary for healthy skin, nerves and oral mucosa
Used For:
o Treat Migraine headaches/dermatological concerns
Vitamin B3 Niacin

Purpose
o maintains good mental health, digestive tract and healthy skin.

Used For:
o Reduce Cholesterol levels
o Alleviates Pellagra & hyperlipidemia

Vitamin B6 Pyridoxine

Purpose
o Essential building block of nucleic acids, RBC formation &
synthesis of hemoglobin; maintains NS integrity (myelin)
Used For:
o Treat Vit B6 Def
o Neonates w/seizures refractive to traditional therapy

Vitamin C

Purpose
o Aids in absorption of IRON and conversion of FOLIC ACID; plays a
role in the metabolism of connective tissue, collagen fiber
synthesis and production of strong skin. It increases the
resistance of the body to fight infections and also keeps the
teeth, gums and joints healthy
Used For:
o Treat Deficiency of vitamin C that results in scurvy

Folic Acid (folate)

Purpose
o Essential for body growth; DNA synthesis; w/out there is a
disruption in cellular division

Used For:
o Folic acid def in 1st trimester
Iron

Purpose
o Vital for hemoglobin regeneration (RBC development)
o O2 transport via hemoglobin

Used For:
o Prevent & treat Iron deficiency

Copper

Purpose
o Formation of RBCs and Connective tissues & production of
neurotransmitters Norepinephrine & epinephrine

Zinc
Purpose
o Important to enzymatic reactions; essential for normal growth
and tissue repair; wound healing and taste & smell
Used for:
o Poss. alleviate common cold

Chromium

Purpose
o Control of type II diabetes by helping to normalize Bl glucose bt
incr the effects of insulin on the cells

Selenium

Purpose
o Cofactor for an antioxidant enzyme that protect protein and
nucleic acids from oxidative damage
Used For:
 o Works w/ Vit E and thought to have Anticarcinogenic effect

Chapter 15:
Know the various types of IV solutions and the uses of each

Crystalloid ( crystals mixed in solution)

Replacement and maintenance of fluid therapy

Ex. Dextrose, Saline, Lactated Ringers

Colloids (draw fluids in )

Volume Expanders
Ex. Dextran solutions; dextran 40-interfere w/platelet function
Ex. Amino Acids
Ex. Hetastarch- isotonic (310 mOsm/l) decr platelet & Hct
Ex. Plasmanate- Comm’l prepared protein product (inst of alb or plasma)

Blood & Blood Products

Whole Blood
o 1 unit -Elevates Hgb by 0.5 to 1.0
Packed RBCs-
o 1 unit-Elevates Hct by 3
o decr chance of Circ overload/less antigen reaction
Plasma
Albumin

Lipids

A fat emulsion solution which is usually indicated in IV therapy that lasts

longer than 5 days
Adds balance to nutritional needs
Safety issues associated with electrolyte replacement

Monitor vital signs

Monitor Urine Output
Measure wt. daily
Ck for signs & symptoms of Fluid Vol. deficit
Ck for signs & symptoms of Fluid Vol. Overload
Monitor lab results
Monitor types fluid client receiving
Ck IV injection site for infiltration or phlebitis
Severe vomiting
Meaning of thirst /old /young

Various types of crystalloids and how they work/issues associated with their tonicity
With fluid Volume loss, Isotonic solution Indicated (similar osmolality to ECF & ICF)
Dextrose
D5W-isotonic- 250 mOsm
In water becomes hypotonic ( 3 L +)
Normal Saline
0.9 % NaCl- isotonic- 310 mOsm
Lactated Ringers
Isotonic- 275 mOsm
Ringers Solution
Isotonic- 310 mOsm

