Final Complex Care Study guide

Care of the Patient with Renal Compromise


  1. How does AKI differ from chronic renal failure?
    • Shorter time period
    • more severe changes in hemodynamics and electrolytes
  2. Review prerenal causes, intrarenal causes and postrenal causes.  Which is the most common cause of AKI?  Know examples of each.
    • Most common causes of AKI: Hypovolemia, Hypotension, Nephrotoxic drugs.
    • Pre: impaired perfusion to kidneys, hypovolemia, hypotension
    • Intra: Acute tubular necrosis, Nephrotoxic drugs, Glomerulonephritis
    • Post: Rare, Kidney stone blockage, BPH blockage, Neurogenic bladder.
  3. Acute tubular necrosis (ATN) is the most common cause of intrarenal AKI – what are some common causes of ATN?
    • Poor perfusion through hypoxia or low blood flow, and nephrotoxic drugs.
  4. What are the three phases of AKI’s clinical course? What do you monitor in each phase of AKI?
    • Oliguria: Low urine output, Increased Potassium and creatinine, increased Ca, low to normal Na,
      • Monitor: fluid and electrolyte balance, High K and Cr
    • Diuretic: High urine output, Decreased Potassium, lowering creatinine, Dehydration
      • Monitor: Fluid and Electrolyte balance
    • Recovery: Normalizing Urine output, normalizing Potassium and creatinine,
      • Monitor: Fluid and Electrolyte balance,
  5. Generally, how long does the oliguric phase last?
    • 10-14 days and starts in 1-7 days
  6. What are the diagnostics used to diagnose AKI?
    • Urine output decrease, High Creatinine
  7. What are the priorities of care of the whole healthcare team for the AKI patient?
    • Normalizing the Potassium levels, replacing fluids.
  8. What are the nurse’s priorities for the AKI patient?
  • Fluid and electrolyte balance
  1. What are the types of dialysis? What are the advantages and risks with each type of


  • HD: need a fistula for long term access, Central line for short term fast access. Blood is filtered through a filter in a machine outside the body. this takes hours at a hospital setting about three times a week.
  • PD: dialysate put into the peritoneum, absorbs waste products and excess electrolytes then is drained. This takes a few hours, multiple times a day.
  • CRRT: continuously connected to a machine that filters the blood.
  1. What are the contraindications for peritoneal dialysis?
    • Peritonitis, abdominal cellulitis, maybe abdominal hernia or adhesions
    • Patient causing infection a certain number of times per hospital policy.
  2. How is continuous renal replacement therapy (CRRT) different from hemodialysis?
    • CRRT: Slow continuous replacement of blood replacing the need for kidneys
    • HD: about three times a week, pt needs to tolerate faster fluid shifts,
  3. When is CRRT contraindicated?
    • The need for emergent hemodynamic stabilization such as high potassium and pericarditis




  1. General concepts of when patients become eligible for organ donation
  • Neurologic death/Brain death, with viable organs.
  1. Organ donation process
  • Patient needs to be perfusing organs, needs to be a donor or family needs to be ok with it.
  1. Role of immunosuppressive agents with organ transplant
  • Suppresses the immune system so that the host does not reject/attack the organ.
  1. Management of the transplanted organ to include HLA matching
  • HLA matching looks at the donor tissue and the host blood to see if the antigens from the donor will be recognized by the host as self instead of non self.


Valvular Heart Disease

  1. Describe the pathophysiologic changes associated with mitral valve stenosis, regurgitation.
  • Mitral Valve stenosis: valve leaflets fuse together and cause a decrease in the blood flow across the valve. Most commonly caused by rheumatic heart disease.
    • Diastolic murmur, loud S1, exertional dyspnea, palpitations, and fatigue.   
  • Mitral Valve regurgitation: incomplete closure of the valve leaflets causing blood to flow backward from the left ventricle to the left atrium. caused by Rheumatic heart disease, endocarditis, cardiomyopathy, and issues with the chordae tendinea
    • s/s: systolic murmur, pulmonary edema, cardiogenic shock
  1. Describe the pathophysiologic changes associated with aortic valve stenosis, regurgitation.
  • Aortic Valve Stenosis: Stenotic valve between the aorta and the Left Ventricle.
    • Systolic murmur, Soft S1,S2, and impressive S4
    • s/s: Angina, Syncope, dyspnea on exertion.
  • Aortic Valve Regurgitation: Floppy valve causing backflow from the Aorta to the LV.
    • Diastolic murmur
  1. Describe the signs/symptoms associated with valvular heart disease. A diastolic murmur is heard with which valvular heart disease?  A systolic murmur is heard with which valvular heart disease? What is the patho associated with each type of murmur?
  • Diastolic murmur in Aortic Regurgitation.
    • During LV diastole blood flows back through the incompetent aortic valve causing a Diastolic murmur.
  • Systolic murmur in Aortic Stenosis
    • During LV Systole the small opening in the stenotic valve causes turbulent blood flow causing the murmur to occur.
  • Diastolic Murmur in Mitral Stenosis
    • During atrial contraction and LV relaxation the small irregular opening in the stenotic mitral valve between the two chambers creates turbulent blood flow creating the murmur.
  • Systolic murmur in Mitral Regurgitation
    • During LV systole blood flows normally out of the aortic valve, but some also goes out of the incompetent mitral valve back into the atrium. This causes turbulent blood flow during Systole.
  1. Describe the assessment, diagnostics and treatment of valvular heart disease.
  • Assess for murmurs, syncope, angina, dyspnea, and any other s/s mentioned above.
  • diagnostic: Chest XR, CBC, ECG, transesophageal echo, cardiac Cath
    • These tests look for the size of vessels and heart chambers, as well as arrhythmias, and pressure changes in the heart.
  • Treatment:
    • Meds: vasodilation(nitro), positive inotropes (digoxin), Diuretics, Anticoagulation, antiarrhythmics, beta blockers,
  1. How does a mechanical valve differ from a biologic valve in terms of anticoagulation therapy?
  • Mechanical valve will need anticoagulation therapy as long as the valve is in use.
    • Risk for hemorrhage with the anticoag therapy.
  • Biologic valve will not need anticoagulation therapy.
  1. “All roads lead to heart failure”.  How is this true for valvular heart disease?  How does this translate into your bedside assessment of the patient with valvular heart disease?
  • Increased work of the heart in all valvular issues causes hypertrophy and decreasing CO. This leads to a backup of blood into the pulmonary vasculature and left sided.
  • Assess for progression of the disease by looking at the patient’s effort doing tasks over time.


Endocarditis, pericarditis, tamponade

  1. What are the pathologic changes associated with endocarditis?  Depending on what valve is involved, what S/S would you see?
  • Endocarditis: Infection of the endocardium usually the heart valves.
    • Strep viridans and staph aureus are the most common types.
    • Effects Left heart 90% of the time, and usually the mitral valve.
    • s/s: new murmur or change in existing murmur, Fever,
    • Right valves are effected at the lower percentage and are correlated with IV drug use.
    • Subacute: Slow and long course, patient usually has a pre-existing heart valve issue.
    • Acute: faster progression of the illness, may not have a pre-existing heart valve issue,
  1. What are the potential complications of  endocarditis?  Would you be able to recognize these complications clinically?  
  • Embolization of a portion of the vegetation: Thrombotic stroke from a vegetation embolus of the bacteria, micro emboli in Kidneys extremities and spleen if the infection is originating on the left side of the heart. If originating on the right side of the heart pulmonary issues are a risk factor.
  • decrease cardiac output due to the infection affecting the valves.
  1. What questions are especially important to ask in taking a history of the patient with   endocarditis?  What are the clinical manifestations of endocarditis?
  • Risk factors: Cardiac conditions, artificial heart valve, IV drug abuse, Bacteremia, Intravascular devices,
  1. What is the treatment of endocarditis?
  • antibiotic therapy
  • prophylactic therapy if the patient is a high risk and has a:
    • GI/GU infection, Dental procedures, and respiratory, tonsil, or adenoid incisions.
  • antimicrobial treatment continued until the patient’s blood cultures come back negative, are afebrile, and have no s/s of endocarditis or heart failure.
  1. What are the physiologic changes that occur with tamponade?  How do these correlate with physical S/S?  Would you be able to tell if your patient was experiencing tamponade?  How?  How is tamponade treated?
  • The pericardium gets inflamed and fluid gets in between the pericardium and the heart decreasing the heart’s ability to fully relax causing a decrease in CO.
  • there will be an narrowing of blood pressure, tachycardia, tachypnea, pulsus paradoxus, and muffled heart tones.
  • Treat with a pericardiocentesis to remove the fluid.
  1. What are the physical S/S of pericarditis?  What are some nursing intervention for the patient with pericarditis?  
  • Pericarditis: inflammation of the pericardium, the sac surrounding the heart.
    • Normal fluid around heart is 15-30ml
    • Increased chest pain with inspiration
    • due to: infection, uremia, acute MI, Trauma, Dissecting AA, Auto immune, Rheumatic diseases, and some medications.
    • s/s:ST elevation on all leads, Echocardiogram to see thickness of pericardial tissue, chest x-ray will show large cardiac shadow, Pericardial tamponade,
    • Pulsus paradoxus – an exaggerated decrease in Blood pressure upon inspiration, greater than 10 mmhg. (you need an arterial line to monitor this.)  
  1. What are the complications associated with pericarditis?
  • Tamponade
  • Pericardial effusion




  • Describe causes of burns and types of injuries it causes.


    • most common cause is flame, then scalding injury.  
  • What are the general principles of burn care?  Know priorities for care in the emergent, acute, and rehabilitation phases.  
    • Phases of burns
      • Emergent first 48 hours
      • Acute – weeks to months
      • Rehabilitation phase – over two years


  • What are the systemic effects of burns?  What type of shock happens with burn patients?  How would the nurse recognize these effects?  What treatment would the nurse anticipate?


    • Electrical injuries – internal burning,visible burns on an entry point and exit point.
      • Deep muscle and nerve injury
      • Difficult to assess the extent of the injury
      • Patient can have rhabdomyolysis and compartment syndrome (five P’s are the s/s for compartment syndrome.)
  • Chemical burns
    • Irrigate the burn to get the chemical out
  • Tar burns
    • Cool the tar then we use oil to get the hard tar off.
  • Frostbite
    • Can regain vasculature to fingers and toes with tPA if treated under 24 hours from injury.


  • What are the special considerations for electrical, chemical, and inhalation burn injuries?


  • How do you assess and what are potential consequences of burns and fluid resuscitation?
    • Fluid resuscitation in burns
      • 2 ml of LR*TBSA*KG
      • Need 30-50 ml/hr of urine output
  • What are risk factors for inhalation injury? Complications? Nursing priorities and concerns?
    • Airway management!
    • inflammation/incompetence of the airway.
  • What are nutritional, pain, and functional concerns for burn patients?
    • Increased nutritional specifically protein due to hypermetabolism
    • Pain needs to be treated on a patient by patient basis and needs to by IV during debridement to control the pain.
    • Bolus or PO pain before debridement
    • Physical therapy is needed to prevent contractures.


Emergency Department Care and Bioterrorism

  • When is a tetanus injection given in the ED?
  • Give when the patient has had less than three doses, unknown doses, 6-10 years since last dose and have a moderate or major trauma, or more than 10 years since last dose.


Emergency severity index 1-5 one being the most severe.

  • 1: Immediate life saving intervention: obvious threat the body or organ
    • MI (cardiac arrest), overdose, severe respiratory distress, intubated trauma patient.
  • 2: High risk: stability of vital functions threatened. likely threat to bod but not always obvious. seen within ten minutes. continuous monitoring, multiple diagnostic studies,
    • chest pain from ischemia, nonresponsive trauma,
  • 3: Two or more resource: stable patient, life or organ threat is unlikely but possible. need to be seen by physician within one hour. medium to high resourses. Hanging fluids will get you here.
    • abdominal pain or gynecological issues (unless severe), hip fracture in older patient.
  • 4: One resource: stable patient with no threat to life or organs. one diagnostic study like x-ray or intervention like sutures, lab studies,
    • lacerations, or closed extremity trauma.
  • 5: stable patient with no life of organ threat. examination only
    • colds, minor burns and wounds, prescription refill.

color system

  • Black: no resps with open airway, no pulses
  • Red: resp > 30(45 for peds),  no radial pulse, altered mental status, cap refill greater than 2
    • control bleeding and open airway before moving on.
  • Yellow: have pulse, can follow commands,
  • Green:  minor injury, walking wounded.

