Pharm Exam 1 Study Guide Ch. 8, 14, 16, 17

Left Sided Heart Failure S/S

- Paroxysmal Nocturnal Dyspnea - Elevated Pulmonary Capillary Wedge Pressure - Pulmonary Congestion > cough > crackles > wheezes >blood-tinged sputum (pink, frothy sputum) > tachypnea - Restlessness > confusion > Orthopnea > Tachycardia > Exertional Dyspnea > Fatigue > Cyanosis

Potassium (K)

3.5-5 mEq/L - Essential for maintaining electrical excitability of muscle, conduction of nerve impulse and regulation of acid/base balance ● Potassium chloride (K-Dur) ● Oral or IV administration ● NEVER give IV push to avoid fatal hyperkalemia ● Dilute potassium and give no more than 40 mEq/L per IV to prevent irritation of vein ● Administer no faster than 10 mEq/L per IV ● Concurrent use with potassium-sparing diuretics or ACE inhibitors can cause hyperkalemia

Calcium (Ca)

9.0-10.5 mEq/L - Essential for normal musculoskeletal, neurological and cardiovascular function - Can slow bone loss and may decrease fractures ● Calcium citrate (Citrical) ● Calcium carbonate or calcium acetate ● Implement seizure precautions during administration and have emergency equipment on hand Food Sources: - Milk products - Green vegetables - Calcium-fortified orange juice - Soy Milk - Collards High food sources: - Whole & skim milk - Yogurt - Turnip greens - Cottage cheese - Ice Cream - Sardines with bones - Spinach

Antidotes

Acetaminophen= acetylcysteine, mucomyst Anticholinergics= atropine, pralidoxine Benzodiazepines= Romazicon (flumazenil) Beta-Blockers= glucagon, epinephrine Ca Channel Blockers= Ca Chloride, glucagon Coumadin= vitamin K Digoxin= digiband Dopamine= Rigitine Heparin= Protamine Sulfate Iron= deferoxamine Malignant Hyperthermia= dantrolene Methotrexate= leucovorin calcium Narcotics= Narcan (naloxone) Potassium= Sodium Polystyrene Sulfonate (Kayexalate) Magnesium Sulfate= calcium gluconate

Hypercalcemia

An abnormally high level of calcium in the blood Causes: - Movement of calcium from bone to circulation - Immobilization - Metastatic bone cancer - Multiple Myeloma - Excess intake of supplemental calcium - Excess intake of dietary calcium - Excess intake of antacids containing calcium - Increased absorption of calcium - Increased levels of parathyroid hormone - Increased levels of vitamin D S/S: - Decreased Deep Tendon Reflexes - Renal calculi (kidney stones) - Lethargy, coma - Constipation - Anorexia, nausea, vomiting - Behavioral changes, including confusion - Thirst, polyuria** - Paralytic ileus - Cardiac dysrhythmias, cardiac arrest - Hypertension - Decreased muscle tone** - Decreased GI motility - Bone pain Nursing Interventions: - Administer diuretics as ordered by the HCP - Encourage patient to drink 3,000-4,000 L of fluids - Monitor I&O

Heparin

Anticoagulant (Indirect Thrombin Inhibitors) Actions: - Decreases clot formation by increasing the amount and action of a protein called antithrombin III Uses: - Used to prevent new clot formation or to stop existing clots from growing in size Antidote: - protamine sulfate Expected Side Effects: - Can cause easy bleeding/bruising, pain, redness, warmth, irritation or skin changes where the drug was injected - Foot itching or bluish-colored skin Adverse Effects: - Hemorrhage - Thrombocytopenia - SOB - Wheezing - Chills - Fever - Alopecia - Hypersensitivity (allergic) reaction Drug Interactions: - Can interact with ASPIRIN, NSAIDs, glucocorticoids and other anticoagulants (warfarin) Nursing Interventions: - Should be used cautiously in patient with liver or kidney disease, or HTN, during menses, after delivery, or in patients with indwelling catheters - Only given in IV injection, IV infusion, or SubQ (NEVER IM injection) - Do Not shake the bottle containing Heparin; only carefully roll between your hands before inserting the needle - DO NOT give in the same IV line or same syringe with any other drug - SubQ heparin is usually given every 12 hrs - AVOID giving IM injections of other drugs while the patient is receiving heparin because hematoma and bleeding into nearby areas may occur - Rotate sites of SubQ injections to avoid formation of hematomas - If IV therapy is prescribed, blood for partial thromboplastin time (PT) determination should be drawn 1 hr BEFORE the next scheduled dosage of heparin - Most commonly used blood test for determining therapeutic range for heparin is the activated (aPTT) - Teach women of child bearing age to notify the HCP if they are pregnant or plan to become pregnant while using heparin. There is a risk of for birth defects/bleeding in the last trimester that is associated with heparin in pregnancy - Breast-feeding is safe during Heparin therapy - Monitor platelet counts for declines that can be associated with HIT or HITT

Glipizide (Glucotrol)

Antidiabetic drug (Insulin Stimulators) - Onset: 10-30 mins - Peak: 30mins-2 hrs - Duration: 12-24 hrs

Sodium Polystyrene Sulfonate (Kayexalate)

Antidote for hyperkalemia Action: - Exchanges sodium ions for potassium ions in the large intestine - Used in the treatment of severe hyperkalemia. - Can be given PO or by 6 hour retention enema - Side effects / nursing care: - Needs to be in contact with GI tract for 6 hours to be most effective - Monitor for hypokalemia and loss of magnesium and calcium - Monitor for sodium overload. 1/3 of sodium is retained. - Rectal administration helps to prevent constipation. - Stop resin administration when serum potassium is 4 - 5 mEq.

Determir (Levemir) Insulin

Long acting insulin. Can remain at room temp for 42 days • Onset - 1 hr • Peak - 6-8 hr • Duration - 5.7-24 hr

Enoxaparin (Lovenox)

Low Molecular Weight Heparin (LMWH) - Is a special formulation with more steady anticoagulation effect than unfractionated heparin sodium - Works by binding to antithrombin and inhibiting factor Xa, which disrupts part of the clotting cascade - Half-life is longer than heparin sodium, ranging from 2-4 hrs after IV injection to 3-6 hrs after SubQ injection - LMWH does not require testing Uses: - The prevention of venous thromboembolism and may often be used when pulmonary embolism is present Nursing Interventions: - Are given by Deep SubQ injection - DO NOT expel air bubble or aspirate before giving injection - Do NOT rub the injection site - All of these actions can cause excessive bleeding, bruising and tissue damage at the injection site

Direct Thrombin Inhibitors (DTIs)

