Pharmacology II

Biologic Response-Modifying Drugs:

Alter the body's response to: Cancer, Autoimmune, Inflammatory, Infectious Disease

Miscellaneous Antineoplastics: Bevacizumab (Avastin)

Angiogenesis inhibitor -Blocks blood supply to the growing tumor -Inhibits O2 and nutrient supply to tumor Treat metastatic colon cancer, rectal cancer in -Used with 5-fluorouracil to treat non-small cell lung cancer, and malignant glioblastoma -Contraindicated in allergy to murine products. Adverse reactions: -CV, hypotension, nephrotoxicity, n/v/d, HA, alopecia

CCNS: Cytotoxic Antibiotics

Anthracyclines: daunorubicin doxorubicin epirubicin idarubicin valrubicin Cytotoxic: bleomycin dactinomycin mitomycin mitoxantrone plicamycin Anthra= have cardiac problems or have the possibility of having cardiac problems -rubicinscause cardiac problems Doxorubicin attacks left ventricle Doesn't necessarily happen at the time of chemotherapy treatment, cardiac problems can present themselves years later

Cisplatin (Platinol):

Antineoplastic drug—destroys cells using alkylating drug methods, contains platinum -Treats bladder, lung, testicular, ovarian cancer Adverse effects: -Peripheral neuropathy -decreased sensation, paresthesia -n/t (numbness and tingling), burning sensation of extremities -Ototoxicity -Low WBCs 2 weeks after tx (nadir)

Hematopoietic Drugs: Adverse Effects

Usually mild; Most common include: -Fever -Cough -bone pain -Muscle aches -Flushing -Edema -Diarrhea -Nausea and vomiting Contraindications: Drug allergy CSFs: >10% myeloid (tumor cells) in bone marrow *****Bone marrow sample shows >10% myeloid, don't give because the stimulating drugs will stimulate the cancer in the bone marrow*******

Case Study:

Which cytotoxic antibiotic does the nurse identify as most likely to cause pulmonary fibrosis? A. plicamycin B. mitoxantrone C. mitomycin D. bleomycin D.

Location of alpha-2 receptors:

located on the actual nerves that stimulate the presynaptic effector cells

Location of alpha-1 receptors:

located on the tissue, muscle, or organ that the nerve is stimulating (postsynaptic effector cells)

Coagulation Cascade:

*-Coagulation pathway where each activated factor serves as a catalyst that amplifies the next reaction* *Extrinsic pathway: external injury to vessel* -Thromboplastin activates factors VII (7), X (10) *Intrinsic pathway:* -Exposed collagen activates factor XII (12), others to X End Result is fibrin, formation of Fibrin Clot

Common Alpha Blockers:

*-phenoxybenzamine HCl (Dibenzyline)* used for Raynaud's disease to increase circulation *-doxazosin (Cardura)* *-prazosin (Minipress)* *-terazosin (Hytrin)* these 3 drugs are common and given to decrease BP and often given at night to decrease the effect of orthostatic hypotension *-phentolamine (Regitine)* used to decrease vascular vasoconstriction to decrease vascular vasoconstriction to the peripheral circulation as a result of adrenergic IV medications and extravasation *(SUBCUTANEOUS)* *IV is given when HTN is too high from pheochromocytoma* *-alfuzosin (UroXatral)* *-tamsulosin (Flomax)* urinary drugs occurs with changes to the prostate and bladder cells, relaxing the muscles and allowing urine flow *First dose phenomenon:* -sudden B/P drop with 1st dose; pt may fall or pass out -Orthostatic hypotension: change positions slowly -may be a continuous problem, so change positions slowly -these medications are given at night to decrease orthostatic hypotension

Monoamine Oxidase Inhibitors (MAOIs):

*1st generation antidepressant drug therapy* -*Rarely used for depression, used for Parkinson's disease* -Inhibit MAO enzyme from break down dopamine, serotonin, norepinephrine; levels rise -Nonselective inhibitors (MAOI Type A&B): isocarboxazid, phenelzine, tranylcypromine -Selective (MAOI Type B): selegiline *Adverse effect:* -hypertensive crisis when taken with tyramine, sympathomimetics, *CV adverse effects:* -OTC cold medications, -serotonin syndrome with SSRI-need "wash-out" *Contraindication:* meperidine, SSRIs

alteplase (Activase, Cathflo):

*A tissue plasminogen activator* -Fibrin specific (not produce systemic lysis) -Does not induce antigen-antibody response *Indications: IV administration* *Emergent treatment of:* -myocardial infarction with ST-elevation (STEMI) -acute ischemic stroke -acute massive pulmonary embolism *Cathflo Activase:* -Open/flush occluded central venous access devices (CVAD), PICC lines

Cardioprotective Effects of ACE Inhibitors:

*ACEI decrease SVR (afterload) and preload* -Decrease workload on heart *Used to prevent complications after MI* -Slows progression of L ventricular hypertrophy (enlargement and thickening of the walls) after MI (cardioprotective) -ACEI have been shown to decrease morbidity and mortality in patients with heart failure -Drugs of choice for HTN patients with HF

Renal Protective Effects of the ACE Inhibitors:

*ACEI: reduce glomerular filtration pressure* -CV drugs of choice for patients with diabetes -ACE inhibitors reduce proteinuria -Standard therapy for diabetic patients to prevent the progression of diabetic nephropathy *Liver Disorders:* Catopril and lisinopril are NOT prodrugs -NOT metabolized in liver to active form -Can be used if patient has liver dysfunction

Drug Interactions:

*Additive effects:* -Alcohol -antihistamines -benzodiazepines -opioids -tranquilizers *Inhibited metabolism* -MAOIs prolong the effects of barbiturates *Increased metabolism* -Reduces anticoagulant response (possible clots) ion -Reduces effect of oral contraceptives

Adrenergic Drugs:

*Adrenergic neuron blockers: central and peripheral* *Central* *Alpha2 receptor agonists* -alpha2-adrenergic receptors are unique in that receptor stimulation reduces sympathetic outflow, in this case from the CNS) -this results in a lack of norepinephrine production, which reduces BP -stimulation of alpha2-adrenergic receptors also affects the kidneys, reducing the activity of renin -renin is the hormone and enzyme that converts the protein precursor angiotensin to the protein angiotensin I, the precursor of angiotensin II (a potent vasoconstrictor that raises BP) *Peripheral* -Alpha1 receptor blockers -Beta receptor blockers -Combination alpha1 and beta receptor blockers

Adverse Effects:

*Adverse Effects* -Myocardial depression is common -Hypotension effects liver, kidneys -Respiratory depression can lead to postop pneumonia -PONV; most common reaction (Postoperative nausea and vomiting) -Elderly at risk d/t impaired renal, liver function -Vary according to dosage, drug used -Affect major organs, peripheral circulation -Toxicity and overdose Cardiac and respiratory arrest can be fatal *General anesthetics: interactions* -Antihypertensive: increased hypotensive effects -Beta blockers: increased myocardial depression *Malignant hyperthermia* Occurs with inhaled general anesthesia, succinylcholine -Sudden body temperature rise > 104 degrees -Tachypnea, tachycardia, muscle rigidity -Life threatening emergency *Treatment:* cardiorespiratory supportive care *dantrolene* (skeletal muscle relaxant)

ACE Inhibitors: Adverse Effects/Contraindications

*Adverse Effects:* *First-dose hypotensive effect may occur* -Fatigue, dizziness -HA, mood changes, impaired taste -*Dry, nonproductive cough, which reverses when therapy is stopped* -Angioedema: rare but potentially fatal Vascular inflammatory reaction of submucosal tissue, can progress to anaphylaxis -Can cause renal impairment: Monitor serum creatinine, BUN, proteinuria *Hyperkalemia* Monitor potassium levels, electrolytes *Contraindication:* -Pregnancy category C&D, Lactation -Renal stenosis, hyperkalemia -Toxicity: Supportive treatment for hypotension (administration of IV fluids to expand the blood volume) *Drug Interactions:* -*NSAIDS* (can decrease effect, and can cause renal failure) -lithium toxicity (if ACEI and lithium are given together, it can result in lithium toxicity)

Neuromuscular Blocking Drugs:

*Adverse effects:* Succinylcholine can cause initial muscle spasms -Muscle fasciculations in face, hands, feet -Postop muscle pain, hyperkalemia -NMBD some cause bronchospasm Toxicity: treat with minimal dose for effect *Antidotes for cisatricurium, rocuronium:* anticholinesterase drugs neostigmine, pyridostigmine, and edrophonium

Beta-Adrenergic Receptors:

*All are located on postsynaptic effector cells* Beta1-adrenergic receptors *-Located primarily in the heart* Beta2-adrenergic receptors -Located in *smooth muscle* of *bronchioles, arterioles, and visceral organs* Responses: -Bronchial, GI, uterine smooth muscle relaxation -Glycogenolysis -Cardiac stimulation