Shock States

  • Underlying pathologic problem with all shock states, knowledge of the various shock states and how you identify, assess, intervene, and anticipated treatment options, to include priority interventions and knowledge of SvO2/ScvO2.  
  • Shock: a decrease in adequate tissue perfusion from low blood pressure.
    • types: Cardiogenic (heart problem), Hypovolemic(low intravascular fluid volume), Distributive (maldistribution of circulating blood), Obstructive (physical blockage to flow)
  • Changes in venous O2 or Arterial O2 (SvO2 vs ScvO2)
  • Increased O2 delivery from: increased SaO2, Increased HGB, Increased cardiac output
  • Decreased O2 consumption: decreased need(hypothermia), access(vasoconstriction), and capability(tissue death)
  • Decreased O2 delivery: decreased O2 sat, decreased HGB, decreased CO
  • Increased


  • Review categories of vasoactive, vasodilator, and inotropic agents.
  • Vasoactive: Epinephrine, Dopamine, phenylephrine.
  • Vasodilator: Nitroglycerin (to decrease after load in cardiogenic shock)
  • Inotropic: Digoxin
  • Principles surrounding the purpose, insertion considerations, use, and monitoring principles of Arterial Lines and Central Venous Catheter lines; no questions on pulmonary artery catheter lines.
  • Arterial Lines:
    • Arterial blood pressure. Catheter inserted into the radial or femoral arteries usually. The tubing is pressurized to overcome the arterial blood pressure. To get an accurate reading the fixture that measures the pressure must be level with the patient.
    • Can draw ABGs more frequently if the patient has an arterial line.
  • Central venous catheter lines:  central venous pressure. Venous central line that measures end vena cava pressure. can also measure venous labs to compare blood gases to arterial gases.
  • What is shock?
  • Shock: a decrease in adequate tissue perfusion from low blood pressure.
  • How do you know what type of shock a patient has? what are the priority interventions for the different shock states?
  • Look at the patient’s vital signs, and history to see if there are risk factors present of a specific type of shock.
  • What do ScvO2 numbers mean?
  • Indicator of global tissue hypoxia, 70-80% indicates stable oxygen balance
  • High SvO2/ScvO2 from increased oxygen delivery (increased SaO2, Hgb, CO) and decreased oxygen consumption (decreased metabolism – hypothermia, access – vasoconstriction)
  • Low SvO2/ScvO2: tissue extracting oxygen faster than can be delivered
  • What are the different categories of drugs? concerns? names of some of these drugs in the categories?
  • Vasopressors – Norepinephrine, Dopamine, Vasopressin
    • Water retention and increased systemic vascular resistance via vasoconstriction, make sure fluid resuscitation has occurred first
      • Increased afterload
      • Watch for MI/heart failure, esp. for cardiogenic shock
    • Administer slowly while monitoring MAP
  • Inotropic agents – Epinephrine, Dopamine, Dobutamine
    • Increases contractility, but also myocardial demand, of heart
  • Vasodilators: indicated for cardiogenic shock to decrease afterload
  • What are the phases of shock states and how do you assess the patient?
  • Compensatory: generally little/no clinical s/sx
    • SNS activated to compensate for initial drop in BP/CO
  • Progressive: compensatory mechanisms and systems begin to fail
    • Massive SNS input causes vasoconstriction
    • Decreased BP, increased HR/RR
  • Irreversible: increased waste products from MODS, cessation of cellular mitochondrial function
  • What is MODS?
  • Multi-Organ Dysfunction Syndrome
    • Failure of 2 or more organs
    • Need to support or bypass the dysfunctional organs
    • Treat or prevent new infections
    • poor prognosis when this stage is reached.


Cardiogenic up down Up w/ crackles down down
Hypovolemic up down Up then D down down
Neurogenic down down dysfunction dysfunction Normal to high
Anaphylactic up down up incontinence Normal to high
Septic up down up Down (none) Down, increased late
obstructive up down up down Normal to down



Test 2 Study Guide Complex Care

  1.   What measurements are used for ECG interpretation? Do you know the normal measurements ?  How do these measurements correlate with what is going on in the heart?
  • The waveform is made up of peaks and valleys that are designated as the letters P through U. Each letter corresponds to a specific part of the Waveform.
  • P wave – Atrial depolarization, rounded and shorter than the QRS complex
  • PR interval – Measurement from the beginning of the p wave to the beginning of the QRS
    • Normal is 0.12-0.2 seconds
    • This is the time is takes for the impulse to travel from the SA node through the AV node and into the ventricles.
  • QRS – ventricular depol, less than or equal to 0.12 seconds
  • ST segment – end of V Depol to the beginning of V Repol
    • Elevation correlates with myocardial infarction
    • Depression correlates with ischemia
  • T – ventricular repolarization
  • QT interval – total duration of depol and repol
  1.   What do these measurements mean to you as a nurse caring for a patient with dysrhythmias?
  • The normal measurements indicate the normal amount of time that it should take for an electrical impulse to do its specific task. Such as Atrial or ventricular depolarization. If the time the impulse takes is increased there may be decreased CO, or increased work of the heart and lungs.
  1.   What are the nursing responsibilities for a patient with a specific dysrhythmia (you will be responsible for only the dysrhythmias we discussed in class).
    • Be able to Identify the rhythm and dysrhythmia
    • See if the patient is tolerating the rhythm ie. Has pulses, awake, oriented, vital signs and breathing normally.
    • When to defibrillate a patient
    • When to use Electro Synchronized cardioversion on a patient.
      • There need to be R peaks in a QRS complex.
      • The shock is automatically delivered on an R peak.
      • There needs to be a pulse
    • what to do with a specific rhythm
      • Sinus Brady that is not tolerated: All Trained Dogs Eat: Atropine, Transcutaneous pacing, Dopamine, Epinephrine
      • Sinus Tach: Beta blockers to reduce rate, If the rate if still uncontrolled Adenosine can be given FAST 4 second push. Adenosine will stop the heart and hopefully restart in a better rhythm.
      • Atrial flutter – saw tooth
        • One ectopic foci that is discharging an impulse at 250-400 times per minute
        • F waves no P waves
        • Saw tooth f waves
        • Need to be on anticoagulants to prevent clots forming in the turbulence of the atria.
        • Controlled is a HR less than 100 uncontrolled is over 100


  • Unstable will need Synchronized Electrocardioversion, beta blockers, Vagal maneuver


      • Atrial Fibrillation
        • Multiple ectopic foci that are discharging at 250-40 times per minute
        • Most common clinically significant dysrhythmia


  • Most common cause of an ischemic stroke.


        • Need to be on anticoagulants to prevent clots forming in the turbulence of the atria.
        • Controlled is a HR less than 100 uncontrolled is over 100


  • Unstable will need Synchronized Electrocardioversion, beta blockers, Vagal maneuver


    • Heart blocks
      • 1st degree
        • Consistent Long PR interval over 0.20
        • Do not treat usually do to lack of signs and symptoms
      • Second degree type one, or wenckebach, or Mobitz 1
        • AV node conduction issue
        • Progressively increasing PR interval until a QRS is missed and the arrhythmia start over
        • Usually asymptomatic
      • Second degree type II, or Mobitz II
        • Normal PR interval with a dropped QRS every so often
        • Monitor for a third degree heart block
      • Third degree heart block
        • No communication between the atria and ventricles
        • Need a pacemaker, from the cath lab
    • Ventricular dysrhythmias
      • PVC – Premature ventricular contraction
        • Can be normal and untreated
        • Bigeminy – on pvc for one normal
        • Trigeminy – two PVC for every normal PQRST
        • Causes – hypoxia
        • Amiodarone is the drug of choice
      • V Tach –
        • Can cardiovert
        • Can easily turn into V fib
        • Pulseless we will defibrillate
        • Large sharp “QRS” complexes one immediately after another with no breaks
      • V Fib
        • Defibrillate to hope the SA node takes over
        • Smooth rapid continuous electrical activity with no breaks
        • Cannot cardiovert
        • AICD is an internal defibrillation device
      • PEA
        • Pulseless electrical activity
        • Give fluids and epi
      • Asystole
        • Straight line on the ECG


  1.   How do you know if a patient is hemodynamically compromised with a cardiac dysrhythmia?  Would you know what to do ?
  • Blood pressure changes, Heart rate changes, LOC decrease, pulselessness, reporting symptoms of chest pain or classic MI symptoms.
  • Yes, treat the problem if the patient is showing symptoms, and sometimes even if there are not.
  1.   How does defibrillation differ from cardioversion?  What is the nurse’s role in each?
  • Synchronized cardioversion – synchronized shock on the R wave
    • Need an R wave
    • Can convert them out of A flutter, fib, or V Tachycardia with a pulse.
    • May keep them in sinus for 3-6 months
    • Amiodarone Is used to prolong the time in sinus
    • May throw a clot that was in the atrium once the rhythm converts back to sinus.
    • Get a transesophageal echocardiogram to look for clots.
  • Defibrillation
    • An electric shock that is delivered and does not have to be synchronized
    • Rhythms to shock: Pulseless V Tach, V Fib
  • Cannot shock or cardiovert: PEA, Asystole


  1.   When is the use of an ICD warranted?  What is the patient education associated with ICD?
  • Implantable Cardioverter-defibrillator
  • when it senses a specific arrhythmia the device charges and delivers a shock.
  • A patient that can have an ICD is someone that has survived VT/VF, or at high risk for VT/VF after a surgery and cannot tolerate the medication or ablation.
  1.   Be able to identify the ECG dysrhythmias we discussed in class by their defining characteristics.  Identify treatment of specific dysrhythmias.
  2.   Pacemakers:
  • Review the patient and family teaching guidelines
  • What are the nursing interventions after a pacemaker is inserted?
  • What are the indications for a pacemaker (permanent and temporary)?




  1. What S/S are involved in DKA?  HHS?  What is the pathophysiology behind these S/S?
    • DKA
      • Ketones in the urine and blood
      • More common in DM1 but possible in DM2
      • s/s dry mucous membranes, tachycardia, hypotension, Kussmaul respirations, glucose over 250, dehydrated Altered LOC.
      • HypoKAlemia, HypoNatremia,
      • The cells cannot take in glucose so they must metabolize fats, which causes a waste product of Ketone acid.
      • Give Insulin and monitor electrolytes and replace any that are out of normal, Give bicarb
    • HHNS
      • No Ketones present
      • Common in DM2 or infections
      • s/s: NO ketones production, GLU > 600, Dehydration, hypotension, serum osmolarity >320 mOsm/L


  • FIRST THING TO GIVE: FLUIDS!!!!!, then insulin


    • Not giving BiCarb
  1. How does DKA differ from HHS?
  • DKA – production of ketones, blood sugar levels > 250, Usually DMI, pH<7.3, CO2 and HCO3 low, osmolality <320
  • HHNS – no ketones, blood sugar > 600, usually DMII, pH>7.3, CO2 and HCO3 levels normal, osmolality >320
  1. How is DKA treated?  HHS?  What are potential complications of DKA and HHS?
  • DKA – give Fluids, insulin, potassium(electrolytes), then bicarb if needed
  • HHNS give Fluids while keeping electrolytes in balance, then insulin.
  1. Differentiate between SIADH and DI.
  • SIADH is too much ADH
  • DI is not enough ADH

How do S/S of SIADH and DI differ in terms of serum osmolarity, serum and urine sodium, and urine osmolarity.  

  • SIADH: high urine osm, Urine sodium, and low serum osm
  • DI: low urine osm, Urine sodium, and high serum osm

What is the pathophysiology behind these differences? Describe the treatment for SIADH and DI.  What are potential complications of SIADH and DI?

  • complications for SIADH are: low serum electrolytes and overhydration
  • complications for DI are: High serum electrolytes and dehydration
  1. The most common cause of Cushing Syndrome is increased levels of _______.  What are the clinical manifestations of increased cortisol levels?  What pt teaching needs to occur around Cushing Syndrome related to exogenous glucocorticoid therapy?
  • ACTH levels are high and the hormone is produced in the pituitary.
  • At risk for everything associated with glucocorticoids
  • Buffalo hump, mustache, hair loss, thin arms, large abdomen, Moon face, weight gain, insomnia, thin skin.
  • Alternate s/s: depression, changes in appetite, Fatigue, decreased concentration and libido.
  1. What are the potential complications of glucocorticoid therapy?  
  • Immunosuppression, cannot stop the medication abruptly.



