Adrenergic Processes and Hemodynamics
Stroke volume
amount of blood ejected from the heart with each beat/systole. The average is 70 milliliters. It depends on 1.Myocardial contractility 2.Cardiac Preload and Cardiac Afterload
Preload -________________________________________ An example that would increase preload is heart failure. A decrease in blood volume and circulation decreases preload.
amount of blood in the ventricle at the end of diastole (EDV).
Beta 2 - smooth muscle relaxation (has control on the heart and lungs, but more on lungs) Activation of the Beta 2 adrenergic receptor by an Beta 2 agonist causes (6) organ effects?
arterioles of the heart, lungs, skeletal: dilation muscles of the bronchi: dilation muscles of the uterus: relaxation muscles of the skeletal: increased contraction muscle and liver: glycogenolysis, the conversion of glycogen into glucose in response to low blood sugar.
Muscarinic Agonist response to (salivary glands)
salivation
Alpha 1 Activation Adverse Effects receptors(3):
Adverse Effects: Hypertension Necrosis Bradycardia
Categories of Cholinergic Drugs
Ganglionic stimulating agents Muscarinic agonists Muscarinic antagonists
Beta-adrenergic antagonists Beta blockade Therapeutic effects (11): Most effects are on beta 1 receptors in the heart.
1.Angina pectoris 2.Hypertension 3.Cardiac Dysrhythmias 4.Myocardial infarction 5.Reduction of Perioperative Mortality 6. Heart Failure (not standard treatment) 7. Hyperthyroidism 8. Migraine Prophylaxis (decrease before migraine starts) 9. Stage Fright 10. Pheochromocytoma 11. Glaucoma (increased intra-ocular pressure)
Beta-adrenergic antagonists(Beta 1 blockade)-adverse effects (4)
1.Bradycardia 2.Reduced cardiac output 3.Precipitation of Heart Failure (signs of failure-shortness of breath, a cough lying down, edema) 4.AV Heart Block
Beta-adrenergic antagonists(Beta 2 blockade)- adverse effects (2)
1.Bronchoconstriction (life threatening to asthmatic patients) 2.Hypoglycemia from inhibition of glycogenolysis (life threatening to diabetic patients)
Alpha 1 Activation receptors Therapeutic Effects are (6):
1.Vasoconstriction (skin, viscera, mucous membranes)** Hemostasis: stops body from bleeding fatally. Nasal decongestion (the Sudafed drug does this) Adjunct for local anesthesia (keeps anesthetic at treatment area.) Elevation of BP 2.Mydriasis (Dilation of pupil for ocular surgery or exam)
Sodium: •Most abundant positively charged electrolyte of the principal extracellular fluid outside cells. •Normal concentration outside cells is _______________ •Maintained through dietary intake of sodium chloride •Salt, seafood, processed meats, foods flavored or preserved with salt
136 to 144 mEq/L
Potassium •Most abundant positively charged electrolyte of principal intracellular fluid inside cells. •95% of body's potassium is intracellular •Potassium content outside of cells ranges from _________________ •Potassium levels are critical to normal body function
3.7 to 5.2 mEq/L
Corticosteroids also called glucocorticoids:____________________
A group of hormones, including cortisol, released by the adrenal glands at times of stress. They also regulate homeostasis, development, cognition, and inflammation. They cause glycogenolysis. They are anti-inflammatory and immune suppressing.
Second spacing of fluid
Abnormal accumulation of fluid in interstitial spaces (edema) which can eventually return to first spacing
_________________ Cause direct blockade of adrenergic receptors *Most* produce reversible (competitive) blockades More selective than agonists (alpha OR beta receptor blockade, not both) ex: Alpha Adrenergic antagonists or blocking agent drugs block alpha adrenergic receptors
Adrenergic antagonists
Beta 1 receptor Activation adverse effects are(2):
Adverse Effects: Altered heart rate or rhythm Angina pectoris
Beta 2 receptor Activation adverse effects:
Adverse Effects: Hyperglycemia: High blood sugar related to liver and skeletal muscle beta 2 activation. Tremors (most common effect)
Alpha-adrenergic antagonists(alpha blockade) adverse effects:
Adverse Effects: Orthostatic hypotension Reflex tachycardia (less dangerous. Caused by heart trying to get to normal blood pressure.) Nasal congestion (dilated nasal blood vessels.) Inhibition of ejaculation
Beta 1 receptor Activation Therapeutic affects are(4)?
Clinical Applications/Therapeutic effects: 1.Heart failure 2.Shock (not only treats shock, but also encourages tissue perfusion) 3.Atrioventricular heart block 4.Cardiac arrest
Alpha 2 receptor function- neurotransmitter inhibition Activation of the Alpha 2 adrenergic receptor by an Alpha 2 agonist causes (1) organ effect?
Clinical Applications/Therapeutic effects: Presynaptic nerve terminals- inhibition of transmitter release
Alpha 1 receptor function - smooth muscle contraction Activation of the Alpha 1 adrenergic receptor by an Alpha 1 agonist causes(6) organ effects?