Phentolamine (Regitine):

*Alpha blocker:* -reduces peripheral vascular resistance, treatment for HTN, pheochromocytoma (this tumor causes SEVERE HTN and can cause the patient to have a stroke) *-Establish a diagnosis of pheochromocytoma* (this drug is given to see if it'll lower the BP significantly, if the BP is significantly lower then doctors can indicate pheochromocytoma is present in the patient) Most commonly used to treat *extravasation* of vasoconstricting drugs such as norepinephrine, epinephrine, and dopamine -Contraindicated in known hypersensitivity, MI (myocardial infarction), CAD (coronary artery disease) *Adverse effects:* tachycardia, dizziness, GI upset *Drug Interaction:* -Alcohol: disulfiram (antibuse) is prescribed -disulfiram is prescribed for alcoholics that need to take phentolamine -disulfiram (antibuse) and alcohol do not mix -if patients drink alcohol while taking (disulfiram) antibuse then the pt will get very sick; nausea and vomiting -this drug helps the pt not drink alcohol because of the response of the pt getting very nauseous -Erectile dysfunction drugs; severe hypotension viagra, Cialis, these drugs are not mixed with potent meds that cause hypotension and can cause *SEVERE* hypotension

carvedilol (Coreg):

*Alpha1 and Beta Receptor Blocker* -Widely used drug, well tolerated *Uses:* -HTN -mild to moderate HF in conjunction with digoxin diuretics, and ACE inhibitors *Contraindications:* -known drug allergy -cardiogenic shock -severe bradycardia or HF -bronchospastic conditions (asthma) -Taper to d/c (#1 drug used for HF)

Mechanism of Action:

*Amphetamines and Phenidates* -stimulate CNS cerebral cortex, respiration -increase norepinephrine, dopamine -Block reuptake mechanisms *Modafinil (nonstimulant)* (used for narcolepsy) -Lacks sympathomimetic properties -Reduces GABA inhibitory transmitters

Beta Blockers: Indications

*Angina (chest pain)* -Decreases demand for myocardial oxygen -the heart can't get enough oxygen for the work that it has to do -beta blockers, then, decrease the demand for myocardial oxygen -people with heart disease get chest pain if they do any minimum activity, so they then take beta blockers *Cardioprotective* -Inhibits stimulation from circulating catecholamines -catecholamines increase BP, HR, and workload of the heart -beta blockers inhibit catecholamines -commonly given to patients after they have experienced an MI to protect the heart *Dysrhythmias* -Class II antidysrhythmic -used to counteract tachycardia -the drug decreases HR *Migraine headache* -Lipophilicity (compatible with lipids) allows entry into CNS -help stabilize vascular flow by dilating the blood vessels *-Antihypertensive* *-Heart failure* -decreases workload on the heart *-Glaucoma:* topical ophthalmic drops

losartan (Cozaar):

*Angiotensin II Receptor Blockers* -Beneficial in patients with HTN and HF -Used with caution in patients with renal/hepatic dysfunction, patients with renal artery stenosis -Administration: oral, daily dose -Additive effect with potassium sparing diuretics -Monitor potassium levels, renal function

Coagulation Modifier Drugs:

*Anticoagulants* -Inhibit action/formation of clotting factors, fibrin clots *Antiplatelet drugs* -Inhibit platelet aggregation, prevent platelet plugs *Hemorheologic drugs* -Alter platelet function *Thrombolytic drugs* -breaks down clots (thrombi) that have already formed *Antifibrinolytic or hemostatic drugs* -Promote blood coagulation

digoxin immune Fab (Digibind):

*Antidote for digoxin toxicity if:* -Hemodynamically unstable, end organ damage -digoxin level > 4 ng/ml if chronic ingestion -digoxin level > 10 ng/ml if acute ingestion -potassium > 5 mEq/L and symptomatic Each vial binds with 0.5mg of digoxin -antibody-antigen complexes -Contraindicated in hypokalemia—further reduces serum potassium precipitating cardiac arrhythmias -Monitor for resolving digoxin toxic effects -Immunoglobulin fragments from sheep that have been immunized with digoxin -Hypokalemia= muscle weakness, confusion, lethargy, Anorexia, nausea, ECG changes -Hypomagnesemia= muscle twitches, agitation, hyperactive reflex, n/v, ECG changes

clopidogrel (Plavix):

*Antiplatelet: ADP inhibitor* -Most widely used antiplatelet after ASA -Effective combined with aspirin in known CVD patients to reduce risk for stroke, MI *Onset of effect: 2 hours, duration 5 days* -stop plavix 5 days before a procedure, because it lasts 5 days in system *Common side effects:* -HA -nausea -easy bruising -itching -heartburn *Severe:* -bleeding -thrombotic thrombocytopenic purpura (clotting in small blood vessels, resulting in a low platelet count) Similar drugs: prasugrel (Cath Lab), ticagrelor (Acute coronary syndrome)

Nursing Implications:

*Assess:* -Patient history, medication history, allergies -Contraindications -Baseline vital signs, laboratory values -Potential drug interactions -History of abnormal bleeding conditions

risperidone (Risperdal):

*Atypical antipsychotic* -Selectively blocks dopamine, serotonin, histamine receptors, decreased motor symptoms *Indication: schizophrenia, including negative symptoms* *Adverse effects:* minimal EPS at therapeutic dosages of 1 to 6 mg/day *Risperdal Consta: long-acting injectable form* -*lasts approximately 2 weeks* *Invega Sustenna (Paliperidone):* -*long-acting injection; lasts 1 mo*

Depressants:

*Benzodiazepines and barbiturates* -increase GABA: inhibits nerve transmission in CNS -Relieve anxiety, irritability, tension -Also used to treat seizure disorders, induce anesthesia *Two main pharmacologic classes:* -Benzodiazepines -Barbiturates -*Flumazenil = benzodiazepine reversal agent (antidote)* -Marijuana ("pot," "grass," "weed") oral or smoked -Cannabinoids: delta-9-trans-tetrahydrocannabinol (THC) -Stimulates cannabinoid CNS receptors -Most common abused drug world wide

Benzodiazepines, Barbiturates:

*Benzodiazepines:* -reduce anxiety, induce sleep, to sedate, and prevent seizures *Barbiturates:* -sedatives and anticonvulsants and to induce anesthesia

Warfarin Toxicity:

*Bleeding is main complication; discontinue warfarin* *-*Takes 36-42 hrs for liver to resynthesize enough clotting factors to reverse warfarin effects -Vitamin K1 (phytonadione) po IVPB Vitamin K (10 mg) reverses warfarin in 6 hrs -Risk of anaphylaxis -Warfarin resistance will occur for up to 7 days *-Life-threatening bleeding: transfuse plasma* -Clotting factor concentrates: Kcentra and Profiline *Drug interactions:* -Aspirin -NSAIDS -Antibiotics -amiodarone -omeprazole -phenytoin -statins

Warfarin Toxicity:

*Bleeding is main complication; discontinue warfarin* *-*Takes 36-42 hrs for liver to resynthesize enough clotting factors to reverse warfarin effects Vitamin K1 (phytonadione) po or IVPB Vitamin K (10 mg) reverses warfarin in 6 hrs -Risk of anaphylaxis -Warfarin resistance will occur for up to 7 days *Life-threatening bleeding: transfuse plasma* *Clotting factor concentrates: Kcentra and Profiline* these can be life-saving *Drug interactions:* -Aspirin (its an anticoagulant) -NSAIDS -Antibiotics -amiodarone -omeprazole -phenytoin (processed through the liver) -statins (processed through the liver) -if patient needs emergency surgery and is on warfarin, we need to give a reversal to get warfarin out of system

Beta Blockers:

*Block stimulation of beta receptors in SNS* -Compete with norepinephrine and epinephrine -Can be selective or nonselective *Cardioselective* beta blockers or beta1-blocking drugs -Beta-1 receptors located primarily on the heart *Nonselective* beta blockers block beta-1 and beta-2 receptors -Beta-2 receptors located primarily on smooth muscles of bronchioles and blood vessels -Carvedilol and labetalol also block alpha receptors at higher doses -lol suffix indicates beta blockers -higher the dose, more adverse effects because it crosses over to the alpha receptors *beta blockers cannot be stopped suddenly!! pt's HR can rebound and be even higher than before, doses are slowly increased and decreased*

Blood Pressure:

*Blood pressure (BP) = CO ×SVR* *CO = cardiac output (stroke volume x heart rate)* -Amount of blood ejected from the left ventricle -Measured in liters/min *SVR = systemic vascular resistance* -Resistance to blood flow -Determined by diameter, musculature of vessel *Hypertension = persistently high BP* -Definitions, TX Guidelines based on clinical research -Medications act to regulate CO, PVR or both

Treatment of Pulmonary Hypertension:

*Bosentan (Tracleer)* -Specifically indicated only for treatment of Pulmonary Artery Hypertension in patients with moderate to severe HF *Action: blocks receptors of the hormone endothelin* -Endothelin is a hormone that acts to stimulate the narrowing of blood vessels by binding to endothelin receptors (ETa and ETb) in the endothelial (innermost) lining of blood vessels and in vascular smooth muscle *Other Drugs Used to Treat Pulmonary HTN:* -epoprostenol -Treprostinil -iloprost -sildenafil and tadalafil -ambrisentan -macitentan

Depressants: Adverse Effects

*CNS* -Drowsiness -sedation -loss of coordination -dizziness -blurred vision -HA -paradoxical reactions *Gastrointestinal* -N/V -constipation -dry mouth -abdominal cramping -Pruritus and skin rash *Marijuana:* -"amotivational" syndrome (pt doesn't have desires to accomplish things) -more prone to respiratory disorders (cough, cold, virus, infections because mostly marijuana is smoked), - memory & attention deficit

Stimulants: Adverse Effects Cardiovascular and GI

*CV* -Headache -Chilliness -Pallor or flushing -*Palpitations* -Tachycardia -Cardiac dysrhythmias -*Angina pain* -Hypertension (stroke level) or hypotension -Circulatory collapse *Gastrointestinal* -*Dry mouth* -Metallic taste -*Anorexia* -N/V/D -Abdominal cramps -Fatal hyperthermia -Muscle contractions

Beta Blockers: Mechanism of Action

*Cardioselective beta blockers (beta-1); block the beta-1 receptors on the heart* -Reduce SNS stimulation of the heart -Decrease HR, prolong sinoatrial (SA) node recovery -Slow conduction rate through the AV node -Decrease myocardial contractility, thus reducing myocardial oxygen demand *Nonselective beta blockers (beta-1 and beta-2)* -Cause same effects on heart as cardioselective beta blockers -Constrict bronchioles: result in narrow airways, SOB (have to consider this with patients that have COPD or asthma) -Produce vasoconstriction of blood vessels -Carvedilol and labetalol also block alpha receptors at higher doses

Responses to Stimulation:

*Cardiovascular:* Blood vessels Alpha1- Vasoconstriction Beta2- Vasodilation Cardiac muscle Beta1-Increased contractility AV node Beta1- Increased HR SA node Beta1- Increased HR *Gastrointestinal* Muscle Beta2 and alpha- Decreased motility Sphincters Alpha1- Constriction *Genitourinary* Bladder Alpha1- Constriction Sphincter Penis Alpha1- Ejaculation *Reproductive* Uterus Alpha1- Contraction Beta2- Relaxation *Respiratory* Bronchial muscles Beta2- Dilation *Endocrine* Liver Alpha1, beta2- Glycogenolysis *Ocular* Pupils Alpha1- Dilation (Mydriasis)

Opioids: Adverse Effects

*Central nervous system* -Miosis (constriction of the eye) -Convulsions -Nausea, vomiting -Respiratory depression Non-central nervous system *Histamine release:* -Hypotension -Constipation -Urinary retention -Flushing of the face, neck, and upper thorax -Sweating, urticaria (hives, rash), and pruritus (itching)

donepezil (Aricept):

*Cholinesterase inhibitor:* -works centrally in brain to increase levels of ACh by inhibiting acetylcholinesterase Tx: mild to moderate Alzheimer's disease -oral -ODT may take 6 wks to see results Similar meds: *galantamine (Razadyne)* *rivastigmine (Exelon)* Adverse effects: -GI (ulcer risk d/t ↑gastric secretions) -drowsiness -dizziness -insomnia -muscle cramps. CV effects may include: -bradycardia -syncope -hypotension with reflex tachycardia -or HTN Interacting drugs: anticholinergics (counteract effects), NSAIDs Often given at bedtime to decrease drowsiness

Centrally Acting Adrenergic Drugs:

*Clonidine and methyldopa* *Stimulate alpha2 -adrenergic receptors in brain:* -Decrease sympathetic outflow from the CNS -Decrease norepinephrine production -Reduces the activity of renin in the kidneys Decreases levels of angiotensin I -Result in decreased BP -Not typically prescribed as first-line antihypertensive drugs -High incidence of unwanted adverse effects: orthostatic hypotension, fatigue, dizziness -Adjunct drugs after other BP drugs have failed -Used in conjunction with other antihypertensives such as diuretics -Methyldopa used in pregnancy HTN

Antidysrhythmic Drugs:

*Contraindications* -2nd or 3rd-degree AV block -bundle branch block -cardiogenic shock -sick sinus syndrome -ECG changes: QT prolongation -Other antidysrhythmic drugs *Adverse Effects* *-ALL antidysrhythmics can cause dysrhythmias!* -Hypersensitivity reactions -n/v/d, dizziness -HA -blurred vision -Prolongation of QT interval *Drug Interactions* -Coumadin: monitor PT/INR -Grapefruit juice: amiodarone, disopyramide, quinidine

Neuromuscular Blocking Drugs:

*Depolarizing drug—Succinylcholine* -Binds to acetylcholine receptors at neuromuscular junction—competitive agonist -Effect; 5-9 minutes *Nondepolarizing drug--pancuronium* -Short, Intermediate, Long acting-- block action of ACh Typical course of NMBD-induced paralysis -Starts with muscle weakness, then... -Total flaccid paralysis: first fingers and eyes then limbs neck and trunk; finally, intercostal muscles and diaphragm -NMBDs do not cause sedation or pain relief -Recovery occurs in reverse order of paralysis

Peripherally Acting Alpha1 Blockers:

*Doxazosin, prazosin, terazosin* -Block stimulation by circulating norepinephrine -Dilate arteries & veins = decreased PVR Marked decrease in systemic and pulmonary venous pressures, BP is decreased *Alpha1 blockers cause severe orthostatic hypotension* *First dose syncopal attack may occur (with loss of consciousness)* -Alpha1 blockers also increase urinary flow (relax bladder muscle), *decrease outflow obstruction (BPH)* -tamsulosin (Flomax) not used for BP *given at bedtime because of orthostatic hypotension effects*

CNS Depressant: Benzodiazepines

*Drug classification:* -Sedative-hypnotic -Anxiolytic (anti-anxiety) *Depress brain activity:* -hypothalamic, thalamic, limbic systems in CNS -GABA receptors- primary inhibitory transmitter (decreases stimulation of the brain) -Benzodiazepine inhibits stimulation of brain -Does not suppress REM sleep as barbiturates -Does not increase metabolism of other drugs -usually used this over barbiturates, enhances sedation, and has a better safety profile -can be sleep aides

General Anesthetics:

*Drugs that alter CNS producing:* -Pain relief -Depression of consciousness -Skeletal muscle relaxation -Reflex reduction *Inhalational anesthetics* -Nitrous oxide, desflurane, sevoflurane *Parenteral anesthetics* -Etomidate, ketamine, propofol, thiopental -Administered by anesthesiologist, CRNA *Adjunct anesthetics:* Drugs used simultaneously with general anesthesia to enhance effects -Neuromuscular blocking drugs; succinylcholine -Anxiolytics; diazepam, midazolam -Sedative-hypnotics; secobarbital *Balanced anesthesia* = use of both general anesthetics and adjuncts

Thrombolytic Drugs:

*Drugs that break down, or lyse, preformed clots* -Older drugs: streptokinase, urokinase (nonspecific) *Current drugs= tPA* -fibrin specific at site of clot -alteplase (Activase, Cathflo Activase) -reteplase (Retavase) -tenecteplase (TNKase) *Mechanism of Action:* -Activate plasminogen and convert it to plasmin, which can digest fibrin; break down clot in blood vessel -Reestablish blood flow to heart muscle via coronary arteries, preventing tissue destruction *Indications:* -Acute MI -arterial thrombolysis -PE -DVT -acute ischemic stroke -occlusion of shunts/ catheters -tPA half-life of 5 min; can be readministered *Adverse Effects:* -Bleeding: Internal, intracranial, superficial *Other effects:* -N/V -hypotension -anaphylaxis -dysrhythmia *Contraindications:* -Drug/preservative allergy -concurrent anticlotting drugs *Nursing Implications:* -Follow strict guidelines for preparation/administration -Monitor IV sites for bleeding, redness, pain -Monitor for bleeding from gums, mucous membranes, nose, wounds, injection sites -Assess urine, stool, emesis, sputum for blood -*Observe for s/s internal bleeding:* *decreased b/p, restlessness, increased pulse MONITOR VS* -Monitor CBC, clotting studies -Avoid invasive procedures: IM injections, catheters

Antipsychotics:

*Drugs used to treat serious mental illness:* -Drug-induced psychoses, schizophrenia, autism -Extreme mania (adjunct to lithium), BPD, resistant depression, Tourette's syndrome, medical conditions (nausea, intractable hiccups) Have been known as tranquilizers or neuroleptics -Conventional, or 1st-generation: phenothiazines -2nd-generation -Atypical antipsychotics *Mechanism of Action* -Block dopamine receptors in brain (limbic system, basal ganglia), areas associated with emotion, cognitive function, motor function -Dopamine levels in the CNS are decreased -Result: tranquilizing effect in psychotic patients *Indications:* -Psychotic illness, most commonly schizophrenia -Extreme mania (with lithium), BPD, resistive depression -Anxiety and mood disorders, HICCUPS -Antiemetic (prochlorperazine)

Miscellaneous Antihypertensive Drugs: Epleronone (Inspra)

*Epleronone (Inspra)* -New class of drugs called selective aldosterone blockers -Reduces BP by blocking the actions of aldosterone at its corresponding receptors in kidney, heart, blood vessels, and brain *Indications: routine treatment of hypertension and for post-MI HF*

Erythropoiesis-Stimulating Agents:

*Epoetin alfa (Epogen, Procrit)* -Biosynthetic form of natural hormone erythropoietin (produced by the kidney) -patients that have kidney disease don't have enough of this hormone -sometimes after dialysis, kidney patients will get iron transfusions as well -Stimulates bone marrow to produce more RBC speeds maturation •Ineffective without adequate body iron stores, bone marrow function •Administer concomitant iron dosage, PO or IV -Dependent on normal kidney function -Administration subcutaneous, IV -rarely IV mostly given subcutaneously -2-6 week for therapeutic effect *Longer acting form of Epogen= darbepoetin(Aranesp)* RBC maturation usu 24-36hr then lifespan 120 days *Treatment of:* -anemia in end-stage renal disease -chemotherapy-induced anemia -zidovudine therapy *Contraindications:* -drug allergy -uncontrolled HTN (drug can cause HTN) -cancer pts with Hgb levels >10 g/dL -renal patients with Hgb>11 g/dL -Controversial for head/neck oncology patient as drug may increase cancer, thrombosis, some cases this drug shows to increase the cancer cell progression -Hgb level should be between 11-14 *Adverse effects:* -HTN -fever -HA -pruritus -rash -n/v -arthralgia -injection site reaction *FDA Advisory:* *if administered with Hgb>11: Increased risk for MI, stroke, death* -a Hgb level should be taken before administering injection -Oncology patients that are receiving this treatment must be registered: ESA Apprise Oncology

Antimigraine Drugs: Second Line Therapy

*Ergot alkaloids-second line therapy* dehydroergotamine mesylate (DHE 45) ergotamine tartrate w/caffeine (Cafergot) -Constrict blood vessels in brain -Main drug prior to triptans -Maximum dose 6 tablet/HA and 10 tablet/week Dependence may occur, wean doses or rebound HA Adverse effects: Do not take with triptans -n/v -dizzy -anxiety -numbness -cold & clammy hands, feet -Bitter taste -irritation with nose spray Contraindications: -Uncontrolled HTN -cerebral, cardiac -peripheral vascular disease -glaucoma -dysrhythmias

Iron:

*Essential mineral in the body* -Principle nutritional deficiency resulting in anemia •Iron deficiency anemia; women>men d/t menses •Given with erythropoietin therapy -*Oxygen carrier* in Hgb/myoglobin, essential part of RBC -Component in enzyme systems, energy transfer -Stored in liver, spleen, bone marrow -Dietary sources: meats, green leafs, grains •*Enhance absorption*: Orange juice, ascorbic acid, veal, fish •*Impair absorption*: antacids, milk, calcium -Supplemental iron: single or multivitamin preparation -Identify cause of anemia; if blood loss correct first, then supplement -Bleeding from trauma, ulcer, Crohn's, hemorrhoids -Oral iron preparations: ferrous salts -*ferrous fumarate (Femiron)* most potent oral only -*ferrous gluconate, ferrous sulfate (FeSO4)* -Iron Liquids may discolor tooth enamel (use a straw) *Parenteral iron:* -*iron dextran* (INFeD) IV or IM -*iron sucrose* (Venofer); infuse over several hours -*ferric gluconate* (Ferrlecit, Nulecit) -*ferumoxytol (Feraheme)*; IVP dose -Most patients need to take with food d/t GI upset, may cause constipation *Indications; Prevention, treatment of:* -iron-deficiency syndromes *S/S iron deficit:* -anemia -dysphagia -lip fissures -nail and skin dystrophy -fatigue -activity intolerance -lethargy -SOB *Adverse Effects:* -Most common cause of pediatric poisoning deaths (kids will find these little red pills and think they're candy) -N/V/D, constipation, abdominal cramps and pain (better absorbed without food, but if patients do take it with food don't take with dairy products, better with citric products) -*Causes black/dark grey, tarry stools* (normal) -Liquid oral preparations may stain teeth (use straw) *Contraindications:* -hemolytic anemia, hemochromatosis *Drug Interactions:* Antibiotic tetracycline, quinolones

gemfibrozil (Lopid):

*Fibric acid derivative* -Decrease synthesis of apolipoprotein, decrease VLDL, triglycerides -Treatment Type IV, V hyperlipidemia *Drug interactions:* -Potentiates warfarin -Concomitant with statins not recommended: increases muscle cramping, myopathy, risk of rhabdomyolysis *Labs:* *Increase* LFT: ALT, AST, bilirubin *Decrease* Hgb/Hct, WBC, increase clotting times

Antimigraine Drugs cont:

*Fioricet (combo acetaminophen/aspirin, barbituate-butalbital, caffeine, may have codeine)* -analgesic + caffeine -Abortive therapy agent NSAIDS-nonsteroidal anti-inflammatory drug -Naproxen -Calcium Channel Blockers -Angiotensin receptor blockers

Diuretics:

*First-line antihypertensives in JNC 8 guidelines* -Decrease plasma, extracellular fluid volumes *Results:* -Decreased preload -decreased CO (cardiac output) -Decreased total peripheral resistance *Overall effect:* -Decreased workload of heart, decreased BP -*Thiazide diuretics (HCTZ)* are most commonly used diuretics for HTN; often used in combo with CCB (calcium channel blockers)

Hematopoiesis:

*Formation of new blood cells* -RBC=erythrocyte -WBC=leukocyte -Platelet=thrombocyte *RBCs:* *-*Manufactured in bone marrow *-*Immature RBCs are called= reticulocytes, mature in 24-36hr *-*Lifespan= 120 day *-*Require erythropoietin hormone (from Kidneys) *More than one third of an RBC is made of hemoglobin* -Heme: red pigment, contains iron (oxygen carrier) -Globin: protein chain -Primary function of bone= hematopoiesis -Erythropoiesis=production RBC

Seizure Classification:

*Generalized onset seizures (grand-mal)* -Bilateral hemisphere in the gray matter -*Tonic-clonic seizures* (spasms of the upper trunk with flexion of the arms) -*Myoclonic* (brief muscular jerks) -*Atonic* ("drop attack") (sudden muscle weakness and syncope) -*Absence* (brief loss of awareness that commonly occurs with repetitive spasmodic eye blinking for up to 30 seconds) *Partial onset seizures* One lobe of brain -*Simple (petit mal) seizures* (brief loss of awareness; blank stare; but without loss of consciousness or spasmodic eye blinking -*Complex*: the level of consciousness is reduced but not completely lost -Secondary generalized tonic-clonic Unclassified seizures

Antifibrinolytic Drugs:

*Hemostatic Drugs* -Prevent lysis of fibrin: promote clot formation -Used for prevention, treatment of excessive bleeding d/t hyperfibrinolysis or surgical complications *Treatment: Hemophilia, von Willebrand's disease* -aminocaproic acid (Amicar) -tranexamic acid (Clomacran) -Desmopressin (increase Factor VIII) *Adverse Effects: Rare thrombotic events* *Uncommon/mild:* -Brady dysrhythmia -orthostatic hypotension -HA -dizziness -fatigue -n/v/d

Anticoagulants:

*Heparins* -Unfractionated Heparin -LMWHs (low-molecular-weight heparins) enoxaparin (Lovenox), daltaparin (Fragmin) *Coumarins:* Warfarin (Coumadin) *Direct thrombin inhibitors* -Human antithrombin III (Thrombate) -argatroban (Argatroban), dabigatran (Pradaxa) *Selective factor Xa inhibitors* -rivaroxaban (Xarelto), apixaban (Eliquis), -Fondaparinux (Arixtra) *Adverse Effects:* *-Bleeding:* local or systemic, dose dependent *-HIT:* Heparin induced thrombocytopenia *-*N/V, abd cramps *-Warfarin:* necrosis, purple toe syndrome *Contraindications:* -drug allergy -Acute bleeding process or high risk for event -Warfarin strongly contraindicated in pregnancy -LMWHs not given with epidural catheter (hematoma)

phenytoin (Dilantin):