General understanding of cancer, risk factors, basic treatment concepts, studies to determine hematologic malignancies, metastasizes, basic function/purpose of chemotherapy and bone marrow transplant, radiation therapy indications and concerns for patient care/side effects, general knowledge related to categories or types of hematologic cancers


Risk factors for cancer


    • leukemia, acute and chronic – Proliferation of leukemia cells in the bone marrow the eventually move into blood circulation. The cells that are produced takeaway from the body’s ability to make blood cells so levels are decreased of RBC and platelets. WBC are decreased in the beginning, then can be increased in later stages of the disease when the Leukemia cells are moving from the bone into blood circulation (Healthy mature WBCs will always be decreased). This causes the signs and symptoms of fatigue, immune suppression, and clotting issues.
      • Acute Lymphoblastic leukemia ALL


  • Most common form of childhood leukemia


        • Increased incidence with age
        • HSCT for recurrence
        • Aplastic anemia.
        • Effects more immature blood cells and grows fast
      • Acute Myeloid Leukemia AML
        • bleeding and infections are an initial sign
        • bruising and fatigue
        • Splenomegaly
      • Chronic Lymphocytic Leukemia CLL


  • most common leukemia in adults
  • Lymphadenopathy is a hallmark (enlargement of one or multiple lymph nodes)


        • 10% have B symptoms (Fever, Night sweats, >10% weight loss in 6 months.)
        • treatment is deferred in early stages
        • doesn’t often show symptoms at diagnosis
        • Effects more mature blood cells and slow progression to s/s (years)
      • Chronic Myeloid leukemia
        • stable for many years without treatment


  • Philadelphia chromosome in 90% of patients


      • Splenomegaly
  • lymphoma, Hodgkin’s and non Hodgkin’s lymphoma characteristics
    • Hodgkin’s Lymphoma
      • Reed-Sternberg cells are in the biopsied lymph nodes
      • Pertussis is common
      • Lymph Node enlargement is the the first presenting symptom
      • Epstein Barr virus is is associated with this
      • Radiation treatment is a part of the high cure rate.
    • Non Hodgkin’s
      • Chromosomal translocation can often correlate with the cause of this
      • CHOP Chemo is used
      • Autoimmune diseases are a risk factor for this
      • No Reed-Sternberg cells
  • Multiple myeloma
    • Cancer of plasma Cells
    • Proliferation of Plasma cells affecting the bone marrow and destroy bone
    • Increased production of a random Ig (antibody) also called monoclonal production
    • Treatable but not often curable.
    • First s/s is BONE PAIN, Pathologic fractures are common
    • Diagnosis with Monoclonal antibody production, X-ray, increased bone marrow plasma cells, Beta 2-microglobulin and albumin
    • Tired, thirsty, fatigue, pallor, dull low back pain, GI issues, common in the elderly
    • Signs and symptoms – Babs the CRAB: HyperCalcemia, Renal failure, Anemia thrombocytopenia, and Bone pain
    • Hypercalcemia is due to high bone turnover causing pathological fractures
    • Renal failure is due to Monoclonal production of Ig
    • Anemia is due to the resources going to make cancerous plasma cells instead of regular RBCs and thrombocytes.
    • Bone pain is due to increased bone turnover
  • what are the main nursing concerns in administration of chemo; complications and nursing care concerns related to decreases in WBC, platelets, H/H
    • PPE
    • WBC – risk for infection
    • Platelets – risk for bleeds
    • H/H – risk for anemia
  • what are the concerns with radiation (internal and external)
    • topical and deep burns
    • adjacent body features and organs that can have side effects of radiation.
  • how are cell counts influenced by cancer and cancer therapy
  • cell counts can decrease if there is a leukemia, myeloma, myeloid cancer taking up the resources to make healthy cells
  • in cancer therapy there can be a decreased number of natural healthy cells and then the low levels will be replaced with healthy stem cells.
  • Chemo induced anemia
  • concepts of targeted therapy, stem cells, and bone marrow transplants; graft vs host disease
    • targeted therapies are biologic therapies
    • BMT is done after chemo kills the cancerous cells then they are replaced through a central line into the bloodstream
  • side effects and symptom management strategies
    • fatigue, pallor, anemias of all types, pain, thirst
    • Manage the symptoms and treat the cause of the disease.

Pharm Final New material:

Here is the study guide for the new material for the final. I don’t have time to do a concise version of the old material, but here is a combined word doc of all the previous study guides so it is easily searchable.



New Material:


estrogen-progesterone combined hormone therapy


  • together there is a lower chance of endometrial cancer
  • Monophasic—fixed ratio of estrogen and progestin that is taken for 21 days
  • Biphasic—supplies 2 different amounts of progestin during the first and second phases of the menstrual cycle
  • Triphasic—dose of estrogen is constant while progestin is progressively increased (three times) for 21 days



  • A class of antiparasitic drugs that expels parasites from the body.
  • Niclosamide (Nicolicide)
    • Use against flatworms.
    • stool sample must be negative for the parasite for three months to be “cured”
    • Action: kills the head (scolex)
    • parasite is digested once killed.
  • Piperazine
    • paralyzes the worm, then it detaches and is excreted.
  • Mebendazole (Vermox)
    • vermacicidial
    • increased absorption w/ fatty food.

estrogen hormone replacement therapy

  • increase synthesis of DNA, and proteins.
  • can cause Na retention and lower cholesterol
  • For estrogen deficiency, osteoporosis prevention and health
  • SE: WEIGHT GAIN, changes in menses pattern
  • gain about 5lbs of weight from the medication.
  • cautions: endometrial cancer with use over 2 years, do not give to breast feeding women, effects liver, clotting(MI, Stroke), bladder stones,
  • contraindications: breast cancer, abnormal vaginal bleeding, Thrombophlebitis, PE, hyperCa, endometriosis
  • smoking can increase cardiac issues and chance of stroke.



  • Amphotericin B
  • Broad spectrum  


      • Cell wall/membrane permeability is disrupted
        • humans have cell membranes…
        • binds -sterols which are also found in the human body (cholesterol) which causes the renal damage.
        • it is very toxic
      • used for SYSTEMIC mycoses that are potentially fatal, admin parenteral: infusion reaction fever and chills, nephrotoxic
      • ADME: can be found up to a year later in the pt body


  • Griseofulvin
  • still in the -azole class
  • just for SUPERFICIAL  (skin infections), not systemic
  • inhibits fungal mitosis


    • s/e: Insomnia, Rash and headache


  • Ketoconazole


    • used in less severe fungal reactions (fungistatic)
    • MOA is it inhibits the synthesis of ergosterol which is a part of the fungal cell membrane
      • this also affects the body’s sterols (sex hormones)
    • -conazols are all less toxic


  • Mycostatin (Nystatin)


    • Candidiasis only
    • It is in the form of a mouth wash
    • alters the permeability of the membrane
    • used for infant thrush often due to the low side effects.


Premarin (estrogen)

  • conjugated estrogen
  • from HORSES
  • see estrogen for SE and other info



  • for malaria:


    • Mefloquine
      • No photosensitivity
      • once a week dose
      • can be used w/ kiddos
      • There are serious psychological SE: anxiety, hallucinations
  • for amebiasis
    • Metronidazole (flagyl)
        • for invasive amebiasis, giardiasis, trichomoniasis
        • SE: neurotoxic, Disulfiram reaction, be cautious with anticoagulants, thrombophlebitis, furry tongue?

oral contraceptives (OCPs, BCPs)

  • Newer OCP have less of the hormones and less side effects.
  • Heavier people have a lower % of “coverage” because of the increased body weight
  • inhibit FSH and LH release
  • many SE and increased coagulability, weight gain, cramps, acne or less acne,
  • Can help with anemia by lessening blood loss during periods.


  • a T shaped piece with a copper coil that is pressed up against the fundis and prevents pregnancy for about 5 years.

topical glucocorticoids

Ring / Patch

  • NuvaRing
    • insert for 3 wk
    • take out after menses
    • higher risk of clot than PO


  • Patches
    • change wkly, three in a box
    • do not put on the breast
    • Higher risk of clot than PO

isotretinoin (Accutane)

  • Anti acne
  • Preg X
  • monitor triglycerides
  • Steven johnson syndrome, Suicide, Necrolysis, severe birth defects.

Estrogen only pills

  • these are for estrogen replacement, secondary for bone health, and vaginal atrophy
  • Estradiol and estrone are natural occurring steroidal estrogens
  • Conjugated estrogen (Premarin)
  • Diethylstilbestrol (DES) is synthetic
  • Transdermal estrogen (Estraderm)
  • Vaginal creams
  • Compounded mixtures

doxycycline (Tetracycline)


  • Broad spectrum
  • Inhibit protein synthesis
  • Effective through PO route
  • for ACNE, lyme Dx, H. pylori, Cholera, Rickettsia, cholera
  • Can treat MRSA with Clindamycin, and Bactrim


  • chelation occurs when calcium, Iron, and magnesium containing supplements and foods inactivate the tetracycline and cause it to be inactive
    • do not take with meals!
    • one hour before or two hours after meals to avoid chelation
  • S/E: photosensitivity, brown teeth, not ok for mothers pregnant and breastfeeding moms, do not give to kiddos.



  • schedule II drug
  • useful for osteoporosis to increases the building blocks for bone growth
  • indicated for hypogonadism, androgen deficiency, may reverse ED, delayed male puberty.
  • administration
    • PO, IM, patches, skin gel
  • SE: ab pain, insomnia, gynecomastia, frequent erections, prostate growth, frequent urination
  • monitor

PDE-5 inhibitors


  • cialis
  • levitra
  • Viagra


    • schedule II drug
    • useful for osteoporosis to increases the building blocks for bone growth
    • indicated for hypogonadism, androgen deficiency, may reverse ED, delayed male puberty.
    • administration
      • PO, IM, patches, skin gel
    • SE: ab pain, insomnia, gynecomastia, frequent erections, prostate growth, frequent urination
    • monitor for vision changes.

ED Drugs (PDE-5 inhibitors)


  • Cialis
  • levitra
  • viagra



5-alpha reductase inhibitors

  • finasteride (Proscar)
    • inhibits conversion of testosterone into androgen DTH resulting in shrinkage of the prostate.
    • Indication: BPH
    • SE: decrease in lebedo and impotence.
    • Women who are pregnant or may become pregnant should not handle this drug. Male changes in genitalia may result.

DDAVP desmopressin

  • Antidiuretic hormones, for DI (deficiency of ADH) or a deficiency of Vasopressin
  • Nasal route, blow nose before administration
  • only works Neurogenic DI not Nephro-
  • so could be used after head injury and surgery
  • can be used for enuresis too which is bed wetting
  • Complications: water intoxication (imbalance of electrolytes and causes drowsiness headache convulsions and coma)
  • cardiac patients are at a high risk for s/s from fluid overload


  • Antidiuretic Hormone
  • for DI from too little ADH and severe vasodilated shock
  • only excrete unbound water
  • alters renal permeability to reabsorb more water.
  • Decreases urine output and increases BP.
  • can cause an MI in a person with a cardiac pathology
  • Monitor BP, HR and ECG in cardiac patients

amyl nitrate

  • For Chest pain
  • cyanide antidote

thyroid labs

    • TRH is released in the hippocampus
    • TSH is released in the pituitary
    • T3 and T4 are released in the thyroid


  • each of these stimulate the production of the chemical below. T3 and T4 slow production/release of TRH telling the hippocampus that there is enough T3/4.  


  • In hyPERthyroidism there is high T3 and T4 and low levels of TRH and TSH.
  • In hyPOthyroidism there is low T3 T4 and high levels of TRH and TSH.
    • this can be different depending on other factors, but the takeaway is that the T3/4 hormones are low in hypo and high in Hyper.

BPH Drugs


  • 5-alpha reductase inhibitors


    • finasteride (Proscar)
  • alpha blockers have an effect shrinking the prostate too


  • this is T4 and gets converted by the body into T3
  • The dose is very patient dependent and there are MANY pill quantities. this also means that a Generic drug which can be plus or minus 20% of the drug, may cause the patient to be getting too much or too little of the drug.
  • Long H life of a week
  • daily dosing
  • takes about a month to get to the therapeutic effects

liothyronine (Cytomel)


  • T3


    • shorter H life
    • more money
    • faster onset

radiocontrast dye


  • antidote: N-acetylcysteine, Na Bicarb, and normal saline



  • for glaucoma
  • Direct acting cholinergic agonist
  • causes meiosis and contraction of ciliary muscles.
  • eye drops 6qd


  • antidote for Benzos (valium, Diazepam)

cycloplegic drugs


  • paralyze ciliary muscles
  • SE: Blurry vision, angle-closure glaucoma, Anticholinergic effects


  • mydriatics – dilate the pupil, for surgery and examinations
    • Phenylephrine – dilated eye



  • Antidote for Contrast induced Nephropathy, w/ sodium bicarb and NS
  • antidote for CONTRAST DYE!!!
  • Antidote for acetaminophen (TYLENOL)
  • also a mucolytic but this may be less important.