Prevents the formation of blood clots, or thrombi, by interfering with the enzyme thrombin (factor II) - This action increases the time it takes for the blood to clot, PREVENTING new clots that have already occurred - These drugs DO NOT dissolve clots that have already occurred Examples: - rivaroxaban (Xarelto)** - dabigatran (Pradaxa) - apixaban (Eliquis) - edoxaban (Savaysa) Uses: - Used to prevent clots in both arteries and veins - Can be used to prevent and treat DVT or pulmonary embolism (PE) or to prevent clotting from atrial fibrillation - They are prescribed for patients who are at risk for systemic embolism and stroke, especially for patients who have A-Fib that is not caused by a heart valve problem Expected Side Effects: - Can cause nose bleeding - Easy bruising is common - Bleeding gums when brushing his/her teeth - Gastric upset when this drug is taken on an empty stomach Adverse Reactions: - Excessive bleeding and thrombocytopenia - Early signs of OD or internal bleeding include: bleeding from gums while brushing teeth, excessive bleeding or oozing from cuts, unexplained bruising or nosebleeds, and unusually heavy or unexpected menses in women Drug Interactions: - Common drugs that INCREASE the activity and bleeding risks with DTIs are: > atorvastatin > azithromycin > carvedilol > clarithromycin > cyclosporine > diltiazem > St. John's Wort - Drugs that DECREASE the effectiveness of DTIs are: > carbamazepine > dexamethasone > phenobarbital > phenytoin > rifampin > antacids Nursing Implications/Patient Teaching: - Assess patient for any s/s of serious bleeding: > unusual bruising > blood in the urine, stool, or vomitus > coughing up blood > headaches, dizziness, or weakness > recurring nosebleeds > unusual bleeding from gums > menstrual bleeding that is heavier than normal - Take DTIs on time - If a dose is missed, the scheduled dose should be taken ASAP on the same day - If there will be less than 6 hrs between scheduled doses, the missed dose should not be taken - Accidental OD may lead to excessive bleeding. If needed, the reversal agent (idarucizumab) can be prescribed by the HCP*** - Do not discontinue medication without talking to their HCP because the risk for serious clotting events increases - Keep drug in the original bottle to protect the drug from moisture and light - Do not chew or break the capsules because the drug may be absorbed too rapidly or destroyed by the stomach acid - Take drug with a FULL glass of water to prevent stomach irritation and improve absorption

Ginkgo Biloba

Provides acetone for extraction that clients who have peripheral arterial disease can use to increase how far they can walk without pain - Causes vasodilation and thus improve blood flow - Suppression of platelet-activating factor can decrease the risk of thrombosis formation

Feverfew

Used for Migraines **Can cause increase risk of bleeding - Client should be informed that it can decrease platelet aggregation - The nurse should report the use of feverfew and other herbal supplements the client's provider

Garlic supplements

Used to decrease triglyceride and LDL cholesterol and increase HDL cholesterol, lower BP, inhibit platelet aggregation and decrease atherosclerotic plaque. - It might also have antimicrobial and anticancer effects - These effects occur from the actions of studies in garlic oil, which can interfere with cholesterol synthesis in the liver, inhibiting thromboxane synthesis, and cause vasodilation

Niacin

Vitamin B3 a. MOA → decreases lipoprotein and triglyceride synthesis (in large doses). Lowers LDL & triglycerides b. S/E → flushing of face, GI distress, hepatotoxicity, hyperglycemiac. Nursing interventions → monitor LFTs, monitor blood glucose

Vitamin K Antagonist (Warfarin)

Warfarin (Coumadin) - Are anticoagulant drugs that interfere with blood clotting by reducing the amount of vitamin K that is available to help the liver form clotting factors Action: - Inhibits the enzyme needed for final activation of vitamin K. Without adequate amounts of vitamin K, the liver cannot make blood coagulation factor II, VII, IX & X Antidote: Vitamin K Uses: - Is the drug of choice and is given orally for the prevention of blood clots and emboli Expected Side Effects: - Easy bruising and bleeding (ex. bleeding gums may occur when brushing teeth; blood in stool/urine is common) - GI upset (ex. diarrhea, nausea) - Headache - Skin Rash Adverse Effect: - Excessive bleeding or hemorrhage - Frank blood or dark, tarry stools - Coffee-colored vomitus - Can cause skin necrosis that can occur within the first 10 days - Can cause birth defects or deaths to the fetus (NOT given during pregnancy) Nursing Interventions: - Teach patients to limit amount of green, leafy vegetables they eat because they are a natural source of vitamin K that can reduce the effect of warfarin - Monitor pts INR to determine effectiveness - Remind pts to keep all appointments for INR lab tests because the dosage is changes based on test results - Stress importance of NOT taking ASPIRIN or NSAIDs with this drug because it can lead to excessive bleeding - Teach pt S/S of abnormal bleeding to report HCP - Ensure that the warfarin antidote, vitamin K, is available so it can be given quickly in case of an overdose - Caution women of childbearing age who are taking this drug to avoid pregnancy - Many drugs and herbal supplements interfere with the action of warfarin and should be avoided

Iron Food Sources

Dark green vegetables: - spinach - swiss chard - kale - greens (dandelion, beet, and turnip) Dried Fruits: - apricots - dates - figs - prunes - raisins - Eggs - Iron-enrisched or iron-fortified breads and cereals - Legumes and nuts - Muscle meats, especially dark meat from poultry Organ meats: - Liver - Kidney - Heart - Tongue - Shellfish - Whole-grain breads and cereals

Beta Blockers (-olol)

Drugs that work as antagonists and block the activity of beta-adrenergic receptors Examples: - metoprolol, propranolol, atenolol, acebutolol - Classified into two groups: 1) Nonselective beta adrenergic 2) Selective beta adrenergic - The nonselective agents block both beta1 and beta2 sites. This is important because you can see that the drug would not only affect beta1 (heart), but also beta2 (lung) receptors. - Blocking beta1 receptors will DECREASE heart contractility and HR (which can decrease BP) - On the other hand, blocking beta2 (lung) receptors will cause bronchoconstriction- a problem especially if you have asthma Nursing Interventions: - HOLD the drug if HR is less than 60 bpm or systolic BP is less than 90 mm Hg to prevent adverse effects - Teach patients that common side effects include decrease sexual ability, dizziness, drowsiness, difficulty sleeping, or weakness. Some patents ma experience cold hands and feet - Tell patients to report symptoms of depression to their HCP - Teach diabetic patients that beta blockers can mask signs of hypoglycemia (except for sweating). remind them to check blood sugars regularly and treat low blood sugar - DO NOT stop beta blockers suddenly, to avoid rebound high BP Patient Teaching: - Take the drug exactly as ordered. If a dose is missed, it should be taken as soon as it is remembered; if it is close to the next scheduled dose, skip the missed dose and return to the regular dosing schedule - Teach proper techniques for home monitoring of BP and HR. If BP is less than 90/60 mm Hg or the HR less than 60, contact your HCP - Keep a daily record of your BP to bring to your appointments. This will help the HCP make sure you are on the most effective drugs - Remember to get up slowly from a lying or sitting position to avoid dizziness form getting up too fast - Notify your HCP of any new or uncomfortable symptoms that develop. These symptoms might indicate an diverse effect or may be relieved by simply changing to a new drug - Avoid alcoholic beverages while taking drugs for HBP