Clinical Applications/Therapeutic effects: eyes-contraction of iris radial muscle which causes pupil dilation(mydriasis) arteries- constriction veins-constriction male sex organs- ejaculation prostate capsule- contraction bladder- contraction of bladder and sphincter
Muscarinic agonist drugs Prototype drug (founding drug): •_____________ (for a urinary retention problem and not for patients with low blood pressure, stomach ulcers, bowel surgery) •Direct acting muscarinic agonists •Binds ______________ to muscarinic receptors to cause activation •Pregnancy C:Shows no benefit or risk to fetus Avoid in asthmatic patient -> bronchoconstriction in lungs Avoid in patients with low blood pressure, stomach ulcers, bowel surgery
Bethanechol (and is the only prototype drug of muscarinic agonist drugs), Reversibly
Muscarinic Antagonists ("Anti-cholinergics") Prototype drug (founding drug): Atropine (it helps with systematic bradycardia, dries respiratory secretions, and is an Under Active Bladder drug) Function:__________________ •Result (depending on route): •Heart-> ________________ •Exocrine glands -> __________________ •Smooth muscle -> ___________________ •eyes -> _______________ Reactions depend on route and dosage.
Blocks the action of acetylcholine increased heart rate decreases secretion relaxation dilation of pupil
Muscarinic Antagonists ("Anti-cholinergics"): Ipratropium bromide •Function: •Treats: ___________, _______________________, _______________, ____________________ •Local application to nasal mucosa inhibits serous and seromucous gland secretions •Nasal spray or inhalation via metered dose inhaler. It works at a lower dose, so side effects are less because it's given through the nasal cavity and respiratory airway. •Pregnancy B •Minimal side effects due to minimal systemic absorption
Blocks the action of acetylcholine at parasympathetic sites in bronchial smooth muscle causing bronchodilation. Asthma, chronic obstructive pulmonary disease (COPD), allergies, and cold symptoms.
Furosemide (Lasix): Most frequently prescribed loop diuretic and most affective diuretic and very powerful. •Mechanism of action: Acts on ascending loop of Henle to block reabsorption of sodium and chloride as well as water. •Pharmacokinetics •Rapid onset of action: •Therapeutic uses:
By mouth it's 60 min and lasts 8 hrs; IV 5 min lasts 2 hours. •Pulmonary edema •Edematous states (fluid overload states) •Hypertension (not usually unless other diuretics don't work) •Heart Failure Renal or cardiac organ dysfunction that are not responsive to other diuretics.
Propranolol Drug Interactions: _________________ and _____________ Dosage: Dose based on patient response (poor correlation between effect and blood levels) Patient needs vary widely Precautions to consider are? Do not use on patients with? (6)
Calcium Channel Blockers (potentiate effects can lead to excessive cardio suppression) and Insulin (can impede recognition of insulin induced hypoglycemia) Precautions: monitor heart rate and dosing of the drug. Do not use on patients with diabetes, heart block, asthma, heart failure, sinus bradycardia, and bronchospasm should be monitored closely or not given the drug. It can suppress glycogenolysis, tachycardia, tremors, and perspiration which are the warning signs of low blood sugar in diabetes.
Adrenergic agonists: Type Noncatecholamines
Can be given orally Metabolized slowly by MAO (monoamine oxidase)—longer half-life More able to cross the blood-brain barrier e.g. ephedrine, phenylephrine, terbutaline and albuterol.
epinephrine is a _____________ and can ______________ (4 therapeutic effects) Administration - Topically or injected (rapid activation) Adverse Effects - any adverse effects of all 4 receptor types Drug Interactions - ___________________________________(2 interactions)- all will increase effects of epinephrine ____________________________(2 interactions) - all will counteract epinephrine Preparation/Concentration - IV doses must be less concentrated (high concentration can be fatal if administered IV) compared to IM or subcut.
Catecholamine (can't be given orally, short duration, cannot cross BBB). It delays absorption of anesthetics, controls superficial bleeding, treats heart block and cardiac arrest Note: monitor for hypertension and dysrhythmias MAO inhibitors (MAOI), tricyclic antidepressants. Alpha-adrenergic blockers, Beta-adrenergic blockers.
____________________: •Agents that influence the activity of cholinergic receptors •Most mimic or block the actions of neurotransmitter acetylcholine •Toxicology encompasses: •Nicotine •Insecticides •Chemical warfare -They work in the peripheral nervous system.
Cholinergic Drugs
Chronic Obstructive Pulmonary Disease (COPD):_______________ Pathology: mucus hypersecretion, cilia dysfunction, airflow limitation, hyperinflation of lungs, alveolar destruction, loss of elastic recoil, gas exchange abnormalities, pulmonary hypertension, systemic effects, and cor pulmonale (abnormal enlargement of the right side of the heart as a result of disease of the lungs or the pulmonary blood vessels.)
