Select one of the folowing normal skin conditions and indicate non-pharmacological 
interventions you might suggest andthen a common medication that would be used.

Is there supposed to be a list of normal skin conditions to address?

Sorry Holly I inadvertently left out speak to someone with dry skin and someone speak 
to an individual with oily skin.

Moisturizers, lubricants, and emollients help to retain water in the skin.  They are 
composed of petrolatum, lnolin, or other agents such as colloidal oatmeal in an 
emulsion.  

Emollients, moisturizers, and lubricants are applied afer the patients bathes.  This 
procedure acts to trap the moisture in the skin.  Ointments provide the most occlusive 
barrier, creams are the next best.  Lotions offer the convenience of easy application over 
large areas of the skin but are not as occlusive as ointments and creams.  Topical 
emollients interact only with the outermost layers of the skin and are not absorbed 
systemically.

There are no true contraindications to emollients, other than to avoid the eyes.  Patients 
who are allergic to wool should avoid Eucerine and other lanolin-containing products.  
There are minimal to no adverse drug reations reported with the use of emollients. There 
are no drug interactions with the use of emollients.

To treat dry sking, the emollient is applied after patients bathe, one to four times per 
day. Pts pat their skin dry and then liberally apply the lotion or cream to all affected 
areas.  This procedure acts to trap the moisture in the skin.  Ointments provide the most 
occlusive barrier, creams are the nest best.  Otions offer the conveinience of easy 
application over large areas of skin but are not as occlusive as ointments and creams.

Wynne, A.L., Woo, T.M., Millard, M.  (2002).  Pharmacotherapeutics for Nurse Practitioner 
Prescribers.  Philadelphia: F.A.Davis Company.

Select 2 of the following lesions, define them and indicate a skin problem where they are 
present.

papule, macule, vesicle, plaque, nodule, keloid, scale, bulla

Papule: a small, solid, raised lesion less than 1 cm in diameter. Most
of it is elevated above rather than deep within the plane of surrounding
skin. A papule is palpable and the elevation is caused by metabolic or
locally produced deposits such as the lesions of lichen planus and
nonpustular acne.


Plaque: A plateau-like elevation above the skin surface that occupies a
relatively large surface area  in comparison with its height above the
skin. It is usually well-defined.
Frequently it is formed by a confluence of papules as in psoriasis and
mycosis fungoides.

Fitzpatrick, T., Johnson, R., Wolff, Suurmond, D. (2001). Color atlas &
synopsis of

     clinical dermatology. McGraw-Hill

Keloid - is a protrusion of scar tissue that extends beyond the wound edges and may 
assume tumorlike massess, that irregular, raised,and red. They are permanent, without 
any tendency to subside. C/O, tenderness, pain, and hyperesthesia. Keloids are thought 
to be hereditary and occur more offten in dark-skinned people, particularly in African 
Americans. It not life threatening, but can cause some serious cosmetic implications. 
Keliods form when the body produces an excess of collagen during healing, they appear 
around wound edges or when someone have their ear pierced and regress in time. 

Scales - are flakes secondary to desquamated, dead epithelium. Flakes adhere to skin 
surfaces, color varies can be silver or white, texture varies, can be thick or fine. Example 
would be, dandruff, psoriasis, dry skin, and pityriasis rosea.

Vesicles are elevated, superficial circular lesions filled with serous fluid. Vesicular lesions 
are characteristic of varicella and herpes zoster (shingles). In chicken pox, lesions 
usually start on the trunk and spread to the extremities, face, head, and in severe cases 
the mouth. The vesicular lesions in shingles tend to follow a dermatome on the trunk. In 
both cases, the lesions are contagious as long as they drain serous fluid. 
Local symptoms are alleviated with compresses, calamine lotion or baking soda. Antiviral 
drugs, vidarabine or acyclovir may help. Antivirals are not recommended for otherwise 
healthy children with chicken pox, but strongly recommended for patients with chicken 
pox over the age of 20. Shingles patients with post herpetic neuralgias may be 
effectively treated with tricyclic antidepressants.

Keloid lesions are irregularly shaped, elevated, progressively enlarging scars which grow 
beyond the wound. Keloids are caused by excessive collagen in the corneum during 
tissue healing. They start as pink or red, firm and well defined rubbery plaques that 
persist for several months following surgery or trauma. Later, uncontrilled overgrowth of 
the scar tissue causes extension beyond the site of the wound. Burn most commonly 
invoke a keloid response.
A familial tendency for keloid formation has been identified. Prevention includes avoiding 
unnecessary surgeries, electrosurgery or chemosurgery. 
Treatment of choice is intralesional steroid injections. Silicone sheeting gell and 
cryotherapy have also been effective.
Blacks and orientals commonly have keloid reactions, which can also occur from 
seemingly minor trauma, and are most common on the chest, shoulders, and back.

Macule: A flat, circumscribed area that is a change in the color of skin,
less than 1cm in diameter. Examples are freckles, flat moles, petechiae, 
measles, scarlet fever.

Vesicle: elevated, circumscribed, superficial, not into dermis, filled with 
serous fluid, less than 1cm in diameter. Examples are varicella (chickenpox),
herpes zoster (shingles).

Select 2 of the following lesions, define them and indicate a skin problem where they are 
present.

Nodule: elevated, firm, circumscribed lesion; deeper in dermis than a papule. 1 - 2 dm in 
diameter. Example: erythema nodosum, lipomas

Bulla: Vesicle greater than 1 cm in diameter. Example blister, pemphigus vulgaris

2. Lesions 
A)   Papule- an elevated solid lesion up to 0.5cm in diameter, color varies
                   Example- acne vulgaris is characterized by small, less than 5mm, raised   
                   erythematous papules. 

B)  Vesicle- circumscribed collection of free fluid up to 0.5 cm in diameter
                  Example- seen in herpes zoster eruptions.  

Select 1 of the following skin problems and briefly discuss cause, presentation, key 
medication used to rs and pt. taeching.

atopic dermatitis, psoriasis, acne, impetigo, tinea corporis, rosacea, cellulitis

Impetigo: is a superficial vesiculopustular skin infection.
Staphylococcus aureus is the most frequent cause of superficial skin
infections. It is a much more common initial cause than group A
beta-hemolytic streptococcus. S. aureus is the primary pathogen in
bullous impetigo occuring anywhere on the body and incrusted facial
impetigo.

Common presentations: are the arms, legs, and face which are more 
susceptible to impetigo than unexposed areas. Lesions vary from pea-
sized vesicopustule to large bizarre, circinate ringworm-like lesions. 
Lesions caused by S. aureus progress rapidly from maculopapules to 
vesicopustules or from bullae to exudative and then honey-colored, 
crusted circinate lesions. Untreated infection in adults can result in 
cellulitis, lymphangitis, or furunculosis. In children, untrated, 
erythematous lesions may persist for months.

Treatment:Application of 2% mupirocin ointment (Bactroban) tid for 10 
days to the affected area or until all lesions have cleared. Patients 
showing no response to mupirocin in 3-5 days should be treated 
systemically. Because most cases are caused by penicillinase-producing 
staphylococci, cloxacillin or a first generation cephalosporin is the
drug of choice. Penicillin-allergic patients should recieve cefadroxill 
30mg/kg/day po divided into 2 daily doses or cephalexin for 10 days
(50mg/kg/day po divided q 6 hours for children, 250mg qid for adults)
rather thatn eerythromycin: the increased frequency of erythromycin-
resistant staphylococci (10-40%) has decreased the drugs 
effectiveness. Prompt recovery usually follows treatment.

Beers, H.,Mark & Berkow, R. (Eds.). (1999). The merck manual. Merck  
     Research Laboratories. Whitehouse Station. N.J.

Acne Vulgaris is a common follicular disorder affecting susceptible pilosebaceous follicles 
(hair follicles). Acne begins when a closed comedones (whitehead) are obstructive lesions 
formed from impacted lipids or oils and keratin that plugs the dilated follicle. Whitheads 
are small, whitish papules with minute follicular openings that generally cannot be seen. 
These closed comedones may evolve into open comedones, in which the contents of the 
ducts are open to the external environment. Open comedones are called blackeheads. 
The color of the blackhead results not from dirt but from an accumulation of lipid, 
bacterial, and epithelial debris.

