Pharmacology for Nurses > Exam 3 Material > Flashcards

Exam 3 Material Flashcards

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1
Q

What is cancer?

A
  • Abnormal, uncontrolled cell division
  • Cells lose normal function and differentiation
  • Can travel to distant sites and create new tumors (metastasis)
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2
Q

Causes of Preventable Cancers

A
  • Smoking
  • Obesity
  • Alcohol
  • UV radiation
  • Physical activity
  • Poor diet
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3
Q

Goals of Chemotherapy

A
  • Cure
    • May not be possible
  • Control
    • Control the growth to help increase length or quality of life
  • Palliation
    • Relieve symptoms
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4
Q

Treatments used in Conjunction with Chemotherapy

A
  • Radiation
  • Surgery
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5
Q

ABVD Chemotherapy Combination

A
  • Adriamycin
  • Bleomycin
  • Vinblastine
  • Dacarbazine
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6
Q

BEACOPP Chemotherapy Combination

A
  • Bleomycin
  • Etoposide
  • Doxorubicin
  • Cyclophosphamide
  • Vincristine
  • Procarbazine
  • Prednisone
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7
Q

Standford V Chemotherapy Combination

A
  • Doxorubicin
  • Vinblastine
  • Mechlorethamine
  • Etoposide
  • Vincristine
  • Bleomycin
  • Prednisone
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8
Q

COPP/ABVD Chemotherapy combination

A
  • Cyclophosphamide
  • Vincristine
  • Procarbazine
  • Prednisone
  • Doxorubicin
  • Bleomycin
  • Vinblastine
  • Dacarbazine
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9
Q

MOPP Chemotherapy Combination

A
  • Mechlorethamine
  • Vincristine
  • Procarbazine
  • Prednisone
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10
Q

Why are combination drugs used in chemo?

A

Drugs are from multiple drug classes (different MOAs, affect cells in various stages of the growth cycle)

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11
Q

What type of cells is chemo most toxic too?

A

Tumors and tissues with rapidly dividing cells (hair follicles, bone marrow, GI epithelium)

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12
Q

Common Toxicities of Chemo

A
  • Alopecia
  • Mucositis: sloughing of mucous membranes
  • N/V: chemoreceptors in the brain
  • Bone marrow suppression (myelosuppression)
    • Anemia (decrease in hemoglobin and/or red blood cells)
    • Leukopenia/neutropenia (decreased white blood cells - increses susceptibility to infection)
    • Thrombocytopenia (low platelets)
  • Long term effects may include infertility, secondary malignancies
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13
Q

Cautions when administering Chemo

A
  • Be cautious when administering - gown/glove up to prevent YOU from getting cancer
  • Be aware that many chemotherapies are vesicants (serious tissue injury if they infiltrate/extravasate)
    • Specially trained to administer
    • Specific antidotes for infiltration/extravasation
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14
Q

Classes of Chemotherapy/Antineoplastics

A
  • Aklylting agents
  • Antimetabolites
  • Antitumor antibodies
  • Natrual products
  • Hormones/hormone antagonists
  • Biologi response modifiers/targeted therapies
  • Miscellaneous
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15
Q

Aklylating Agents for Cancer

A
  • Dates back to nitrogen mustarg used as chemical warfare agent in WWI
  • Most widely prescribed class
  • Examples: cyclophosphamide (Cytoxan), cisplatin (Platinol), busulfan
  • Cyclophosphamide is also used to include immunosuppression for autoimmune diseases such as rheumatoid arthritis and lupus
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16
Q

Antimetabolites for Cancer

A
  • Resemble nutrients used by the cell (folid acid, purine, pyrimidine analogs)
  • Examples: methotrexate, cytarabine, fluorouracil
  • Methotrexate rescue - leucovorin (form of folid acid) is given to rescue normal cells from the toxicity of the treatment
  • Methotrexate is also used in the treatment of rheumatoir arthritis, ulcerative colitis, lupus, and psoriasis
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17
Q

Antitumor Antibiotics for Cancer

A
  • Isolated from bacteria and have antitumor properties
  • Examples: doxurubicin (Adriamycin), idarubicin (Idamycin)
  • Cardiotoxicity is a dose limiting effect of many drugs in this class
    • May have a lifetime dose that can’t be exceeded due to its effects on the heart
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18
Q

Natural products for Cancer

A
  • Includes plant extracts
  • American Indians used May Apple to treat snakebites and warts
  • Examples: vincristine, etopside, paclitaxel
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19
Q

Hormones/Hormone Antagonists for Cancer

A
  • Used for hormone dependent tumors
  • Not cytotoxic, do not see toxicities associated with other chemo drugs
  • Examples: corticosteroids, progestins, estrogens, and androgens
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20
Q

Biologic Response Modifiers for Cancer

A
  • Enhance immune system to destroy cancer cells (immunostimulants)
  • Target specific antigens on surface of cancer cells
  • Includes interferons, interleukins, and other cytokines
  • Fewer adverse effects than cytotoxic chemo drugs
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21
Q

Targeted Therapies for Cancer

A
  • Specific to one type of tumor cells
  • Monoclonal antibodies (rituximab)
    • Also used to treat autoimmune diseases
    • Often require premedication for hypersensitivity reactions
  • Other targeted therapies: imatinib, bortezomib
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22
Q

Chemo Precautions

A
  • Use appropriate PPR
  • Signage outside of room
  • Dispose of IV bags, tubing, packaging, etc. in appropriate container
  • Be aware of how to handle spills
  • Patient body fluids are considered contaminated for at least 48 hours after last dose
    • Sexual realtions - wait 48 hours
  • Know your hospital’s policy for handling of body fluids
  • Some “non-chemo” medications may require “chemo-precautions”
  • Chemo certification is often required for administration
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23
Q

Endocrine System Function

A
  • The endocrine system is a collection of glands that secrete hormones to regulate the functions of cells, tissues, and rogans
  • Hormones are chemical messangers released in response to a change in the body’s internal environment to maintain body homeostass
  • Negative feedback system: one hormone controls secretion of another hormone, and the last hormone in the pathway provides feedback to turn off secretion of the first hormone
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24
Q