Chronic airflow limitation. It is a combination of emphysema and chronic bronchitis. Cigarettes smoking is the number 1 cause and it's a permanent, destructive pulmonary disorder
Beta 2 receptor Activation therapeutic effects (2):
Clinical Applications/Therapeutic effects: 1.Asthma 2.Delay of Pre-term labor
Muscarinic Toxicity "cholinergic crisis" symptoms/effects: • The effects create the acronym D.U.M.B.E.L.L.S what are they? •Treatment: ___________________
D.iarrhea (and diaphoresis) and muscle cramping U.rination M.iosis (pinpoint pupils) B.radycardia (muscarinic) or Tachycardia (nicotinic) E.mesis L.acrimation L.ethargy S.alivation •muscarinic antagonist•
Cholinergic Muscarinic receptor subtype activation response
Decreased HR Increased Glandular secretion Smooth muscle contraction
Albuterol- a Short Acting Beta 2 Agonist drug (SABA) SABA's are also called the rescue inhaler Beta 2 agonist - causes smooth muscle relaxation Indications: For asthma and are good for emergency asthma attacks, quick relief in an acute attack, and prevent exercise induced bronchospasms. _______________- can be given orally, longer duration, can cross BBB Administration - inhaled Adverse Effects - tremors, tachycardia Minimal in appropriate doses (jittery)
Emergency use, acute asthma attack, prevent exercise induced bronchospasms. Is a bronchodilator to treat bronchoconstriction and allows for expectoration of mucous, prevents wheezing and decreases coughing It's a Non-catecholamine. It affects the lungs leading to bronchodilation. If given in large doses it will lose it's selectivity and activate beta 1 receptors and cause cardiac effects.
Adrenergic agonists (sympathomimetics)
Endogenous (naturally occurring in the body) and synthetic chemicals that activate adrenergic receptors in effector cells. In doing so they mimic the action of the sympathetic nervous system, which is why they are also called "sympathomimetics". Adrenergic drugs effect the CNS system.
Muscarinic Toxicity "cholinergic crisis": _______________________________ •Sources •Certain mushrooms •Organophosphate poisoning (Pesticides) •Nerve agent exposure (Sarin)
Excessive cholinergic (acetylcholine) receptor stimulation
Cough Medicines 2 types: ____________________ Avoid use of cough medicines in children younger than 2 years old.
Expectorants and Mucolytics
hypovolemia. Signs: feeling weak or dizzy, confusion, or restlessness, extreme thirst, dry mucous membranes, decreased skin turgor and capillary refill. They may exhibit orthostatic hypotension and increased pulse with low urine output. Can also result in seizures or comas if severe.
Fluid volume deficit, less than 30 ml an hour. Possible causes hemorrhage, severe vomiting or diarrhea, overactive nasogastric tube or patient not drinking enough fluids as well as severe burns. Also, overuse of diuretics.
hypervolemia Signs: headache, confusion, peripheral edema. Jugular venous distension, extra heart sound, high blood pressure, bounding pulse and polyuria if normal renal functions. Lung crackles with pulmonary edema, dyspnea, muscle spasms, and increased weight. It also may cause seizures and coma if severe.
Fluid volume excess. Possible causes heart failure, renal failure, long term use of corticosteroids, excessive I.V. fluid intake.
Salmeterol-long acting beta 2 agonist Indications/therapeutics: _______________________ Contraindications: do not use alone, particularly in asthma patients. Use alone can cause higher chance of morbidity. To offset this they are combined with ____________________. Adverse effect:
For long term control of Chronic obstructive pulmonary disease (COPD) also, reduces inflammation. Glucocorticoids. A side effect is insomnia
•Hypokalemia: potassium deficit, less than 3.7 mEq/L •Causes: ___________________ •Manifestations: __________________ •Medical management: increased dietary potassium suppliment, potassium replacement medication like Klor-Con, IV for severe deficit potassium levels it must be infused slowly no faster than _____________ and never___________. •Nursing management: assessment, severe hypokalemia is life-threatening, monitor ECG, dietary potassium, nursing care related to IV potassium administration
GI losses, medications, alterations of acid-base balance, hyperaldosterism, poor dietary intake. fatigue, anorexia, nausea, vomiting, dysrhythmias, muscle weakness and cramps, paresthesias, glucose intolerance, decreased muscle strength, decreased deep tendon reflexes. 10 mEq/h in adults, potassium I.V. push or boluses of potassium it is irritating to the veins and lethal. This is similar to giving a lethal injection.
Representative drugs of the categories of Cholinergic drugs
Ganglionic stimulating agents: Nicotine Muscarinic agonists: Bethanechol Muscarinic antagonists: Atropine
Inhaled drugs: Give an enhanced therapeutic effect, minimize systemic effects, and provide rapid relief. It's the most common route of drug administration for quick effect and low doses necessary compared to oral that is longer time to react and more adverse effects due to higher doses. _________________: May be called metered dose medications in text. Allow 1 minute between puffs. A spacer is used to get maximum drug. Normal inhaler. You must fully exhale before use then slow breathe drug in. ________________: No spacer needed for these. Disk shaped inhaler. Rinse mouth after use. You must fully exhale before use then slow breathe drug in. ________________: The drug is converted to mist.
High Flow Inhalers Dry Powder Inhalers Nebulizers
Muscarinic Antagonists ("Anti-cholinergics"): Diphenhydramine, brand-benadryl •Competes with _______________ for H1-receptor sites making it an H1 blocker on effector cells in the gastrointestinal tract, blood vessels, and respiratory tract •Anticholinergic and _____________ are also seen •Uses: (4) ____________________________ •Pregnancy B •Anticholinergic side effects: Can cause confusion in elderly
Histamine. sedative effects in CNS. Allergic reactions, anti-tussive, motion sickness, rhinitis.