  • PO 140mg/kg, then 70mg/kg q4hr
  • Action: Decreases viscosity of mucus to expectorate
  • inhaled through nebulizer
  • DX that need this are COPD and cystic fibrosis
  • Onset > 1 min Peak 5-10 min
    • Bad odor
  • side effects are runny nose, throat and lung irritation, rash and stomatitis

Sodium bicarb

    • is basic and used to maintain the pH balance


  • CHECK IV med compatibility, will get viscous like concrete if mixed with incompatible fluids.
  • enhances renal secretion  
  • antidote for radiocontrast dye with N-acetylcysteine



ranibizumab (Lucentis)

  • angiogenesis inhibitor
  • can improve visual acuity and reduce risk of further impairment
  • SE: inflammation of the eye, seek medical attention if: eye pain, blurry vision, discharge


  • can help prevent Age related macular degeneration
  • reduce cold/cough time?


  • a progestin
  • regulates ovulation
  • build up the endometrium for the implantation of the egg

ocular decongestants

  • decrease redness and swelling by vasoconstriction
  • only work on symptoms

Depo Provera

  • IM injection contraceptive
  • lasts three months

angiogenesis inhibitor


  • ranibizumab (Lucentis)


  • can improve visual acuity and reduce risk of further impairment
  • SE: inflammation of the eye, seek medical attention if: eye pain, blurry vision, discharge

passive vs. active immunity

  • passive immunity is through antibodies
  • active immunity is acting against an active pathogen

Floxin Otic

  • fluoroquinolone, for ear infections in this case
  • can irritate the skin
  • DD interactions w/ amiodarone, and quinidine.

Hep A and B vaccines


  • IM inactivated virus injection
  • A
  • Children 12 months or older, 2 doses
  • Duration: 10 years Schedule; first shot, needs booster in 6-12 months Contraindicated in patients with bleeding disorders or febrile illness
  • B


    • three doses
    • provides 90% protection; duration unknown
    • May produce mild SE Continue schedule even if delay
    • Most have some immunity after 2 doses.

radioactive Iodine therapy I133

  • for hyperthyroidism and thyroid cancer.  
  • emits gamma and beta particles
  • 8 day H life
  • blocks hormone synthesis
  • needs synthroid after treatment for life (hypothyroid for life)
  • destroys the thyroid gland
  • Lugol’s solution – surgery prep, thyrotoxic crisis, it is an antiseptic

when not to administer a vaccine

  • MMR: not in preg, immunocompromised; allergies to neomycin, gelatin, eggs
  • Varivax: not in preg, immunocompromised, allergies to neomycin, gelatin
  • DTaP: fever, pain
  • OPV: VAPP so use IPV
  • Hib: OK
  • Hep B: anaphylaxis to baker’s yeast; Hep A: OK
  • Influ, Pneumococcal, rotavirus, meningococcal


what tetanus to administer by age / circumstance


  • If the person has tetanus: Airway, antibiotics, td vaccine, tetanus immunoglobulin
  • DTaP < 10 y.o.; Tdap > 11-12 y.o. as booster; Td if pt has hx of seizures
  • DTap – Schedule: 5 doses; first 3 are 2 mo apart, 4th at least 6 mo after 3rd dose, then between ages 4-6 Not recommended after age 7
  • Contraindicated if previous reaction Report serious rxn: high fever, convulsions, screaming or inconsolable crying, shock



  • Route: SQ; inactivated whole virus
  • Schedule: requires several to reach immunity
  • Protective immune response cannot be assured in immunocompromised
  • Contains trace amounts of streptomycin, neomycin, bacitracin


Pharm Test 4 study guide



OD Reversal Drugs





      • Opiate antidote
      • given even if there is an OD of unknown cause


  • Flumazenil


    • Antidote for benzos


  • Amyl Nitrate


    • For Chest pain
    • cyanide antidote


  • Ipecac


    • To Puke
    • mallory weiss tear from violent puking
    • vomiting like the exorcist


  • Atropine


    • to stop cholinergic effects
    • It is an anticholinergic


  • Charcoal


      • Binds med in the gut so it cannot be absorbed then is passed in the stool.
      • Powder form mixed in water and sucked through a straw to prevent reddining of the teeth.


  • Vitamin K


      • Antidote for Warfarin


  • Protamine Sulfate


    • Antidote for heparin






  • 5FU (fluorouracil)
  • Pyrimidine analog (disrupts nucleic acid fxn)


      • IV or topical admin (topical for skin cancer and we may not need to know this)
      • Cell cycle S-phase specific, prevents thymidine production
      • bone marrow depression
      • High alert medication


  • MTX methotrexate
  • Folic acid analog (prevents folic acid conversion)


    • Sphase specific
    • PREG category X
    • High alert med
    • dose limiting bone marrow supression
    • Kills rapidly dividing cells, and causes immunosuppression
    • SE: Pulmonary fibrosis, Hepatotoxicity, nephrotoxic, Steven-Johnson’s syndrome, and aplastic anemia
    • for the pulmonary toxicity, early signs are a dry nonproductive cough
    • for SJS, assess for rash as an early sign
    • for nephrotoxicity low back and flank pain is an early sign as well as changes in urination patterns or pain.


Alkylating agents

alkylates DNA and binds 2 guanines together to prevent the helix from becoming unbound, therefore inhibiting replication. The dose is limited by bone marrow suppression, but can be given in a bolus.


  • Mustargen (mechlorethamine)


      • inhibits DNA and RNA protein synthesis
      • for hodgkin’s disease and malignant lymphomas.
      • Cell cycle phase nonspecific
      • Contraindicated in pregnancy
      • SE: thrombocytopenia, Leukocytopenia, Seizures
      • monitor for bleeding and bone marrow suppression
      • notify provider for sore throat, neph-toxic s/s, bruising, bleeding, red stools
      • DO not drink alcohol, or take NSAIDs, or ASPIRIN, this will increase bleeding risk


  • Mustard Gas


      • similar to the nitrogen mustards, but for warfare.


  • Cytoxan (cyclophosphamide)


    • High alert med
    • most common alkylating agent
    • cell cycle phase nonspecific
    • SE: Pulmonary fibrosis, myocardial fibrosis, hemorrhagic cystitis(increase fluid intake to 3000ml/day), leukopenia(monitor for , thrombocytopenia(monitor for bleeding), anemia.  
    • increases effects of warfarin, phenobarb and rifampin increase toxicity of this drug. Prolongs the effects of cocaine.
    • monitor for edema, crackles, cardio/resp distress, HF s/s.
    • crosses BBB


Antibody Anti-tumor


  • Doxorubicin (Adriamycin)


    • antitumor antibiotic
    • binds directly to DNA and stops replication
    • High alert med
    • dose limiting heart failure, and bone
    • cell cycle S phase specific
    • SE: CARDIO TOXIC, dark urine stools, palms and nails, alopecia, leukopenia,
    • monitor uric acid levels, bleeding and CBC, I’s and O’s




  • Cisplatin


    • produces crosslinks in DNA and is cell cycle nonspecific
    • dose limiting kidney failure
    • metastatic, head and neck, testicular, ovarian, bladder ,lung, and colon cancer
    • tubular necrosis in the kidney, ototoxic, bone marrow suppression,  severe nausea and vomiting in the first hour after administration.
    • MOA similar to alkylating agents
    • Kidney Failure is a dose limiting factor.


Mitotic Inhibitors


  • Vincristine


    • prevents cell division (m-phase specific)
    • SE: peripheral neuropathy (Neurotoxic), barely and bone suppression!!
      • vinblastine causes bone marrow suppression and not peripheral neuropathy, so when used together there is not stacking of those side effects.




  • Tamoxifen
  • antiestrogen


    • for treatment and PREVENTION of estrogen related cancers ie. breast
    • SE: causes CANCER, birth defects, vaginal discharge w/ bleeding.
    • DD: carbamazepine = rapid metabolism. and erythromycin = slowed metabolism.   



  • prednisone
  • use in high doses
  • glucocorticoids
  • toxic to lymphocytes and lymph tissues




  • progestin (megace)
    • For breast cancer and endometrial cancer
    • used in AIDS pt for anorexia, weight gain and stim of appetite





  • Aspirin


      • suppress platelet aggregation for the platelet’s life span through cyclooxygenase inhibition.
      • doubles bleeding time for up to seven days
      • can be used for prophylaxis of MI in men and questionable in women.
      • risk of GI hemorrhage
  • Heparin


      • Interrupt coag pathway in factor X and thrombin
      • prevents thrombosis, post op thrombus, and more clots forming
      • SE: HEMORRHAGE, HIT, Sensitivity reaction bc it is animal product, All kinds of bleeding (gums, bruises, petechiae, hematoma, red or black stool)
      • HIT heparin induced thrombocytopenia – antibodies develop against Heparin, and the person can NEVER GET THE DRUG AGAIN, there will also be long term bleeding issues associated with this
      • RAPID acting, and only given IV never PO or IM
      • Made from animals
      • normal aPTT is 40 seconds
      • therapeutic aPTT with heparin is 60-80 seconds
      • PROTAMINE SULFATE is the antidote
    • Lovenox
      • LMW Heparin – low molecular weight heparin
      • only stops factor X not thrombin
      • for prevention and treatment of DVT, prevents complications with unstable angina
      • do not need to check aPTT
      • never givin IM


  • Argatroban


      • direct thrombin inhibitor
      • Use this drug if the patient is experiencing HIT
        • also bivalirudin does this (monitor with ACT test)
      • monitor with aPTT
      • no reversal agent
      • expensive


  • Streptokinase


      • Thrombolytic: Dissolves clot after formation
      • stick all IV’s before giving drug
      • converts plasminogen to plasmin
      • for acute MI, pulmonary emboli, to break up a clot in a central line
      • can cause bleeding, Allergic RXN,


  • tPA alteplase


      • thrombolytic: Dissolves clot after formation
      • stick all IV’s before giving drug
      • major bleeding issues. but not as much of an allergy risk
      • very similar to streptokinase


  • Dabigatran (Pradaxa)


      • direct thrombin inhibitor
      • ORAL anti coag for stroke PT’s w/ non valvular Afib
      • very expensive,
      • bleeding problems as well


  • clopidogrel (Plavix)


      • ADP receptor antagonist
      • given with ASA sometimes, but do not take ASA
      • for PAD and CVA
      • these are contraindicated with HERBALS
      • proton pump inhibitors makes plavix not effective


  • Warfarin (coumadin)


    • indirectly decreases many clotting factors
    • works in the LIVER not the blood
    • normal tests while on warfarin are INR(2-3sec) and PT (12sec)
    • effects IIV, IX, X and prothrombin
    • for long term treatment of thrombosis, or pulmonary embolism, also prophylaxis of clot formation(TIA, Prosthetic valve, Afib)
    • Lasts much longer than heparin
    • SE: bleeding like the rest
    • keep Vit K levels consistent throughout treatment
    • Vit K is the antidote
    • d/d interactions increase clotting: quinidine, antibiotics, NSAIDs, cimetidine, thyroid hormones, ASA, Tylenol even





  • Diazepam (Valium)


      • Centrally acting MM relaxants
      • flumazenil is the antidote for this
      • used to treat spasticity
      • CNS depression, sedation
      • benzo


  • Selegiline (Eldepryl)


    • for parkinson’s and for pt’s taking levodopa



  • Baclofen


      • for spasticity
      • analog for GABA
      • SE: sedation and HA, dizziness, diplopia and weakness
      • do not stop the administration of this drug suddenly
      • taper over 2 weeks or: hallucinations, fever rigidity, paranoia, seizures
      • DO NOT mix with ALCOHOL
      • given 2-3 times/day
      • herbal interactions: kava-kava, valerian root, or chamomile these can cause CNS depression
      • no antidote
    • Carbamazepine (tegretol)
      • SZ med
      • nerve pain and bipolar disorder


  • cyclobenzaprine (Flexeril)


      • Centrally acting MM relaxants
      • do not use in:hyperthyroidism, heart conduction difficulties, heart failure, recent MI.
      • urine color change
      • do not use with other SSRI’s


  • Metaxalone (Skelaxin)


      • Centrally acting MM relaxants
      • ACH effects, caution in sedation w/ elderly


  • methocarbamol (Robaxin)


      • Central acting MM relaxant
      • unknown MOA
      • for acute injuries
      • give ¾ x/day, urine color change, dizzy, drowsy, metallic taste.
      • intensifies with ETOH
      • chemically similar to tricyclic antidepressants


  • Tizanidine (Zanaflex)


      • Centrally acting MM relaxants
      • ACH effects, caution in sedation w/ elderly


  • NM Blocker in general
  • Bisphosphonates (alendronate)


      • decrease bone resorption
      • SE: esophageal irritation, Heartburn, osteonecrosis of the jaw, atypical femur fracture
      • SEVERE esophagitis, stand for 30 MINUTES after swallowing with water only
      • do not take with other drugs


  • Teriparatide


      • STIMULATES bone formation
      • SQ injection
      • can be taken for up to 2 years


  • NSAIDs (COX 1 and 2)


      • used in RA until the DMARDS kick in, (this is changing from NSAIDS to glucocorticoids though)
      • 1st line treatment for gout


  • DMARDs (MTX, Arava, Plaquenil)
  • Disease-modifying anti-rheumatic drugs


      • given first for RA
      • take glucocorticoids until DMARD’s take effect
      • suppress autoimmune inflammatory process
        • TNF is a part of the inflammatory process…


  • Synvisc


      • injectable directly into the joint
      • cartilage and synovial fluid synthesis


  • Indomethacin


    • NSAID for gout
    • inhibits prostaglandins
    • only give for 3-6  days


  • colchicine


    • older gout drug
    • stops inflammation cycle, by decreasing mobility of granulocytes
    • treats acute gout attack


  • Allopurinol


    • febuxostat (Uloric)
    • Xanthine oxidase inhibitor, stops production of uric acid
    • for chronic gout
    • Drink 3 liters of water per day


Diabetes Mellitus


Proinsulin is the prohormone to insulin, and is bound to a C-peptide. The peptide will be found in T2DM, but not T1DM.

type 1 can have Ketoacidosis (DKA), and type 2 can have Hyperosmolar hyperglycemic non ketotic state (HHNK)


incretins stimulate insulin release, suppresses glucagon, slows GI emptying, as well as suppress appetite.