Presentation - most commonly found on the face, neck, and upper trunk of the body 
where the glands are most dense. Neonatal acne occurs in reponse to material androgen, 
first appears at 2 to 4 weeks of age, and last until 4 to 6 months. Acne can contribute to 
psychosocial problems such as clinical depression, anxiety, self-imposed isolation, low-
self esteem, and negative body image. 

Medications - may either be topical or systemic.  Topical agents are retinoids and 
antibotics. Retinoids are tretinoins, a naturally occurring derivative of vitamin A. 
Adapalene is a topical retinoid-like drug used for the treatment of mild to moderate acne 
vulgaris. Tazarotene is a retinoid prodrug that is converted to its active form, AGN 
190299, which is the cognate carboxylic acid of tazaritene. Topical retinoids are applied to 
affected areas daily after washing face with a gentle cleanser, usually before bedtime.
Antibotics are benzoyl peroxide, which has antibacterial activity against P. acnes, the 
predominant organism in sebaceous follicles and comedones of acne. Erythromycin is a 
bacteriostatic macrolide antibotic but may be bactericidal in high concentration. 
Clindamycin demonstrates in vitro activity against isolates of P. acnes, the common 
bacteria found in acne. Tetracycline mechanism of action on how it improves acne is 
unknown. Metronidazole the mechanism of action on how it improves acne is uknown. 
Azelaic acid in acne it has an antimicrobial effect against P. acnes and Staphylococcus 
epidermidis, the mechanism of action may be due to inhibition of microbial cellular 
synthesis. Topical antibotics are applied to the affected area twice a day after washing 
with a gentle cleanser.
Systemically, oral antibotics, such as tetracycline in small doses over a long period of 
time have shown be effective. oral retinoids, isotretinoin (accutane) is used for for 
nodular cystic acne and active inflammatory papular pustular acne that has a tendency to 
scar. 

Teaching - instructions on how to use the medicaton and when, adverse reactions. keep 
hands cleans and away from face as much as possible. use gentle facial cleansers such as 
mild soaps and facial washes. Avoid scrubbing, picking, and squeezing blackheads and 
whiteheads. Do not use products that will aggravate acne, such as oil-based cosmetics, 
hair spray, mousse, shaving creams and facial creams and moisturizers. Use sunscreens 
that are oil-free at all times because of the increased photosensitivity due to acne 
preparations. drink plenty of water if allowed and eat a healthy nutritious diet.

Select 1 of the following skin problems and briefly discuss cause, presentation, key 
medication used to rs and pt. taeching.

atopic dermatitis

Atopic dermatitis is an inflammatory skin disorder characterized by erythema, edema, 
intense pruritus, exudation, crusting, xerosis, and lichenification. Many patients have a 
family history of allergy or a personal history of asthma, hay fever, or allergic rhinitis.

Cause:  
True origin of disease unknown. Hypothesized to be multifactorial, including genetic, 
environmental, and infectious conditions. Currently thought that a defect of a bone 
marrow-derived cell causes a variety of cutaneous and generalized immune 
abnormalities. 
Contributory or predisposing factors:
Family history of allergy in the parents or in a sibling 
B cell IgE overproduction is a predisposing factor (allergy)
Depressed cell-mediated immunity 

Medications: 
Topical immunomodulators are a newer class of agents that are effective in reducing the 
inflammatory process. Two agents are approved, tacrolimus ointment and pimecrolimus. 
They should only be used as a last alternative when other therapies have failed due to 
potential increased risk of immunosuppression and cancer.
Topical steroids are effective in reducing the inflammatory process. Mild creams and 
ointments include hydrocortisone and triamcinolone acetonide (0.025%); moderate-
strength creams and ointments include triamcinolone acetonide (0.5% and 0.1%); potent 
creams and ointments include betamethasone dipropionate (0.05%) and fluocinonide 
(0.05%).
Water-miscible creams are suitable for moist or weeping lesions. They are usually 
preferred by patients as they are easier to apply than the stickier ointments. Ointments 
are generally chosen for dry, lichenified or scaly lesions or for cracked skin.

Pt. teaching: Diminish dryness of the skin: 
Emollients should be used frequently and liberally to protect the skin from drying and 
cracking. Daily application following bathing should become part of the patient's regular 
routine. For dry lesions, liberal use of emollients between steroid applications can 
minimize steroid exposure while maximizing the benefits of therapy.
Soap substitutes, which are emulsifying solutions (e.g. Cetaphil) used in the same 
manner as soap, will diminish drying of the skin during washing.
Bath additives increase lubrication of the skin and reduce itching.

Tinea Corporis (ringworm) is caused by direct contact with infected people, animals, or 
inanimate objects that transmits the fungal infection. Most ringworm infections result 
from human dermatophytes. Still, you can develop ringworm through exposure to 
animals (commonly the household pet) and from the soil.

Presentation: Tinea corporis (ringworm) looks like its name. It forms a red, elevated, 
rapidly growing, ringlike sore on the skin. The center of the ring may be clear. The sore 
itself may contain scales, crust, or fluid-filled areas. Itching and pain may accompany the 
sore (lesions). Each lesion is less than 5 cm across (about 2 inches) and occurs alone or 
in groups of 3-4.

Apply topical antifungals to the lesion itself and 1 inch beyond its border twice daily for a 
minimum of 2 weeks, and at least 1 week after it goes away. Keep the infected area 
clean and dry. Over-the-counter medications available at retail pharmacies  include 
miconazole 2% (with brand names such as Monistat and Micatin) or clotrimazole 1% (with 
brand names such as Lotrimin and Mycelex).
If only 1 or 2 lesions exist, topical antifungal therapy is sufficient. A patient  may be 
given a prescription for any of the following topical medications: Imidazoles (clotrimazole 
or Lotrimin, miconazole or Micatin, ketoconazole or Nizoral, econazole or Spectazole, 
oxiconazole or Oxistat, and sulconazole or Exelderm). Allylamines (naftifine or Naftin, 
terbinafine or Lamisil). Naphthiomates (tolnaftate or Tinactin). Substituted pyridines 
(ciclopirox olamine or Loprox).In addition, a topical corticosteroid to help relieve the 
itching. It is never used as the only treatment in ringworm infections.

Patient teaching: Avoid touching suspicious lesions. Maintain proper hygiene by washing  
hands and body frequently and laundering the linens and clothes of an infected family 
member separately. Avoid contact sports such as wrestling until the lesions have been 
treated for at least 48 hours.

     Cellulitis is a painful bacterial infection of soft tissue usually the result of 

Streptococcus pneumoniae, Staphylococcus aureas, or Haemophilus influenzae. The 

condition appears as a swollen, red area of skin that feels hot and tender. The infection 

may only be superficial, but it may also affect the tissues underlying your skin and can 

spread to your lymph nodes and bloodstream (Mayo Foundation, 2005.) A doctor usually 

diagnoses cellulitis based on its appearance and symptoms. Laboratory identification of 

the bacteria from blood, pus, or tissue specimens usually is not necessary unless a 

person is seriously ill. Treatment consists of antibiotics. Antibiotics, such as dicloxacillin 

and cephalexin, that are effective against both streptococci and staphylococci may be 

used (Merck, 2004.) Patients should be instructed to elevate the affected extremity and 

take all medications as directed. If infection appears to worsen (increased swelling, 

tenderness, pain, redness) patient should report to health care practitioner immediately 

(Leeds Teaching Hospital, 2001.)

References:

Leeds Teaching Hospital (2001) Multidisciplinary Clerking Form: Cellulitis Retrieved on 

     June 15, 2005 from 

     http://www.leedsth.nhs.uk/emibank/clinicians/cdu/documents/scell6.pdf 

Mayo Foundation (2005) Cellulitis Overview Retrieved June 15, 2005 from 

     http://www.mayoclinic.com/invoke.cfm?id=DS00450

Merck (2004) The Merck Manual Online Retrieved on June 15, 2005 from 

     http://www.merck.com/mmhe/sec18/ch211/ch211b.html

3. Rosacea
Etiology- unknown. A significant increase in the hair follicle mite demodex  
folliculorum, is found in rosacea. An increase in mites may play a role in the   
pathogenisis of rosacea by provoking inflammatory or allergic reactions, by  
mechanical blockage of follicles, or by acting as vectors for microorganisms.