Prazosin- An alpha 1 blocker Alpha-adrenergic Antagonist: dilation of arterioles and relaxation of smooth muscle It treats: ________________ and ________________________________________ Administration:Oral Adverse effects(5): *hint same as the general adverse effect of an alpha 1 antagonist*
Hypertension and Benign Prostatic Hyperplasia, orthostatic hypotension (watch out for this), reflex tachycardia, nasal congestion, inhibited ejaculation, "first-dose" effect (one percent of patient's experience a loss of consciousness 30-60 min after first treatment. The suggestion is to take the first dose at bedtime.)
Anaphylactic Shock manifestation of severe allergy caused by multiple receptor activation. It causes three reactions: _______________, ______________, ______________ Treatment: EPINEPHRINE, it is the sole treatment usually given in epi-pen and causes the below reactions in the three receptors. Alpha 1 - ______________ Beta 1 - ________________ Beta 2-_________________
Hypotension (vasodilation), Bronchoconstriction, Edema of glottis vasoconstriction for increased BP and decreased edema increases cardiac output to increase BP bronchodilation
Epipen: pediatric and adult versions Auto-injector, spring loaded, single use device administered through what route: ______________ Two dosages in miligrams -__________________ Give 1 dose, give second dose if first not completely effective, second dose may be given. After epipen use seek medical attention. Sensitive to heat and light - store per manufacturer specs.
IM injection. 0.3 mg for individuals > 66lbs 0.15 mg for individuals 33-66 lbs
Hydrochlorothiazide [HydroDIURIL]- A prototype drug of Thiazides, it sometimes be referred to as HCTZ. It's the most commonly used Thiazide diuretic. _______________________________ •Action: Early segment distal convoluted tubule •Peaks in 4-6 hours, but diuresis may persist for 12 hrs Therapeutic uses:_____________ Administration: Only by mouth, avoid late day dosing because night bathroom effect.
It promotes urine production by blocking sodium and chloride reabsorption which causes water retention and leads to diuresis. It's weaker than loop diuretics and effects depend on good kidney function. •Essential hypertension( it is mostly used for hypertension) •Edema (it's preferred for edema associated with mild to moderate heart failure and hepatic and renal diseases) Diabetes insipidus
Classification of diuretics •Three major categories 1.Loop: Furosemide 2.Thiazide: Hydrochlorothiazide 3.Potassium-sparing: Spironolactone
Loop: Furosemide, Thiazide: Hydrochlorothiazide, Potassium-sparing: Spironolactone
Adrenergic Receptors selectivity is relative Ability of a drug to activate certain receptors depends on the amount of drug administered.term-14
Low or therapeutic dose = selectivity increased As dosage of the drug increases = selectivity declines
___________________: Beta-adrenergic Antagonist: Selective beta 1 antagonist (does not cause beta 2 blockade unless administered in high dose.) It treats: ___________, ___________, ____________, and ___________ Administration: Oral tablets and IV injection Adverse effects: beta 1 (cardiac) Use with care in patients with heart failure. Safer with patients with diabetes and asthma. But can also mask the symptoms of hypoglycemia.
Metoprolol Lopressor, Toprol XL, betaloc hypertension, angina pectoris, heart failure, and myocardial infarction
Parasympathetic/sympathetic Muscarinic receptor response (lungs)
Parasympathetic: Constrict Bronchi Sympathetic: Dilate Bronchi
Parasympathetic/sympathetic Muscarinic receptor response (eyes)
Parasympathetic: Dilate pupils Sympathetic: Constrict Pupils
Parasympathetic/sympathetic Muscarinic receptor response (bladder)
Parasympathetic: contracts bladder Sympathetic: relaxes bladder
Parasympathetic/sympathetic Muscarinic receptor response (Heart)
Parasympathetic: slows heart beat Sympathetic: accelerates heartbeat
Parasympathetic/sympathetic Muscarinic receptor response (stomach)
Parasympathetic: stimulate digestion Sympathetic: inhibits digestion
Parasympathetic/sympathetic Muscarinic receptor response (intestines)
Parasympathetic: stimulate peristalsis and secretion Sympathetic: inhibit peristalsis and secretion
Parasympathetic/sympathetic Muscarinic receptor response (liver)
Parasympathetic: stimulates bile release Sympathetic: stimulates glucose release
Parasympathetic/sympathetic Muscarinic receptor response (salivary glands)
Parasympathetic: stimulates salvation Sympathetic: inhibit salvation/ dry mouth
________________ Beta-adrenergic Antagonist: NON-SELECTIVE blockade It treats (4): Administration: Oral tablets- Highly lipid soluble (readily crosses membranes, well absorbed orally), First pass (30% reaches systemic circulation) Adverse effects (7): _____________, ____________, ____________, ___________, ___________, __________________, ____________________________________________
Propranolol-Inderal LA, Innopran XL. hypertension, angina pectoris, cardiac dysrhythmias, and myocardial infarction (MI). Beta 1 (cardiac), beta 2 (lungs), CNS effects (depression), insomnia, nightmares, (hallucinations), Neonates - crosses placental barrier.
¢Chronic bronchitis- _________________ atrophy, ciliary abnormalities, smooth muscle hyperplasia, inflammation, bronchial wall thickening ¢"blue bloaters"
airway changes
Asthma diagnosis often based on history and physical exam Work of breathing, breath sounds, capillary refill, and pulse oximetry. Asthma diagnostic tests are?