Hormones in Pharmacotherapy

A
  • Replacement therapy when insufficient quantities of endogenous hormones are produced
    • Examples: insulin in diabetes or levothyroxine (Synthroid) in hypothyroidism
  • Cancer treatment: to shrink the size of hormone-sensitive tumors
    • Examples: testosterone for breast cancer, estrogen for testicular cancer
  • Exaggerated response: of a normal action of a hormone
    • Example: hydrocortisone to suppress inflammation
  • Anti-hormones: block actions of endogenous hormones
    • Examples: propylthiouracil (PTU) in hyperthyroidism
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25
Antidiuretic Hormone (ADH)
* Component in fluid homeostasis * Desmopressin (DDAVP) and vasopressin are medications that mimic ADH
26
What happens to urine output when you have too much ADH (SIADH)?
A little urine that is very concentrated
27
What happens to urine output when you have too little ADH (Diabetes Insipidus)?
A lot of urine; can become very dehydrated; will give lots of fluids
28
Therapeutic class of Desmopressin (DDAVP)
Hormone
29
Pharmacologic class of Desmopressin (DDAVP)
Antidiuretic hormone
30
Indications of Desmopressin (DDAVP)
* Diabetes insipidus * von Willebrand's disease (blood clotting disorder) * Bet wetting
31
MOA of Desmopressin (DDAVP)
Acts on the kidneys to reabsorb water; controls bleeding in certain clotting disorders; contraction of smooth muscle in vascular system
32
Adverse effects of Desmopressin (DDAVP)
* Drowsiness * Headache * Symptoms of water intoxication (edema, weight gain, HTN, hyponatremia/low serum sodium [diluting]) * With low sodium - worry about seizures/comatose
33
Nursing implications of Desmopressin (DDAVP)
* Closely monitor intake and output, fluid volume status, urine specific gravity * Use with caution in clients with renal disease, hyponatremia, HTN * Available PO, intranasal spray, SC, IV
34
Thyroid Hormones
* The thyroid gland affects basal metabolic rate; growth and development in children * Thyroid hormones affect almost every cell in the body * The thyroid hormones consist of triiodothyronine (T3) and tetraiodothyronine (T4) * Iodine is required for synthesis of thyroid hormones * Disorder results from either hyper- or hypo-function of thyroid gland; arising from thyroid disease, or abnormalities of piututary gland or hypothalamus * TSH is a common lab value we look at * T3 is the more effective/active hormone * T4 is typically given and it needs to be converted into T3 * T3 has a shorter half life than T4
35
Symptoms of hypothyroidism
* Intolerance to cold * Receding hairline * Facial and eyelid edema * Dull-blank expression * Extreme fatigue * Thick tongue - slow speech * Anorexia * Brittle nails and hair * Menstural disturbances * Hair loss * Apathy * Lethargy * Dry skin (coarse and scaly) * Muscle aches and weakness * Constipation * Late clinical manifestations * Subnormal temp * Bradycardia * Weight gain * Decreased loss of consciousness * Thickened skin * Cardiac complications
36
Symptoms of Hyperthyroidism
* Intolerance to heat * Fine, straight hair * Bulging eyes * Facial flushing * Enlarged thyroid * Tachycardia * Increased systolid BP * Breast enlargement * Weight loss * Muscle wasting * Localized edema * Menstrual changes (amenorrhea) * Increased diarrhea * Tremors * Finger clubbing
37
Therapeutic Class of Levothyroxine (Synthroid)
Thyroid hormone replacement
38
Pharmacologic class of Levothyroxine (Synthroid)
Thyroid hormone
39
Indications of Levothyroxine (Synthroid)
Hypothyroidism
40
MOA of Levothyroxine (Synthroid)
Synthetic T4; increases metabolic rate of body tissues
41
Adverse effects of Levothyroxine (Synthroid)
Symptoms of hyperthyroidism * Tachycardia * Anxiety * Insomnia * Weight loss * Heat intolerance * Diaphoresis * Menstrual irregularities
42
Nursing Implications of Levothyroxine (Synthroid)
* Administer 30-60 min before breakfast (empty stomach; prevent insomnia) * Narrow therapeutic range, blood levels monitored * Long half-life, given once a day * Steady state is achieved in 6-8 weeks * Many drug interactions * Use with caution in elderly with heart disease (start low and slow) * Educate clients that this is a life-long therapy (does not cure hyperthryoidism) * Monitor TSH levels * There is an IV formulation
43
What changes in lab values would you expect to see with hypothyroidism?
Low T4 High TSH
44
Hyperthyroidism therapy
* Methimazole (Tapazole) is used for hyperthyroidism; often prior to thyroidectomy or radioactive iodine therapy (I-I#I) * Interferes with synthesis of T3 and T4 * Adverse effects: * Symptoms of hypothyroidism * Hetpatotoxicity * Bone marrow suppression (decreased white blood cells, red blood cells, platelets) * Seond line drug therapy for hyperthyroidism is propylthiouracil (PTU)
45
Adrenal hormones
Adrenal gland secretes three class of steroid hormones * Glucocorticoids (ex. cortisol) - sugar * Mineralocorticoids (ex. aldosterone) - salt * Androgens/gonadocorticoids (ex. testosterone) - sex
46
Glucocorticoids
* Examples: hydrocortisone (Solu-Cortef), methylprednisone (Solu-Medrol), cortisone, prednisone, dexamethasone (Decadron) * Can be used to manage adrenal insufficiency (due to Addison's disease, sudden withdrawal of corticosteroids, or insufficient amounts in the critically ill * Too much can cause Cushing's disease or Syndrome Symptoms * Too little can cause Addison's disease
47
Diabetes
* Deficiency in insulin secretion, or a decreased sensitivity of insulin receptors, leading to elevated blood glucose levels (hyperglycemia) * Normal blood glucose is 70-110 * Insulin allows glucose to enter cells in order to be used for energy (major energy source) * If insulin is not avilable to facilitate the entry of glucose into the cells, the body then metabolizes lipids as a source of energy, leading to a state of acidosis
48
Signs and Symptoms of Hyperglycemia (BG ~ 180)
* Three Ps * Polydipsia - thirst * Polyphagia - hunger * Polyuria - frequent urination * Headache * Difficulty concentrating * Blurred vision * Decreased vision * Weight loss * Vaginal or skin infections * Delayed wound healing * Erectile dysfunction * Painful or insensitive feet * Cold feet * Chronic constipation or diarrhea * Fatigue
49
Signs and Symptoms of Hypoglycemia (BG \< 70)
* Usually sudden onset * Pale, cool, moist skin * Hunger * Dizziness * Decreased LOC * Confusion, slurred speech * Loss of consciousness * Coma * Double or blurred vision * Seizures * Palpitations * Tachycardia * Anxiety
50
Diabetes Type I
* Goal: prevent long term consequences * Disease of childhood (juvenile-onset); insulin dependent diabetes mellitus * 1/4 are adults * Autoimmune destruction of pancreatic cells * Pancreas can't secrete insulin (insulin must be administered) * Etiology - genetic, immunologic, and environmental factors * Fasting blood sugar \> 126 on 2 separate occassions * Symptoms: * Polyuria * Polyphagia * Polydipsia * Glucosuria * Weight loss * Fatigue * Diabetic ketoacidosis * Long term: * Heart disease * Stroke * Kidney failure * Blindness * Neuropathy of extremities * Impaired wound healing * Amputations