Presentation 
Rosacea occurs after the age of thirty and is most common in people of 
Celtic origin. The cardinal features are erythema, edema, papules and pustules 
and telangiectasias. These manifestations appear on the forehead, cheeks, nose 
and occasionally about the eyes. 
Granuloma formations occurs in some patients (granulomatous formations) and 
is characterized by hard papules or nodules that may be severe enough and lead to  
scarring. Chronic deep inflammation of the nose leads to an irreversible hypertrophy 
called  Rhinophyma. 
Ocular rosacea has a 58% prevalence with 20% of those pt’s developing ocular rosacea 
symptoms before skin lesions. S/S: mild conjunctivitis with soreness, foreign body 
sensation and burning, grittiness and lacrimation.

    Key medication(s) 
Doxycycline 100 to 200 mg/day or tetracycline or erythromycin  500 mg bid. 
Resistant cases may be treated with minocycline 200 mg daily or with oral
metronidazole 200 mg bid. The antibiotic treatment is stopped after pustules have 
cleared. 
Patients with mild to moderate to severe rosacea may respond  
to 0.75% metrogel (metronidazole) cream applied bid or 1% metronidazole 
(noritate) cream applied qd. Metrogel may also be used as maintenance therapy 
after oral antibiotic therapy. 
Sulfacetamide/sulfur lotion (sulfacet-r) is used for the control of pustules. This       
treatment may also be combined with oral antibiotics. 

             Patient resistant to conventional treatment were treated with oral isotretinoin 10 
mg/day for 16 weeks. Papular and pustualr lesions were significantly reduced at 
the end of 16 weeks. Isotretinoin given at 0.5mg /kg/day for 20 weeks, was 
effective in treating severe refractory rosacea, 85% had no relapse at the end of  a 
year.
For patients who do not respond to antibiotic therapy may have mite infestation.  
Diagnosis is confirmed with a KOH prep examination. The patient is then treated 
with crotamiton (eurax). Lindane lotion or sulfur and salicylic acid soap can also 
be effective. 

    Patient teaching 
The response after treatment is unpredictable. Some patients 
clear in 2-4 weeks and stay in remission for weeks or months. Others flare and 
require long term suppression with oral antibiotics. The treatment is tapered to a 
minimum dosage that provides adequate control. 
Photosensitivity and protection from sun- avoidance, use of sunscreen, should be 
discussed when pt is undergoing oral antibiotic therapy. As well as possible loose stools 
with antibiotic therapy.

Psoriasis is a commonly occurring skin disease which affects
approximately 5 million Americans.  (Youngkin, Sawin, Kissinger, Israel,
2005)  Psoriasis affects both males and females but females seem to have
the disease earlier than males.  It occurs more often in Whites than in
Asians or African Americans and is rarely seen in Native Americans. 
(Youngkin, et al, 2005)

     Causes:  influenced by environmental, immunological, and genetic
     factors (exact cause not known), certain HLA antigens are more
     common among populations of psoriasis patients (Youngkin, et al, 2005)


     Presentation:  whitish, scaly patches of varying size, most
     commonly seen on the elbows, knees, and scalp


          4 types:  

          1)  Chronic plaque psoriasis is the most common type, patients
          exhibit one to many erythematous, clearly demarcated, oval
          plaques several centimeters in diameter, the plaques are
          covered by silvery-white scales

          2)  Guttate psoriasis is the second most common, characterized
          by an acute exanthum-like eruption with flat-topped scaly
          papules usually 1mm to 1cm in diameter over the entire body
          (frequently follows an infection after 2-3 weeks 
          such as streptococcal pharyngitis or a viral URI)

          3)  Erythrodermic psoriasis is infrequently seen,
          characterized by generalized 
          exfoliative erythroderma (can be life threatening)


          4)  Pustular psoriasis is also uncommon, characterized by a
          generalized scaly plaque, and small superficial nonfollicular
          pustules develop
          (Youngkin, et al, 2005)



Medications:  Treatment depends on severity and type of the psoriasis

     -	for chronic plaque psoriasis – mild emollients and keratolytics
     with low-potency topical corticosteroids are all that is necessary
     such as:  1% coal shampoo, white petrolatum or mineral oil, 1%
     hydrocortisone, zinc pyrithione shampoo or salt water, if it
     becomes worse oral Psoralen therapy given three times weekly
     with ultraviolet A radiation is indicated

     -	Topical corticosteroids may be necessary – triamcinolone 0.1% or
     fluocinonide with 10% salicylic acid are useful

     -	Methotrexate azathioprine given 2.5 mg every 12h for three doses
     orally should be reserved for severe recalcintrant psoriasis

     -	Etretinate (ethyl ester of retinoic acid) and acitretin
     (metabolite of etretinate) are effective in pustular psoriasis

     -	Calcipotrien (synthetic analog of Vitamin D) is approved for
     plaque psoriasis, applied twice a week for 8 weeks with a maximum
     dose of 300g per week
     (Youngkin, et al, 2005)

Patient Teaching:  since the majority of treatments used to treat
psoriasis is topical the patient should be instructed to call back for
acute inflammation, rash, burning or blistering and have them
discontinue use, for drugs such as methotrexate it is important to
monitor the patients for damage to the liver so they should be
instructed to call back for yellowing of skin or eyes, also they need to
be checked for pregnancy and instructed to use some form of birth
control measures while taking methotrexate as it is contraindicated in
pregnancy, if the patient is taking an oral corticosteroid they should
take it with food or milk as it can cause GI upset  (Youngkin, et al, 2005)


Reference:

Youngkin, E. Q., Sawin, K. J., Kissinger, J. F., and Israel, D. S.  (2005). 
     Pharmacotherapeutics a primary care guide.  Prentice Hall: 
     New Jersey.

Psoriasis:

Cause: Psoriasis is a skin disorder that is controlled by the immune system, especially 
the white blood cels called a T cell. The T cells are activated by mistake and become so 
active that they trigger other immune responses, with cause inflammation and a rapid 
turn over of skin cells. 1/3 of the cases are related to a family history; genes have been 
linked to the gene by researchers. Conditions that may cause flareups are infections, 
stress, and changes in the climate that dry the skin. Lithium and betablockers, which are 
for high blood pressure, may trigger and outbreak or worsen the disease 
(www.niams.nih.gov). 

Diagnosis/Presentation: Small skin samples may need to be looked at under the 
microscope because psoriasis can present like other skin diseases. 

*Plaque psoriasis- skin lesions are red at the base and covered by silvery scales.

*Guttate psoriasis- Small, drop-shaped lesions appear on the trunk, limbs, and scalp. 
Guttate psoriasis is usually triggered by upper respiratory infections.

*Pustular psoriasis- Blisters of noninfectious pus appear on the skin. May be triggered by 
medications, infections, stress, or exposure to certain chemical.

*Erythrodermic psoriasis- Widespread reddenin and scalin of the dkin may be a reaction 
to sever sunvurn or taking corticosteriods, or increased activity of psoriasis that is not 
controlled.

*Inverse psoriasis- Smooth, red patches occur in the folds of the skin near the genitals, 
under the breasts, or armpits. The symptoms may worsen with friction.

Treatment: Physicians treat based on the severity of the disease, size of areas involved, 
type of psoriasis, and the patient's response to initial treatments.

Step 1: Topical treatments: Corticosteroids, Calcipotriene,Retinoid, Coal tar, Anthralin, 
Salicylic acid, Clobetasol propionate, Bath solutions ( Coal tar, oiled oatmeal, epsom salt, 
dead sea salt), Moisturizers.

Step 2: Light treatemnts: Sunlight, Ultraviolet B phototherapy, Psoralen and ultraviolet A 
phototherapy, Light therapy combined with other therapies.

Step 3: Systemic therapy: Taking medications by injection or mouth to treat the immune 
system. Methotrexate, retinoids, cyclosporine 6-Thioguanine, Hydoxyurea, alefacept, 
etanercept, atiobitics to treat streptococcus.

Patient teaching: Patient should be taught about different options for treatment and side-
effects, be provided emotional/psychological support, offered resources, and encouraged 
to maintain follow up appointments to follow therapy solutions.

Reference: 

National Institute of Arthritis and Musculoskeletal and Skin Diseases. Health Information. 

     Retrieved June 18, 2005, from 

     http://www.niams.nig.gov/hi/topics/psoriasis/psoriafs.htm.