Pulmonary Function Testing (PFT) Peak Flow monitoring: helps assess chronic disease management Arterial blood gas (ABG): helps to see how blood is exchanging oxygen and CO2. Chest x-ray (CXR) Allergy skin testing Complete Blood Count (CBC): looking for eosinophils Allergen testing for immunoglobulin E
Beta 2 Agonists 2 types: _____________________ Function:__________________ Route: Nebulizer: through humidification, by mouth (PO), or inhaler: this route has high selectivity at low doses. Adverse effects: _____________________(8) Contraindications: patient has history of dysrhythmia or myocardial infarction. Use is limited in children younger than 6 and not recommended for breast feeding women.
Saba-Albuterol and Laba- salmeterol They activate beta 2 receptors in bronchial smooth muscle to cause bronchodilation. headaches, throat irritation, nervousness, restlessness, tachycardia, angina, seizures, allergic reactions.
Muscarinic Antagonists ("Anti-cholinergics") :________________ •Blocks the action of acetylcholine at parasympathetic sites in smooth muscle, secretory glands and the CNS Functions: •______________ , Suppresses ______________ and _______________, _____________ •Onset of action: Oral, IM: 0.5 to 1 hour; IV: 10 minutes; Transdermal (patch): 6 to 8 hours •Precautions:________________ •Anticholinergic side effects •Beer's Criteria Works in CNS and PNS
Scopolamine. Dries secretions, Emesis and motion sickness, Pre-operatively to dry excess secretions Open angle glaucoma, elderly (increased likelihood of hallucination, confusion, and dizziness).
What is the only treatment for intermittent level asthma?
Short Acting Beta Agonist (SABA) drugs
Muscarinic Agonist Side effects: __________, ___________, ____________, ________________________, ____________, ____________
Side effects: bradycardia, hypotension, and increased salivation, increased gastric acid secretions, diarrhea, and cramps
Potassium Sparing Diuretics: They are used to counteract potassium losses from loop diuretics (furosemide) and thiazides. •Useful responses •Modest increase in urine production •Substantial decrease in potassium excretion •Rarely used alone for therapy •Aldosterone antagonist: A category of potassium sparring diuretics. ___________________- a prototype of aldosterone antagonist potassium sparring drugs and the one currently used in the U.S. for diuresis. •Nonaldosterone antagonists: A category of potassium sparring diuretics.
Spironolactone
Sympathetic nervous system Muscarinic receptor response (kidneys)
Stimulate epinephrine and norepinephrine release
Muscarinic Antagonists ("Anti-cholinergics") Oxybutynin (for "overactive bladder") •Blocks muscarinic receptors on the bladder detrusor, inhibiting contractions and the urge to void. •Result: _______________________ •Short half-life requiring frequent dosing, but there's an XL version for extended dosing. •Rare but serious Adverse effects: ___________________ •Side effects: ___________, _____________, and ___________
Suppresses involuntary contractions of smooth muscle of bladder. Angioedema/ hypersensitivity reaction (swelling of the neck and airways). Dry eyes, constipation, decreased secretions, less sweating, dry mouth, and tachycardia
Cholinergic Muscarinic receptor subtype locations
Sweat Glands Blood vessels Heart, liver, kidneys, eyes, intestines, salivary glands, lungs, stomach, and bladder
Cardiac Output Cardiac Output= Heart Rate x Stroke volume.
The amount of blood pumped through the circulatory system in one minute. In the average adults it's 5 liters per minute.
First spacing of fluid:
The normal distribution of fluid in the ICF and ECF compartments.
Methylxanthines Prototype drug: ____________________, traditionally called a bronchodilator. It also has anti-inflammatory, immune regulating and bronchoprotective effects. Also, not used often. Narrow margin of safety: reference range in adults is 5-15 microgram/ml side effects common: _________________ Used for: Caution: use caution in elderly patients and children and not recommended in women breastfeeding.
Theophylline. nausea, vomiting, CNS stimulation. long-term prophylaxis of asthma that is unresponsive to beta agonist or corticosteroids and is not a rescue drug.
Alpha-adrenergic antagonists(alpha blockade) therapeutic affects (3):
Therapeutic Applications: 1. Vasodilation of arterioles and veins to cure hypertension 2.Reversal of toxicity from alpha 1 agonists 3.Pheochromocytoma: a catecholamine secreting tumor particularly norepinephrine and epinephrine. Usually located on the adrenal medulla. Alpha blockers stop the secretions, but does not remove the tumor.
Another symptom of COPD is Tripoding
When patients will lean forward to provide more space for their lungs to expand towards their back. -Extra info: People with COPD will also do pursed lipped breathing which keeps the alveoli open longer to make breathing easier by pursing your lips when you breath.-
Orthostatic hypotension/postural hypotension: refers to____________________ Inadequate reflex compensation upon position change results in orthostatic or postural hypotension. Orthostatic changes occur with prolonged bed rest, older age, hypovolemia, and some medications. Hypotension is blood pressure below 100/60 mm Hg. Low blood pressure readings can be normal for some healthy, young adults and are no cause for concern. Even in older individuals, a low reading without symptoms may not be significant. A sudden drop in blood pressure, significantly below the normal range for a person, causes hypotension. A significant change from baseline values is more important than any one specific measurement.
a drop in systolic pressure of greater than 20 mmhg or diastolic pressure greater than 10 mmhg after changing to standing position. These changes are caused by abrupt peripheral vasodilation without a compensatory increase in cardiac output. Orthostatic patients are at risk for falling. Instruct patients with chronic orthostatic hypotension to change positions slowly, allowing several minutes to elapse between positions when moving from lying to sitting to standing.