51
Diabetes Type II
* Previously called adult-onset * Increasing larger number of children are getting it * Pancreas secretes insulin, but usually in small amounts; insulin receptors in target tissues are unresponsive (insulin resistance) * Can regain sensitivity through diet and exercise * Treated with antidiabetic first, insulin if necessary * Overweight, low HDL cholesterol, high triglycerides, hyperosmolar hyperglycemic state (HHS) * May be asymptomatic * Long term: as cells become more resistant, blood glucose levels rise and pancrease hypersectreiton of insulin leads to beta cell death * Same physical effects as with Type I * More common than Type I
52
Gestational Diabetes
* Around the 24th week of pregnancy, women who have never had diabetes develop hyperglycemia * Incidence as high as 9.2% * Unknown cuase, but believed to be due to increased hormones from the placenta that block the mother's insulin leading to insulin resistance; mother may need as much as 3 times normal insulin * High blood glucose in mother effects unborn chlid by crossing the placenta and stimulating the baby's pancreas to secrete large amounts of insulin leading to macrosoma (fat baby) * Long term: mother usually ok after birth; baby can have hypoglycemia and respiratory complications at birth * Increases child's risk of obesity and adult type II diabetes mellitus
53
Insulin
* Produced from human recombinant DNA rechnology; effective, few allergic reactions, little resistance * Insulins are mofied for rapid, short, intermediate, or long onset of action * Must individualize doses of insulin for maximum control * Those with latex allergies - one punctire before vial needs to get tossed * Don't hold basal level of insulin even in NPO unless levels are really low * Insulin is destroyed by the acids in the GI tract, so it must be injected SQ or given IV * HA1C - blood test that gives a percentage that shows how well glucose has been managed over the last 3 months * Insulin pump is programmed to release insulin at predetermined intervals throughout the day, may also be used to deliver bolus dose
54
Insulin Aspart (Novolog)
* Action: rapid * Onset: 15 min * Peak: 1-3 hours * Duration: 3-5 hours * Administration: SQ 5-10 min before meals * Compatibility: Can give with NPH - draw up first and give immediately
55
Insulin Lispor (Humalog)
* Action: rapid * Onset: 5-15 min * Peak: 0.5-1 hour * Duration: 3-4 hours * Administration: SQ 5-10 min before meals * Compatilibility: Can give with NPH, draw up lispro first and give immediately
56
Insulin Glulisine (Apidra)
Action: rapid Onset: 15-30 min Peak: 1 hour Duration: 3-4 hours Administration: SQ 15 min before min or within 20 min of starting Compatilibility: Can give with NPH, draw up glulisine first and give immediately
57
Insulin regular (Humulin R, Novolin R)
Action: short Onset: 30-60 min Peak: 2-4 hours Duration: 5-7 hours Administration: SQ 30-60 min beofre meals; IV in emergency Compatilibility: Can give with NPH
58
Isophane suspension (NPH, Humulin N, Novolin N)
Action: intermediate Onset: 1-2 hours Peak: 4-12 hours Duration: 18-24 hours Administration: SQ 30 min before meals Compatilibility: Can mix with aspart, lispro, or regular; mix clear (regular) to cloudy (NPH)
59
Insulin detemir (Levemir)
Action: long Onset: gradual over 24 hours Peak: 6-8 hours Duration: up to 24 hours Administration: SQ 1 time a day; evening meal or before bedtime Compatilibility: do not mix with any other insulin
60
Insulin glargine (Lantus)
Action: long Onset: gradual over 24 hours Peak: no peak Duration: up to 24 hours Administration: SQ 1 time a day, same time each day Compatilibility: do not mix with any other insulin
61
Rapid insulin
* -og * 15 min onset * 1 hour peak * Can mix with NPH
62
Short insulin
* -in * 30 min onset * 3 hour peak * Can mix with NPH
63
Intermediate insulin
* NPH * Onset 30-60 min * Peak 1-2 hours * Can mix with short and rapid insulin
64
Therapeutic class of regular insulin (Humulin R, Novolin R)
Hormone, drug for diabetes
65
Pharmacologic class of regular insulin (Humulin R, Novolin R)
Hypoglycemic
66
Indications of regular insulin (Humulin R, Novolin R)
Treatment of hyperglycemia, treatment of acute ketoacidosis, treatment of hyperkalemia (off-label use)
67
MOA of regular insulin (Humulin R, Novolin R)
Short acting insulin; promotes entry of glucose into cells for use as energy
68
Adverse effects of regular insulin (Humulin R, Novolin R)
* Hypoglycemia * Tachycardia * Confusion * Sweating * Restlessness * Coma and death if severe hypoglycemia is untreated * Hypokalemia
69
Nursing implications of regular insulin (Humulin R, Novolin R)
* Can be given IV or SQ * Only use insulin syringe * Administered 30 min before meal
70
Lipohypertrophy
* Lumps (lipohypertrophy) below the surface of the skin from repeated insulin injections into the same area * May be mildly painful and can change the timing or completeness of insulin action
71
Nursing Considerations for Insulin
* Only use approvd calibrated syringes * Opened insulin vials can be stored at room temperature, out of sunlight and excessive heat for up to 1 month * Mark date opened and expiration day 28 days after on the bottle * Don't use if precipitate forms in vial * Draw up "clear to cloudy" when mixing insulins * Check blood sugar levels before administering * Give before meals if rapid, short, or intermediate acting * Rotate injection site - do not inject in raised, swollen, itchy areas * Increase frequency of glucose monitoring with fever, N/V, diarrhea * Hba1c is a lab value that indicates average glucose levels over the past 3 months * Pregnancy category B
72
Tye II Diabetes Risk Factors
* Obesity * Fat distribution in abdomen * Dyslipidemia * Sedentary lifestyle * Family history * Race * Age * Pre-diabetes * Gestational diabetes * Polycystic ovarian syndrome
73
Oral Antidiabetic Medications
* Lower blood glucose, some may cause hypoglycermia * Not effective for Type I diabetes * Multiple class, start with one and add on as necessary * Failure to achieve results with 2 drugs may require a 3rd oral med or insulin
74
Therapeutic class of metformin (Glucophage)
Antidiabetic
75
Pharmacologic class of metformin (Glucophage)
Biguanide
76
Indications of metformin (Glucophage)
Type II diabetes (first line drug)
77
MOA of metformin (Glucophage)
Decrease hepativ production of glucose and reduces insulin resistance Benefits is that it does not cuase hypoglycemia; also lowers triglyceride and LDL and promotes weight loss)
78
Adverse effects of metformin (Glucophage)
* N/V * Diarrhea * Abdominal bloating * Metallic taste
79
Black Box Warning of metformin (Glucophage)
Increased risk of lactic acidosis (may be fatal) with liver/renal disease, excess alcohol intake, or serious infection
80
Nursing implications of metformin (Glucophage)
* Contraindicated with impaired renal function, heart failure, liver failure, serious infection * Must be held 2 days before and after receiving IV contrast * In emergency, will do the contrast and then hold metformin and will monitor
81
Sulfonylureas