Select 1 drug class used to treat skin problems. Briefly indicate action, side effects and 
pt. teaching.

retinoids, coal tars, methotrexate, PUVA, topical corticosteroids

 Psoriasis is a chronic skin disorder characterized by lesions or plaques that are made up 
of excessive skin cells produced by the body. Methotrexate is an antimetabolite 
antineoplastic medication that is sometimes used to treat psoriasis because it targets this 
rapid proliferation of epithelial cells.
    Some possible side effects associated with methotrexate are anemia, insomnia, 
lethargy, nausea, and loss of appetite.
    Patients should be educated about the importance of informing their prescriber of all 
of the medications they are taking (prescription, otc and herbal product).  Patients should 
be aware that they may be more susceptible to infection and more sensitive to sunlight.  
Educate the patient to avoid alcohol and avoid pregnancy during treatment with 
methotrexate.  Inform the patient of future routine blood work that will be needed and 
make sure the patient understands the dosing regimine (po or IM) given only once 
weekly.
retrieved on June 13, 2005 from LEXI-COMP

What blood work would be important with this drug?

blood work important would be cbc and liver enzymes

Yes, as bone marrow depression is a risk with MTX

 Psoriasis is a chronic skin disorder characterized by lesions or plaques that are made up 
of excessive skin cells produced by the body. Methotrexate is an antimetabolite 
antineoplastic medication that is sometimes used to treat psoriasis because it targets this 
rapid proliferation of epithelial cells.
    Some possible side effects associated with methotrexate are anemia, insomnia, 
lethargy, nausea, and loss of appetite.
    Patients should be educated about the importance of informing their prescriber of all 
of the medications they are taking (prescription, otc and herbal product).  Patients should 
be aware that they may be more susceptible to infection and more sensitive to sunlight.  
Educate the patient to avoid alcohol and avoid pregnancy during treatment with 
methotrexate.  Inform the patient of future routine blood work that will be needed and 
make sure the patient understands the dosing regimine (po or IM) given only once 
weekly.

PUVA is a combination of psoralen (P) and long-wave ultraviolet
radiation (UVA) that is used to treat many different skin conditions.
Psoralen is a drug taken by mouth, that makes the skin disease more
responsive to ultraviolet light. Psoralen has been used in combination
with sunlight for the treatment of skin disease for centuries. Psoralen
is taken one hour before ultraviolet light treatment. One to two days
after treatment, the skin becomes red. Light treatment is given 2-3
times per week for 12-15 weeks. After 15 weeks, maintenance therapy is
often required once a week.
Side Effects: Headache and dizziness, skin burn and blistering, nausea,
redness of the skin, itching, stinging sensation and tan or darkening of
the skin. 
Most of the side effects are temporary. People who have had PUVA have an
increased risk of squamos cell carcenoma, which is a common form of skin
cancer easily treated by minor surgery. PUVA causes the skin to look
older (photo aging). PUVA can also cause white and brown spots to appear
on the skin. PUVA can cause cataracts to form if the eyes are
unprotected while receiving treatment.A typical PUVA session consists of
coming into the office, removing clothes from the affected body areas
and standing in a five foot square by seven foot high light box. The
lights are then turned on for 1-10 minutes. The length of each session
is increased by a small amount over the previous session. One must wear
protective goggles and groin protection (underwear or towel) while in
the light box. 
Patient teaching:
 Patients must wear UVA-absorbing, wrap-around sunglasses for
twenty-four hours following a PUVA treatment. These glasses must be worn
outside and indoors if any sunlight is coming into the room through a
glass window. You must also avoid sunlight on the skin for 24 hours
after a Puva treatment.

retrieved  from www.skinsite.com

comprehensive answer

     Coal tar, or crude coal tar, is obtained by the destructive distillation of bituminous 

coal at very high temperatures. Coal tar is used to treat eczema, psoriasis, seborrheic 

dermatitis, and other skin disorders. In animal studies, coal tar has been shown to 

increase the chance of skin cancer. Some of these preparations are prescription only. 

When used on the scalp, coal tar may temporarily discolor bleached, tinted, light blond or 

grey hair. Coal tar may stain skin and clothing (DermNet NZ.) Coal tar may cause 

photosensitivity. Patients should inform practitioners of unusual or allergic reaction to 

coal tar, any other tar, or any other substances, such as preservatives or dyes. Coal tar 

products should not be used on infants, unless otherwise directed by a doctor. After 

applying coal tar, protect the treated area from direct sunlight and do not use a sunlamp 

for 72 hours. Do not apply this medicine to infected, blistered, raw, or oozing areas of 

the skin. Keep this medicine away from the eyes (Medline, 2005.) Coal tar may interact 

with tetracycline, psoralens, and topical retinoids (Wynne, Woo, and Millard, 2002, 599.)

References:

DermNet NZ (2005, May) Coal Tar Retrieved on June 15, 2005 from 

     http://dermnetnz.org/treatments/coaltar.html

Medline (2005) Coal Tar (Topical) Retrieved on June 15, 2005 from 

     http://www.nlm.nih.gov/medlineplus/druginfo/uspdi/202158.html

Wynne, A., Woo, T., and Millard, M. (2002) Pharmacotherapeutics for Nurse Practioner 

     Prescribers Philadelphia: F.A. Davis Company

and most patients stop taking this class of drug because of the side effects.

Generic Name: methotrexate (meth oh TREX ate)
Brand Names: Rheumatrex Dose Pack, Trexall
Generic Name: methotrexate (meth oh TREX ate)
Brand Names: Rheumatrex Dose Pack, Trexall
What is methotrexate?
•	Methotrexate interferes with the production and maintenance of DNA, which is 
the genetic material in the cells of the body. Methotrexate has a greater effect on cells 
that reproduce often such as cancer cells, bone marrow cells, skin cells, and others. This 
is how methotrexate works in the treatment of cancer and psoriasis. It is not known 
exactly how methotrexate works in the treatment of rheumatoid arthritis. Methotrexate is 
used to treat certain types of cancer, psoriasis, and rheumatoid arthritis. 
•	What is the most important information I should know about methotrexate?
•	Methotrexate should only be administered under the supervision of a qualified 
healthcare provider experienced in the use of this medication. 
•	Methotrexate may cause side effects that could be dangerous or life-
threatening. Discuss with your doctor the risks and benefits of using methotrexate before 
starting treatment. Methotrexate has been reported to cause blood and bone marrow 
problems (fever, chills, sore throat, unusual bruising or bleeding, black, bloody or tarry 
stools,); lung problems (unexplained shortness of breath, coughing, or wheezing); 
stomach problems (diarrhea, abdominal pain, sores in or around the mouth); liver 
problems (yellow skin or eyes, unusual fatigue); kidney problems (blood in the urine; 
darkened urine, swelling of the feet or legs); and others. Notify your doctor immediately 
if you develop any of these symptoms. 
•	Do not take methotrexate if you are pregnant or could become pregnant 
during treatment. Methotrexate is in the FDA pregnancy category X. This means that it is 
known to cause birth defects in an unborn baby. Methotrexate can affect a baby both 
when a woman is treated and when a man is treated. If the woman is being treated with 
methotrexate, pregnancy must be avoided during treatment and for one ovulatory cycle 
following treatment. If the man is being treated with methotrexate, pregnancy must be 
avoided during treatment and for 3 months following treatment. 
•	Do not take aspirin or nonsteroidal anti-inflammatory drugs (NSAIDs) such as 
ibuprofen (Advil, Motrin, Nuprin, others), ketoprofen (Orudis KT, Orudis, Oruvail), 
naproxen (Aleve, Naprosyn, Anaprox), and others except under the direction of your 
doctor. Although these medications may be prescribed together to treat certain 
conditions, methotrexate may interact with aspirin and NSAIDs, and possibly cause 
serious side effects. Discuss the use of aspirin and NSAIDs with your doctor. 
•	Do not drink alcohol while taking methotrexate. 
www.medlibrary.org

comprehensive answer.