Impaired fasting glucose (IFG) 100-125

impaired glucose tolerance (IGT) 140 – 199 two hours after the oral glucose tolerance test

6.5% > HgA1c > 5.7%


Diabetes Diagnosis

HgA1c > 6.5%

FBG > 126

glucose tolerance > 200



(also promotes K uptake by the cells, so can also be given for hyperK)


  • Lantus


      • no peak, duration of 24 hours


  • Detemir


      • no peak, duration of 24 hours


  • NPH


      • O: 60-120 P: 6-14 D: 16-24
      • cloudy solution


  • 70/30


      • 70% NPH, 30% Regular
      • roll gently to mix


  • Regular


      • O: 30-60 min P: 1-5hr D: 6-10hr


  • Lispro


    • O: 5-10 min P: 30min-2.5hr D: 3-6.5hr




  • Biguanide (Metformin)


      • stops liver glucose production in liver, increases glucose uptake in the periphery skeletal muscles.
      • Will NOT cause insulin production. this means that this drug does NOT put a person at risk for hypoglycemia.
      • Can be used with regular insulin and sulfonylureas
      • SE: Renal issues from LACTIC ACIDOSIS. If a person has renal insufficiency they are put at a much higher mortality rate.
      • MONITOR renal fxn.


  • Sulfonylureas (glipizide, Amaryl)


      • First line, promotes insulin secretion,
      • similar structure to a sulfonamide antibiotic
      • these are 2nd gen. and have longer durations than the 1st gen and fewer d/d interactions.
      • D/D: all cause HypoGLY: ETOH, sulfonamides, Cimetidine, NSAIDs, beta blockers


  • Glitazones (pioglitazone)


      • decrease insulin resistance, and decreases liver glucose production
      • Not a first line med
      • D/D interactions: CIMETIDINE, ketoconazole, rifampin, Atorvastatin


  • Glinides


      • stimulates pancreatic secretion of insulin
      • Can be used with metformin
      • DD: Gemfibrozil


  • A-Glucosidase inhibitors (acarbose, miglitol)


      • Delays carb absorption
      • 2% of drug is absorbed orally
      • SE: abb cramps, borborygmus bowel sounds, flatulence


  • DPP-4 inhibitors (Sitagliptin)


    • Stops DPP-4 from breaking down incretin
    • the hormone Incretin increases insulin release, decreases hepatic glu production and release.
    • Few SE and DD


Injectable noninsulin



  • INcretin mimetics (exenatide – Byetta)


      • increase release of insulin, decrease glucagon secretion, makes you feel full, and slows GI emptying
      • SQ INJECTION at breakfast and supper
      • from Gila monster spit
      • Nausea and vomiting
      • Hypoglycemia possible WITH sulfonylureas
      • a new formulation is once a week SQ injection!
      • SE: weight loss


  • Amylin mimetics (pramlintide – Symlin)


    • Slows GI emptying, decrease glucagon release, pt will feel more full, decrease postprandial glucose levels


Antianemics (heme)



  • Iron sulfate


      • use a straw
      • toxic in kids
      • Makes RA worse
      • for iron deficiency anemia


  • B12


      • treats b12 or pernicious anemia
      • b12 is needed to synthesize folic acid for cell growth and development
      • Cyanocobalamin


  • Folic Acid (folate)


      • for folic acid anemia
      • essential for cell replication
      • anemia can be from alcoholism, liver damage.


  • Deferoxamine


      • high affinity for ferric iron
      • do not take with oj


  • Erythropoietin


    • stimulates RBC production
    • mimics a natural hormone produced in the kidney
    • needs the supplies to make RBC’s: iron, folate, and B12
    • indications: chronic renal failure, anemia from chemo, or a chronic anemic patient having surgery.
    • can cause HTN
    • if HGB increases above 11 MI, CVA, and HF chances are increased dt increased clotting

Pharmacology Study guide #3:

The test three study guide if finally here! I have the drugs arranged into the categories of indication, slightly alphabetized, and the drugs and categories are all bold. This is a very long list of these drugs and if there is anything that you would like to add or change please leave a comment and I will make the adjustment as soon as possible.

Quick tip! If you are looking for a specific drug, search the text using “Command + F” on mac, and on pc open the edit drop down and click find on this page, maybe.

Happy studying!


Anesthesia and analgesia

  • Acetaminophen (Tylenol)
  • anti-prostaglandin
  • metabolized in liver (watch out for this)
  • 3 g per day is the most dose per day
  • works in CNS
  • low GI irritation
  • can be used with kids
  • s/e: liver damage with ETOH is a high risk,
  • toxicity: 25 grams for adult
    • top cause of acute liver failure
    • the OD patient will die in 3-5 days from the liver damage
  • Acetylsalicylic acid Aspirin (ASA) – COX 1
      • gen 1 NSAID
      • inhibits platelet aggregation until there is a reproduction of more platelets
        • irreversible in the platelets that it affects
      • anti prostaglandin (inflammation)
      • do not use in kiddos
      • s/e: salicylism (ringing in ears points towards OD), reye’s syndrome, Renal impairment
      • Too Much? Tinnitus, respiratory depression, HypERthermia, can cause metabolic acidosis, then resp alkalosis to compensate.
  • COX inhibitors
    • COX 1: promotes Platelet aggregation, GI protection, renal fxn, (GOOD)
    • COX 2: promote inflammation (bad)
  • Anticholinergics
      • Can be used in pre anesthesia to reduce secretions
  • “Caine” drugs for numbing
      • local anesthesia
      • for: fingers, ears, nose, toes, and those
  • Codeine
  • Narcotic
  • *1/10th power of morphine
  • 5x power of aspirin, or acetaminophen
  • Epinephrine with Lidocaine
      • keeps the lidocaine local due to the vasoconstrictive properties of epi
  • Celecoxib (Celebrex) – COX 2
      • similar strength to ibuprofen
      • less stomach ulcers than other NSAIDs (some evidence)
  • Fentanyl
  • narcotic
  • **one hundred times stronger than morphine
  • Lollipop form in some cases for chronic pain (cancer)
  • will kill a kiddo!
  • -fluranes
      • Isoflurane
      • Strong anesthetic
        • weak analgesic
      • Volatile liquids mixes with O2 and inhaled
      • Resp depression, HYPOtension, arrhythmias, Hyperthermia
      • ***can be mixed with Nitrous oxide
        • for the strong analgesic properties
        • allows for a lower amount of each inhalant to get the desired effect, which lowers the risk for depression of resp. and the heart
  • Ibuprofen (Motrin, Advil) – COX 1
      • S/E: can cause renal damage, and GI bleeding, Retention of NA and H2O (watch out for HF patients)
  • Inhaled anesthetic agents
      • Works very quickly
  • IV anesthesia agents
      • lasts longer than inhaled
  • Methadone
  • narcotic
  • longest duration of action
  • long QT interval
  • for coming off of narcotics and given in clinics
  • Meperidine (Demerol)
  • narcotic
  • same action as morphine with a shorter action
  • treats post anesthesia shivers or rigors that can occur
  • no cough suppression effect
  • Morphine
  • narcotic
  • moderate to severe pain
  • can be given through almost all routes
  • cross BBB
  • S/E: resp depression, constipation, nausea, Miosis(pinpoint pupils)
  • morpheus god of sleep
  • give before the pain occurs if possible
  • PCA pump allows for the patient to not fall out of the TPR
  • is better than PRN, or fixed schedule
  • decreases overdose
  • can use smaller doses
  • empowers patient
  • cross olerance to other opiates
  • Naloxone (Narcan)
      • opiate antidote
      • also given when there is an OD of unknown cause
      • gen 1: inhibit COX one and two
        • inhibit inflammation
        • inhibits prostaglandins in the stomach, so there is a higher chance for ulcers
      • Gen 2:
      • some studies show slowed healing of muscle, bone and ligament injuries.
  • Propofol
      • rapid onset and short duration
      • no analgesic effect
      • s/e: resp depression, rhabdo
  • Tramadol (Ultram)
      • Non opiate CNS acting analgesic
      • schedule 4
      • not an opiate but binds to the receptor
  • Pyridium (Phenazopyridine)
    • Treats pain from lower UTI’s
    • do not take if the pt has DM, or liver Dx
    • can cause a bright red or orange urine,take with food or there may be a Headache after dose
    • OTC

HA and migraines

All of these drugs vasoconstrict except for CCB and beta blockers. OTC is the most effective, and Ergot is not prescribed often

  • Beta-blockers and Calcium Channel Blockers
    • are prophylactic and chronically reduce the BP and cause the vessels to be less spastic.
  • Ergot Alkaloid
  • Ergotamine
      • for prophylaxis of migraines,
      • Alpha blocker vasoCONstriction
      • Rebound HA
      • S/E: HTN, MI trigger
      • increased risk of stillborn pregnancy increased uterine stim, and decreases the blood flow to the placenta
      • separate 24hrs between the use of ergotamine and sumatriptan.
      • related to ACID
  • Excedrin Migraine
    • OTC
    • one of the best if not the best remedy for HA and migraines
    • formulation: ASA, ibuprofen, and some caffeine
    • basic and effective
  • Triptans
    • Serotonergic  
    • sumatriptan and zolmitriptan
    • stim 5 – HT in the brain
    • it vasoconstricts and inhibits inflammation
    • not for prophylaxis of migraines only treat
    • S/E: stroke, MI, cerebral hemorrhage
    • WAIT 2 weeks to use a MAO-I med
    • DON’T take within 24 hours of ergotamine
      • toxicity w/ other 5-ht blockers, prozac,paxil, zoloft


too much ACH and not enough DA causing dyskinesia and Akinesia. Drugs do not cure but only slow the decline of symptoms, and treat the Bradykinesia, Gait, and improve daily activities. Comes from the degeneration in the extrapyramidal system which controls posture and gait (and others)

  • Anticholinergic
      • reduce ACH to bring balance to the Dopamine/ACH teeter totter
      • Benzotropine (Cogentin) and trihexyphenidyl (Artane)
          • similar to atropine, antimuscarinic
  • Dopaminergic
      • MAO-B inhibitors are used in patients with mild symptoms
  • Selegiline and rasagiline
          • inhibit DA breakdown
        • when the symptoms are increased, given meds change to levodopa and Dopamine agonist
        • S/E: drooling, constipation
  • Levodopa
        • DA prodrug
        • best effect in the first two years
        • take time off the drug “holiday”
        • many d/d interactions
        • vitamin B6 allows less levodopa to get to the CNS
  • Carbidopa
          • no bad effects on its own
          • increase usable levels of levodopa in the CNS
            • Is the CAR that drives levodopa to the CNS
  • COMT inhibitors:
  • blocks breakdown of Levodopa
  • Entacapone, and Tolcapone
        • CAPONE “protects” levodopa, like the mob
  • Levodopa/Carbidopa (Sinemet)
  • Levodopa/Carbidopa/Entacapone (Stalevo)
  • increase TP effects by stopping the breakdown of Levodopa
  • more convenient than taking 3 pills
  • Pramipexole (Mirapex)
  • dopamine agonist
  • first given alone in early parkinson’s then added to Levodopa in late.
  • S/E: sexy grandpa/grandma
  • MAO Inhibitors
    • 2 kinds
      • MAOA helps metabolize norepinephrine and serotonin
      • MAOB metabolizes dopamine
        • Selegiline (Eldepryl) inhibits this so DA is not metabolized.
      • food interactions: aged cheeses and meats, yeast, bread, BEER
      • stop antidepressants 2-7 weeks befor using
  • Selegiline
    • MAOI
    • look MAOI’s
    • many s/e and dd interactions
  • Tricyclic antidepressants (Amitriptyline)
  • Are the only antidepressants that should be used in PA
  • Do not use is ALZ
  • blocks ACH


progression can only be slowed not cured. Medicine is creating new treatments, and there is a link to chromosome 21 (like in down’s). Tangles in the brain may be related to cholesterol so statins may be useful for prophylaxis. Know the lifestyle risk factors: low activity and education, smoking, DM, HTN, depression.