* 1st and 2nd generations equally effective in lowering glucose levels * 2nd generation as fewer drug-drug interactions * Stimulate release of insulin and increase sensitivity of insulin receptors on target cells * Adverse effects: * Hypoglycemia * Weight gain * GI distress * Hypersensitivity reactions (caution if hypersensitivity to sulfonamide drugs) * Hepatotoxicity * Taken with alcohol: flushing, palpations, nausea
82
Neurodegenerative Diseases
* Neurodegenerative diseases cause degeneration and/or death of neurons; results in problems with movement and/or cognitive functioing * Chronic * Progesive * Debilitating * Examples: Parkinsons, Alzheimer's Multiple Sclerosis, Amyotrophic Lateral Sclerosis, Huntington's * Goals of pharmacotherapy: slow progression of disease, provide symptom relief
83
Parkinson's Disease
* Low levels of dopamine due to loss of dopamine producing neurons * Acetylcholine works in conjunction with dopamine to produce smooth muscle movement * Results in decreased smooth muscle movement * Symptoms often include tremors, muscle rigidity, bradykinesia (slow movement), impaired balance/coordination, shuffling gait, pill-rolling
84
Pharmacotherapy for Parkinson's
* Dopaminergic medications * Dopamine replacement therapy * Helps with motor symptoms * Levodopa (L-dopa) is first line therapy Given in gombination with carbidopa (peripheral decarboxylase inhibitor) * Prevents it from converting to dopaine systemically - helps reduce adverse effects of having increased dopamine in the peripherals) * Levodopa is a precursor to dopamine * Levodopa crosses the blood-brain barrier (dopamine does not) * Other drug classes that increases dopamine levels: * MOA-B: inhibits the breakdown of dopamine * COMT inhibitors: inhibits the breakdown of dopamine
85
Therapeutic class of carbidopa/levodopa (Sinemet)
Antiparkinson agent
86
Pharmacologic class of carbidopa/levodopa (Sinemet)
Dopamine agonist
87
Indications of carbidopa/levodopa (Sinemet)
Parkinson's disease
88
MOA of carbidopa/levodopa (Sinemet)
Levodopa is converted to dopamine in the CNS where it serves as a neurotransmitter Carbidopa prevents peripheral destruction of levodopa Relieves tremor and rigidity
89
Adverse effects of carbidopa/levodopa (Sinemet)
* Uncontrolled and purposeless movements * N/v * Orthostatic hypotension * Dark urine/sweat * Hepatotoxicity * Cardiac arrhythmias * Psychosis
90
Nursing implications for carbidopa/levodopa (Sinemet)
* Monitor liver function * Instruct clients to rise slowly when standing * Taking with high protein foods may decrease absorption of the medication * Vitamin B6 promotes breakdown of levodopa * Avoid abrupt withdrawal of medication
91
Anticholinergics
* Block acetylcholine, inhibiting over-activity * Help in controlling tremors * Adverse effects include dry mouth, blurred vision, urinary retention, constipation, tachycardia * Example: benztropine (Cogentin) * This medication is also used to relieve extrapyramidal symptoms associated with antipsychotic medications
92
Alzheimer's Disease
* Form of dementia (progressive memory loss, confusion, and inability to think or communicate effectively) due to loss of functioning neurons * Characterized by: * Neurofibrillary tangles * Beta-amyloid plaques
93
Pharmacotherapy for Alzheimer Disease
* Therapy started as soon as client is diagnosed * May discontinue in later stages of disease due to number of damaged neurons (risk outweights benefits) * Medications may provide symptom relief and slow disease progression * Cholinesterase inhibitors * Acetylcholine deficiency is thought to be partly responsible for cognitive decline and behavioral changes * Examples: donepezil (Aricept), rivastigmine (Exelon), galantamine (Razadyne) * Glutamatergic inhibitors * Thought to slow intracellular calcium accumulation and thereby help prevent further nerve damage * Example: memantine (Namenda) * Adjunct therapies for secondary symptoms, such as depression, agitation, aggression, hallucinations, delusions, and sleep disorders
94
Therapeutic class of donepezil (Aricept)
Anti-alzheimer's agent
95
Pharmacologic class of donepezil (Aricept)
Acetylcholinesterase inhibitor
96
Indications of donepezil (Aricept)
Alzheimer's disease
97
MOA of donepezil (Aricept)
Inhibits acetylcholinesterase, making more acetylcholine available; enhances effects of acetylcholine in neurons that have not yet been damaged, improving memory and cognition in mild to moderate dementia
98
Adverse effects of donepezil (Aricept)
* N/V * Diarrhea * Poor appetite * GI bleeding * Abnormal dreams * Muscle cramps
99
Nursing implications of donepezil (Aricept)
Can take weeks to notice any effect, maximum benefit may take up to 6 months Administer at bedtime
100
Causes of Muscle Spasms
* Overuse of muscle * Injury * Dehydration * Electrolyte abnormalities * Adverse effect of antipsychotics * Neurological disorders (stroke, cerebral palsy)
101
Treatment of Muscle Spasms
* Nonpharmacologic * Heat/cold, exercise, massage, complementary therapy * Pharmacologic * Analgesics * Anti-inflammatory * Skeletal muscle relaxants
102
Therapeutic class of baclofen (Lioresal)
Skeletal muscle relaxant
103
Pharmacologic class of baclofen (Lioresal)
GABAB receptor agonist
104
Indications of baclofen (Lioresal)
Muscle spasticity
105
MOA of baclofen (Lioresal)
GABAB receptor agaonist; general CNS depression; exact MOA is unkown (thought to inhibit transmission or mono/polysynaptic reflexes)
106
Adverse effects of baclofen (Lioresal)
* Hypotension * N/V * Constipation * Poor muscle tone * Dizziness * Sedation
107
Nursing implications of baclofen (Lioresal)
* Avoid activities requiring mental alertness until effects are known * Avoid alchol and other CNS depressants * Avoid stopping abruptly * May be administered via intrathecal pump
108
Osteoporosis
* Asymptomatic until fracture occurs * Secondary to: * Lack of vitamin D and calcium * Bone resorption \> bone deposition * Most common risk factor is menopause * Decreased estrogen levels leads to increased bone demineralization (resorption) * Corticosteroids * Birth control (certain types)
109
Incidence rate of osteoporosis
1 in 2 women 1 in 5 men
110
Pharmacotherapy for Osteoporosis
* Early intervention may prevent osteoporosis * Treatment of already established osteoporosis may halt progression * Calcium, vitamin D * Calcitonin * Given SQ or nasall * Can be used for people with too much calcium in the bloodstream * Bisphosphates * SERMS (selective estrogen receptor modulators)
111
Bisphosphonates
* Most common class of drug used for osteoporosis prevention and treatment * Inhibits bone resorption by suppressing osteoclast activity (increasing bone density) * Adverse effects: * Bone pain * Abdominal pain * Esophageal irritation * Nursing impplications: take on an empty stomach with a full glass of water, remain upright for 30 minutes, long duration of action (may be given daily, once a week, or once a month) * Examples: alendronate (Fosamax), ibandronate (Bonvia)
112
Selective estrogen receptor mondulates (SERMS)