Retinoids, which are derivatives of vitamin A, function by slowing the desquamation 
process, thereby decreasing the number of comedones and microcomedones. Retinoids 
are the most effective comedolytic agents in use. 
  | www.aafp.org/afp/20000115/357.html  | Save
Topical retinoids are effective treatments for mild to moderately severe acne. When they 
first entered the dermatology scene they were thought to be miracle creams for acne. 
Now with over 20 years of use, they have gained even more popularity.Tretinoin and 
isotretinoin are prescription medications derived from Vitamin A. Topical retinoids 
available in Australia for the treatment of acne include :Retin-A ,Differin gel 
RETINOIDS ARE USED IN THE TREATMENT OF:
sun-damaged skin ,skin pigment disorders ,certain pre-cancerous states and ,before 
chemical peels 
Retinoids cause the body to shed outer skin cells. This unclogs pores. It also seems to 
have anti-ageing effects on the skin. Fine wrinkles are reduced as a result of the retinoid 
effect on the formation of collagen. The top layer of skin thickens and produces a more 
youthful appearance.
Many dermatologists prescribe alpha-hydroxy acids in the morning and retinoids at night 
to those who want to reverse the signs of ageing. Available only by prescription, retinoids 
come in three forms: cream, gel, or topical solution. Creams help moisturise and work 
well for winter weather. Gels are lighter and good for warm weather. Always follow the 
instructions for use. If you do not, you may increase the risk of severe skin irritation that 
requires medical care.
SEEK MEDICAL CARE IF YOU HAVE ANY OF THE FOLLOWING SYMPTOMS WHEN USING 
RETINOIDS ,blistering ,crusting ,severe burning or redness ,swelling of skin 
SIDE EFFECTS THAT MAY OCCUR BUT DO NOT REQUIRE MEDICAL CARE INCLUDE:
a feeling of warmth or a mild stinging on the skin ,peeling of the skin occurring a few 
days after treatment, which lasts less than 2-3 weeks ,skin redness 
www.askjeeves.com Article #4976
Copyright (c) 2002 McKesson. All Rights Reserved.

Be sure you instruct women of child bearing age to prevent pregnancy during the time 
they take retinoids. Baseline determine she is not pregnant and then advise use of 2 
contraceptive methods to prevent pregnancy.

Topical Corticosteroid Treatment
Topical corticosteroids, as a result of their anti-inflammatory actions, are the mainstay of 
treatment for the eczematous lesions, and should be used in conjunction with emollients 
that help promote hydration of the epidermis. However, patients should be carefully 
instructed in their use in order to avoid potential side effects. The potent fluorinated 
corticosteroids should be avoided on the face, the genitalia and the intertriginous areas. 
A low potency corticosteroid preparation is generally recommended for these areas. Low 
potency corticosteroids are generally recommended for infants. The patients should be 
instructed to apply topical corticosteroids to their skin lesions and to use emollients over 
uninvolved skin.
There are seven classes of topical corticosteroids ranked according to their potency 
based on vasoconstrictor assays, and some of those commonly used are listed in Table 
3. (22) More potent topical corticosteroids may be used for several days in nonfacial, non-
skin-fold areas to treat acute skin rashes. Patients should then be instructed to reduce 
the potency of topical corticosteroids applied to their skin. In Table 3, group I includes 
the super-potent topical corticosteroids with the greatest potential for side effects, both 
localized and systemic. Group VII includes the least potent topical corticosteroid and, as 
a group, has the least potential for side effects.
Due to their potential side effects, the ultra high potency corticosteroids should be used 
for only very short periods of time and in areas that are lichenified and not on facial or 
skin fold areas. The goal of treatment is to use emollients to enhance skin hydration and 
low potency corticosteroids for maintenance anti-inflammatory therapy. The high potency 
corticosteroids should only be used for short periods of time (generally up to 3 weeks) 
for clinical exacerbations. Intermediate potency corticosteroids such as 0.1% 
triamcinolone can be used for longer periods of time to treat chronic atopic dermatitis 
involving the trunk and extremities. Corticosteroids in gels are usually in a propylene 
glycol base and are irritating to the skin in addition to promoting dryness, limiting their 
use to the scalp and beard areas. Side effects from topical corticosteroids are directly 
related to the potency ranking of the compound and the length of use, so it is incumbent 
on the clinician to balance the need for therapeutic potency with the potential for side 
effects.
In addition, ointments have a greater potential to occlude the epidermis resulting in 
enhanced systemic absorption compared with topical creams. Further, certain anatomic 
areas including mucous membranes, the genitalia, the eyelids, and the face all have 
increased potential for transepidermal corticosteroid penetration, and for this reason, 
potent corticosteroids should be avoided in these areas. Side effects from topical 
corticosteroids can be divided into local side effects and systemic side effects, the latter 
including suppression of the hypothalamic-pituitary-adrenal axis. Local side effects 
include the development of striae and atrophy of the skin, in addition to the development 
of perioral dermatitis, and rosacea. Systemic side effects are related to the potency of 
the topical steroid, the site of application, the occlusiveness of the preparation, the 
percentage of the body covered and the length of use. The potential for prolonged use of 
potent topical corticosteroids to cause adrenal suppression is greatest in small children 
and infants. (23,24) Identification and Elimination of Triggering Factors.
WWW.ASKJEEVES.COM

Methotrexate:

Action: Interferes with the production and maintance of DNA. Methotrexate effects cells 
that reproduce.

Side effects: Fever, chills, sore throat, bleeding, bruising, black, bllody or tarry sools 
(blood and bone marrow problems), Lung problems (SOB, coughing, wheezing), stomach 
problems (diarrhea, abdominal pain, sores in or around the mouth), liver problems 
(yellow skin or eyes, unusual fatigue), kidney problems (blood in urine, dardened urine, 
swelling of the feet or legs).

Patient teaching: Do not take if pregant (Class X), Do not take aspirin or nonsteroidal 
anti-inflammatory drugs (Advil, Motrin, Nuprin), Do not drink alcohol, Notify physcian 
immediately of side-effect, encourage to follow up visit for lab work.

Tina, please read previous postings so we do not have duplication. Only time to add is 
something was wrong that was posted or a piece was left out. If that is the case indicate 
what posting you are adding to.

Reference:

Drug Information Online. Drugs.com. Retrieved June 18, 2005, from  

     http://www.drugs.com/methotrexate.html.

4. Retinoids
       Use- acne (e.g Retin-A), psoriasis (e.g. Tazarotene), 
    pityriasis rubra pilaris ( e.g. Isotretinoin), kaposis sarcoma
                (e.g. Alitretonoin).

       Retinoid action
 In acne reverse the abnormal pattern of keratinization.
 In psoriasis it thins the stratum corneum of the epidermis. 
             In pityriasis rubra pilaris it improves erythema, scaling and keratoderma. 
             (Isotretinoin is thought to normalize keritinization, reversible decrease size of  
             sebaceous glands  and alter composition of sebum to a less viscous form that is 
             likely to cause follicular plugging).       
             In Kaposis sarcoma Alitretinoin gel has significant antitumor activity as a topical 
             treatment for AIDS-related KS lesions, substantially reduces the incidence of 
             disease progression in treated lesions, and is generally well tolerated.                

      Side effects
             Topical: photosensitivity, erythema and dry skin.
                          Oral: depression, pyschosis, aggressive behavior, conjunctivitis, N/V, 
                          abd pain, acute pancreatitis, increased platelet count, elevated ESRD, 
                          hypertriglyceridemia, arthralgia, back pain, cheilosis.

        Patient teaching
                    Avoid foods high in vitamin-A and vitamin-A supplements.  
                    Topical application: photosensitivity, erythema and dryness of skin
                    In patients taking oral retinoids e.g. isotretinoin monitor LFT’s, HCG in  
                    women of childbearing age, lipids, CBC, platelet count

Frank, Again this drug was addressed in a previous posting. Only post if you are adding 
missing info and then refer to the previous posting. Thanks. Cuts down on repetitious 
reading for all.