Right Sided heart Failure S/S

(Cor Pulmonale) - Fatigue - Peripheral Venous Pressure - Ascites (accumulation of fluid in the abdominal cavity) - Enlarged Liver & Spleen - May be secondary to pulmonary problems - Distended Jugular Veins - Anorexia & complaints of GI Distress - Weight gain - Dependent Edema

Folic acid Food Sources

- Asparagus, broccoli - Enrished and fortified breads and cereals - Fish - Green, leafy vegetables - Legumes - Meat - Organ meats: Liver - Whole-grain breads and cereals

Vitamin C Food Sources

- Cantaloupe - Citrus Fruits - Leafy, green vegetables - Strawberries

Herbal Supplements and UTIs

- Cranberry has been used to mange UTIs, particularly in women prone to recurrent infection. Studies supporting its use are limited. It has also been used to treat acute UTI. Monitor patients for lack of therapeutic effect - Echinacea stimulates the immune system and treats UTI. Patients with Immunodeficiency Virus Infections, including AIDS, TB, Collagen Disease, Multiple Sclerosis, or other autoimmune disease, should avoid its use. Echinacea should not be used in place of antibiotic therapy - Sea Holly (Eryngium campestre) specifically the above-ground plant parts, have a mild diuretic effect The roots have an antispasmodic effect. The above-ground parts are used in UTI and prostatitis; the roots are used to treat kidney and bladder calculi, renal colic, kidney and urinary tract inflammation and urinary retention - Nettle (Urtica dioica) currently is being investigated as irrigation for the urinary tract and to treat benign prostatic hypertrophy. Patients with fluid retention caused by reduced cardiac or renal activity should NOT use this herb - Some believe that acupuncture applied to the abdominal meridian may help relieve cystitis - Some advocate massage with diluted rosemary, juniper, or lavender to aid in relieving pain associated with cystitis

Amino Acid Food Sources

- Eggs - Fish - Legumes - Meat - Milk and milk products (cheese, ice cream) - Nuts - Poultry

Vitamin B12 Food Sources

- Eggs - Milk and cheese - Muscle meats - Organ meats: Liver and kidney

Herbal Supplements that react to anticoagulants

- Garlic (can causes bleeding) - Ginkgo - Angelica - Anise - Bilberry - Devil's Claw - Goldenseal - Licorice Root - Parsley - Red Clover **Patients taking anticoagulants should be cautious regarding the use of herbs - These substances can have potent actions, which may enhance the action of anticoagulant medications

Iron Administration

1. Best absorbed in an acidic environment 2. To avoid binding the iron with food, iron should be taken about an hour before meals (duodenal mucosa is most acidic) 3. Take with vitamin C or orange juice, which contains ascorbic acid, enhances absorption 4. GI side effects may necessitate ingesting iron with meals 5. Do not take with antacids (they reduce the absorption of iron) 6. If dose is missed, continue with schedule, do not double dose 7. May interfere with absorption of oral tetracycline antibiotics, do not take within 2hrs of each other 8. Dilute liquid iron preparations in juice or water, administer with a straw to avoid staining teeth, provide oral hygiene after 9. Check for constipation or diarrhea, record color and amount 10. Toxic, store out of a child's reach

Magnesium (Mg)

1.3-2.1 mEq/L - Regulates skeletal muscle contraction and blood coagulation ● Magnesium sulfate ● Magnesium gluconate or magnesium hydroxide ● Monitor BP, pulse and respirations with IV administration ● Decreased/absent deep tendon reflexes indicates toxicity ● Have injectable calcium gluconate on hand to counteract toxicity when giving magnesium sulfate via IV

Sodium (Na)

135-145 mEq/L - Major electrolyte in extracellular fluid **Administer isotonic IV therapy of 0.9% NS or Ringer's Lactate

Nitrates

A class of drugs that vasodilator (widen blood vessels) by relaxing vascular smooth muscle in the peripheral venous system and reducing resistance to blood flow in the arterial system - These effects work together to help the heart receive more oxygen and pump more easily Uses: - Rapid-acting nitrates (sublingual nitro & IV nitro) are used to relieve pain in acute angina - Long-acting oral nitrates, topical NTG paste & transdermal patches can PREVENT angina and reduce the severity and frequency of anginal attacks - They reduce the work of th heart after MI or in patients with HF Expected Side Effects: - Throbbing headaches, caused by rapid blood vessel dilation in the head and face - The headaches usually occur very quickly after administration and usually go away quickly if the patient is taking low doses - For patients taking high doses, acetaminophen or other analgesics may be needed to help reduce pain - It is common for patients to experience a slight drop in BP after taking this drug because of venous dilation Adverse Effects: - Severe postural hypotension (low BP when a person suddenly stands up) - Reflex tachycardia (rapid heart beat) - Paradoxical bradycardia - Vertigo (feeling of dizziness or spinning) - Severe weakness may occur Drug Interactions: - Alcohol, antihypertensive drugs, opioids and diuretics can INCREASE the effect of nitrate drugs - Caffeine, pseudoephedrine, methylphenidate and certain anti diabetic drugs can DECREASE the effectiveness of nitrates - Drugs given for erectile dysfunction (ex. sildenafil) can cause severe hypotension if given while the patient is taking nitrates Nursing Interventions: - Monitor BP carefully because decrease BP is a common side effect - Teach patient that they may experience a headache - wear gloves when applying nitroglycerin ointment or paste to avoid absorption into your skin - Rotate sites when using paste or patches as directed to avoid skin breakdown - Make sure to remove used patches according to directions (usually at bed time) because patients need a drug-free period to avoid tolerance to the drug - Store NTG tablets in a dark, glass container to prevent breakdown of the drug - Make sure to check expiration date of NTG tablets because they deteriorate quickly and then are not effective in treating chest pain

Iron Deficiency Anemia

A condition in which the RBCs contain less Hgb than normal - Common Causes: > Excessive iron loss > A diet low in iron sources > Bleeding from gastric or duodenal ulcers > Esophageal Varices > Hiatlal Hernias > Colonic Diverticula > Tumors > Non-absorption of Vitamin B12 *Even without excessive blood loss, this disorder can result when the body's demand for iron exceeds its absorption, which commonly occurs in infants, young adolescents and pregnant women - May also result from malabsorption of iron caused by diseases such as celiac disease or sprue Clinical Manifestations: - Pallor - Glossitis (red, smooth tongue) - Fatigue - Weakness - SOB - Pagophagia (the desire to eat ice, clay or starches) - Cold extremities - Complaints of chest pain Objective Data: - Tachycardia - Pallor - Fingernails may be fragile and shaped like the head of a spoon with a center depression and raised borders - Mucus membranes of the mouth may be inflamed (stomatitis) and lips may be erythemic with cracking at the angles Diagnostics: - Peripheral blood counts show that RBCs, Hgb levels and Hct are DECREASED - Serum Iron levels are LOW Medical Management: - Administration of iron salts such as ferrous sulfate often is required (In 3 weeks Hct should rise 5-15% & Hgb levels should rise by 2-5 g/dL) - Iron is administered orally or by injection - Ascorbic Acid (Vitamin C) has been shown to enhance iron absorption - Food sources of Iron include: > meat, fish, poultry, eggs, green leafy vegetables, whole grains and dried beans Nursing Interventions/Patient Teaching: - Plan for rest periods when fatigue is present - Educate about nutritional needs relative to the condition may prevent this anemia - The patient must know which signs and symptoms are significant and must be reported to the HCP > Diarrhea or nausea is significant but black tarry stools are not (these are expected with iron therapy)