* Prevention and treatment of osteoporosis in postmenopausal women * Decreases bone resorption through estrogen receptors, increasing bone density * Also used for breast cancer prevention * Lowers cholesterol * Black box warning: increased risk of DVT, pulmonary embolism, increased risk of stroke in those with heart disease * Example: raloxifene (Evista)
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Arthritis
Inflammation and stiffness of joint (painful)
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Osteoarthritis
Erosion of cartilage at joint surface(s) Most often affects weight bearing joints due to wear and tear (knees, spine, hips)
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Rheumatroid arthritis
* Auto-immune disease * Leads to inflammation and disfigurement of multiple joints * Systemic effects
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Pharmacotherapy for Osteoarthritis
* Goal of therapy is to decrease pain and inflammation * Topicals (capsaicin, NSAIDS) * Acetaminophen - first line * NSAIDS (oral) - anti-inflammatory * Tramadol * Corticosteroid injections for flare ups * DMARDs (biologic and nonbiologic)
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Disease Modifying Anti-Rheumatic Drugs (DMARDs)
* Most important class of medication for successful treatment * Clients may be "bridged" with analgesic, anti-inflammatory, or corticosteroid medications until DMARDs take effects * Can take several months before maximum benefit is achieved
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Traditional DMARDs
* Methotrexate * Lefunomide (Arava) * Sulfasalazine (SSZ, Azulfidine) * Hydroxychloroquine (HCQ, Plaquenil) * Azathiopine, cyclosporine
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Biologic DMARDS
* TNF antagonists * Etanercept (Enbrel) * Adalimumab (Humira) * Infliximab (Remicade) * Certolizumab pegol (Cimzia) * Golimumab (Simponi) * Abatacept (Orencia) * Rituximab (Rituxan) * Tocilizumab (Actemra) * Tofacitinib (Xeljanz)
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Anxiety Disorders
* Anxiety is a state of "apprehension, tension, or uneasiness that stems from the anticipation of danger, the source of which is largely unknown or unrecognized" * Most common psychiatric diagnosis * Common cormorbidities include depression, alcohol abuse, and drug abuse * Imbalances in norepinephrine, serotonin, dopamine, and GABA are thought to contribute to symptoms of anxiety
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Situational Anxiety
Stressful environment or situation; can be motivational (take action)
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Generalized anxiety disorder
Excessive anxiety lasting longer than 6 months; interferes with daily activities
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Panic disorder
Immediate feelings of apprehension, fearless, terror, impending doom
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Phobias
Fear associated with specific objects or situations
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Treatment of Anxiety Disorders
* Combination of: * Psychotherapy (cognitive behavior therapy, biofeedback, counseling, meditation) * Pharmacotherapy (anxiolytics) - when anxiety interferes with activities of daily life * Antidepressants (Selective Serotonin Reuptake Inhibitprs -SSRI) * CNS depressants (sedatives/hypnotics) * Benzodiazepines * Barbiturates * Miscellaneous medications
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Use of Antidepressants
* Overlapping features between depressive disorders and anxiety disorders * May have initial worsening of anxiety, agitation, and irritability when treatment is started * Can take 4-6 weeks for full effects * Adverse effects noticed with initiation of therapy or dose changes typically resolve within days to weeks
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CNS Depressants
* Used as an adjunct to antidepressants * Helpful for acute attacks, short term use * Can lead to physical and psycholigical dependence (withdrawal symptoms when stopped abruptly) * Benzodiazepines * Barbiturates * Miscellaneous medications
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Benzodiazepines
* Indications: anxiety, insomnia, seizures, muscle relaxation, sedation, induction of anesthesia, alcohol withdrawal * Intended for short term use * Useful in actue anxiety situations aor as a bridge until SSRI takes effect * Drugs in this class are similar in effect, but differ in their onset and duration of action * Intensify effects of GABA (inhibitory neurotransmitter) * Avoid use with other CNS depressants * Schedule IV * Reversal agent - flumazanil (Romazicon) * Examples: lorazepam (Ativan), diazepam (Valium), clonazepam (Klonopin), alprazolam (Xanax), midazolam (Versed)
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Barbiturates
* Indications: anxiety, insomnia, seizures * Replaced mostly by benzodiaepines due to safety profile * Serious adverse effects - respiratory depression, hypotension, shock * Intensify action of GABA * Schedule II * Withdrawal symptoms can be severe, even fatal * Examples: phenobarbital (Luminol), pentobarbital (Nembutal)
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Miscellaneous Drugs for Anxiety
* Valproic acid (Depakene): indications include panic disorder, bipolar disorder, seizures, migraine prevention * Atenolol (Tenormin): indications include performance anxiety, social anxiety, HTN, myocardial infarction, angina * Buspirone (BuSpar): indications include generalized anxiety disorder, OCD, depression
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Seizures
* Seizure is a disturbance of electrical activity in the brain that may alter consciousness, motor activity, or sensation * Caused by abnormal neuronal discharges * May remain focal or move to other areas of the brain * Symptom of an underlying disorder
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Status epilepticus
Seizure lasts too long or seizure recurs without recovery in btween (life threatening)
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Causes of Seizures
* Medications * Drug abuse/withdrawal (ETOH, sedatives) * Infection * Trauma * Hypoxia/altered perfusion * Tumor * Severe HTN in pregnancy (eclampsia) * Strobe/flickering lights * Electrolyte imbalances * High fever in children
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Electrocephalogram (EEG)
Electric monitoring that measures and records electrical activity in the brain
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Pharmacotherapy for Seizures
* Depends on type of seizure and associated pathology * Started on one medication; dose is increased until seizure is controlled or adverse effects limit the dose * If a second drug is needed, the first drug is tapered off while the second drug is increased * Abrupt withdrawal of a medciation may precipitate seizures * Serum drug levels are often monitored * Other conditions may be treated with anti-seizure meducations: various psychiatric diagnoses, migraines, neuropathic pain, ADHD, PTSD (calms the nerves)