•Hyponatremia: A low sodium level, lower than 136 mEq/L •Causes: ____________________ •Manifestations: poor skin turgor, dry mucosa, headache, decreased salivation, decreased blood pressure, nausea, abdominal cramping, neurologic changes •Medical management: ________________________ •Nursing management: assessment and prevention, dietary sodium and fluid intake, identify and monitor at-risk patients, effects of medications (ex. diuretics)
adrenal insufficiency, water intoxication, SIADH, vomiting, diarrhea, sweating, diuretics. water restriction, sodium replacement.
Muscarinic Agonist response to (lung)
bronchoconstriction increased secretion
Muscarinic Antagonist response to (lungs)
bronchodilation decreased secretion
Symptoms of orthostatic hypotension are those related to decreased ____________, such as __________, ____________, ____________, __________, and marked changes in blood pressure and heart rate.
cerebral perfusion, dizziness, weakness, blurred vision, syncope.Measure orthostatic blood pressure in patients exhibiting symptoms of dizziness, blurred vision, or weakness when changing position; patients taking diuretic medications; and patients with a history of volume loss.
Muscarinic Antagonist response to (Central Nervous System)
confusion, sedation
Muscarinic Agonist response to (ciliary muscle)
contraction
Muscarinic Agonist response to (iris)
contraction
Muscarinic Agonist response to (heart)
decreased heart rate
Muscarinic Antagonist response to (Lacrimal gland)
dry eyes
Muscarinic Antagonist response to (salivary glands)
dry mouth
•Muscarinic agonist drugs therapeutic uses: •1) Promotes contraction in smooth muscle (detrusor muscle) and promotes relaxation of the trigone and sphincter, increasing voiding pressure •2) Result: __________________
emptying of the bladder
Muscarinic Agonist response to (Central Nervous System)
enhanced cognition
•Hypernatremia: A high sodium level, higher than 144 mEq/L •Causes: _____________________ •Manifestations: thirst; elevated temperature; dry, swollen tongue; sticky mucosa; neurologic symptoms; restlessness; weakness •Note: thirst may be impaired in elderly or the ill •Medical management: hypotonic electrolyte solution or D5W •Nursing management: assessment and prevention, assess for OTC sources of sodium, offer and encourage fluids to meet patient needs, provide sufficient water with tube feedings
excess water loss, excess sodium administration, diabetes insipidus, heat stroke, hypertonic IV solutions.
Antitussives or expectorants: inhibit cough Prototype drugs: Opioid version- codeine, Non-opioid version-dextromethorphan Mechanism of action: acts in medulla to inhibit cough reflex. Primary use: ________________________ adverse effects: _____________________
for severe cold and flu symptoms. dizziness, drowsiness, and GI upset.
Myocardial contractility - ___________________________
force with which the ventricles contract
Beta 1 - increased rate of and force of contraction (has control on the heart) *Function is one of the effects.* Activation of the Beta 1 adrenergic receptor by an Beta 1 agonist causes(2) effects?
heart- increased rate of and force of contraction Kidneys- renin release
Adrenergic agonists: Type Catecholamines
hormones secreted by the adrenal medulla that affect the sympathetic nervous system in stress response e.g. dopamine, norepinephrine, and epinephrine. Cannot be taken orally, short action, and cannot cross blood-brain barrier (highly polar molecules). Also, given parenterally and colorless ONLY when first mixed throw out if not.
•Hyperkalemia: excess potassium, higher than 5.2 mEq/L •Causes:____________________________ •Manifestations: cardiac changes and dysrhythmias, muscle weakness with potential respiratory impairment, paresthesias, anxiety, confusion, GI manifestations (nausea, vomiting, diarrhea) •Medical management: cardiac monitor ECG, limitation of dietary potassium, cation-exchange resin (Kayexalate) medication, IV sodium bicarbonate, IV calcium gluconate, regular insulin and hypertonic dextrose IV, b-2 agonists, dialysis
impaired renal function, hypoaldosteronism, tissue trauma, acidosis, treatment related
Muscarinic Antagonist response to (heart)
increased heart rate
Corticosteroids also called glucocorticoids Prototype drug: FluticaSONE- most -SONE drugs are a corticosteroid. (Flovent, Flonase) (Fluticasone/salmeterol= advair) Mechanism of action: suppresses _________________ that is present in asthma by decreasing synthesis and release of inflammatory mediators, decreasing infiltration and activity of inflammatory cells and decreased edema of the airway mucosa. Primary use: _________________ Adverse effects: Oropharyngeal Candidiasis (a super infection), risk of adrenal suppression in long term use. Watch for infection
inflammation. To decrease frequency of asthma attacks through prevention than treatment.
Cough Medicine Expectorants:
inhibit mucus production. Ex: Guaifenesin (mucinex). They are given orally and the side effects are drowsiness, gi upset, and headache.
Cough Medicine Mucolytics:
loosen thick bronchial secretions. Ex: Acetylcysteine (Mucomyst). It's given through inhalation and side effects are nausea.