HMG-CoA Reductase Inhibitors (statins)

Antihyperlipidemic drugs that lower blood LDL levels by slowing liver production of cholesterol. They do not remove dietary cholesterol from the blood Examples: - atorvastatin - fluvastatin - lovastatin - pravastatin - rosuvastatin - simvastatin Uses: - To lower blood LDL levels to reduce the risk for atherosclerosis, HTN, heart attack, peripheral arterial disease and stroke - They are only approved to lower blood cholesterol levels Expected Side Effects: - Abdominal pain - headache - diarrhea - muscle and joint discomfort - sore throat and heart burn - Patients with Diabetes may experience an elevation of blood glucose Adverse Effects: - Liver failure - Rhabdomyolysis (muscle breakdown) s/s are general muscle soreness, muscle pain, muscle weakness, stomach pain and brown (tea-colored) urine - Is dangerous if used during pregnancy - If taken during pregnancy, statins can lower cholesterol levels in the fetus, which results in brain deformities - Statins are contraindicated for breast-feeding women Drug Interactions: - Alcohol and acetaminophen increase the liver toxicity effects of statins - Aspirin and antacids decrease the effectiveness of statins - GRAPEFRUIT JUICE can INCREASE the concentration of statins in the blood and should be AVOIDED to reduce the risk for toxic side effects Nursing Interventions: - remind patients to remain on a low cholesterol diet while taking statins because drugs do not reverse a high-cholesterol diet - Teach patients to avoid alcohol - Tell patients to report severe muscle aches, changes in urine color, or decreased urine output because statins can cause rhabdomyolysis - Teach patients to avoid grapefruit juice Patient Teaching: - Lifestyle changes like exercise, a low-cholesterol diet, and good weight management are just as important while you are taking statins to help prevent cardiovascular disease - Make note of the recommended best time of day to take your statin and take it at the same time each day - Inform you HCP if you might be pregnant or plan to become pregnant because statins can CAUSE birth defects - AVOID grapefruit juice when you are taking statins because this can cause the drug to accumulate in the blood and increase the risk for toxic effects - If you have any signs of liver problems such as light-colored bowel movements, yellow-tinge to the skin or eyes, or dark urine, notify your HCP immediately because these are indications of adverse effects - If you have severe muscle aches, notify your HCP because this is an indication of a possible adverse drug effect - Expected side effects include headache, upset stomach and mild ashiness. These usually get better after a few weeks of starting the statin

Metformin (Glucophage)

Biguanide antidiabetic Diabetes Type 2 - Onset: Unknown - Peak: Up to 2 hrs - Duration: 2 weeks after drug discontinued

Bisphosphonates

Calcium-modifying drugs that prevent bones from losing calcium by moving blood calcium into the bone, binding to calcium in the bone and by preventing osteoclasts from destroying bone cells and reabsorbing calcium Example: - ALENDRONATE - Used mainly in women to prevent and manage osteoporosis - Reducing bone density loss reduces the risk for bone fractures - Also used for prevention skeletal fractures in patients with bone metastases and multiple myeloma, Paget's disease and the treatment of cancer-induced hypercalcemia - Contains nitrogen and their effectiveness requires that patients have an adequate intake of both calcium and vitamin D** Expected Side Effects: - Headache - Esophageal Reflux - Nausea Adverse Reaction: - Jawbone necrosis (osteonecrosis) can develop with tooth extraction or other invasive dental procedures in which the jawbone is damaged (more common in patients who are taking higher doses or the IV form of the drug) Nursing Interventions/Patient Teaching: - Take the drug early in the morning, right after breakfast and drink a FULL glass of water - Remain in the upright position (sitting, standing, walking) for at least 30 mins after taking these drugs to prevent esophageal irritation and reflux - Be sure to inform your dentist or oral surgeon that you are taking this drug before you have any tooth extraction or invasive dental procedure involving the jawbone

ACE Inhibitors (-pril)

Captopril, lisinopril a. Indications → HTN, HF, MI, diabetic nephropathy b. MOA → blocks ACE enzyme (functions to convert Angiotensin I to AII) which results in vasodilation, sodium and water excretion, and potassium retention c. S/E → Angioedema, Cough, Elevated potassium i. Others include hypotension, rash, dysgeusia (altered taste)ii. Angioedema is treated w/ epinephrine and symptoms will resolve once med is stopped d. Possible first dose orthostatic hypotension - educate pt to monitor BP for at least 2 hr aftere - Captopril - educate pt to take at least 1 hr before meals - all other ACEs not affected by food f. Captopril - may cause neutropenia (rare, but very serious). - Educate on signs of infection. Interactions - Other BP meds - ↑ hypotension effect - Potassium supplements or potassium sparring diuretics - ↑ risk of hyperkalemia - Lithium - ↑ serum lithium levels (may lead to lithium toxicity) - NSAIDs - can ↓ therapeutic effects of ACE inhibitors Nursing Interventions: - Avoid sudden changes in position because most antihypertensive drugs cause orthostatic hypotension - Teach patients that these drugs can have a "first dose effect" leading to an in creased risk for falls and dizziness - Remind patients to keep taking drugs as prescribed because they do not cure high BP - ACE-Is and ARBs can cause HYPERKALEMIA (high potassium levels), so remind patients to AVOID high-potassium foods including salt substitutes - Monitor patients BP regularly to determine how well the patients responding to the drug - Some patients may experience a dry cough while taking ACE-Is. If so, report this to the HCP immediately because an ARB usually does not cause a cough - If the patient experiences any swelling of the eyes, mouth, face or tongue, contact the HCP immediately because this could be a sign of angioedema, a potentially life-threatening condition - These drugs can cause severe brith defects if taken during pregnancy, so they should NOT be taken by patients who are or may become pregnant - Teach patients taking these drugs to AVOID alcohol because it can cause hypotension - Remind patients to avoid all OTC drugs until checking with the HCP to avoid dangerous drug interactions