*Hydantoin* -First line drug: tonic-clonic, partial seizures -Narrow therapeutic index: 10-20 mcg/mL *Contraindication:* -drug allergy -bradycardia Adverse effects -lethargy -abnormal movements -confusion -osteoporosis -rash -Gingival hyperplasia; overgrowth of gum tissue -Dilantin facies acne, hirsutism, and hypertrophy (enlargement) of subcutaneous facial tissue IV administration in saline diluent, vein irritant -Slow IVP (IV Push) administration, check incompatibilities, use filter -medication irritates the vein so slow IV push -usually incompatible with other IV meds #1 seizure medication that will work

Cocaine:

*Illicit stimulant drug from leaves of coca plant* -strong CNS stimulation, treated as narcotic releases norepinephrine from nerve terminals -Snorted or injected intravenously -Highly addictive: physical & psychologic dependence -Initial illusion of limitless power, energy—then depressed, edgy, craving more -Can dominate addict's life -Powder form; "dust," "coke," "snow," "flake," "blow," "girl" -Crystallized form (smoked) crack," "freebase," rocks,"

Sodium:

*In the nephron, where sodium goes, water follows* *-*60% to 70% of sodium and water is returned to bloodstream by the *proximal tubule* *-*20% to 25% of all sodium is reabsorbed into bloodstream in the *ascending loop of Henle* *-*5% to 10% is reabsorbed in the *distal tubules* where Aldosterone actively exchanges sodium for potassium *-*3% is reabsorbed in *collecting ducts* influenced by *ADH (antidiuretic hormone)* -If water is not absorbed, it is excreted as urine

Heart Failure: Causes:

*Inadequate contractility:* -MI -CAD -Cardiomyopathy -Valvular insufficiency *Inadequate Filling:* -Atrial fibrillation -Tamponade -Ischemia *Increased Workload:* -Pulmonary HTN -Systemic HTN *Volume overload:* -Hypervolemia -Thyroid disease -Infection -Diabetes Physical defects within myocardium, outside of myocardium

Adrenergic Drugs:

*Indications: Hypertension* -Glaucoma (decreases IOP) -BPH: doxazosin, prazosin, and terazosin -Heart failure treatment with cardiac glycosides, diuretics *Adverse Effects:* High incidence of orthostatic hypotension *Most common:* -bradycardia -reflex tachycardia -dry mouth -drowsiness -sedation -constipation -depression -edema -impotence *Less common:* -HA -sleep disturbances -nausea -rash -cardiac disturbances (palpitations)

Anti-Platelet Drugs continued:

*Indications: thromboprevention in the following* *Vary:* -stroke -TIA (pre-stroke) -ACS (acute coronary syndrome) -post MI -PVD (peripheral vascular disease) -PAD (peripheral artery disease) *Mechanism of action:* *-*Inhibit cyclooxygenase, which prevents TXa (a substance that causes blood vessels to constrict and platelets to aggregate) *-*Aspirin; for life of platelet (the effects of aspirin last the lifespan of a platelet, or 7 days) *-*Aspirin inhibits cyclooxygenase, which then inhibits TXa, and results in dilation of the blood vessels and prevention of platelets from aggregating or forming a clot *ADP inhibitors:* *-*Clopidogrel (Plavix) (inhibits *-*prasugrel (Effient) (used primarily after interventional cardiac procedures and for patients who don't respond to plavix) *-*ticagrelor (Brillinta) (indicated for patients with acute coronary syndrome) *GP IIb, IIIa inhibitors used in coronary angioplasty* -Eptifibatide (Integrillin), tirofiban, abciximab (ReoPro) (GP IIB/ IIIa are glycoprotein receptors) *Hemorheologic drug: stimulate prostacyclin* Pentoxifylline (Trental)—improves blood flow -hemorheologic drugs act to thin the blood *Adverse effects: -Risk for inducing serious bleeding -SE vary according to drug *Contraindications:* -known allergy -Thrombocytopenia -active bleeding -leukemia -GI ulcer -Vit K deficiency -recent stroke *Interactions:* -Additive effects antiplatelet -ASA -NSAIDs -anticoagulants

Antiepileptic Drugs:

*Indications:* -Prevent / control seizure activity -Long-term maintenance: chronic, recurring seizures -Acute tx: convulsions and status epilepticus -Prophylactic (prevention) for brain surgery, tumors, head injury *Contraindications:* -Allergy -Pregnancy (C, D) -birth defects -Drug interactions; increased toxicity, CNS depression *Adverse Effects:* -Many intolerable adverse effects -Necessitate a change in medication -BBW (2008): Suicidal thoughts and behavior Monitor for depression, mood/behavior changes -Common GI side effect= n/v/d -Additive CNS depression= dizzy, drowsy, lethargy -Altered CYP45 pathway= increase/decrease levels

Central Nervous System:

*Indications:* -Decreasing muscle rigidity and muscle tremors -Parkinson's disease -Drug-induced extrapyramidal reactions; drugs that cause tremors, anticholinergics helps (associated with antipsychotic drugs) *Adverse Effects:* -CNS excitation -restlessness -irritability -disorientation -hallucinations -delirium these AE especially affect and raise risks infants, children, people with brain damage, and elderly Parkinson's disease; -anticholinergics decrease tremors, muscle rigidity, episodes of dystonia and dyskinesia -improves motor function

Gastrointestinal:

*Indications:* -PNS controls gastric secretions, gastric motility. -Blockade of PNS results in: -Decreased secretions, relaxation of smooth muscle -Decreased GI motility and peristalsis •Glycopyrrolate (Robinal) preop Helpful for treatment with: Irritable bowel disease, GI hypersecretion Adverse Effects: -Decreased salivation (chew on hard candy, drink water, chew gum) -decreased gastric secretions -decreased motility (causing constipation)

Infiltration Anesthesia:

*Infiltration anesthesia* -Minor surgical and dental procedures -Injection: intradermally, subcutaneous, submucosal, or IM across the path of nerves supplying target area -May be given in a circular pattern around operative area Infiltration anesthesia and epinephrine -Local anesthetic used for infiltration are combined with vasoconstrictors •To prevent systemic absorption of anesthetic •To help confine local anesthetic to injected area •To reduce local blood loss during procedure Epinephrine constricts the blood vesselsso anesthesia doesn't circulate to other parts of the body

Fibrinolytic System:

*Initiates breakdown of clots, balances clotting process* *Fibrinolysis:* process that breaks down formed thrombi, prevents excessive clot formation and blood vessel blockage -Fibrin in the clot binds to circulating plasminogen. This binding converts *plasminogen* to *plasmin* -*Plasmin=* enzymatic protein that eventually lyses (breaks down) fibrin thrombus into fibrin degradation products *-*Keeps thrombus localized to prevent emboli in a major blood vessel

Stimulants:

*Intended effects:* -Elevation of mood -Reduction of fatigue -Increased alertness -Invigorated aggressiveness *Amphetamines: commonly abused stimulant drug* -Chemical variants; "designer drugs" psychoactive properties *Methamphetamine; pill, powder, snort, inject, smoke* -Crystal meth, (or ice) 15-20x potency of original amphetamines -Mix with OTC products—pseudoephedrine (sales restrictions) *Methylenedioxymethamphetamine MDMA ecstasy, E* -Illegal home labs, pill, snort, inject; "love drug"—calmer effect *Molly-crystal powder MDMA produces euphoric high* -Intense CNS stimulant effects, high body temp danger, severe tachycardia, severe hypertension, vasoconstriction, severe dehydration

Lorazepam (Ativan):

*Intermediate-acting benzodiazepine* -Can be given oral, IVP, IM -Useful in treatment of acute agitation -Continuous infusion for agitated patients who are undergoing mechanical ventilation -Treat or prevent alcohol withdrawal

Alpha1 and Beta Receptor Blockers:

*Labetalol and Carvedilol* -Dual antihypertensive effects of reduction in HR (beta1blocker) and vasodilation (alpha1 blocker) -Act in heart and peripheral blood vessels -Used with glycosides (digoxin), diuretics in management of severe heart failure

Indications:

*Local anesthetics are used for:* -Surgical, dental, and diagnostic procedures -Treatment of certain types of chronic pain -*Spinal* anesthesia: to control pain during surgical procedures and childbirth *Local anesthetics are given by:* 1.) -*Infiltration anesthesia* small amounts of anesthetic solution are injected into the tissue that surrounds the operative site Commonly used for procedures like wound suturing and dental surgery 2.) -*Nerve block anesthesia* - anesthetic solution is injected at the site where a nerve innervates a specific area such as a tissue -This allows large amounts of anesthetic drug to be delivered to a very specific area without affecting the whole body -This method often reserved for more difficult-to-treat pain syndromes such as cancer pain and ortho pain

Diazepam (Valium):

*Long acting benzodiazepine; duration 12-24 hr* *Indications:* -relief of anxiety -manage alcohol withdrawal -reversal of status epilepticus -preop sedation -relief of skeletal muscle spasms -Avoid in patients with hepatic dysfunction (Metabolized primarily in the liver) *Adverse effects:* -HA -confusion -slurred speech *Interactions:* -alcohol -OCP -azoles -phenytoin -SSRI -opioids -rifampin -theophylline -Administration: oral, IM, IVP, rectal