Spironolactone (Aldactone): Adverse effects •Hyperkalemia (normal range:____________) •Endocrine effects Drug interactions •Thiazide and loop diuretics •Agents that raise potassium levels
normal potassium 3.7-5.2 mEq
Heart Rate (HR)
number of times the heart beats per minute. The average is 70 beats per minute in a range of 60-100 bpm. It's controlled by the autonomic nervous system and receptors in the sinoatrial node (SA).
Third spacing of fluid:
occurs when too much fluid accumulates in nonfunctional areas between cells. You may see this as a result of burns, sepsis, or trauma.
¢Emphysema- ________________________________ Decline in alveolar surface area for gas exchange ¢Loss of alveolar walls- elastic recoil loss ¢Loss of supporting structure-airway narrowing ¢"pink puffers"
permanent airspace enlargement of alveoli
Afterload - _________________________________ Hypertension increases afterload. Low blood pressure decreases afterload.
pressure that must be overcome to pump blood through the aortic valve out of the ventricle
Leukotriene Modifiers Prototype (founding) drug: monteLUKAST (no other versions. -Lukast drugs are always leukotriene modifiers) An oral medication Mechanism of action:_____________________ Primary Use: _________________ Adverse effects: headache, nausea, diarrhea, neuropsychiatric effects, including depression, suicidal thinking, and suicidal behavior( not for suicidal people).
prevents airway edema and inflammation by blocking leukotriene receptors in airways. Prophylaxis of persistent, chronic asthma, treat allergic rhinitis
Muscarinic Antagonist response to (Ciliary muscle)
relaxation
Muscarinic Antagonist response to (Iris)
relaxation
Anticholinergic (muscarinic receptor antagonists) Prototype drug: ipratropium (atrovent) tiotropium (spiriva) Mechanism of action: causes bronchodilation by blocking cholinergic receptors in bronchial smooth muscle. Primary use: ________________________ Maintenance rather than quick, acute treatment Adverse effects: __________________ Assess for history of: narrow-angle glaucoma, benign prostatic hyperplasia, renal disorders, and urinary bladder neck obstruction
relief of bronchospasm cough, drying of nasal mucosa, hoarseness, bitter taste
Anticholinergic toxicity: Excessive cholinergic (acetylcholine) receptor blockade Side effects of toxicity in pneumonic: •Hot as a hare (hyperthermia) •Dry as a bone (dry skin) •Red as a beet (flushed skin) •Blind as a bat (mydiasis) •Mad as a hatter (delirium) •Other symptoms: ____________, _______________, ______________, ____________, __________________
seizures, tachycardia, hypertension, constipation, urinary retention, respiratory depression (can lead to death)
Nursing Management Fluid Volume Deficit: •I&O, daily weight: is the most accurate measure of volume status, vital signs, labs •Monitor for signs and symptoms: __________________________ •Oral care •Administration of oral fluids •Administration of parenteral fluids Ensure patient safety
skin appearance, turgor, oral mucosa, furrowed tongue, urine output, mental status Implement measures to minimize fluid loss
Muscarinic Agonist response to (bladder)
smooth muscle contraction
Muscarinic Agonist response to (GI)
smooth muscle contraction and acid secretion
Muscarinic Antagonist response to (GI)
smooth muscle relaxation
Muscarinic Antagonist response to (bladder)
smooth muscle relaxation
Muscarinic Agonist response to (Lacrimal gland)
tearing
Adrenergic receptors are located in all organs regulated by the sympathetic nervous system
true
Alpha 2 Activation Therapeutic Effects: Therapeutic Effects: Peripheral Alpha 2 receptors -- Located presynaptically and have little clinical significance in the periphery. Do have clinical significance in the CNS.
true
Chronic Bronchitis acute management: Inhaled short-acting B2 agonist inhaled anticholinergic bronchodilators- Ipratropium bromide Cough suppressants antimicrobial agents inhaled/oral corticosteroids Theophylline low dose O2 therapy.