  • Memantine (Namenda) NMDA antagonist
  • Regulates calcium influx into the neuron
  • Indication is moderate to severe AD, but some neurologists start it early with Aricept
  • SE: dizzy, HA, confusion, constipation, hallucination
  • donepezil (Aricept) Acetylcholinesterase inhibitors
  • stop ACHesterase, increasing ACH
  • treatment of early dementia


  • Antivirals
  • Acyclovir (Zocirax)
      • similar to a purine nucleoside, and suppresses protein synthesis
      • S/E: phlebitis, nephrotoxic, stinging sensations.
  • Flu drugs:
      • Amantadine
  • Oseltamivir (Tamiflu)
    • Interferon alpha-2b
      • For hep B
      • causes flu like symptoms, and Hep causes flu like symptoms….
    • Ribavirin
      • Treats hep C with pegylated interferon-Alpha and a PI
  • HIV drugs
      • Reverse transcriptase, protease, and integrase are main targets of treatment to disrupt the virus.
      • HAART therapy – highly active antiretroviral therapy. two nucleoside reverse transcriptase inhibitors, and a protease inhibitor.
      • six classes of drugs to treat HIV
        • Non-nucleoside reverse transcriptase inhibitors (NNRTIs) Nucleoside reverse transcriptase inhibitors (NRTIs) Protease inhibitors (PIs) Fusion inhibitors, CCR5 antagonists or entry inhibitors (CCR5s) Integrase strand transfer inhibitors (INSTIs)
        • focus on the first three plus the fusion inhibitors
          • examples
            • NRTI: Zidovudine (Retrovir)
              • stops replication, slows the Dx, and increases the white blood cell (CD4) levels
              • Two of these are in the First set of Meds given along with on of the following: INSTI, NNRTI, or PI
            • NNRTI: Nevirapine (Viramune) Efavirenz (sustiva)
              • binds reverse transcriptase and stops the transcription
              • Can be a part of the first line of meds along with two NRTI’s
            • PI: Indinavir (Crixivan)
              • very effective
              • Can be a part of the first line of meds along with two NRTI’s
            • FI: Fuzeon, T-20
              • fusion inhibitors
              • stops HIV envelope from fusing with a CD4 cell membrane.
            • INSTI (HIV)- Integrase strand transfer inhibitors
              • Can be a part of the first line of meds along with two NRTI’s
  • CCR5 Antagonist (HIV) – Maraviroc (selzentry)
            • Entry inhibitors
            • Blocks HIV from binding to the CD4 cell (similar to the FI)
            • Can have an allergic rxn, cough, nausea, dizzy
  • Antibiotics
  • Aminoglycosides
        • Inhibit protein synthesis and are bactericidal
        • Causes injury to the inner ear and Kidneys
          • Nephro, and Ototoxic that is permanent
        • Narrow spectrum
        • draw drug levels
          • Peak thirty minutes after IV
          • Trough an hour before the next dose
          • given once a day
  • Amoxicillin
        • Broad spectrum
        • Aminopenicillins
        • disrupt cell wall with beta lactam ring
        • Amoxicillin and Clavulanic acid is Augmentin
          • This increases the effectiveness by breaking down the PenASE enzyme
  • Antibiotic resistance
  • Bacteria can adapt to a drug and create defences from a drug such as the PenicillinASE enzyme.
    • Carbapenems:
  • Imipenem (primaxin)
    • broad spectrum
    • resistant to beta lactam break down (penASE resistant)
    • used in Pseudomonas aeruginosa
    • Superinfections are an adverse effect as well and an allergic RXN
    • Cephalosporins
      • break down cell wall, for G+ and an increasing effectiveness with G-
      • bactericidal, and more resistant to PenASE than penicillin
      • spectrum broadens from gen 1 and 2 (narrow) to gen 3 and 4 are broad
      • ADME: poorly absorbed through PO route, no metabolism, excreted in kidneys and stool
      • allergy in 10% of people w/ the pen allergy
      • four generations: they all have the Cef- or Ceph- prefix.
  • Clindamycin
    • inhibits protein synthesis, Bacteriostatic
    • Narrow spectrum
    • Given with Tetracycline and Bactrim in MRSA
    • only for anaerobic infections such as in the gums, colon, sepsis
      • not effective in the CNS
    • Can give orally (IM,IV as well)
    • S/E: pseudomembranous colitis severe bloody diarrhea, Hepatic and renal toxicity, hypersensitivity
  • Erythromycin (macrolides)
    • Broad spectrum
    • inhibits bacterial protein synthesis
    • use is allergic to penicillin
    • for G+
    • long QT interval
    • S/E: GI upset, cholestatic hepatitis, superinfection
    • D/D: interacts with CCB, HIV protease inhibitors, and antifungal increase the serum levels of erythromycin
  • Fluoroquinolones (Ciprofloxacin) Metronidazole (Flagyl)
    • Broad spectrum
    • inhibits DNA gyrase in bacteria
    • Tendon rupture!!! do not give to kiddos under 18
    • undergo chelation just like tetracycline
  • Gentamycin
    • Aminoglycoside, Inhibits protein synthesis
    • for G- serious (aerobic) infections
    • nephro and ototoxicity
      • draw peak and trough levels to avoid toxicity
  • Penicillins
    • bactericidal in gram positive bacteria
    • safe to humans b/c we do not have cell walls
    • D/D interactions with anticoags increase bleeding, contraceptives with estrogen can be made ineffective when used with Penicillins.
    • beta lactam ring weakens the cell wall
      • beta lactamASE is used by some bacteria, breaks up the ring in the drug to make the drug ineffective
    • unstable absorption when taken orally
    • very thick and viscous IM needs to be givin Z track. it is thick and a lot of pressure is needed to administer.
    • few side effects, but 5% of the population has an allergic reaction
    • PenASE (beta lactamase) makes bacteria resistant to Penicillins
  • Classes of Pen. – Maybe just skim this, the individual drugs are not on the review list.
    • Pen G
      • Benzylpenicillin
        • narrow specturom, and sensitive to penASE
        • Bac-cidal to G+
        • prophylaxis in dental/invasive procedures for endocarditis and syphilis
    • Dicloxacillin
      • Narrow, PenASE resistant
      • Treat staph
    • Aminopenicillins
      • Ampicillin, Amoxicillin (broad spectrum)
      • G+ and some G- are treated
      • S/E: rash and Diarrhea
    • Extended spectrum Penicillins
      • Ticarcillin
      • Piperacillin
      • less important Carbenicillin indanyl, and mezlocillin
  • Ampicillin and sulbactam is Unasyn
  • Amoxicillin and Clavulanic acid is Augmentin
  • Sulfa drugs (sulfonamides) – Trimethoprim-Sulfamethoxazole (Bactrim)
    • Broad spectrum
    • inhibits folic acid to slow down growth
      • folic acid is used in the synthesis of Nucleic acid (DNA RNA and other nucleic acid strands)
      • (this is also why pregnant women should take folic acid supplements)
    • collect urine sample before giving any antibiotic
    • used in UTI G+ or G-
      • UTI is usually caused by e. coli
        • some elderly pts can have bacteria in the bladder and be asymptomatic and done not necessarily need to be treated.
    • Hypersensitivity reaction results in stevens- johnson syndrome
        • Bc it is a sulfa drug
  • Tetracyclines
  • Broad spectrum
  • Inhibit protein synthesis
  • Effective through PO route
  • for acne, lyme Dx, H. pylori, Cholera, Riskettsia, cholera
  • Can treat MRSA with Clindamycin, and Bactrim
  • chelation occurs when calcium, Iron, and magnesium containing supplements and foods inactivate the tetracycline and cause it to be inactive
    • do not take with meals!
    • one hour before or two hours after meals to avoid chelation
  • S/E: photosensitivity, brown teeth, not ok for mothers pregnant and breastfeeding moms, do not give to kiddos.
  • Vancomycin***
    • inhibit Cell wall synthesis
    • most used antibiotic in the US
    • for severe G+ infections: MRSA, C diff, prophylaxis endocarditis
    • ADME: PO is ok with this drug,
    • S/E:**altered taste, OTOTOXICITY**, redneck syndrome if given to quick IV
  • Antifungals
  • Amphotericin B
  • Broad spectrum  
      • Cell wall/membrane permeability is disrupted
        • humans have cell membranes…
        • binds -sterols which are also found in the human body (cholesterol) which causes the renal damage.
        • it is very toxic
      • used for SYSTEMIC mycoses that are potentially fatal, admin parenterally
      • S/E: infusion reaction fever and chills, nephrotoxic
      • ADME: can be found up to a year later in the pt body
  • Griseofulvin
  • still in the -azole class
  • just for SUPERFICIAL  (skin infections), not systemic
  • inhibits fungal mitosis
    • s/e: Insomnia, Rash and headache
  • Ketoconazole
    • used in less severe fungal reactions (fungistatic)
    • MOA is it inhibits the synthesis of ergosterol which is a part of the fungal cell membrane
      • this also affects the body’s sterols (sex hormones)
    • -conazols are all less toxic
  • Mycostatin (Nystatin)
    • Candidiasis only
    • It is in the form of a mouth wash
    • alters the permeability of the membrane
    • used for infant thrush often due to the low side effects.


  • alprazolam (Xanax)
  • Anti anxiety
  • schedule IV, pregnancy class D
  • S/E: Dizzy, Lethargy, Drowsiness, CNS depression
  • grapefruit increases increases effects and the measurable levels of the drug
    • Estrogens
      • may increase risk of ALZ
      • inactivated with Gentamicin
      • contraceptives with estrogen can cause penicillin to be ineffective
    • Food and meds
  • Antacids, Fe, Ca, and Mg Causes chelation in tetracyclines and Fluoroquinolones all the previous + Alu, Zn, and sucralfate
  • Pre-op medication
      • reduce the bad effects of anesthesia
  • Atropine
        • Lomotil treats diarrhea from the use of anesthetics
        • also decreases secretions  
  • Baclofen
  • Anti-spastic
      • treats MM spasms from cerebral palsy, or Multiple sclerosis
      • Can cause seizures!
      • Increase CNS depression with opiates and MAO’s
        • MAO’s with this can also cause HYPOtension
      • Preg category C
    • Narcotics (pain), Benzos and barbs (anxiety), phenothiazines (nausea), MM relaxers.

Nursing Care of Child Bearing Families Study guide #1:

Things to know for test one in Nursing care of childbearing families:

Contractions – Duration is the length of a wave, intensity can only be measured by an IUPC not an external monitor, And frequency is the length of time from the start of one wave to the start of the next.

baseline variability – How much the heart rate moves from the baseline

  • absent – flat line
    • associated with sleep
  • minimal – less than or equal to 5 bpm of variance from baseline
  • Moderate – best rhythm(best parasympathetic/sympathetic teeter-totter), 6-25 bpm variance from baseline
  • Marked variability – more than 25 bpm from base, usually does not last long

Accelerations are always good and show that the baby is reacting to stimulus

  • greater than 15 seconds and shorter than 2 min

folic acid, – start taking in healthy amounts of folic acid before you get pregnant, 500mg is the goal amount to take in each day.