Select 1 of the following anemias. define cell abnormalities, dx tests, key medication 
used and how therapeutic effect is determined,pt. teaching

folic acid deficiency, iron deficiency anemia, pernicious anemia

Pernicious anemia is a macrocytic anemia characterized by defective dna synthesis that 
produces inneffective erythropoesis. In this case the defective dna synthesis is a result of 
the body's inability to absorb dietary vitamin B12. Pernicious anemia is chronic and the 
most common type of megaloblastic anemia. At one time, it was fatal. 
This anemia can be congenital or adult onset and possibly autoimmune. Patients with 
pernicious anemia lack sufficient cells in gastric parietal glands to produce an intrinsic 
factor necessary for the absorption of B12. Partial or complete gastrectomy will also 
result in pernicious anemia. Individuals with pernicious anemia are also at risk for 
developing gastric cancer.
Cell abnormalities in pernicious anemia manifest with megaloblastic red cell precursers 
and giant metamyelocytes. The chromatin in the RBC nucleus are more dispesed than a 
normal cell at a comparable stage of maturation

Labs                    Results
H&H                      low
Retic count            low
mean corpuscular
 volume                elevated
plasma iron           elevated
total iron binding
capacity               WNL
ferritin                  elevated
Serum B12           low
folate                   WNL
total biliruben       slightly elevated
transferrin            slightly elevated

key medication used is cyanocabalamin 1000 micrograms IM or SQ weekly until 
deficiency is corrected, then monthly. Effective treatment is evidenced by a rising retic 
count. Within 5-6 weeks, blood counts return to normal. Blood transfusions are given if 
the individual shows signs of circulatory collapse or heart failure.

patient teaching should include: Pernicious anemia is for life. compliance with monthly 
injections is imperative. Patient should report jaundice, shortness of breath, abdominal 
pain, fever, chest pain, peripheral edema, weakness, or ataxia immediately. Patient 
teaching should also include self administration of B12. Patient should be seen weekly 
until blood counts return to normal, then every 6 months. more frequently if needed.  

Neuro changes are reversible with early rx.

Iron Deficiency Anemia: Three overlapping stages of development.
Stage I-the body's iron stores for erythropoiesis are depleted. Erythropoiesis proceeds 
normally with the hemoglobin content of red blood cells remaining normal also.
Stage II-iron transportation to bone marrow is diminished and iron -deficient 
erythropoiesis takes place. 
Stage III-begins when small hemoglobin-deficient cells enter the circulation in sufficient 
numbers  and replace normal erythrocytes that have reached maturity and have been 
removed from the circulation. Characterized by depletion of iron stores and diminished 
hemoglobin production.

Dx. Tests: The laboratory diagnosis of IDA is supported by the following findings.
Early Disease: CBC- Low normal hemoglobin, hematocrit, and total RBC count and 
normocytic, possibly hypochromic, RDW >15%.
Later Disease: CBC-Microcytic, hypochromic anemia with low RBC count and elevated 
RDW >15%.
Low Serum Iron: reflects iron concentration in circulation. This level may be falsely 
elevated due to recent high iron intake.
Elevated Total Iron Binding Capacity (TIBC):an indirect measure of transferrin, a plasma 
protein that easily combines with iron. When more transferrin is available for binding, the 
TIBC rises, reflecting iron deficiency.
Iron Saturation Less > 15%:calculate by dividing the serum iron by the TIBC.
Low Serum Ferritin: the body's major iron storage protein.
Absence of Iron from Bone Marrow:if aspiration is done.

Key Medications Used:
Adults-
Ferrous fumarate 200mg bid-qid
Ferrous gluconate 325mg-650mg qid 
Ferrous sulfate 300mg bid-qid
Children-
Ferrous gluconate 16mg/kg/daily

Therapeutic Effect: Reticulocytes at 1 to 2 weeks to ensure marrow response to iron 
therapy, hemoglobin at 6 weeks to 2 months to ensure anemia recovery, and ferritin at 2 
months after measure of normal hemoglobin to ensure documentation of replinished iron 
stores.

Patient Teaching: Drug interactions with iron are numerous and potentially serious, the 
iron dose should be seperated by at least 2 hours from any other medication. Ferrous 
sulfate should be taken on an empty stomach to enhance iron absorption. Taking Vitamin 
C 200mg or more with the iron dose increases absorption by at least 30%. Both of the 
above stategies significantly increase the risk of gastrointestinal upset. Iron staining of 
the teeth may be seen with liquid preparations. Children may find the taste 
objectionable. Mixing the medication with orange juice to mask it's taste and having the 
child sip the mixture through a straw placed toward the back of the mouth may help with 
both problems. Since the staining is superficial, it will resolve after iron therapy is 
complete. Brushing the teeth after an iron dose may also minimize this problem. 
Side Effects:Gastrointestinal irritation, epigastric pain, nausea, vomiting and constipation 
are the most common. Advise the patient that if constipation occurs they may add extra 
fiber and liquids to their diet if not contraindicated. Can eliminate the GI sxs by taking 
the drug with a meal, recognizing that it will reduce iron absorption and lengthen 
treatment. Also, may initiate therapy with a single dose once a day, and then add 
additional doses on a weekly basis until the desired effect is reached. Keep iron 
supplements out of reach of children due to poisoning. Call if any adverse effects are 
noted. Important to keep follow up appointments to monitor blood work for resolution 
of IBC.

References: 

Youngkin, W.Q., et al. (2005). Pharmacotherapeutics: A Primary Care Guide. 2nd   
     edition. Upper Saddle River, N.J.: Pearson Prentice Hall.
  
McCance, K. & Huether, S. (2002). Pathophysiology: The Biologic Basis For Disease In 
    Adults & Children. Saint Louis, M.I.: Mosby, Inc.    
                               
 

Also remind pt. stool will be darkened with iron supplementation.

     Folic acid deficiency is one of the most common vitamin deficiencies in the United 

States, largely owing to its association with excessive alcohol intake as well as pregnancy 

(Vohra, 2004.) Certain anticonvulsants such as phenytoin and phenobarbital and drugs 

used to treat ulcerative colitis such as sulfasalazine decrease the absorption of this 

vitamin. Methotrexate and trimethoprim-sulfamethoxazole interfere with the metabolism 

of folic acid (Merck, 2005.) Folic acid deficiency and effectiveness of therapeutic regime 

is diagnosed based on simple laboratory blood tests of the folic acid level. Folic acid is 

distributed widely in green leafy vegetables, citrus fruits, and animal products. Humans 

do not generate folate endogenously because they cannot synthesize PABA or conjugate 

the first glutamate. A healthy individual has about 500-20,000 mcg of folate in body 

stores. Treatment consists of taking daily doses of a folic acid supplement. Humans need 

to absorb approximately 50-100 mcg of folate per day in order to replenish the daily 

degradation and loss through urine and bile (Vohra, 2004.) Educate patients regarding 

proper nutrition, including eating fruits and vegetables. Educate patients regarding the 

need to reduce alcohol ingestion. Discuss the need to take folic acid supplementation.

References:

Merck (2005) Merck Manual of Medical Information Second Home Edition Online: Folic 

     Acid (Folate) Retrieved on June 15, 2005 from 

     http://www.merck.com/mmhe/sec12/ch154/ch154k.html 

Vohra, M (2004) Folic Acid Deficiency Retrieved on June 15, 2005 from 

     http://www.emedicine.com/med/topic802.htm
 

What results with this folic acid deficiency in pregnancy?

Module 3-B
5. Pernicious anemia (seen in vitamin B12 deficiency).
        
        Cell abnormality 
        DNA synthesis in the RBC’s is impaired, thus impairing RBC’s and bone 
        marrow. There is development of macrocytosis secondary to a high RNA: DNA 
        ratio. These changes are seen in lab values as increased RBC MCV.  

         Diagnostic tests
         CBC, Serum iron, folate and B12, Schilling’s test (test for intrinsic  
         factor deficiency), reticulocyte count.
	
         Key medications
         Vitamin B12 (cyanocobalamine), folic acid and iron.

         Determining therapeutic effect
         Patient has a sense of well-being (24 hrs. after onset of treatment), neurological 
         improvement (improved peripheral neuropathy, balance, memory) if treatment is 
         begun before 6 months of anemia onset. 
         Improvement in above lab values.

         Patient teaching
         Patient is to continue taking vitamin B12 for lifespan with strict adherence. 
         Hematologic evaluation through lifespan, dietary intervention.

Select either the intrinsic or extrinsic coagulation pathway. Illustrate with an example of 
drug.

     The extrinsic pathway a route to activation of the clotting cascade 

is activated by damage to tissue, such as a break in skin integrity by a cut.  

Tissue thromboplastin, a phosholipid, is exposed. Clotting is rapid in onset, usually in 

seconds. There are two components unique to the extrinsic pathway, Tissue Factor 

(Factor III), and Factor VII. Both factors are implicated in the activation of Factor X, via 

a complex of activated factor VII, Ca++, and phospholipid. Tissue, rather than platelets, 

forms extrinsic pathway phosholipid.