true
Chronic Bronchitis chronic management: smoking cessation bronchodilator therapy reduction to exposure of irritants adequate rest proper hydration physical reconditioning
true
Hydrochlorothiazide (HydroDIURIL) Drug interactions: •Digoxin (increased digoxin toxicity due to low potassium levels.) •Augments effects of hypertensive medications •Can reduce renal excretion of lithium (leading to accumulation) •NSAIDs may blunt diuretic effect •Can be combined with ototoxic agents without increased risk of hearing loss
true
Hydrochlorothiazide [HydroDIURIL] Adverse effects (smaller impact on sodium, chloride, and water compared to Furosemides): •Hyponatremia, hypochloremia, and dehydration •Hypokalemia: Potassium-sparing diuretics may be used to off set this effect. •Use in pregnancy and lactation •Hyperglycemia: watch out with patient with diabetes •Hyperuricemia: watch out with patients with gout. •Impact on lipids, calcium, and magnesium
true
Nursing Management Fluid Volume Excess: •I&O and daily weights; assess lung sounds, edema, other signs and symptoms •Monitor labs and responses to medications—diuretics •Promote adherence to fluid restrictions, patient teaching related to sodium and fluid restrictions and frequent patient repositioning. •Monitor, avoid sources of excessive sodium, including medications •Promote rest •Semi-Fowler's position for orthopnea- head of bed is 30-45 degrees •Skin care, positioning/turning
true
Pneumonia supportive treatments: ¢Oxygen Fluids: IV Fluids, PO ¢Suctioning/bronchial hygiene (TCDB) ¢Nutrition support Active range of motion/ Early mobilization Turn, Cough, and deep breath Spirometer
true
Pneumonia treatments ¢Beta-agonists ¢Corticosteroids ¢Antibiotic therapy: Macrolides, and fluoroquinolones. Based on sensitivity of the culture. ¢Antipyretics/analgesias ¢Antitussives or expectorants
true
Thiazide Diuretics-Also known as benzothiadiazides •Effects similar to those of loop diuretics •Increase renal excretion of sodium, chloride, potassium, and water •Elevate levels of uric acid and glucose •Maximum diuresis is considerably lower than with loop diuretics •Not effective when urine flow is scant (unlike with loop diuretics)
true
Volume Contraction = loss of body water Volume Expansion = increase in body water
true
•Hyperkalemia (continued) •Nursing management: assessment of serum potassium levels, mix IVs containing K+ well, monitor medication effects, dietary potassium restriction/dietary teaching for patients at risk •Salt substitutes, medications may contain potassium •Potassium-sparing diuretics may cause elevation of potassium •Caution in patients with renal dysfunction
true
Signs and symptoms of COPD (15):
¢Cough- Often worse in the morning ¢Dyspnea ¢Wheezing ¢Accessory muscle use to breathe ¢Barrel chest ¢Decreased breath sounds ¢Prolonged expiration or expiratory time. ¢Crackle sound when breathing Bronchitis: increased sputum Finger clubbing: also effect of chronic hypoxia Frequent respiratory infections easily fatigued thin in appearance orthopneic
Pneumonia tests
¢Serum chemistry panel ¢Complete blood count (CBC) with differential ¢Blood and sputum cultures ¢Chest X-ray Arterial blood gas (ABG) Chest CT Serum lactate Serum free cortisol C reactive protein
Pneumonia symptoms
¢Temperature > 100.5 ¢Tachycardia ¢Altered mental status ¢Chills, rigors ¢Body aches, headache ¢Cyanosis Dyspnea Crackles Wheezing Rhonchi Decreased breath sounds Dullness to percussion Pleurisy Pleural friction rub Cough, with or without sputum
Asthma pathophysilogy ¢Airway inflammation ¢Intermittent airflow obstruction ¢Bronchial hyper-responsiveness ¢Airway remodeling Asthma signs and symptoms are?
¢Wheezing ¢Coughing ¢Shortness of breath ¢Chest tightness/pain use of accessory muscles is sign of struggling to breathe
Drugs with Anti-cholinergic (muscarinic antagonist properties)
•Antihistamines- Benadryl, diphenhydramine •Antidepressants, •Cardiovascular, •Gastrointestinal, •Anti-Parkinson, •Anti-psychotics, •Anti-vertigos, •Muscle relaxants, •Anti-emetics, •Urinary incontinence
Spironolactone (Aldactone) Mechanism of action •Blocks aldosterone in the distal nephron •Retention of potassium •Increased excretion of sodium Administered: orally Therapeutic uses:
•Hypertension •Edematous states •Heart failure
Furosemide (Lasix): Adverse effects (14):
•Hyponatremia, hypochloremia, and dehydration (electrolyte imbalances) •Hypotension- dizziness, light headed •Loss of volume •Relaxation of venous smooth muscle •Hypokalemia- normal potassium 3.7-5.2 mEq •Ototoxicity- hearing impairment •Hyperglycemia- high blood sugar •Hyperuricemia- high uric acid levels •Use in pregnancy-only used if necessary. •Impact on lipids(decrease in healthy cholesteral and increase in unhealthy cholesterol), calcium, and magnesium Chest pain
Diuretics Mechanism of action: •Blockade of sodium and chloride reabsorption Treatment: They are drugs that increase urine output. Also hypertension, heart failure, liver cirrhosis and kidney disease. Site of action •Proximal tubule produces greatest diuresis (65% of NA+ and Cl- reabsorbed in the PCT) Adverse effects:
•Hypovolemia •Acid-base imbalance •Electrolyte imbalances
•Potassium is responsible for: Isotonicity: quality of uniform tone and tension.
•Muscle contraction •Transmission of nerve impulses •Regulation of heartbeat •Maintenance of acid-base balance
Furosemide (Lasix) Drug interactions: •Digoxin- used in the treatment of heart failure and cardiac dysrhythmias. •Ototoxic drugs: increase Furosemides ototoxic effect •Potassium-sparing diuretics: used to off set Furosemides hypokalemia effect. •Lithium •Antihypertensive agents: reduce the hypertensive effect of Furosemide. •NSAIDs: they can reduce Furosemides effectiveness Preparations, dosage, and administration:
•Oral: can cause voiding at night when given by mouth, so give earlier in the day. •Parenteral
Muscarinic Antagonists Side effects/ Adverse effects (9)
•Xerostomia (dry mouth) •Blurred vision and photophobia (bright light hurts eyes) •Elevation of intraocular pressure (can be caused by paralysis of the iris sphincter or glaucoma in these people atropine can cause vision loss) •Urinary retention •Constipation •Anhidrosis (can't sweat) •Tachycardia •Asthma (caused by profound drying of bronchial constrictions, or from the increased dosage needed for atropine to affect the lungs.)