Hypertension:

*Major risk factor:* -CAD, CVD, can lead to death -Stroke, heart failure -Renal failure, peripheral vascular disease -The higher the B/P, the greater risk for CVD *40-70-year-old:* -risk doubles with every 20pt increase in systolic B/P -10pt increase in diastolic BP

Osmotic Diuretic; Mannitol:

*Mannitol (Osmitrol)= Most used osmotic diuretic* Urea, Organic acids, Glucose also included in this category *Mechanism of Action:* -Nonabsorbable solute, producing an osmotic effect *-*Increases osmotic pressure in glomerular filtrate; pulls water into renal tubules from the surrounding tissues which reduces cellular edema *-*Produces rapid diuresis without electrolyte loss *-*Induces vasodilation, increases glomerular filtration, renal blood flow; good for acute renal failure *Drug Effects:* *-*Increases glomerular filtration rate, renal plasma flow; helps to prevent kidney damage during ARF (acute renal failure) *-*Reduces intracranial pressure or cerebral edema associated with head trauma *-*Reduces excessive intraocular pressure *Indications:* -Treatment of early phase ARF -Promote excretion of toxic substances -Reduce intracranial pressure, treat cerebral edema *Adverse Effects:* -Convulsions -thrombophlebitis (a blood clot in the vein causes inflammation and pain) -pulmonary congestion *Administration:* IV infusion only, use of filter Crystallizes when exposed to low temperatures *Contraindications:* -allergy -severe renal disease -pulmonary edema -active intracranial bleed -anuria

Anemias:

*Maturation Defects:* *Cytoplasmic: reduced/ abnormal Hgb synthesis* *-Iron deficiency* d/t: blood loss, surgery, GIB, childbirth, menses -Thalassemia *(genetic disorder)*: defective globin synthesis *-*mainly from people of middle eastern, greek, Italian decent and some portions of south Asia and Africa *-*Appear hypochromatic (pale), microcytic (small) *Nuclear: defective DNA or protein synthesis* -Pernicious Anemia *(lack Vitamin B12)* due to lack of intrinsic factor (a gastric glycoprotein that allows vitamin b12 to be absorbed in the intestine) -pernicious anemia can also be due to lack of diet -*Folic Acid deficiency d/t poor diet intake: infant, child, pregnancy* -Appear *megaloblastic*, large immature RBC -immature because they're lacking DNA and don't function to carry oxygen -can use large doses of IM b12 injections with pernicious anemia due to lack of intrinsic factor Another form of anemia *Excessive RBC destruction: Hemolytic Anemias* *Intrinsic RBC abnormalities* •Genetic Defect -Sickle Cell; Portion of RBC malformed, sickle cells and inferior and mis-shapen and don't last as long as 120 days -*G6PD Deficiency;* genetic disorder that leads to hemolytic anemia meaning destruction of RBC -stress, illness, and eating certain types of chemicals, medications (NSAIDS, ASA, sulfa abx) foods (java beans), can trigger this deficiency and cause hemolytic destruction in the spleen *Extrinsic mechanisms* -Drug induced antibody destruction of RBC -Septic shock with DIC (disseminated intravascular coagulation) -Mechanical forces= intraaortic balloon pump -improper matching of a blood type in a blood transfusion

ACE Inhibitors:

*Mechanism of Action* *Disrupts renin-angiotensin-aldosterone system* -Inhibit ACE (angiotensin converting enzyme) -Prevents formation of angiotensin II -Inhibits aldosterone, causing diuresis (↓preload) -Prevents breakdown of vasodilating bradykinin and substance P -Results in decreased SVR (↓ afterload), vasodilation -*decreases BP* *MOA in detail:* --ACE inhibitors inhibit angiotensin-converting enzyme, which is responsible for converting angiotensin I (formed through the action of renin) to angiotensin II --Angiotensin II is a potent vasoconstrictor and induces aldosterone secretion by the adrenal glands --Aldosterone stimulates sodium and water resorption, which can raise blood pressure --cardiovascular effects; reduced BP by decreasing systemic vascular resistance (SVR) --this happens by preventing the breakdown of bradykinin and substance P (a potent vasodilator) and preventing the formation of angiotensin II --these combined effects decrease after load (the resistance against which the left ventricle must pump to eject its volume of blood during contraction) --ACE inhibitors are beneficial in the treatment of HF because they prevent sodium and water resorption by inhibiting aldosterone secretion --this causes diuresis, which decreases blood volume and return to the heart --this then decreases preload, or the left ventricular end-diastolic volume, and the work required of the heart

Angiotensin II Receptor Blockers:

*Mechanism of Action* -Affect vascular smooth muscle, adrenal gland -Selectively block the binding of Angiotensin I to the Angiotensin II receptors in these tissues -Block vasoconstriction and aldosterone secretion *Indications:* -Hypertension -Adjunct drug for treatment of HF -Used alone or with other drugs (diuretics) *Adverse Effects:* -Chest pain -Fatigue -Anemia -Weakness -Hypoglycemia -Diarrhea -Urinary tract infection -Hyperkalemia -cough less likely than with ACEI *Contraindication:* -Pregnancy *Drug Interactions:* -NSAIDs -Lithium -Rifampin *Toxicity:* -overdose may manifest as hypotension and tachycardia -treatment is symptomatic and supportive (meaning it includes the administration of IV fluids to expand the blood volume)

Beta Blockers:

*Mechanism of Action* -Block beta1receptors on the heart -Decrease HR, resulting in decreased myocardial oxygen demand, increased oxygen delivery to heart -Decrease myocardial contractility, helping to conserve energy or decrease demand -After MI, a high level of circulating catecholamines irritates the heart, causing imbalance in supply/demand ratio and even leading to life-threatening dysrhythmias -Beta blockers block the harmful effects of catecholamines, thus improving survival after an MI *Indications:* -Angina, Antihypertensive, Cardiac dysrhythmias -Cardioprotective effects, especially after MI -Also used: migraine HA, essential tremor, stage fright *Contraindications:* -Systolic HF, conduction disturbances -Caution: bronchial asthma d/t level of blockade of beta2receptors--can promote bronchoconstriction -DM: can mask hypoglycemia-induced tachycardia -PVD: may compromise cerebral/peripheral blood flow *Adverse Effects:* -CV: Bradycardia, hypotension, AV block -Metabolic: Hyperglycemia, hypoglycemia, hyperlipidemia -CNS: Dizziness, fatigue, depression, lethargy -Respiratory: bronchospasm in asthma, COPD -Other: Impotence, wheezing, dyspnea -Drug Interaction: additive hypotensive effects with .. diuretics, CCB, BP meds

Antiplatelet Drugs: Nursing Implications

*Monitor for abnormal bleeding* -Labs: CBC, monitor platelets (<80,000 d/c Rx) -Withhold 7 days prior to surgery *Drug-drug interactions* -Avoid concurrent anticoagulants, antiplatelets, antifibrolytics, NSAIDs *Adverse effects:* -Orthostatic hypotension -joint/back pain -dizziness -severe HA -dyspepsia -flu-like s/s -Take ASA with fluids/foods, remain upright 30 min because it can have dyspeptic AE and can upset stomach *Aspirin not given:* -to children & teens d/t risk for Reyes Syndrome -Teratogenic effects in pregnancy -Peptic ulcer disease, Vitamin K deficiency -Cross reactivity with aspirin and NSAIDs -Dipyridamole is used to decrease platelet aggregation in thromboembolic disorders •Reaches therapeutic level in 2-3 months -Vorapaxar contraindicated in CVA, TIA, bleeds •Combined with aspirin or Plavix

warfarin (Coumadin):

*Most commonly prescribed oral anticoagulant* *-*Natural plant anticoagulant: coumarin *-*Inhibits Vitamin K dependent clotting factors II, VII, IX, X, which are normally synthesized in liver *-Final effect = prevention of fibrin clot formation* *Monitor PT/INR: loading, maintenance dosing* -Normal INR (without warfarin) = 1.0 -Therapeutic INR (with warfarin) = 2-3.5 -Genetic variants: CYP2CP, VKORC1 affect metabolism *Antidote= Vitamin K (phytonadione)* *Dietary considerations: avoid large amount Vitamin K foods* INR= standardized test -if you have valve disorders or PE and want more coagulation and would want more clotting, so level should be closer to 3-3.5 instead of 2-3 range

warfarin (Coumadin):

*Most commonly prescribed oral anticoagulant* -Natural plant anticoagulant: coumarin -Inhibits Vit K dependent clotting factors II, VII, IX, X, which are normally synthesized in liver *Final effect = prevention of fibrin clot formation* Monitor PT/INR: loading, maintenance dosing -Normal INR (without warfarin) = 1.0 -Therapeutic INR (with warfarin) = 2-3.5 -Genetic variants: CYP2CP, VKORC1 affect metabolism *Antidote= Vitamin K (phytonadione)* *Dietary considerations: avoid large amount Vitamin K foods*

furosemide (Lasix):