Platelet Inhibitors

Class of drugs that inhibit platelet aggregation (clumping) to prevent clots. - Works in the cardiovascular system to prevent clotting events in a patient who might be having reduced blood circulation to the heart before a MI (heart attack) Examples: - acetylsalicylic acid (ASA) or ASPIRIN - clopidogrel** - dipyridamole - eptifibatide - prasugrel - ticlopidine - tirofiban - cilostazol Uses: - Are often the first drugs used to PREVENT clots in blood vessels (vascular system) - Sometimes these drugs are used in situations where blood vessels become blocked, to keep venous and arterial grafts open and to prevent strokes - ASA, or ASPIRIN, is the MOST commonly used anti-platelet drug** - ASA reduces the risk for major blood vessel blockage that can lead to acute MI, ischemic stroke, angina, and peripheral arterial disease (PAD)** - ASA also carries the risk for GI bleeding in older patients, those with a history of peptic ulcer disease and patients using other NSAIDs or more than one anti-platelet therapy** - Clopidogrel (Plavix) is a drug that is used for patients who have had an MI caused by a clot (thrombus) formed in a coronary artery - For patients who have had a stent placed into the coronary artery as a result of severe narrowing or blockage of the artery, clopidogrel PREVENTS platelets from sticking to the stent mesh - For these patients, clopidogrel MUST be taken daily for a year or longer to prevent clots from developing and plugging up the stent - It is also used in PAD to prevent blood clots in the legs, for prevention of an MI Expected Side Effects: - Easy bruising is common - Bleeding gums can occur when brushing teeth - Diarrhea - Nausea - Dyspepsia (stomach discomfort after eating) - Vomiting - Flatulence - Anorexia (lack of appetite) - Rash, pruritus (itching) and purpura (bruising) Adverse Reactions: - Excessive bleeding, including acute hemorrhage (most common) - Allergic reactions to aspirin and NSAIDs generally occur within a few hrs of taking drug - S/S of allergic reaction include: itching, hives, & runny nose - Severe allergic reactions include: swelling of lips, tongue, or face - Acute cardiovascular events can occur when these drugs are stopped abruptly - Clopidogrel can result in a decrease in platelet counts (thrombocytopenia) and WBC count (neutropenia) Drug and Food Intercactions: - Aspirin and NSAIDs taken with other drugs that reduce coagulation, CAN cause excessive bleeding - Alcohol beverages can also increase the risk for bleeding because of their affect on the liver - Oral contraceptives and Vitamin K DECREASE the effects of anticoagulants - PPIs can interact with clopidogrel and DECREASE its effectiveness - Geen, leafy vegetables contain vitamin K and can decrease the effectiveness of anticoagulants - St. John's Wort INCREASES the risk for bleeding when used while taking anticoagulant - Multivitamins containing Vitamin K reduces the effectiveness of Warfarin Nursing Intervention/Patient Teaching: - Ask patient what other drugs he/she has taken in the past week, including OTC drugs, vitamins, minerals, and herbal products - Assess for signs of bleeding such as: + severe abdominal pain/tenderness + vomiting or diarrhea that is frank red blood or coffee-colored + cold, clammy hands - Watch for signs of OD & internal bleeding such as: + bleeding gums when brushing teeth + blood in urine +coughing up blood

Cardiac glycosides

Decrease the speed of conduction through the atrioventricular node, decreasing the number of atrial polarizations and slow the ventricle rate Example: - Digoxin - Digoxin is still used as an antidysrhythmic and an adjuvant agent in HF - Digoxin lowers HR, so ALWAYS measure the patients apical HR for 60 sec with a stethoscope BEFORE giving these drugs Action: - Digoxin activates contractile proteins in the heart muscle, increasing their ability to contract. - Digoxin affects the conduction system of the heart, decreasing HR - As a result, digoxin can effectively TREAT atrial fibrillation Uses: - Positive inotropic drugs are primarily used for symptom management in patients with advanced HF Adverse Reactions: - Inotropic drugs are very powerful and can be toxic - Symptoms of digoxin toxicity include: > anorexia, nausea, vomiting, diarrhea, visual disturbances such as blurred vision or yellow vision, and irregular HR (at times with palpitations) - Patients may experience anxiety, depression or confusion - Some patients are more likely to develop high digoxin blood levels if they are older, have renal insufficiency, or have electrolyte imbalances caused by dehydration or drugs taken for other types of heart conditions Drug Interactions: - Beta blocking agents, calcium gluconate, calcium chloride, succinylcholine and verapamil INCREASE both the therapeutic and the toxic effects of inotropic drugs - Any drug that changes the electrolyte balance may also lead to digoxin toxicity - Patients who take drugs that reduce potassium levels, such as diuretics, are particularly susceptible to digoxin toxicity Nursing Interventions: - Calcium channel blockers such as verapamil and diltiazem are replacing use of digoxin for atrial dysrhythmias. Nevertheless, if you do have a patient who is taking digoxin, monitor the patients very carefully for symptoms of digoxin toxicity, such as lack of appetite, nausea, vomiting and vision changes - Monitor potassium levels carefully - If patients experience any symptoms of digoxin toxicity, make sure to contact the HCP. Optimal blood levels range between 0.5 and 0.8 ng/mL - Take an apical pulse BEFORE giving digoxin. Do NOT give the drug if the pulse is less than 60 bpm - Give digoxin at the same time every day to prevent irregular drug levels - Teach patients that a missed dose may be taken within 12 hrs of the scheduled time and to NEVER take a double dose because of the high risk of drug toxicity

Negative Inotropic Drug

Decreases contractility and ability of the heart

Loop Diuretics

Drugs that increase urine output by blocking active transport of chloride, sodium and potassium in the thick ascending loop of Henle Ex. bumetanide (Bumex), furosemide (Delone, Lasix) *Has a half life of 6 hrs (laSIX) - Widely considered the MOST powerful of diuretics - Can result in significant decreases in fluid volume and increase in urine output Uses: - HF - Pulmonary Edema - Cirrhosis of the liver with ascites **Potassium is one of the major electrolytes that can be LOST after the administration of this diuretic drug Nursing Interventions: - Side effects are more severe with this type of diuretic than an other diuretic drug - Watch for symptoms of low potassium including dry mouth, increased thirst, muscle cramps, fatigue, weakness and mood changes - Remind patient to stand up slowly to avoid orthostatic hypotension - Notify HCP if patient reports decreased hearing or ringing in the ears because this diuretic can be ototoxic - Monitor blood glucose in patients with diabetes because these drugs can cause hyperglycemia - Check and record urine output - Urination typically occurs within 1 hr, so inform the patient that he/she will need to be close to a bathroom to avoid urinary urgency or incontinence