  • neural tubes do not close correctly if there is not enough folic acid resulting in spina bifida, anencephaly, cleft palate, premature and/or low birth weight, and miscarriage.

weight gained in pregnancy – 1st trimester weight gain is 3-5 lbs

  • .5 – 1 lbs per week after 1st trimester
  • How much weight a person should gain determined by pre pregnancy BMI
    • Underweight BMI <18.5: 28-40 lbs.
    • Normal BMI 18.5-24.9: 25-35 lbs.
    • Overweight BMI  25-29.9: 15-25 lbs.
    • Obese BMI greater than 30: 11-20 lbs.


  • progesterone – Hormone of pregnancy, dominant in ovarian cycle in the luteal phase (days 15-28)
  • estrogen – subtle dark skin on face and linea alba from estrogen
    • Estradiol
      • in the reproductive years
    • Estriol
      • only during pregnancy
    • Estrone
      • Menopause
  • HCG – Human chorionic gonadotropin, produced by the placenta only, pregnancy test for this.  
  • oxytocin starts labor through contractions, lactation, bonding, and orgasm. Positive feedback loop.
  • prolactin – enable production of milk, and produced by the pituitary gland
  • relaxin – produced in the placenta and the ovaries, and relaxes the ligaments in the pelvis to allow for the baby to pass through more easily.
  • human placental l (HPL) – produced by the placenta, allows more glucose to get to the baby from the mother’s blood stream by blocking the mother’s cells from using the glucose.

don’t lie women flat on her back or it will occlude the vena cava causing a drop in BP, also it may be harder for the mother to breathe due the shifting of organs allowing for less space for the lungs to expand.

changes in blood values and know the risk factors from lab values (HCT, and Hemoglobin),

  • hypercoagulable
  • left shift in WBC’s (elevated count)
  • Anemia
    • fetus starts to store Iron from the mother at twenty weeks
  • Decrease in HCT and Hemoglobin, treat the HCT if it drops below 11.
  • Increase in the GFR in the kidneys due to the increased blood volume.

Maternal mortality in the US and infant mortality in the US are ranked very low when compared to other developed countries, and this is due to minimal prenatal care.

Know the broad System changes that occur in a pregnant woman’s body.

Know the leopolds – so the lie of the baby and how to describe the positions: oblique, transverse, breach, cervical. 

Gs and Ps,  

  • Gravidity – # of pregnancies including the current one.
  • Parity – # of births after 20 weeks
  • Nulligravida – never been pregnant
  • Nullipara – never given birth
  • Primigravida – first time to give birth
  • Primipara – has given birth to a less than 20 week old fetus one time.
  • TPAL
    • Term – # of births after 37 6/7 weeks
    • PreTerm – # of births between 20 and 37 6/7 weeks
    • Abortion – # of miscarriages, spontaneous or therapeutic abortions
    • Living children – self explanatory

TORCH infections

  • Toxoplasmosis, Other, Rubella, Cytomegalovirus, Herpes
  • these infections need to be treated in pregnant women especially, because they correlate highly with congenital defects.

Chadwick’s sign is the darkening of the labia, cervix and vagina. this comes from the increased blood flow associated with pregnancy.  

Hegar’s sign is the separation of the cervix from the uterus upon palpation, and the softening of the uterus.

fetal development milestones,

  • Heartbeat at 6 weeks on ultrasound, can be heard at 10 week GA for the doppler.
  • Fetal movement at 18-22, it is sooner in women who have been pregnant previously, (multips)

Umbilical cord anatomy – two arteries carrying DEoxygenated blood AWAY from the fetus, and one vein carrying OXYgenated blood TO the fetus.

Pharmacology Test 2 study guide:

Finally the test two study guide is here. The list has information the was given to us as well as supplementary info that I think is important. There are drugs on this list that have more information than others and that is in concurrence with how important or complex that drug or concept is and hopefully how important it is. This list may have errors so please comment with any additions or subtractions that you see, and I will edit the post as soon as I get a chance. Thank you so much for reading and happy studying!


ACE Inhibitor

  • Angiotensin converting enzyme inhibitors
    • stops RAAS system stop hypertension
    • step 1 for HTN meds
    • African population tend to respond poorly to ACE inhibitors

adenosine (Adenocard)

      • slows AV node conduction
  • for PSVT Paroxysmal supra ventricular tachycardia
    • rate of delivery is over 3 seconds by an MD, Very unique

Alpha blocker

  • Block the Alpha receptors which cause vessels to dilate
    • Lower BP

alprazolam (Xanax)

  • Anti anxiety
    • schedule IV, pregnancy class D
    • S/E: Dizzy, Lethargy, Drowsiness, CNS depression
    • grapefruit increases increases effects and the measurable levels of the drug

amiodarone (Cordarone)

  • Group III K channel blockers: delay repolarization
    • delays ventricular repol at qt
    • prolongs action potential
    • increases effective refractory period
  • Pulmonary toxicity
  • grapefruit interaction
  • Side effects: thyroid issues, blue grey skin,
  • D/D interactions: increase effect Digoxin, anticoags, statins, dilantin
  • life threatening dysrhythmias

Angiotensin Receptor Blocker

  • for HTN
  • blocks angiotensin II receptor from binding and causing vasoconstriction
  • ex.
    • Losartan (Cozaar)
      • Actions – more specific than ACE


Antacids that can be bought over the counter (the goal is to bring pH of the stomach to about 3.5): Tums, Caltrate, OsCal, Viactiv(not w/ coumadin), Citracal (not w/ KD)

  • Action: increase stomach pH
  • indications: Peptic ulcer, GERD, hernia
  • ADME:
    • onset: 20-40 min (give 1-3hr before meal + night)
    • not meant to absorb, just buffer the acid
    • excreted in the feces
  • reduces Absorption of other drugs (chelation) due to the raise in stomach pH
  • S/E: constipation, bone deg, increased acid secretion, Kidney failure, Diarrhea
    • increased Ca, K and NA, decreased Mg
    • Kidney failure in chronic use


  • used to treat H.pylori with bismuth and proton pump inhibitors
    • lasts for 2, and then the Antibiotics and bismuth drop off and the PPI is prescribed for 4 more weeks, about 90% of people are recovered after this treatment.
    • antibiotic- induced Diarrhea for the elimination of C. diff with the antibiotic fidaxomicin (Dificid)

antidysrhythmic drugs

Antidysrhythmic drug classes or group (listen to heart for 1 min)

  • I – quck Na channel blockers (broken up into three classes, but do not need to know that for the test
    • Ia – quinidine
      • procainamide (more side effects)
    • Ib – lidocaine
    • Ic – flecainide  
  • II – Beta Blockers
    • Propanolol
    • metoprolol
  • III – K channel blockers
    • Amiodarone
  • IV – Ca channel blockers
    • Verapamil
    • Dilitiazem
  • V – variable mechanism
    • Adenosine
    • Digoxin
    • Magnesium sulfate


  • Action: Block CTZ (chemoreceptor trigger zone)
    • relieve nausea and vomiting
  • Anticholinergic: Scopolamine (Transderm-Scop)
    • for motion sickness
    • Side effects: Blurred vision, dry mouth and CNS depression
  • Antihistamines
    • Diphenhydramine (Benadryl)
    • Dimenhydrinate (Dramamine)
      • H1 blocker (antihistamine), CNS depression
  • Phenothiazine:
    • Prochlorperazine (compazine)
      • similar to atropine
  • Dopamine receptor blocker
    • Metoclopramide (Reglan)
      • Drousie, extrapyramidal effects, Diarrhea
  • Cannabinoid
    • Dronabinol (Marinol)
      • Made from THC


  • NSAID’s
  • Steriods
  • C-reactive protein levels reflect inflammation
    • high levels associated w/ increased risk of CV problems

Antiseasickness pills

Antiemetics will help, but not all.

    • Action: Block CTZ (chemoreceptor trigger zone)
      • relieve nausea and vomiting
  • Anticholinergic: Scopolamine (Transderm-Scop)
  • for motion sickness
  • Side effects: Blurred vision, dry mouth and CNS depression
  • Antihistamines
    • Diphenhydramine (Benadryl)
    • Dimenhydrinate (Dramamine)
      • H1 blocker (antihistamine), CNS depression

Atorvastatin (Lipitor)

  • Class: HMG-CoA reductase inhibitors
    • Action:block the synthesis of cholesterol
      • inhibits HMG-CoA reductase: so the pathway for cholesterol synthesis is blocked.
    • Indications: Hypercholesterolaemia, Coronary heart disease, Stroke, MI and chest pain
    • S/E: Rhabdomyolysis (ask about muscle pain and tell the patient to report any pain or weakness), Angioneurotic edema
    • stronger than simvastatin, not as strong and Rosuvastatin


  • Anticholinergic/antiarrhythmic
    • Action: blocks vagal stimulation, which increases (HR) SNS
      • blocks Acetylcholine at prostaglandin sites
      • Tachy arrhythmias, Pulmonary edema, physostigmine is the antidote for an OD
      • side effects: red as a beet, mad as a hatter, hot as a hare,

Benzodiazepine drugs

    • for insomnia, anxiety, seizures, alcohol withdrawals
  • for acute use not chronic (does not cure Dx, can develop tolerance and dependence)
  • 14 days tops
      • schedule IV (most)
      • may be related
      • patho: increases the effect of GABA, calming, sedative
          • GABA receptors are dense in the limbic system, which messes with your emotions
  • abnormal non-REM sleep
        • BZ1 receptor: cerebellum: controls anxiety
        • BZ2 receptor: basal ganglia, and hippocampus: MM relaxation
      • side effects and interactions: Smoking decreases effectiveness, parental rout can cause cardiovascular issues and must adhere strictly to the rate, hypotension depression of RR(with IV), and CNS, Pregnancy risks.
  • IV, give slowly, needs to be monitored
      • make resp issues worse
    • will not cure, or meant to cure the symptoms
    • used for conscious sedation (colonoscopy)
    • Withdrawal: starts in 1 to 3 days and peaks in 1 to 2 weeks (depends if short or long acting drug)
      • weight loss, anxiety, weakness, insomnia, and tremors
    • ex: diazepam (Valium),
      • used for: Calms a person down so they don’t puke as much before chemo, alcohol withdrawal
      • the metabolites can collect over time and cause CNS depression
        • Resp. ↓ and hypotension
      • when given IV the vessel gets irritated  
        • burns in IV so dilute or slow down the rate of admin
      • #1 drug in the US
    • ex: lorazepam (Ativan)
      • similar to diazepam
      • for status epilepticus
      • dosing too fast can lead to bradycardia, RR depression, and apnea about 2 mg/min

Beta blockers

  • reduces heart rate and force of contraction and therefore O2 demand
  • long term only
  • makes vasospastic angina worse (prinzmetal)
  • Non-selective – decrease Cardiac contractility, drops bp and renin release
    • HTN, tachycardia, and angina
  • Some are more lipid soluble and more water soluble
  • Education – don’t change the regimen
    • OTC cold meds with pseudoephedrine/ phenyleprine
    • HR <45 don’t give
    • orthostatic hypotension
  • don’t stop the regime or the opposite effects happen, HTN, rapid HR

Bile acid sequestrants

  • Colesevelam (Welchol)
    • binds bile acid so it cannot reabsorb
    • does not decrease vitamin absorption and not many other meds
    • Not absorbed
    • for hyperlipidemia and high LDL
    • take with lots of fluids
  • cholestyramine (Questran)
    • Binds bile so it cannot be reabsorbed
    • used with statins
    • take with lots of fluids

Bismuth subsalicylate (Pepto-Bismol)

  • Antidiarrheal
    • promotes absorption in the intestines to decrease diarrhea  
    • bismuth is not absorbed, subsalicylate is
    • S/E constipation, grey stool,
    • OTC
    • if taken with ASA increases toxicity risk


psyllium (metamucil)

  • encreases stool size and softens by absorbing water, this increases the size of the bolus and pushes against the wall of the intestine to stimulate peristalsis
  • takes 12hr -3 days work
  • excreted in stool
  • NEED fluid for it to work!