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Pregnancy and Epilepsy
* Severl antiseixure drugs decrase effectiveness or oral contraceptives * Most anti-seizure drugs are associated with high fetal risk in pregnancy (Category D) * May require high doses of folic acid due to deficiency caused by medication * Encourage registration with antiepileptic drug pregnancy registry
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Valproate Syndrome
* Prenatal exposure to valproid acid (depakene, depakote) durinf the first trimester * Distinctive facial features * Neural tube defects * Congenital heart disease * Cleft lip and/or palate * Genitourinary malformations * Tracheomalacia * Arm/hand defects * ARachnodactyly/overlapping digits * Abdominal wall defects * Intellectual impairment
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Pharmacotherapy for Seizures
* Goal is to suppress neuronal activity just enough to prevent abnormal firing * Influx of sodium or calcium increases neuronal activity * Influx of chlorine suppresses neuronal activity * Mechanism of action (one or more of the following): * Delay influx of sodium ions * Delay influx of calcium ions * Stimulate influc of chlorine ions (associated with the increasing action of GABA) * Classes of anti-seizure medications * Barbiturates * Benzodiazepines * Hydantoins * Succinimies * Many others
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Therapeutic class of phenobarbital (Luminal)
Anti-seizure drug, sedative
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Pharmacologic class of phenobarbital (Luminal)
Barbiturate, GABAA receptor drug
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Indications of phenobarbital (Luminal)
Seizure, sedation
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MOA of phenobarbital (Luminal)
Enhances GABA, suppressing abnormal neuronal discharges
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Adverse effects of phenobarbital (Luminal)
* Drowsiness * Respiratory depression * Vitamin deficiencies (D, folate, B9, B12) * N/V
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Nursing considerations of phenobarbital (Luminal)
* Schedule IV drug * Pregnancy category D * Avoid use with other CNS depressants
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Overdose of phenobarbital (Luminal)
CNS depression, coma, death
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Therapeutic class of diazepam (Valium)
Anti-seizure drug, sedative, anxiolytic, skeletal muscle relaxant
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Pharmacologic class of diazepam (Valium)
Benzodiazepine, GABA receptor drug
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Indications of diazepam (Valium)
* Seizure * Sedation * Anxiety * Muscle spasm * Alcohol, benzo withdrawal
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MOA of diazepam (Valium)
* Enhances action of GABA, suppressing abnormal neuronal discharges
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Adverse effects of diazepam (Valium)
* Hypotension * Muscle weakness * Drowsiness * Respiratory depression * More pronounced adverse effects when given IV
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Nursing considerations of diazepam (Valium)
* Schedule IV drug * Pregnancy category D * May take 1-2 weeks to reach max concentration when taken orally * Avoid use with other CNS depressants * Quick onset and lasts about 20 minutes awhen given IV * For short term use, can be given rectally
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Therapeutic class of phenytoin (Dilantin)
Anti-seizure drug, antidysrhythmic
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Pharmacologic class of phenytoin (Dilantin)
Hydantoin
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Indications of phenytoin (Dilantin)
Seizures
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MOA of phenytoin (Dilantin)
Desensitizes sodium channels in CNS, preventing abnormal neuronal discharges
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Adverse effects of phenytoin (Dilantin)
* Drowsiness * Nausea * Gingival hypertrophy * Hirsutism * Suicidal thoughts * Ataxia (lack of muscle coordination) * Hematologic toxicities (RBC, WBC, platelets)
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Nursing considerations of phenytoin (Dilantin)
* Many drug-drug interactions * Never administer IV in the same line as another drug or with dextrose solution (NS only) * Monitor drug levels * Can cause tissue necrosis if there is IV infiltration * IV administration requires a filter * Hold tube feeding for 2 hours before and after administration
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Purple Glove Syndrome
* Typically, within 2 to 12 hours after infusion, erythema and blue-purple discoloration occur around the intravenous site, and there may be petechiae on the fingers and palms * 12 to 24 hours after infusion, spreading discoloration, edema, skin blistering, sloughing, and ulcerations may occur, with possible extension thereafter * Resolution may take weeks to months, with discoloration receding toward the original intravenous site
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Situational depression
Related to circumstances, such as illness, divorce, loss of job, death of loved one, substance abuse, medication
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Biologic depression
Imbalance of neurotransmitters; genetic, hormonal, secondary to another condition such as traumatic brain injury or stroke
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Seasonal depression
Related to change in seasons and not receiving as much sun
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Treatment of Depression
* Assess for causative factors, or other disease processes that mimic deprssion * psychotherapy * Pharmacotherapy * When depression is unresponsive to other therapies and become life threatening: * Electroconvulsive therapy (ECT) * Repeitive treancranial stimulation (rTMS) * Vagus nerve stimulation (surgical implant) * Very aggressive treatment - involves implanting in the brain
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Antidepressants
* Reduce depressive symptoms by correcting chemical imbalances (norepinephrine, dopamine, and serotonin in particular) * Antidepressants also used to treat anxiety, phobias, OCD, and neuropathic pain * Improvement in symptoms usually occurs within the first 2 weeks; may take 6-8 weeks for full effect * May feel worse while chemical changes are occurring * Black box warning: increased risk of suicidal thinking and behavior in children and young adults * Do not take with St. John's wort * Can cause serotonin syndrome
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Neurotransmitters associated with depression
* Norepinephrine * Serotonin * Dopamine
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Types of Antidepressants
* Selective Serotonin Reuptake Inhibitors (SSRIs) * Selective Serotonin and Norepinephrine Inhibitors (SNRIs) * Tricyclic antidepressants (TCAs) * Monoamine Oxidase Inhibitors (MAOIS)