Thyroid Hormone Agonists

Drugs that mimic the effect of thyroid hormones, T3 and T4, helping to regulate metabolism Examples: - levothyroxine sodium** - liothyronine sodium Expected Side Effects: - Diarrhea - Rapid Pulse - High BP - Difficulty sleeping (insomnia) - Excessive sweating - Heat intolerance Adverse reactions: - Increased cardiac activity can lead to angina (chest pain), MI (heart attack) or heart failure (HF) - Increased nervous system activity can lead to seizures, although this is more likely to occur in patients who already have a seizure disorder Drug Interactions: - When this drug is taken with drugs that reduce blood clotting (anticoagulants), especially warfarin (Coumadin), their actions are increased which can cause excessive bleeding and bruising Nursing Interventions: - Check patients HR and BP before giving this drug because increased HR and BP can result - Check patients entire prescription and OTC drug list for potential interactions - Report the use of anticoagulants or NSAIDs because these drugs can interact with LEVOTHYROXINE and cause excessive bruising and bleeding** - Pregnant women may need a higher dose, and women who are taking thyroid hormone agonists are advised to NOT breast feed, because this drug can be found in the mother's breast milk - Check the dose and the specific drug name carefully. Thyroid hormone agonists are NOT interchangeable because the strength of each drug varies - LEVOTHYROXINE may affect the blood sugar of diabetic patients. Check blood sugar levels closely** Patient teaching: - Take only the dose that is prescribed for you, because increasing the drug too quickly can lead to adverse effects such as a heart attack or seizures - DO NOT SKIP DOSES and you must take the drug daily to maintain normal body function - Take a missed dose as soon as you remember it. However, if it is almost time for your next dose, skip the missed dose and continue with you regular dosing schedule. DO NOT take a double dose to make up for the missed one - DO NOT STOP the drug suddenly or change the dose (up or down) without contacting you HCP, to prevent OD or under dosing - Take the drug 2-3 hrs BEFORE a meal or BEFORE taking a fiber supplement or at least 3 hrs after a meal or after taking a supplement because food and fiber greatly decrease absorption of the drug - Check your pulse each morning before taking the drug and again each evening before going to bed - Go to the ER immediately if you start to have chest pain - If you take Warfarin (Coumadin), keep all follow-up appointments and appointments for blood-clotting tests because these drugs increase the effectiveness of Warfarin

Benign Prostatic Hypertrophy (BPH)

Enlargement of the prostate gland **The prostate enlarges, exerting pressure on the urethra and vesicle neck of the urinary bladder, which prevents complete emptying** - Common in men older than 50 yrs - Cause is unclear but may be influenced by hormonal changes Clinical Manifestations: - symptoms associated with urinary obstruction - UTI - hematuria - oliguria (decreased urine output) - signs of renal insufficiency Subjective Data: - Describing urination as painful - The urine stream as difficult to start and to slow - Complaints of frequency and nocturia - May be referred to as prostates (any condition of the prostate gland that causes retention of urine in the bladder) Objective Data: - Eliciting information about voiding patterns to aid in determining the severity of the obstruction Diagnostic Tests: - On rectal examination, the HCP may palpate the enlarged prostate gland, which has an elastic consistency - The hypertrophied prostate is enlarged symmetrically with a uniform, boggy presentation - Residual urine or cystoscopy or IVP can determine the severity of the process by detecting the alterations in blood chemistry - Cystologic evaluation determines whether the process is benign or malignant Medical management: - Pharmacologic agents include: alpha blockers, which improve the ability to urinate by relaxing the bladder neck and the fibers of the prostate. These drugs elicit improved voiding in a few days. These drugs include: terazosin, doxazosin (carder), & tamsulosin (Flomax). - To shrink the prostate 5-alpha-reductase inhibitors are prescribed (finasteride [Proscar], dutasteride [Avodart]). May take weeks to months before changes in condition are noted - Transurethral microwave thermotherapy - Transurethral needle ablation - Photoselective vaporization of the prostate Nursing Interventions: - Relieving the obstruction, usually by insertion of a Foley catheter - Take care to avoid rapid depression of the bladder to prevent rupture of mucosal blood vessels - Usually no more than 1,000 mL of urine should be removed from a distended bladder initially - Prostatectomy (removal of the prostate gland) is indicated to relieve or prevent further obstruction of the urethra > Preoperatively, the HCP may order an enema to reduce the possibility of the patients straining to defecate after surgery, which could cause bleeding - TURP is the resection most often chosen because it is less invasive and less stressful for the patient - The patient who has a TURP may have continuous closed bladder irrigation or intermittent irrigation to prevent occlusion of the catheter with blood clots, which could cause bladder spasms

Foods high in Potassium (K+)

Fruits (including juices) - Apricots - Bananas (very high) - Cantaloupe - Dried fruits (ex. figs, dates, raisins)(very high) - Grapefruit - Honeydew - Melon - Oranges - Prune Juice (very high) - Mango (very high) Protein Foods - Beef - Chicken - Liver - Milk, chocolate (very high) - Nuts - Peanut Butter - Pork - Veal - Turkey Vegetables - Asparagus - Broccoli - Cabbage - Carrots (very high) - Celery - Dried beans & peas - Mushrooms - Potatoes w/ skin, baked potatoes (very high) - Sweet potatoes (very high) - Spinach - Squash - Tomatoes - Beet greens (very high) - Black beans, cooked (very high) Beverages - Cocoa - Cola drinks - Fruit & vegetable juices Miscellaneous - Bouillon, low sodium (very high) - Pizza (very high) - Salt Substitute (very high) - Yogurt (very high) - Milkshake (very high) - Cappuccino (very high)

Hyperkalemia

High potassium Causes: - Adrenal insufficiency - Aminoglycosides - Angiotensin-converting enzyme inhibitors (ACE Inhibitors) - Beta Blockers - Entrance of potassium into the bloodstream from injured cells with extensive trauma (shift of potassium out of the cells into extracellular fluid) - Excessive use of salt substitutes - Infusion of large volume of blood nearing expiration date - Metabolic Acidosis - Nonsteroidal Anti-inflammatory Drugs (NSAIDs) - Potassium intake (parenteral or oral) in excess of kidney's ability to excrete - Potassium-sparing diuretics - Renal Failure - Tumor lysis syndrome after chemotherapy S/S: - Cardiac dysrhythmias - ECG changes (tall peaked T waves, prolonged PR interval) - Hypotension - Irregular pulse rate - Irritability - Nausea, vomiting** - Diarrhea, colic** - Numbness, tingling - Paresthesias - Skeletal muscle weakness, especially of lower extremities Severe or prolonged potassium excess: - Anuria - Cardiac Arrest** (serious dysrhythmias become especially dangerous when serum potassium levels reaches 7 mEq?L or more!) - Flaccid paralysis Nursing Interventions: - Administer lopp diuretics - Administer sodium polystyrene sulfonate (Kayexalate) as prescribed by the HCP (Kayexalate can be given orally, through a NG Tube, or as a retention enema); Keep in mind that Kayexalate can sometimes cause serum sodium levels to rise; Monitor for CHF - Assess VS - Decrease intake of foods high in potassium - Decrease or stop medications associated with high potassium level - Monitor bowel sounds, as well as number and character of bowel movements - Monitor I&O (report a urine output of less than 30 mL/h) - Monitor serum potassium levels - Monitor telemetric values to t=detect dysrhythmias - Monitor underlying disorders that may lead to high potassium level