     One example of a drug implicated in the intrinsic, extrinsic, and common coagulation 

pathways is warfarin. Warfarin is an anticoagulant which inhibits the synthesis of vitamin 

K - dependent factors: II, VII, IX, and X.

References:
McCance,K.L., and Heuther, S.E.,(2002). PATHOPHYSIOLOGY: THE BIOLOGIC 
     BASIS FOR DISEASE IN ADULTS AND CHILDREN (4th  ed.). St. Louis, MO:   
     Mosby Company. 

Skidmore-Roth, L. (2005). MOSBY'S DRUG GUIDE FOR NURSES (6th ed.) St. 
     Louis, MO: Elsevier Mosby.

Clarify with pathway is associated with Heparin and which one with coumadin.

Hemostasis is a normal body defense mechanism to help stop bleeding from
a damaged vessel as a result of trauma and minimize the loss of blood
from the cardiovascular system.  It involves platelet adhesion and
aggregation to form a plug that is reinforced with fibrin for long term
stability.  Intrinsic factors are factors in the plasma that are
activated for clotting, for example factors II, VII, and IX.  An example
of a drug that would be used for would be any type of replacement
clotting factor such as Factor VIII which hemophiliacs use to help with
clot formation.  (Lehne, 2005)


Reference:

Lehne, R.A.  (2005).  Pharmacology for nursing care.  Saunders: 
     Missouri.

good.

Without proteins and amino acids, erythrocyte production decreases and the life span of 
cells that are produced may be shortened because of structural defects.  One of the most 
important proteins is intrinsic factor (IF), a glycoprotein necessery for gastrointestinal 
absorption of vitamin B12.  Lack of vitamin B12 causes pernicious anemia.  IF is secreted 
by the parietal cells in the gastric mucosa and facilitates vitamin B12 uptake at its 
absorptive site, the ileum.  Vitamin B12 deficinencies that are related to a lack of intrinsic 
factor can be caused by gastrectomy (partial or total), inflammatory bowel disease, or 
surgical resection of the ileum.  To correct the B12 defecency due to a lack of IF, vitamin 
B12 is injected (Cyanocobalamin or hydroxocobalamin).  Hydroxocobalamin is preferred 
because it is more highly protein bound and therefore remains longer in the circulation.  
Initial therapy should consist of 100-1000ug of Vitamin B12 IM qd or qod for 1-2 weeks 
to replenish body stores then maintainance therapy of 100-1000ug IM once a month for 
life.

Reference:
Katzung, B.G.  (2001).  Basic and clinical pharmocology.  (8th ed).  McGraw-Hill: New 
         York.

McCance, K.L., Huether, S.E.  (2002).  Pathophysiology: The biologic basis for disease in  
adults and children.  (4th ed).  Mosby: St. Louis.

Select either coumadin or Heparin. Briefly note conditions treated by the drug, side 
effects, monitoring practices and pt. teaching.

Select either coumadin. Briefly note conditions treated by the drug, side effects, 
monitoring practices and pt. teaching.

Coumadin (Warfarin)

Conditions treated: deep vein thrombosis, ischemic heart disease, rheumatic heart 
disease, pulmonary embolism, lifelong use in patients c/ artificial heart valves.

Side effects: bleeding, hemorrhage, necrosis, GI upset.

Monitoring practices: prothrombin time.

Pt. teaching: Teach signs of hemorrhage: ecchymoses, hematuria, uterine and intestinal 
bleeding. Aspirin increases effect- may cause toxicity. Cimetidine, metronidazole, 
bactrum, and other anti-infectives may increase anticoagulation effect. Anticoagulation 
effect are decreased by drugs which induce P-450 enzymes. 

Which coagulation pathway is followed by coumadin?

Warfarin- a vitamin K antagonist, warfarin is an oral drug that acts against coagulation 
Factors II, VII, IX, and X.  Highly protein-bound, warfarin is a narrow therapeutic index 
(NTI) medication and is subject to numerous drug interactions.  The mechanisms of the 
interactions range from displacement of warfarin from the protein-binding site to 
induction of hepatic enzymes and decreased drug metabolism.

In the case of treating an acute thromobitic disease like deep vein throbophlebitis or 
pulmonary embolism--warfarin therapy is overlapped with heparin for 4-5 days until the 
INR is at goal.  This reason for overlapping heparin with oral warfarin is because of the 
initial transient hypercoagulable state in duced by warfarin, the length of this state is 
related to half-lives of protein C,protein S, and the vitamin K-dependent clotting Factors 
II, VII, IX, and X.

Reference-
Youngkin, E.Q., Sawin, K.J., Kissinger, J.F., and  Israel, D.S.  (2005).  
         Pharmacotherapeutics: A primary care guide.  (2nd ed).  Prentice Hall: New Jersey

The reason that Heparin and Coumadin overlap in treating an acute problem is that it 
takes several days for coumadin to achieve a therapeutic blood level.

     Heparin is a heterogeneous group of straight-chain anionic mucopolysaccharides, 

called glycosaminoglycans having anticoagulant properties (RxList, 2005.) Heparin is 

used to decrease the clotting ability of the blood and help prevent harmful clots from 

forming in the blood vessels. This medicine is sometimes called a blood thinner, although 

it does not actually thin the blood. Heparin will not dissolve blood clots that have already 

formed, but it may prevent the clots from becoming larger and causing more serious 

problems. Heparin is often used as a treatment for certain blood vessel, heart, and lung 

conditions. Heparin is also used to prevent blood clotting during open-heart surgery, 

bypass surgery, and dialysis. It is also used in low doses to prevent the formation of 

blood clots in certain patients, especially those who must have certain types of surgery 

or who must remain in bed for a long time (Medline Plus, 2000.) Heparin acts at multiple 

sites in the normal coagulation system. Small amounts of heparin sodium in combination 

with antithrombin III (heparin cofactor) can inhibit thrombosis by inactivating activated 

Factor X and inhibiting the conversion of prothrombin to thrombin. Once active 

thrombosis has developed, larger amounts of heparin sodium can inhibit further 

coagulation by inactivating thrombin and preventing the conversion of fibrinogen to fibrin. 

Heparin is strongly acidic because of its content of covalently linked sulfate and 

carboxylic acid groups. Side effects include increased bleeding time. Laboratory tests 

should include INR, PT, PTT, and a complete blood count (CBC.) Patients should be 

instructed to monitor for bleeding. Patients should refrain from activities that may result 

in injury. Patients should use soft bristle tooth brush and avoid blowing their nose 

forcefully. Caution patients taking other medications that may increase bleeding such as 

salicylates (Springhouse, 2003.)

References:

Medline Plus (2000) Heparin (Systemic) Retrieved on June 16, 2005 from

     http://www.nlm.nih.gov/medlineplus/druginfo/uspdi/202280.html 

RxList (2005) Heparin Sodium Injection Retrieved on June 16, 2005 from 

     http://www.rxlist.com/cgi/generic/heparin.htm

RxList (2005) Clinical Pharmacology Retrieved on June 16, 2005 from 

     http://www.rxlist.com/cgi/generic/heparin_cp.htm

Springhouse (2003) Nursing 2003 Drug Handbook (23rd ed.) Philadelphia: Lippincott, 

     Williams, and Wilkins

Candice,
Review what lab tests are used to monitor Heparin vs Coumadin. Aptt is for Heparin, PT 
and INR for coumadin.

Select a LMWH or an antiplatelet agent. Briefly discuss its action, what conditions are 
treated, side effects, relevant monitoring, pt teaching.

2 students answer per class of drug

The low molecular weight heparin I have chosen to evaluate is lovenox or enoxaparin.  
Standard heparin consists of constituents with molecular weights ranging from 4000-
30,000 daltons with a mean of 16,000 daltons. Heparin acts as an anticoagulant by 
enhancing the inhibition rate of clotting proteases or enzymes by antithrombin III 
impairing normal hemostasis and inhibition of factor Xa. Low molecular weight heparins 
have a small effect on the activated partial thromboplastin time and strongly inhibit factor 
Xa. Enoxaparin is derived from porcine heparin that undergoes benzylation followed by 
alkaline depolymerization. The average molecular weight of enoxaparin is 4500 daltons. 
Enoxaparin has a higher ratio of antifactor Xa to antifactor IIa activity than 
unfractionated heparin.

Lovenox is used to treat DVT (acute): Inpatient treatment (patients with and without 
pulmonary embolism) and outpatient treatment (patients without pulmonary embolism).