How do you know if a client is adequately responding to fluid replacement vs having

side effects/adverse effects

Electrolytes would be within their narrow ranges

Magnesium 1.5 - 2.5 mg/dL
Calcium (total) 8 - 11 mg/dL
Chloride 96 - 112 mEq/L
Phosphorus 2.2 - 4.8 mg/dL
 Potasssium 3.5 - 5.5 mEq/L
Sodium 135 - 148 mEq/L

Hct (Hct (Male) 39 - 54%) and BUN (BUN 6 - 23 mg/dL ) are Normal

If both values elevated, indicates Fl Vol deficit (dehydration)

BUN > 60 mg/dl indicates Renal Failure

Urine Output would be normal

Normal output > 35 ml/hr or 1000-1200 ml per day
Report < 25 ml/hr or < 600ml per day

Urine Specific Gravity (SG) would be normal

Normal 1.005 to 1.030

> 1.030 indicates Hypovolemia (dehydration)

Ck types of IV fluids

Report Continuous use of D5W/promotes hypo-osmolality

Signs & symptoms of Fluid Over load

Constant irritated cough; Neck Vein Engorgement; hand Vein Engorgement

Moist Rales in Lungs

Sign & Symptoms of Fluid Deficit

Excess Thirst (mild Thirst ), Marked Thirst: Dry Mucous membranes, poor skin
turgor , decr urine output, tachycardia, Slight decr in Systolic Blood Press
Chapter 16:
Compare and contrast the uses, complications, side effects, and which clients are
candidates for enteral vs. parenteral nutrition therapy

Enteral Nutrition Therapy (preferred method)

1st Choice-less risk of sepsis/maintains GI integrity/less costly

Route for adm nutritional support orally(can swallow) or by feeding tubes

(cannot swallow)
o Nasogatric tube (gastrostomy) SHORT TERM
o Nasoduodenal/nasojejunal/jejunostomy (small Intestinal) LONG TERM

Enteral Solutions- Carbs/protein/fat

o Blenderized (liq that pass thru tube)
o Polymeric (milk based & lactose free) Supplement/Ensure
o Elemental or Monomeric (partial GI tract dysfunction)

Methods for Delivery

o Bolus- 250-400ml rapidly
o Intermittent- every 3-6 hrs over 30 to 60 minutes
o Continuous (critically ill/in intestine) slow rate over 24 hrs
o Cyclic(continuous) 8-16 hrs

Complications/side effects
o Dehydration-if not enough water is given( some hyperosmolar)
o Diarrhea: caused by rapid adm/corrected by decr rate of infusion
o Ck residual: <100 ml

Parenteral Nutrition

Primary method for providing complete nutrients by the parenteral route ( IV)
 The infusion of Hyperosmolar Glucose, Amino Acids, Vitamins, Electrolytes,
Minerals, Trace Elements
o Severe burns, GI disorder, Debilitating Disease (AIDS/CANCER)
Avg % of Dextrose 25 %/High glucose concentration w/ protein & lipid (fat
emulsion incr calories & carrys fat soluble Vit)

COMPLICATIONS
o Result from catheter insertion & TPN infusion
o Pneumothorax/hemothorax/hydrothorax/air
embolism/infection/hyperglycemia/fluid overload
 Valsalva Maneuver prevents air embolism
 Hyperglycemia when infusion rate too rapid
o TPN excellent medium for organism growth

Chapter 17-25:

• In these chapters’ guys, you are responsible for primarily the classes and prototypes. For each, you
should be familiar with mechanism of action, selectivity, safety concerns, client teaching, side effects,
adverse reactions, issues with dosing (times, preparation, anything the book highlights) , antidotes,
and relevant nursing assessments. I assure you that anything you are tested on is important and a big
deal. This test OVERALL is very general....but there are a few specific things pulled out that we definitely
went over in class...and EVERYTHING ON THE TEST COMES STRAIGHT FROM YOUR BOOK!!