Hypernatremia

High sodium Causes: - Abnormally large intake of sodium - Consumption of antacids containing sodium - Dairy products in large amounts - Loss of more water than sodium from the body - Overuse of table salt - Prepared foods: frozen, canned, smoked - Taking too many salt tablets - Too-rapid infusion of IV saline solution S/S: - Dry mucous membranes with tenacious (thick) mucus - Firm, rubbery tissue turgor - Low urinary output - Restlessness, agitation, confusion, flushed skin Severe or prolonged sodium excess: - Death - Manic excitement - Tachycardia Nursing Interventions: - Decrease sodium intake in patient's diet - Monitor & record VS, especially BP & Pulse - Monitor for increased respiratory rate - Monitor I&O - Monitor serum sodium levels - Monitor water loss from fever, infection - Provide a safe environment for a confused or agitated patient - Weigh patient daily to check for body fluid loss

Positive Inotropic Drug

Increases contractility and the ability of the heart to pump

Potassium-Sparring Diuretics

Increases the excretion of water and sodium, leading to increased urine output WITHOUT the loss of potassium Ex. amiloride (Midamor), *spironolactone *(Aldactone), triamterene (Dyrenium) - Acts by slowing down the sodium pump in the collecting duct of the nephron so that more sodium and water are excreted as urine - This drug does NOT waste potassium, which often happens with thiazide and loop diuretics Nursing Interventions: - Monitor potassium levels because higher than normal blood potassium levels can occur with these drugs - Report potassium levels greater than 5.0 mEq/L or 5.0 mol/L to the HCP because high potassium levels can cause dangerous cardiac problems - Teach patients signs of high potassium levels, including confusion, irregular heartbeat, nervousness, numbness or tingling in the hands or feet, unusual fatigue and heavy feeling of the legs - Teach patients to stand up slowly to avoid orthostatic hypotension because these drugs decrease fluid volume and decrease BP - Teach patient to avoid foods high in potassium to prevent hyperkalemia - Remind patients to avoid salt substitutes because they are often high in potassium

Thiazides

Increases urine output by preventing water, sodium, potassium and chloride from going through the walls of the nephron to be reabsorbed back into the blood Examples: - chlorothiazide (Duiril) - hydrochlorothiazide (Esidrix, Ezide, Hydrodiuril, Oretic, Zide) - Most commonly used diuretic and often are the first line in the management of HIGH BP - Over long term, this diuretic also act to dilate the smooth muscles in the arterioles, the smallest vessels in the arterial system - Approved for use during pregnancy and may be used in low doses for breast-feeding mothers without adverse effects on the infant - High doses of diuretics for breast-feeding women may suppress lactation Nursing Interventions: - Weigh the patient daily while he/she is taking diuretics to monitor trends and prevent dehydration - Monitor I&O to make sure patient achieves fluid balance - Monitor potassium levels to assess that they are within normal levels because these drugs can reduce potassium levels - Monitor patients BMP to check for abnormal electrolytes, BUN, and/or creatinine. These lab test can indicate fluid and electrolyte imbalance or kidney problems - Report potassium levels below normal to HCP because low potassium levels can have serious effects on muscles and breathing. - Inform the HCP if your patient has a history of gout because this diuretic can cause a flare-up - If patient has Diabetes, monitor his/her glucose level carefully because diuretics can cause elevated blood sugar - HOLD diuretics if patients have a BP less than 90/60 mm Hg because this can be a symptom of dehydration or other adverse effects

NPH (Humulin N)

Intermediate-acting insulin Onset: 1.5 hours. Peak: 4-12 hours. Duration: 16-24 hours.

Urinary Tract Infection (UTI)

Is caused by the multiplication of microorganisms in any urinary system structure - Infections may result from bacteria, viruses or fungi - Bacteriuria (bacteria in the uriine) is the most common of all nonsocomial (hospital acquired) infection - Escherichia coli is the most common pathogen Risk Factors include: - Instrumentation (catheterization, surgical manipulation and invasive diagnostic testing such as cystoscopy) - Diaphragm use - Condom use - Conditions causing urinary stasis or retention - Immobility, sensory impairment and multiple organ impairment may increase the chances of infection in older adults - Women are more susceptible to UTIs than men because of the urethra is short and proximal to the vagina and rectum Clinical Manifestations: - Urgency, frequency, burning on urination and hematuria that is microscopic to gross (visible without the aid of a microscope) - Nocturia (excessive urination at night) - Abdominal discomfort, perineal pain or back pain may be present - Urine may be cloudy or blood tinged - Are identified by the location of infection: > urethritis (urethra) > cystitis (urinary bladder) > pyelonephritis (kidney) > prostatitis (prostate gland) - Infections of the bladder are said to be lower UTIs, whereas infections of the kidneys are upper UTIs Diagnostic Tests: - Urine culture and bacteriologic tests - IVP and a voiding cystogram (are used to assess the extent of involvement and damage to the structures of the urinary tract) - Microscopic inspection of the urine often reveals bacteria, hematuria and pyuria (pus in the urine) - Prostatitis is confirmed by patient history and culture of prostatic fluid or tissue Medical Management: - Medications to treat uncomplicated UTIs often include a 3-day regimen of sulfamethoxazole-trimethoprim (Bactrim, Septra) or ciproflaxacin (Cipro) - Longer therapies for 7-10 days of amoxicillin or ampicillin, nitrofurantoin (Furadantin, Macrodantin) and levofloxacin (Levaquin) also may be prescribed - Most patients report symptom relief within 24-48 hrs - It is important for the patient to complete the the full prescribed therapy to aid in the prevention of recurrence - Phenazopyridine, an OTC, may be encouraged to manage the discomfort. It should be limited to 2 days and this drug will turn the urine's color to a BRIGHT ORANGE Nursing Interventions/Patient Teaching: - Because these infections tend to recur or persist, patient education must include early detection - Comfort measures include a regimen of anti infective agents, urinary analgesics (ex. phenazopyridine), adequate fluid intake and perineal care - For those who practice self-catheterization should include return demonstration to evaluate the success of maintaining clean technique

Hypokalemia

Low potassium Causes: - Conditions causing very large urine output - Decreased poatssium intake - GI losses (vomiting, diarrhea, GI suctioning) - Ileostomy - Increased aldosterone activity - Increased potassium loss - Loss from cells, as in trauma, burns, fistulas - Metabolic alkalosis - Potassium shift into cells - Potassium-losing diuretics - Skin losses, diaphoresis - Treatment of acidosis - Villous adenoma (tumor of the intestine that produces potassium-containing mucus) S/S: - Cardiac Dysrhythmias; weak, irregular pulse - Decreased bowel sounds, cramps, constipation, anorexia, nausea, vomiting** - Diminished deep tendon reflexes, lethargy, confusion; paralysis involving the respiratory muscles; coma - Electrocardiographic changes - Orthostatic Hypotension - Paresthesia, hyporeflexia - Polyuria - Skeletal muscle weakness (especially in the lower extremities), leg cramps** Severe or prolonged potassium deficit: - Cardiac or respiratory arrest - Flaccid paralysis - Kidney damage - Paralytic ileus Nursing Interventions: - Administer potassium chloride (KCI) supplement as prescribed byHCP (oral or IV)** - Assess patients who are taking digitalis glycosides, especially if they are taking a diuretic. The low potassium levels could potentiate the action of the digitalis glycoside & cause digitalis toxicity - Encourage increased intake of foods high in potassium - Monitor bowel sounds - Monitor I&O - Monitor lab findings related to kidney function.If renal function is impaired, there is a risk for hyperkalemia - Monitor serum potassium - Monitor telemetric values