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Selective Serotonin Reuptake Inhibitors (SSRIs)
* First line treatment of depression * Slows reuptake of serotonin into presynaptic nerve terminals * Increased levels of serotonin enhance mood * Safer than other classes of antidepressants * Less sedation, fewer sympathomimetic and anticholinergic effects * Low toxicity with overdose * Monitor for serotonin syndrome * Examples: citalopram (Clexa), escitalopram (Lexapro), fluoxetine (Prozac), sertraline (Zoloft)
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Therapeutic class of sertraline (Zoloft)
Antidepressant
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Pharmacologic class of sertraline (Zoloft)
SSRI
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Indications of sertraline (Zoloft)
* Depression * Anxiety * OCD * Panic disorder * Premenstrual dysphoric disorder * PTSD * Social anxiety disorder
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MOA of sertraline (Zoloft)
Inhibits the reuptake of serotonin
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Adverse effects of sertraline (Zoloft)
* Insomnia * Headache * Dizziness * Fatigue * Dry mouth * Sexual dysfunction * Naursea * Diarrhea * Side effects taper over time
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Nursing considerations of sertraline (Zoloft)
* Many drug-drug interactions (digoxin, warfarin, diazepam, aspirin, NSAIDS) * Avoid use with alcohol * Monitor for suicidal ideation * Avoid abrupt discontinuation * Do not give concurrently with MAOI
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Serotonin syndrome
* Anticholinergic effect: too much fight or flight response * Care: stopping the treatment and supporting the patient through the episode
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Serotonin and Norepinephrine Reuptake Inhibitors (SNRIs)
* Inhibit reabsorption of serotonin and norepinephrine; may also affect levels of dopamine * Safety and side ffect profile same as for SSRIs with addition of HTN * Examples: venlafaxine (Effexor), duloxetine (Cymbalta) * Used to help women in menopause with hot flashes
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Tricyclic Antidepressants (TCSa)
* Inhibit reuptake of serotonin and norepinephrine * Less commonly used than SSRIS and SNRIs due to adverse effects and toxicity with overdise * Adverse effects include: orthostatic hypotension, sedation (develop tolerance), anticholinergic effects (dry mouth, constipation, urinary retention, blurred vision, tachycardia) * Avoid use with alcohol * Take at bedtime due to sedative effects, use caution iwth activities that require alertness * Examples: amitriptyline (Elavil), imipramine (Tofranil), nortriptyline (Pamelor)
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MOA of MAOIs
* MAO is a mitochondiral enzume found in nerve and other tissues * MAO breaks down norepinephrine, serotonin, and dopamine * When MAO is inhibited, norepinephrine, serotonin, and dopamine are not broken down, increasing the concentration of all three neurotransmitters in the brain
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MAOIs
* Oldest class of medications used to treat depression * Adverse effects include: orthostaic hypotension, insomnia, headache, diarrhea, sexual dysfunction * As effective as other classes, but have significant drug-drug and drug-food interactions and risk of hepatoxicity * Tyramine is degraded by MAO, so inhibiting the MAO enzyme leads to high levels of tyramine in the blood * Similar to norepinephrine and displaces it from receptor sites, leading to high levels of norepinephrine in the blood - can result in hypertensive crisis (headahce, flushing, palitations, sweating, and nausea)
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MAOIs food interactions
* Aged food: cheese and wine * Alchol: beer * Soybeans * Bananas * Cured meats * Bovril * Marmite
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Drugs to aovid with MAOIs
* Sympathomimetic agents: * Dopamine * Ephedrine * Levodopa * Pseudoephedrine * Opioid analagesics * Amphetamine * Dextromethorphan * CNS depressant (alchol, narcotics) * SSRIs * TCAs
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Bipolar disorder
* Alternate between periods of depression and overexcitement * Excess of excitatory neurotransmitters (norepinephrine, glutamate) or deficiency of inhibitory neurotransmitters (GABA) * Treatment: depends on current symptoms * Lithium cabonate (mood stabilizer) * Antipsychotics * Anti-seizure medications * Benzodiazepines
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Therapeutic class of lithium carbonate (Eskalith)
Antimanic
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MOA of lithium carbonate (Eskalith)
Exact mechanism unknown Affects synthesis, release, and reuptake of acetylcholine, dopamine, GBA, norepinephrine; alters Na+ transport in nerve cells
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Adverse effects of lithium carbonate (Eskalith)
* Metallic taste * Tremors * Polyuria * Polydipsia * diarrhea * Fatigue * Weight gain
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Nursing considerations for lithium carbonate (Eskalith)
* Monitor serum drug levels (narrow therapeutic indix, patients vary widely in absorption and excretion) * Take with food to decrease N/V * Consistent salt intake * Therapeutic effects may take 7-10 days * Contraindicated in pregnancy * Black box warning: monitor serum levels (high toxicity)
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Signs of toxicity of lithium carbonate (Eskalith)
* Unsteady gait (ataxia) * Vomiting * Diarrhea * Drowsiness * Tremor * muscle weakness * Blurred vision * Large volume diuresis
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Attention Deficit/Hyperactivity Disorder
* Inattention and distractibility, with or without hyperactivity * Thought to be related to deficit or dysfunction of dopamine and norepinephrine * Pharmacotherapy * CNS stimulants * Heighten alertness, increase focus * Schedule II * May cause paradoxical hyperactivity * Examples: dextroamphetamine/amphetamine (Adderall), methylphenidate (Ritalin) * Non-CNS stimulants * Norepinephrine reuptake inhibitors * Newer alternative to CNS stimulants * No abuse potential * Examples: atomoxetine (Strattera) * Make sure there is not an underlying biopolar disorder ( can exacerbate manic episodes)
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Therapeutic class of methylphenidate (Ritalin)
drug for ADHD
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Pharmacologic class of methylphenidate (Ritalin)
CNS stimulant
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Indications of methylphenidate (Ritalin)
ADHD, narcolepsy
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MOA of methylphenidate (Ritalin)
Activates reticular activating system (increasing alertness); blocks uptake of norepinephrine and dopamine
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Adverse effects of methylphenidate (Ritalin)
* HTN * Tachycardia * Hepatoxocity * Decreased appetite * Anxiety