*Most commonly used loop diuretic* -Characteristic therapeutic and adverse effects of loop diuretics -Administration: oral tablet, liquid, IM, IVP/infusion -Can be used in patients with renal disease *Indications:* -pulmonary edema -HTN -edema associated with HF -liver disease -nephrotic syndrome -ascites (excess abdominal fluid) *Caution: may cause orthostatic hypotension*

Beta1 Receptor Blocker: Nebivolol (Bystolic)

*Nebivolol (Bystolic)* Newest Selective Beta1 Blocker *Uses:* HTN and HF -Action: blocks beta1 receptors and produces vasodilation, which results in decrease in SVR -Less sexual dysfunction -*Do not stop abruptly; taper over 1 to 2 weeks*

Nerve Block Anesthesia:

*Nerve block anesthesia* -Used for surgical, dental, and diagnostic procedures -Also used for therapeutic management of pain -The anesthetic drug is injected directly into or around the nerve trunks or nerve ganglia that supply the area to be numbed

Stages of Sleep:

*Non-REM Sleep* *1.)*Dozing, easily awakened. Slow eye movements 2-5% Insomniacs longer *2.)* Sleep deepening, higher arousal threshold 45-55% of our sleep cycle *3.)* Deep sleep, difficult to wake, VS decrease (normal) 3-9% -Delta sleep, slow-wave sleep -decrease respiratory, HR, BP *4.)* Deep sleep, groggy if awakened, dreams 10-15% of our sleep -Sleepwalk, bedwetting *REM Sleep* REM, vivid dream, irregular breathing 25-33% of our sleep cycle, occurs towards the end of our sleep -we use meds to help us sleep, but we also use non-meds to help us sleep

New ACC/AHA High Blood Pressure Guidelines:

*Normal:* Less than 120/80 mm Hg *Elevated:* Systolic 120-129 and diastolic < 80 *Stage 1:* Systolic 130-139 or diastolic 80-89 *Stage 2:* Systolic at least 140 or diastolic at least 90 mm Hg *Hypertensive crisis:* Systolic >180 and/or diastolic >120, -Need prompt changes in medication -Need immediate hospital care if symptomatic

memantine (Namenda):

*Not a cholinergic drug* -An NMDA drug: blocks activity at NMDA receptors in CNS, (stimulation is part of Alzheimer's disease process causing cognitive symptoms) -Used in tx of Alzheimer's disease *Effects are likely temporary* -some improvement in general function, QOL -*Oral dose*, no drug interactions -Adverse effects: uncommon Hypotension, GI, MSK, fatigue, HA, dyspnea (these adverse effects are rare) -(NMDA= N-methyl-D-aspartate) blocks this neurotransmitter and decreases excitation -if you stop taking Alzheimer's drugs, the effects go away, the disease process continues, progressive deterioration of moods, behaviors

amitriptyline (Elavil):

*Oldest and most widely used of all TCAs* -Original indication was depression *Common use:* -treat insomnia, neuropathic pain *Contraindications:* -drug allergy -pregnancy -recent MI -recent MAOIs *Adverse effects:* -dry mouth -constipation -blurred vision -urinary retention -dysrhythmias Administration: oral

hydralazine (Apresoline):

*Orally: routine cases of essential HTN* *Injectable: hypertensive emergencies* -Recheck BP 10 min after dose *Contraindications:* -CAD -mitral valve dysfunction -drug allergy *Adverse Effects:* -HA -dizzy -anxiety -tachycardia -edema -dyspnea -n/v/d -hepatitis -SLE (lupus) -B6 deficiency -rash *BiDil:* -a combination drug apresoline + isosorbide dinitrate specifically indicated as adjunct treatment of HF in African-Americans

Mechanism of Action: General Anesthetics

*Overton-Meyer theory* -potency varies directly with lipid solubility -Lipid-soluble anesthetic drugs concentrate in nerve cell membranes d/t their high lipid content . -Easily cross the blood-brain barrier, affect CNS cells of brain and spinal cord Overall effect varies according to drug -Systematic reduction of sensory, motor CNS functions -Loss sight, touch, taste, smell, hearing; consciousness -Progressive loss of organ/system functions -Requires mechanical ventilation support

Depressants Withdrawal:

*Peak period* -2-4 days for short-acting drugs 4-7 days for long-acting drugs *Duration* -4-7 days for short-acting drugs 7-12 days for long-acting drugs *Signs* -Increased psychomotor activity -agitation -hyperthermia -diaphoresis -delirium -convulsions -elevated Temp -elevated B/P, HR *Symptoms* -Anxiety -depression -euphoria -incoherent thoughts -hostility -grandiosity -disorientation -hallucinations -suicidal thoughts -Treatment involves tapering of the drug 7-14 days

Herbal Products: St. John's Wort:

*Plant based-Hypericum perforatum* *Used for:* -depression -anxiety -sleep disorders -nervousness *May cause:* -GI UPSET -fatigue -dizziness -confusion -dry mouth -photosensitivity *Severe interactions with:* -MAOIs -SSRIs (Zoloft) -hypnotics -warfarin -phenytoin -many other drugs -Food-drug interaction with tyramine foods *Contraindication:* -BPD -schizophrenia -dementia

Herbal Products: Ginseng

*Plant based: Panax quinquefolius* -Three varieties; used for more than 5000 years *Uses:* -stress reduction -improves physical endurance -concentration *May cause:* -elevated BP -chest pain -palpitations -anxiety -insomnia -headache -GI symptoms *Interactions with:* -anticoagulants -immunosuppressants -anticonvulsants -anti diabetic drugs *Contraindication:* -children -pregnancy

Symptoms of Schizophrenia Positive and Negative:

*Positive symptoms:* -hallucinations -delusions -conceptual disorganization *Negative symptoms:* -apathy -social withdrawal -blunted affect -poverty of speech -catatonia -All antipsychotics show efficacy in improving the positive symptoms of schizophrenia -Conventional drugs are less effective in managing negative symptoms -Atypical antipsychotics have improved efficacy in treating both positive and negative symptoms

spironolactone (Aldactone):

*Potassium Sparing Diuretic- most common* *Mechanism of action:* *-*Synthetic steroid binds to aldosterone receptors in distal tubules *Indications:* *-*High doses to treat ascites due to cirrhosis *-*Standard treatment for children and adults with HF *-*Antihypertensive *Adverse Effects:* *-*Gynecomastia *-*amenorrhea *-*Irregular menses *-*Postmenopausal bleeding *Complication:* -hyperkalemia

Loop Diuretics:

*Potent diuretics:* -Bumetanide, furosemide, torsemide related to sulfonamides *Mechanism of Action:* *-*Renal, CV, metabolic effects for treatment of edema *-*Act on ascending loop of Henle: block chloride, sodium resorption *-*Activate renal prostaglandins: dilate blood vessels in kidney, lungs, systemic; reduce PVR, preload *-*produce a potent diuresis and loss of fluid, resulting in decreased fluid volume which leads to a decreased return of blood to the heart, or decreased filling pressures bumetanide (Bumex), ethacrynic acid (Edecrin) furosemide (Lasix), torsemide (Demadex) *Drug Effects:* *-*rapid diuresis, even with decreased renal function Duration effects; 2 hr -*Decreased fluid volume causes reduction in:* B/P, CVP (central venous pressure), Pulmonary vascular resistance *-*Systemic vascular resistance, LVEDP (left ventricular end-diastolic pressure) potassium and sodium depletion *Indications; Treatment for:* -Edema due to HF, hepatic or renal disease -Control of HTN -Hypercalcemia: Increase renal excretion of calcium *Adverse Effects:* •*CNS* -Dizziness -HA -tinnitus -blurred vision •orthostatic hypotension, low B/P •*GI* -n/v/v -Rare ototoxicity •*Skin* -Stevens-Johnson syndrome (torsemide can cause this) -dermatitis (furosemide can cause this) •*Hematologic* -Agranulocytosis -neutropenia -thrombocytopenia •*Metabolic:* -hypokalemia -hyperglycemia -hyperuricemia (excess of uric acid in the blood) *Main toxic effects: electrolyte loss, dehydration* Treat with fluids, electrolyte replacements *Interactions:* -Neurotoxic, nephrotoxic; additive effects -Increase serum levels of uric acid, glucose, ALT, AST, LDH -Combined use with a thiazide, especially *Metolazone*, results in the blockade of sodium and water resorption in nephron: sequential nephron blockade Increased diuresis -With NSAIDs diminish effect on PVR -Increase lithium, digoxin vancomycin toxicity *Contraindication:* -allergy -hepatic coma -electrolyte loss -hypovolemia (decreased volume of circulating blood in the body) -anuria (low urine output)