Calcium carbonate (TUMS)

  • Action: increase stomach pH
  • indications: Peptic ulcer, GERD, hernia
  • ADME:
    • onset: 20-40 min (give 1-3hr before meal + night)
    • not meant to absorb, just buffer the acid
    • excreted in the feces
  • reduces Absorption of other drugs (chelation) due to the raise in stomach pH
  • S/E: constipation, bone deg, increased acid secretion, Kidney failure, Diarrhea
    • increased Ca, K and NA, decreased Mg
    • Kidney failure in chronic use


  • Diltiazem (Cardizem)
  • Verapamil (Calan)
  • Calcium channel blockers
    • used in stable vasospastic angina, Arrhythmias, HTN
    • Slows HR

Cimetidine (Tagamet)

  • Peptic ulcer Drug
  • Acid-Neutralizing Drugs
  • H2 receptor blocker


– positive inotropic, negative chronotrope, neg dromotrope

  • increased cardiac contractility
  • decreased conduction
  • indications: CHF, AFIB
  • use loading doses
  • SE: bradycardia, av block, anorexia, vision issues, green- yellow tint, halo around lights, gynecomastia with long term use.

dopamine (Intropin)

  • catecholamine (sympathomimetic)
    • increase BP, CO, vasoconstriction (B1, A2)
    • Very toxic to tissues
    • need large bore IV
    • For Cardiogenic shock primarily and vasoconstriction (neurogenic shock)


  • catecholamine (sympathomimetic)
  • Bronchodilation, vasoconstriction
  • A1, vaso constriction
  • Beta1, increase BP
  • can have a paradoxical bronchospasm

Eszopiclone (Lunesta)

  • Benzo-like drug
    • for sleep only, not anxiety
    • for increasing the duration of sleep
    • S/E sleepwalking, driving and such
      • Bitter after taste


  • Benzo antagonist
    • no effect on a person not on a benzodiazepine
    • antidote for benzo OD or excessive effect
    • short half life so it is given through a drip or multiple IVP
    • S/E: hypotension, decreased respers, and cardiac arrest

H2 Blockers

  • Cimetidine (tagamet)
  • ranitidine (Zantac) fewer side effects and strogerew
    • Better value to prevent ulcer than PPI
    • Action: Lowers H2 secretion by stopping histamine from stimulating H2 receptors
    • Prevents PUD, acid reflux, hypersecretion

IV fluids


  • Osmotic Laxatives
  • and milk of magnesia
    • sugar, and salt that don’t absorb well and then attract water to induce peristalsis.
    • ↓serum Ammonia in people with chronic liver disease
    • works in 1-3 days and not much is absorbed into the body

Lidocaine (Xylocaine)

  • Group IB Na channel blockers
    • ↓ depol of mm contraction (decreases the time of action potential)
      • monitor on EKG
    • works first on the tissues with the issues
    • for Ventricular dysrhythmias acutely  
    • narrow therapeutic range
      • the maximum dose is 3mg/kg
    • Side effects – CARDIAC ARREST, confusion, tremors, twitching, blurry vision, tinnitus, dizziness, fainting, Bradycardia
    • D/D interactions with propranolol and cimetidine increase the drug levels

Lovastatin (Mevacor)

  • HMG-CoA reductase inhibitors
  • Stops the pathway for the synthesis of cholesterol
    • for hyperlipidemia when diet is not enough
    • Side effects: MYALGIA, can lead to mm damage, Kidney injury
      • more risky when taken w/ niacin or gemfibrozil
    • Grapefruit interaction, increase the level of the med


  • remelton (Rozerem)
    • activates melatonin receptors
    • hypnotic, for falling asleep
    • effect in 30mins, ok for chronic use
    • no dependence symptoms when stopped
    • safe for long term use

Metoclopramide ( Reglan)

Dopamine receptor blocker

  • gastric stimulant
    • Drousie, extrapyramidal effects, Diarrhea
    • S/E: Gynecomastia, bone marrow suppression

Misoprostol (Cytotec)

  • Prostaglandin
    • cytoprotective agent
    • PG E1 analog – ↓Acid secretion, ↑ Bicarb (HCO3) and mucus secretion
    • Category X, miscarriage
    • Prevents NSAID ulcers

Mylanta or Maalox liquids

  • Aluminum and magnesium antacid
    • neutralizes acid in the stomach increasing pH
    • may affect absorption of some drugs and foods


  • Opiate Antagonist
    • Antidote for opiates
      • reverses the CNS and Respiratory effects of opioids
    • S/E V. fib


  • nicotinic agent, lipid lowering agent
    • coenzymes for lipid metabolism
    • increased risk of myopathy with Statins
    • Flushing occurs
    • Vitamin B 3


Nitroglycerin SL, ointment, patch (NTG)

  • Organic Nitrate Vasodilators
    • nitroglycerin
      • both short and long term
      • vasodilates peripheral and coronary arteries
        • does not dilate the atherosclerotic vessels (so the elderly may not respond well)
        • Hypotension Fall risk
        • will get a headache and that’s OK
        • taken sublingual(minutes), ointment (half hour to hour and can cause tolerance)
      • wear gloves when applying the patch to avoid headache
  • Use for chest pain emergency
      • one SL wait 5mins
      • if after second dose pain is still happening call 911
      • take no more than 3 doses
    • Capsules
      • sustained release
    • Ointment
      • apply to hairless chest wall and cover with plastic
    • transdermal patch
      • don’t soak in water
  • rotate placement of patch
  • 10-12 hr time w/out patch
    • D/D interactions: any hypertension meds
      • nicotine
      • Phosphodiesterase
    • Light and heat will break down the drug and make it ineffective
  • Others for chronic angina
    • Beta blockers
      • reduces heart rate and force of contraction and therefore O2 demand
      • long term only
      • makes vasospastic angina worse (prinzmetal)
    • Calcium channel blockers
      • used in stable vasospastic angina


  • Non steroidal anti inflammatory
    • Ibuprofen, ASA, acetaminophen
    • can cause ulcers
      • misoprostol and sucralfate can prevent these ulcers

Omega 3 fatty acids

    • fish oil
    • RX is Lovaza
    • not complete evidence in: dementia, Diabetes

Omeprasole (Prilosec)

  • Proton pump inhibitor
  • better at repairing ulcers than H2 blocker
  • Blocks acid secretion
    • Blocks ATPase at the parietal cells that would produce H2
    • treats: esophagitis from GERD, Duodenal ulcer, long term HTN
    • quick onset, 2h to peak, and ends effectiveness at 3-4 days
    • Side effects are: Heartburn, weakness, dizziness, C.diff risk increases, also cannot absorb Ca as efficiently
  • Ulcers can heal in a matter of weeks

Ondansteron (Zofran)

  • Block serotonin 5 HT3 receptors, antiemetic
    • D-D interaction with apomorphine causing hypotension
    • monitor EKG in patients with hypoK and Mg, HF, brady arrhythmias
    • can be hepatotoxic over 8mg for day  

Osmotic laxatives

  • lactulose and milk of magnesia
    • sugar, and salt that don’t absorb well and then attract water to induce peristalsis.
    • ↓serum Ammonia in people with chronic liver disease
    • works in 1-3 days and not much is absorbed into the body
  • polyethylene glycol (Golytely) (Glycerin sup in children)
    • draws water into intestine (sugar, salt, and PEG)
    • Cleansing before colonoscopy
    • (Other) metoclopramide (Reglan)
  • ↑ ACH, stim PSNS
  • ↑secretions, and motility
  • for GERD, risk of ileus, and to eliminate barium
  • Contra indicated in patient with intestinal blockage


Pancreatic enzymes (Prancrelipase)

    • ind: Pancreas insufficiency (pancreatitis, cystic fibrosis, Pancreatectomy)
    • Act: increased digestion in GI (enzymatic)
    • Enteric coated
    • S/E all abdominal, Fibrosing
    • hold if NPO, give before meals (dose based on calories)


    • Barbiturate
    • patho: increases the effect of GABA, calming, sedative
    • used in addition to anesthesia
    • for insomnia, seizures, anxiety (acutely)
  • develop tolerance to the therapeutic effect, but not to the side effects
  • liver makes more enzymes to break down the drug, and lowers the therapeutic half life.
    • used to treat neonatal kiddos to use this increased metabolic effect w/ hyperbilirubinemia.
  • S/E: ↓ CNS, cardiovascular function, and RR.
    • hangover, porphyria (werewolf?), suicide
  • withdrawal: seizures (if they have epilepsy), anorexia, weakness, chills, poor sleep
    • This is called abstinence syndrome

Phenothiazine antiemetics

  • Prochlorperazine (compazine)
    • antiemetic
    • management of nausea and vom.
    • depresses the CTZ, changes the effect of dopamine  
    • S/E: Neuroleptic malignant syndrome, and med leads to Reye’s syndrome in kids younger than 16
      • dry eyes and mouth, pink or reddish brown urine, agranulocytosis
  • similar to atropine

Phenytoin (Dylantin)

  • For tonic clonic seizures
    • blocks Na channels selectively
    • take often (tid)
    • low therapeutic index
      • half life is variable even in the same patient: 8-60 hr
    • S/E: gingival hyperplasia, CV effects, cognition issues, steven johnson syndrome and toxic epidermal necrolysis (like being burned inside out)
    • screws up Vitamins: deficiencies Folic acid, D and k

Pravastatin (Pravachol)

  • HMG-CoA reductase inhibitor, lipid lowering agent
    • Blocks synthesis of cholesterol
    • additive med for the prevention of CV disease in people that already have CHD
    • S/E: Rhabdomyolysis,
    • least impactful to most impactful
      • Lova-, Prava-, Simva-, Atorva-, Rosuva-
      • rosuvastatin newest, strongest, most side effects
      • HDL changes start at simvastatin

Promethazine (Phenergan)

  • Antiemetic
    • CTZ depression,  changes the effect of dopamine
    • S/E: agranulocytosis, neuroleptic malignant syndrome
      • dry eyes and mouth, blurry vision, and constipation


  • propranolol(only one that is not beta 1 selective), acebutolol, esmolol, sotalol
    • Decreases contractility, automaticity in SA, and slows conduction
    • cardioprotective for post MI and HF? this is now uncertain, and may not be true
    • slows conduction, HR, renin, BP,
    • increases cardiac output

Proton Pump Inhibitors (PPIs)

omeprazole (Prilosec) -prazole

  • better at repairing ulcers than H2 blocker
  • Blocks acid secretion
    • Blocks ATPase at the parietal cells that would produce H2
    • treats: esophagitis from GERD, Duodenal ulcer, long term HTN
    • quick onset, 2h to peak, and ends effectiveness at 3-4 days
    • Side effects are: Heartburn, weakness, dizziness, C.diff risk increases, also cannot absorb Ca as efficiently
  • Ulcers can heal in a matter of weeks

Ramelteon (Rozerem)

  • Hypnotic
    • melatonin agonist (activates receptors)
    • for insomnia, works in 30mins
    • more selective and effective than supplement of melatonin
    • D/D interactions: Fluvoxamine, Liver Dx’s, and alcohol
    • S/E: basically getting too sleepy, also amenorrhea

Ranitidine (Zantac)

ranitidine (Zantac) fewer side effects and strogerew

  • H2 receptor blocker
  • Better value to prevent ulcer than PPI
  • Action: Lowers H2 secretion by stopping histamine from stimulating H2 receptors
  • Prevents PUD, acid reflux, hypersecretion

Rosuvastatin (Crestor)

  • Strongest Statin
    • this means that it also has the most severe side effects
    • HMG-CoA reductase inhibitors

Sildenafil (Viagra)

    • erectile dysfunction and vasodilation
      • can treat pulmonary artery HTN
  • contraindicated use with Nitrates (nitroglycerin)
  • causes hypotension
    • S/E: MI, hepatic toxicity

Sodium Nitroprusside (Nipride)

  • vasodilation
    • breaks down into Nitrous oxide


  • HMG-CoA reductase inhibitors
  • Not all statins are alike
    • least impactful to most impactful
      • Lova-, Prava-, Simva-, Atorva-, Rosuva-
      • rosuvastatin newest, strongest, most side effects
      • HDL changes start at simvastatin

Stimulant laxatives

bisacodyl (Dulcolax)

  • stimulate peristalsis by affecting the muscle and mucus secreting cells
  • works in 6-8hr
  • can cause fluid loss (watery discharge), cramping, and dependence

Stool softeners

  • Docusate sodium
    • absorbent, water is pulled into fecal matter
    • causes the retention of water and electrolytes not letting them be absorbed into the body
    • takes 12 hours to 3 days

Sucralfate (Carafate)

  • anti ulceral, GI protectant
  • Protects ulcer by forming a barrier with the ulcer cells from acid in the stomach.
  • For PUD, and protect other ulcers from forming. (NSAID’s)


  • Caused muscle spasms including high HR and HTN
    • vaccination is Tdap

Zaleplon (Sonata)

  • Benzo-like drug
    • for sleep only, not anxiety
    • for falling asleep
    • S/E: sleepwalking, driving and such
    • rebound insomnia after tolerance is built over a time of longer than a week
    • Motor Paralysis “locked in”

Zolpidem (Ambien)

  • Benzo-like drug
    • for sleep only, not anxiety
    • for falling asleep and asleep and staying asleep
    • S/E: sleepwalking, driving and such
    • rebound insomnia after tolerance is built over a time of longer than a week