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Nursing implications of methylphenidate (Ritalin)
* Symptoms typically improve within a few weeks * Schedule II * Period drug-free holiday recommended to reduce dependence and asses patient for underlying disorders * Taken early in tay to prevent disruption of sleep pattern * Black box warning: cardiovascular effects
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Psychoses
* Severe mental disorders where there is a loss of contact with reality * Delusions * Hallucinations * Disorganized behavior * Paranoia * Difficulty relating to others
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Pharmacotherapy for Psychoses
* Offer symptom relief, not cure * Goal is for client to maintain social relationships, cre for self, hold a job * Long-term or life-ling therapy is required * Compliance can be an issue * Adverse effects * Feel well; denial of problem * Relapse rates 60-80%
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Conventional/typical Antipsychotics (first generation)
* Thought to block dopamine receptor sites, reducing positive symptoms * Positive symptoms: hallucinations, delusions, dysfunction, sedation, neuroleptic malignant syndrome, extrapyramidal symptoms * Adverse effects: anticholinergic effects, sexual dysfunction, sedation, neuroleptic malignant syndrome, extrapyramidal symptoms * Black box warning: older adults with dementia - related psychosis are at increased risk of death * Examples: * Phenothiazines: chlorpromazine (Thorazine), prochlorperazine (Compazine), thioridazine (Mellarill) * Haloperidol (Haldol)
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Atypical Antipsychotics (Second Generation)
* Thought to block dopamine, serotonin, and alpha 1 adrenergic receptor sites * Broader spectrum of action than first generation * Less incidence of extrapyramidal symptoms, less sedating * May cause neutropenia, weight gain diabetes, seizure, neuroelptic malignant syndrome (life-threatening) * Examples: clozapine (Clozaril), olanzapine (Zyprexa), quetiapine (seroquel), risperidone (Risperdal), ziprasidone (Geodon)
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Neuroleptic malignant syndrome (NMS) Clinical Manifestations
* Hyperthermia: higher than 38C * Rigidity * Mental status changes: agistated delirium with confusion * Autonomic instability tachycardia, tachypnea, labile or high BP * Acute onset
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Dopamine-Serotonin System Stabilizers (Third Generation)
* Dopamine partial agonists * Lower incidence of EPS, less weight gain, no anticholinergic effects * Common adverse effects include: N/V, headache, fever, constipation, anxiety * Example: aripiprazole (abilify)
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Long Term Metabolic Effects Associated with Antipsychotics
* Weight gain, obesity * Hyperlipidemia * Insilin resistance, diabetes * Antipsychotics should be used with caution in older adults - increased risk of sudden cardiac death and stroke
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Female Sex hormones
Estrogen and progesterone
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Indications of female sex hormones
* Contraception * Hormone replacement therapy * Dysmenorrhea (painful menstruation) * Abnormal uterine bleeding * Hormone sensitive prostate cancer * Gender reassignment therapy
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Male sex hormone
Testosterone
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Indications for testosterone
* Low testosterone levels * Delayed puberty in males * Gender reassignment therapy
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Oral contraceptives
* Estrogen/prgestin * Prevents ovulation * Various combinations of dose and type * Progestin only "mini-pill" * Suppresses ovulation, creates thick mucous layer at the cervix preventing sperm from entering the uterus * Less effective than estrogen/progestin * Increased menstrual irregularities * Used when estrogen is contraindicated * Women with personal or family history of breast cancer shoud seek non-hormonal methods of birthcontrol
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Advantages of oral contraception
* Regular/predictable menses * Protection from endometrial and ovarian cancer
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Disadvantages of oral contraception
* Success depends upon daily administration * Adverse effects: N/V, breast tenderness, weight gain, break-through bleeding, headache * Additional risks: HTN, DVT (increases with smoking), stroke, breast cancer/cervical
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Erectile Dysfunction Causes
* Increased age * Disease processes (DM, CVA, HTN, atherosclerosis, renal disease) * Smoking, ETOH * Psychogenic causes (depression, fatigue) * Medications (beta blockers, SSRIs, TCAs, ACE inhibitors)
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Therapeutic class of sildenafil (Viagra - erectile dysfunction; Revatio - pulmonary HTN)
Erectile dysfunction agent, vasodilator
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Pharmacologic class of sildenafil (Viagra - erectile dysfunction; Revatio - pulmonary HTN)
Phsophodiesterase -5 inhibitor
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Indications of sildenafil (Viagra - erectile dysfunction; Revatio - pulmonary HTN)
Erectile dysfunction, pulmonary arterial hypertension
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MOA of sildenafil (Viagra - erectile dysfunction; Revatio - pulmonary HTN)
Inhibiting PDE-5 increases levels of cGMAP, which produces smooth muscle relaxation and icnreases blood flow to the corpus cavernosum (Viagra) or vasodilation of the pulmonary vascular bed (REvatio)
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Dosing of sildenafil (Viagra - erectile dysfunction; Revatio - pulmonary HTN)
Viagra is generally higher dose (50mg) and is taken 30 min to 1 hour before sexual activity and only once a day. Revatio dose is generally lower (5-20 mh) and taken 3 times a day
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Adverse effects of sildenafil (Viagra - erectile dysfunction; Revatio - pulmonary HTN)
* Headache * Dizziness * Facial flushing * Nasal congestion * Hypotension
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Contraindication of sildenafil (Viagra - erectile dysfunction; Revatio - pulmonary HTN)
Concurrent use of nitrates may cause refractory, life-threatening hypotension
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Nursing implications of sildenafil (Viagra - erectile dysfunction; Revatio - pulmonary HTN)
* Viagra; there is no effect in the absence of sexual stimulation, seek medicatl attention if erection lasts more than 4 hours (priapism), counsel on STI/HIV prevention * REvatio: monitor vital signs, cardiac fucntion, excercise tolerance prior to and during therapy
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Pharmacology for Nurses
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