Chapter 17

CLASS: Adrenergics-agonists (Sympatheomimetics/adrenomemetics)

Drugs that stimulate the SYMPATHTIC NERVOUS SYSTEM

Mimic SNS

Act on Adrenergic Receptors (cells of muscles: heart, Bronchioles, GI, Urinary bladder,
cilary eye muscles

Alpha 1 Receptor: When stimulated

 Arterioles & venules CONSTRICT incr peripheral resistance & bl return
to heart (BP incr)

Alpha 2 Receptor: When stimulated

Inhibits the release of Epinephrine leading to decr in vasoconstriction
(BP decr)
Beta 1 Receptor: When stimulated
Increases Myocardial Contractibility and Heart Rate (smooth muscle)

Beta2 Receptor: When stimulated

Causes relaxation in smooth muscles in lungs
Incr Blood flow to skeletal muscles
Relaxation of Uterine muscles

Dopaminergic Receptor; When stimulated

Vessels dilate & blood flow increases

Adrenergic Blockers (antagonist) SYMPATHOLYTICS

Drugs that block the effects of adrenergic neurotransmitters, alpha/beta, by

directly occupying the alpha/beta receptors or indirectly inhibiting the release
of the neurotransmitters Norepinephrine & epinephrine
Effects of Adrenergic Blocker at Receptors
Alpha1
o causes VASODILATION; decr BP; reduce smooth muscle
contraction
Beta1
o Decr HR; reduces force of contractions
Beta2
o Constricts Bronchioles, Contracts Uterus; inhibit Glycogenolyisis
(decr bl sugar)

Alpha-Adrenergic Blockers
PROMOTE VASODILATION & DECR BP
 Block or inhibit a response at the alpha adrenergic receptor site
Selective alpha blockers-Alpha1 only
Nonselective- Alpha1 & Alpha2

Beta-Adrenergic Blockers
DECR HR; DECR BP FOLLOWS;

Nonselective blocking Beta 1 & 2

o caution COPD(bronchiole constriction & HR)
Selective Beta1
o Good for decr Hr & BP
o Atenolol

Adrenergic Neuron Blockers (sub of Adrenergic Blockers)

Blocks the release of Norepinephrine to DECR BP

Chapter 18

Cholinergics (parasympathomimetics) AGONIST

Mimic PNS neurotransmitter Acetylcholine (Ach)

Cholinergic Receptors
o Muscarinic receptor
Stimulate smooth muscle & slow heart rate
o Nicotinic receptors
Affect skeletal muscles

Direct Acting Cholinergic Drugs

o Act on the receptors to activate a tissue response
o Primarily selective to Muscarinic receptors but are nonspecific because
receptors are located on smooth muscle-GI,GU, glands, heart
o Bethanechol Cholride (Urecholine) Increases urination
 Indirect Acting Cholinergic Drugs (anticholinesterase/Cholinesterase
inhibitors)
o Inhibit the action of the enzyme Cholinesterase (ChE)
(Acetylcholinesterase) by forming a chemical complex, thus permitting
acetylcholine to persist and bind to the receptor
o Primary use to treat Myasthenia Gravis, Glaucoma
o Reversible Cholinesterase Inhibitors
 Pupil constriction (Glaucoma)
 Incr muscle strength (Myasthenia Gravis)
o Irreversible Cholinesterase Inhibitors
o Permanent

AntiCholinergics (Parasympatholytics) Antagonist

o Drugs that inhibit the actions of acetylcholine by occupying the acetylcholine
receptors
o By blocking PNS, the SNS (adrenergic) dominates
o Major response is decr GI motility, decr salivation, decr pupils (mydraisis), incr
pulse rate
o Can act as an antidote to Cholinesterase inhibitors/organophosphate ingestion
o Atropine- Preoperative med to decr salivation, HR, dilate pupils

Anti Parkinson/Anticholinergic Drugs

o Trihexyphenidyl HCL
 Decr involuntart symptoms of Parkinson or drug induced Parkinson
(pseudo)
 Blocks cholinergic (muscarinic) receptors