Hyponatremia

Low sodium in the blood Causes: - Ascites - Burns - Diaphoresis - Diarrhea - Fistulas - GI or biliary drainage via NG Tube or T tube - Inadequate sodium intake - Large open lesions (burns) - Loss of GI fluids - Loss through skin - Massive edema - Shifting of body fluids - Small bowel obstruction - Vomiting S/S: - Increased HR - Decreased BP - Abdominal cramps - Apathy - Apprehension - Fatigue** - Headache** - Muscle weakness, muscle twitching, tremors - Nausea/vomiting - Postural Hypotension** Severe or Prolonged sodium deficit: - Altered LOC (lethargy, confusion)** > usually accompanies a serum sodium level lower than 125 mEq/L & indicates that the patients condition is deteriorating - Coma - Seizures - Shock Nursing Interventions: - Monitor & record VS, especially BP & Pulse - Monitor I&O and if patient is receiving diuretic medications - Monitor neurologic status frequently; report any change in level of consciousness - Monitor skin turgor at least every 8 hrs - Observe for abnormal fluid losses from GI system, kidneys or skin - Replace fluid loss with fluids containing sodium, not with plain water - Restrict fluid intake as ordered. This is primary treatment for dilutional hyponatremia; post a sign about fluid restriction in the patient's room - Weigh patient daily

Angiotensin II Receptor Blockers (ARBs)

Lower blood pressure by blocking the angiotensin II enzyme from causing vasoconstriction Examples: (-sartan) - losartan (Cozaar) - valsartan (Diovan) - irbesartan (Avapro) - candesartan (Atacand)

Calcium Channel Blockers (-dipine)

Nifedipine, Amlodipine, Nicardipine, Felodipine, Verapamil, Diltiazem a. Indications → HTN, angina b. MOA → blocks calcium channels in blood vessels and heart, leading to vasodilation and ↓ HR c. S/E → ↓ HR, ↓ BP, dysrhythmias, constipation, peripheral edemad. NO GRAPEFRUIT JUICE!!! Nursing Interventions: - AVOID sudden changes in position because most antihypertensive drugs cause orthostatic hypotension - Remind patients to keep taking the drugs as prescribed because they do not cure HTN - Monitor patients BP regularly to determine how well the patients responding to the drug - AVOID alcohol - AVOID OTC drugs until checking with their HCP - Notify their provider if patient experiences swelling in the legs because this can be a sign of fluid retention - Patients with HF should avoid taking this medication because of the potential for fluid retention - Report HR less than 60 bpm and BP less than 90 mm Hg systolic to the HCP before giving the drug, to avoid significant hypotension

Lispro (Humalog) Insulin

Rapid acting insulin • Onset - 15 mins • Peak - 30 mins - 1.5 hrs • Duration - 5 hrs

Regular Human Insulin (Humulin R)

Short-acting Insulin - Onset: 30 mins - Peak: 2-4 hrs - Duration: 5-7 hrs

Antithyroid Drugs

These drugs reduce thyroid hormone levels by entering the thyroid gland and combining with the enzyme responsible responsible for connecting iodine (iodide) with tyrosine. Without iodide-tyrosine connection, thyroid hormone production is suppressed Examples: - propylthiouracil - methimazole Expected side Effects: - Taste changes - Headache - Itchiness - Rash - Muscle and joint aches - Drowsiness - Nausea and vomiting - Enlarged lymph nodes - Swelling of the lower extremities Adverse Effects: - Bone marrow suppression can occur and make the patient anemic and more at risk for infection - Propylthiouracil can be hepatotoxic (liver damage) - In some patients these dugs can also damage the kidneys Drug Interactions: - Both methimazole and propylthiouracil drugs INCREASE the effectiveness of anti clotting drugs, especially warfarin (Coumadin) - Patients taking these drugs are at greater risk excessive bleeding and bruising. Nursing Interventions: - Check patients complete blood cell count for signs of bone marrow suppression such as a low white blood cell count,, anemia, or thrombocytopenia - Asses patient for signs of infection - Assess patients skin for signs of bruising or bleeding such as ecchymosis or petechiae - Check patients drug list for drugs that have anti platelet actions, such as warfarin - Check patients liver function tests before giving these drugs. Both thyroid suppression drugs are hepatotoxic. Check the patient daily for yellowing of the skin or sclera that indicates jaundice - Check the dose and the specific drug name and prescribed dosage carefully Patient Teaching: - Even if you do not notice a reduction of your symptoms in the first 1-2 weeks, DO NOT increase the dosage on your own. These drugs take several weeks to be effective - Keep all follow-up appointments and appointments for blood-clotting tests because these drugs increase the effectiveness of warfarin - Avoid situations that can lead to bleeding and other drugs that can make bleeding worse - Avoid crowds and people who are ill because these drugs can reduce your immunity and resistance to infection - Check the color of the roof of the month and the whites of your eyes daily for a yellow tinge that may indicate a liver problem

Hypocalcemia

an abnormally low level of calcium in the blood Causes: - Alkalosis - Anticonvulsants, such as phenobarbital and phenytoin (Dilantin) - Chronic Renal Failure - Deficiency of parathyroid hormone or Vitamin D - Dietary deficiency of calcium and vitamin D - Disease of small bowel; malabsorption - Diuretics (Lasix, Edecrin) - Draining intestinal fistulas - Excess alcohol intake - Excessive NG suctioning - Excess binding of calcium ions - Increased magnesium - Injury or disease of parathyroid gland - Large amount of citrated blood - Low serum albumin levels - Pancreatic disease - Severe burns - Severe diarrhea - Thyroid surgery (surgical removal of parathyroid glands, removal of parathyroid tumor) S/S: - Chvostek's sign - Trousseau's sign - Muscle spasms of feet and hands** - Numbness/tingling in nose, mouth, ears, fingers and toes** - Diarrhea** - ↓BP - ↓HR - Anxiety, confusion, irritability - Calcium deposits in body tissues - Cardiac dysrhythmias, cardiac arrest - Diminished response to digitalis glycosides - Hyperactive deep tendon reflexes - Laryngeal spasms - Nausea/vomiting** - Osteoporosis, pathologic fractures - Twitching Nursing Interventions: - Administer calcium and vitamin D as prescribed by the HCP** - Encourage intake of diet high in calcium-rich foods, vitamin D and protein - For acute hypocalcemia, keep a tracheotomy tray and resuscitation bag at bed side in case of laryngeal spasms and IV administration of either calcium gluconate or calcium chloride** - Monitor EKG - Monitor I&O - Monitor lab values, such as calcium, albumin, & magnesium - Monitor VS; especially monitor respiratory status, including rate, depth and rhythm; be alert for stridor, dyspnea, or crowing (laryngeal spasms)