 It is used for DVT prophylaxis: Following hip or knee replacement surgery, abdominal 
surgery, or in medical patients with severely-restricted mobility during acute illness in 
patients at risk of thromboembolic complications.  Patients at high-risk for 
thromboembolic complications include those with one or more of the following risk 
factors: >40 years of age, obesity, general anesthesia lasting >30 minutes, malignancy, 
history of deep vein thrombosis or pulmonary embolism.

Lovenox is also used for unstable angina and non-Q-wave myocardial infarction (to 
prevent ischemic complications).

Side effects of Lovenox are as follows: As with all anticoagulants, bleeding is the major 
adverse effect of enoxaparin. Hemorrhage may occur at virtually any site. At the 
recommended doses, however, single injections of enoxaparin do not significantly 
influence platelet aggregation or affect global clotting time (ie, PT or APTT).

1% to 10%:
  Central nervous system: Fever (5% to 8%), confusion, pain
  Dermatologic: Erythema, bruising
  Gastrointestinal: Nausea (3%), diarrhea
  Hematologic: Hemorrhage (5% to 13%), thrombocytopenia (2%), hypochromic anemia 
(2%)
  Hepatic: Increased ALT/AST
  Local: Injection site hematoma (9%), local reactions (irritation, pain, ecchymosis, 
erythema)

<1% (Limited to important or life-threatening): Allergic reaction, anaphylactoid reaction, 
eczematous plaques, hyperlipidemia, hypersensitivity cutaneous vasculitis, 
hypertriglyceridemia, itchy erythematous patches. pruritus, purpura, skin necrosis, 
thrombocytosis, urticaria, vesicobullous rash. Retroperitoneal or intracranial bleed (some 
fatal). Spinal or epidural hematomas can occur following neuraxial anesthesia or spinal 
puncture, resulting in paralysis. Risk is increased in patients with indwelling epidural 
catheters or concomitant use of other drugs affecting hemostasis. Cases of heparin-
induced thrombocytopenia with thrombosis (some complicated by organ infarction, limb 
ischemia, or death) have been reported. Prosthetic valve thrombosis, including fatal 
cases, has been reported in pregnant women receiving enoxaparin as 
thromboprophylaxis.

It is important to monitor platelets, occult blood, and anti-Xa activity, if available; the 
monitoring of PT and/or PTT is not necessary.

Patients should be instructed as follows:   Wear disease medical alert identification. If 
you are 65 or older, use this medicine with caution. You could have more side effects.
If you have kidney disease, talk with healthcare provider. Tell dentists, surgeons, and 
other healthcare providers that you use this medicine. You will bleed easily. Be careful. 
Avoid injury. Use soft toothbrush, electric razor. Check medicines with healthcare 
provider. This medicine may not mix well with other medicines. Talk with healthcare 
provider before using aspirin, aspirin-containing products, other pain medicines, blood 
thinners, garlic, ginseng, ginkgo, or vitamin E. Use caution if you weigh less than 100 
pounds. Use caution to prevent injury and avoid falls or accidents. Tell healthcare 
provider if you are pregnant or plan on getting pregnant. Tell healthcare provider if you 
are breast-feeding.

Report the following to your healthcare provider immediately:  If you suspect an 
overdose, call your local poison control center immediately or dial 911. Watch for signs 
of a life-threatening reaction. These include wheezing; chest tightness; fever; itching; 
bad cough; blue skin color; fits; or swelling of face, lips, tongue, or throat. Report severe 
dizziness or passing out, falls or accidents, especially if you hit your head. Talk with 
healthcare provider even if you feel fine. Report significant change in thinking clearly and 
logically, severe headache, unusual bruising or bleeding and, any rash.

     Danaparoid sodium is a low molecular weight heparin indicated in the treatment of 

prophylactic deep vein thrombosis (DVT.) Danaparoid sodium prevents fibrin formation 

by inhibiting generation of thrombin by factor Xa and factor IIa (Springhouse, 2003.) 

Thus, the aPTT, a measure of antithrombin (anti-factor IIa) activity, is not used to 

measure the activity of low-molecular-weight heparins. Low molecular weight heparins 

are derived from depolymerization of standard heparin, which yields fragments 

approximately one third the size of the parent compound (Yeager and Matheny, 1999.) 

Compared to other available low molecular weight heparins, danaparoid sodium is 

relatively expensive. This medication should be used cautiously in patients with impaired 

renal function. Danaparoid sodium contains sodium sulphite and should not be used in 

individuals who are allergic to sulphites. This medication should not be used in active 

uncontrolled bleeding disorders, bacterial endocarditis,cerebral hemorrhage, 

hemophilia, children, and thrombocytopenia. The safety of this medicine during 

pregnancy and breastfeeding is not established (NetDoctor, 2004.) Complete blood count 

and fecal occult blood tests are recommended during therapy. Instruct patient to monitor 

for signs of bleeding or abnormal bruising and avoid over the counter drugs containing 

salicylates (Springhouse, 2003.)

References:

NetDoctor (2004) Danaparoid sodium Retrieved on June 16, 2005 from 

     http://www.tiscali.co.uk/lifestyle/healthfitness/health_advice/netdoctor

Springhouse (2003) Nursing 2003 Drug Handbook (23rd ed.) Philadelphia: Lippincott, 

     Williams, and Wilkins

Yeager, B. and Matheny,S. (1999) Low-Molecular-Weight Heparin in Outpatient Treatment 

     of DVT American Family Physician Retrieved on June 16, 2005 from 

     http://www.aafp.org/afp/990215ap/945.html 

     Ticlopidine is an anti-platelet whose action is blocking the activation of platelets by 

adenosine diphosphate (ADP). Ticlopidine is used to reduce the risk of thrombotic strokes 

in patients with a history of stroke or those patients who have experienced stroke 

precursors such as Transient ischemisc attacks (TIAs). The side effects of ticlopidine 

aredizziness, anorexia, epistaxis, diarrhea, nausea, hematuria ecchymosis and 

subcutaneous bleeding. Relevant monitoring includes CBC with WBC differentials, and 

liver function tests. The patient instructions includes informing patients that ticlopidine 

should be taken with a full glass of water, with food, or after a meal. They should also be 

informed to report severe or persistent diarrhea, skin rashes, yellowing of the skin or 

eyes, dark colored urine or light colored stools. Instruct patient to avoid flossing and to 

use electric razors for shaving. 

References:

Springhouse (2003) Nursing 2003 Drug Handbook (23rd ed.) Philadelphia:  

     Lippincott, Williams, and Wilkins

Wynne, A.L., Woo, T.M., and Millard, M. (2002). Pharmacotherapeutics for Nurse 

     Practitioner Prescribers. Philadelphia: F.A. Davis Company.

Antiplatlet- Aspirin

Action-the formation of a clot requires that platelets aggregte to form the organizing base 
for the clot.  The prostaglandin thromboxane A2 is an arachidonate product that causes 
platelets to change shape, release their granules, and aggregate.  Aspirin antagonized 
this pathway and interferes with platelet aggregation.

Conditions treated-Prophylactic use of ASA to prevent TIA and or stroke in at risk males 
and to prevent recurrent myocardial infarction (MI) and angina in both genders.  ASA has 
not been shown to be affective in the prevention of TIA's in women.  Also mild to 
moderate pain and fever especially in rheumatoid arthritis, and osteoarthritis and othe 
inflammatory conditions. 

Side effects-tinnitus, hearing loss, nausea, GI upset, occult bleeding, dyspepsia, GI 
bleeding, prolonged bleeding time, abnormal liver functions tests, rash, bruising, uticaria, 
Reye's syndrome, hypersensitivity reactions.

Relevant monitoring-during prolonged therapy these test should be assesssed 
periodically: Hgb/Hct levels, PT, INR and renal functions and salicylate levels. 

Patient teaching-due to prolonged bleeding time teach pts to stop ASA therapy 5-7 days 
prior to elective surgery or as ordered by PCP, take with food if GI upset, tinnitus may 
be a sign of toxicity, watch for petechia, use soft bristle brush on teeth to decrease 
bleeding, signs of GI bleeding, maintain adequate fluid intake.

Reference-
Wynne, A.L., Woo M. T., and Millard, M.  (2002).  Pharmacotherapeutics for nurse 
         practitioner prescribers.  F.A. Davis: Philadelphia.