Anti-Platelet Drugs:

*Prevent platelet adhesion* -aspirin -clopidogrel (Plavix) -ticagrelor (Brilinta) -Prasugrel (Effient) -Treprostinil (Remodulin) -eptifibatide (Integrilin) -abciximab (ReoPro) -tirofiban (Aggrastat) -cilostazol (Pletal) -pentoxifylline (Trental) -dipyridamole (Persantine) (not as often) -Vorapaxar (Zontivity) (becoming more prescribed)

Types of Hypertension:

*Primary 90%* -Essential, Idiopathic (unknown cause) *Secondary* Disease, medications -Renal artery stenosis, sleep apnea -Thyroid disease, Cushing's disease, Addison's ds -Pheochromocytoma (adrenal tumor) -Preeclampsia of pregnancy -*if cause treated, B/P returns to baseline*

lisinopril (Zestril):

*Primary use: treat high BP, HF, and post MI* -Also used to prevent kidney, eye complications in people with diabetes -Contraindication: history of angioedema taking aliskiren (direct renin inhibitor) *Adverse effects:* -hypotension -dry cough -angioedema *Pregnancy category:* -C in the first trimester and D in the second and third trimester

Calcium Channel Blockers:

*Primary use: treatment of HTN and angina* *First line drug for HTN* *Amlodipine (Norvasc)—most common* -HTN: cause smooth muscle relaxation by blocking the binding of calcium to its receptors, thereby preventing contraction -Decrease muscle tone, SVR, B/P -Antidysrhythmic, antianginal -*Nimodipine* drug used to prevent cerebral artery spasms that can occur after a subarachnoid hemorrhage *CCB's can be used in the treatment of:* -Raynaud's disease, -migraine HA -Combined with statin, ACE, ARB

Electrolytes:

*Principal ECF electrolytes* -Sodium cations (Na+) -Chloride anions (Cl−) *Principal ICF electrolyte* -Potassium (K+) *Others* -Calcium, magnesium -phosphorus

disulfiram (Antabuse):

*Produces acute sensitivity to ethanol (drinking alcohol)* -inhibits the enzyme acetaldehyde dehydrogenase, "hangover" effects felt immediately after alcohol consumed *Disulfiram + alcohol = Acetaldehyde Syndrome* -Flushing -throbbing HA -respiratory difficulty -nausea -copious vomiting -sweating -thirst -chest pain -palpitation -dyspnea -hyperventilation -tachycardia -hypotension -syncope -marked uneasiness -weakness -vertigo -blurred vision -confusion -*Triggered by 7ml alcohol, symptoms severe, last 30 min-several hr* -Absorbed slowly through GI tract, eliminated slowly by the body: effects may last two weeks after initial intake

Beta Blockers:

*Propranolol, metoprolol, atenolol* -Reduction of HR via beta1 receptor blockade *Cause reduced secretion of renin* -Decreases angiotensin II mediated vasoconstriction -Decreases aldosterone volume expansion -Long-term use causes reduced PVR -Do not stop abruptly: taper over 1-2 week *Contraindicated* -asthma -Use with caution in DM (beta blockers lower HR and will mask hypoglycemia effects)

fluoxetine (Prozac):

*Prototypical SSRI* *Indications:* -depression -bulimia -OCD -panic disorder -premenstrual dysphoric disorder *Contraindications:* -drug allergy, concurrent MAOI *Adverse effects:* -anxiety -dizzy -drowsiness -insomnia

Hemophilia:

*Rare genetic disorder in which natural coagulation, hemostasis factors are limited or absent* *Two Main Types of Coagulation Deficits* *A=* Factor VII (7) deficiency (80%) *B=* Factor VIII (8) and/or factor IX (9) deficiency (20%) -X chromosome genetic mutation, prevalent in males, female carriers *-*Patients with hemophilia can bleed to death if coagulation factors (rVII, rVIII, rIX) are not given *Risk for joint bleeding, brain bleed*

Tricyclic Antidepressants:

*Replaced by SSRIs as 1st line antidepressant drugs* -*2nd line for patients who fail with SSRIs or newer drugs* -*Adjunct therapy with newer antidepressants* *Mechanism of Action:* -Block reuptake of neurotransmitters, increasing concentrations will correct the abnormally low levels of neurotransmitters that lead to depression *Indications* -Depression -Childhood enuresis (bedwetting) (imipramine) -OCD (clomipramine) -Chronic pain (trigeminal neuralgia) -Neuropathic pain -weight gain *Adverse Effects:* -Sedation -impotence -orthostatic hypotension -Elderly--dizziness, postural hypotension, constipation, urine retention, edema, muscle tremors *Overdose* -Lethal: 70-80% die before reaching hospital Increase with alcohol -Primary organs affected are the CNS and CV systems; Death from seizures or dysrhythmias *No specific antidote* -Decrease drug absorption with activated charcoal -Speed elimination by alkalinizing urine -Manage seizures and dysrhythmias, provide BLS

duloxetine (Cymbalta):

*SSNRI (serotonin-norepinephrine reuptake inhibitor)* *Indications:* -depression -GAD (generalized anxiety disorder) -diabetic peripheral neuropathy pain -fibromyalgia *Adverse effects:* -dizziness -drowsiness -HA -GI upset -anorexia -*hepatoxicity* *Drug interactions:* -SSRIs and triptans (increased risk of serotonin syndrome) -alcohol (risk of liver injury) *Contraindication:* -MAOI -can worsen uncontrolled angle-closure glaucoma Administration: oral

Bile Acid Sequestrants:

*Second line antilipemic drugs after statins akabile acid binding resins, ion exchange resins* -cholestyramine (Questran), colestipol (Colestid) colesevelam (Welchol) *Mechanism of Action* -Binds with bile acids; prevents resorption from small intestine; excretes bile resins via GI tract -Bile acids are necessary for absorption of cholesterol, are synthesized from cholesterol in liver -Results in lower cholesterol in liver, blood circulation -Disrupts cholesterol cycle—decreases resorption of cholesterol from gut, takes out bile resins which then need replacement from liver—this lowers liver cholesterol , Also liver increases LDH receptors to get back more circulating cholesterol—this decreases blood levels Win-Win situation *Indications: (can use with statins)* -Type II hyperlipoproteinemia -decrease LDL -Cholestyramine relieves pruritus d/t partial biliary obstruction -Cholesevelam tolerated by liver/kidney ds patients, transplants *Adverse Effects: (take with meals to prevent GI upset)* -Constipation -Heartburn, nausea, belching, bloating (transient) •Increased fiber/fluids to decrease bloating/ constipation -Mild increases in triglyceride levels *Overdose:* can cause GI obstruction because bile acid sequestrants are not absorbed *Tx:* restore gut motility *Drug interactions:* -Take all meds at least 1 hr before or 4-6 hr after administration of bile acid sequestrants -High doses decrease absorption of fat-soluble vitamins (A, D, E, and K) *Contraindications:* -Allergy -phenylketonuria (PKU) -biliary/bowel obstruction -Pregnancy and lactation: decreased fat soluble vitamin absorption to fetus/infant *Indication:* Treatment of chronic diarrhea -Caution when administering dry powder (mix well)

Selective Serotonin Reuptake Inhibitor (SSRI):

*Second-Generation Antidepressants* -Now considered 1st-line drug for depression -Fewer adverse effects than TCAs and MAOIs -Very few drug-drug or drug-food interactions -Takes 4-6 weeks to reach max clinical effect *Mechanism of action:* inhibition of serotonin reuptake and possible effects on norepinephrine and dopamine reuptake -SNRI inhibit reuptake serotonin, norepephrine *Indications:* -Depression -BPD -obesity -eating disorders -OCD -panic attacks -social anxiety disorder -PTSD -premenstrual dysphoric disorder -myoclonus -substance abuse (alcoholism) *Adverse effects:* -Insomnia, weight gain, sexual dysfunction *Drug interactions: MAOIs require 2-5 week wash out"* -Linezolid (Zyvox), phenytoin, warfarin, St Johns Wort -Serotonin Syndrome: serotoninergic activity (this occurs with combining medications that increase serotonin level) *Discontinuation Syndrome*: withdrawal, flu-like -Taper to d/c

CNS Depressants:

*Sedatives* -Drugs that have an inhibitory effect on the CNS to the degree that they reduce: -Nervousness, Excitability, Irritability *Hypnotics* -Cause sleep -Much more potent effect on CNS than sedatives -A sedative can become a hypnotic if it is given in large enough doses *Sedative-hypnotics: dose dependent* -At low doses, calm CNS without inducing sleep -At high doses, calm CNS to the point of causing sleep Classified into three main groups: -Barbiturates -Benzodiazepines -Miscellaneous drugs

selegiline transdermal patch (Emsam):

*Selective MAO-B inhibitor* -Indicated for major depression -*Contraindication:* drug allergy *Adverse drug effects:* -nausea -syncope -hypotension -dyskinesia *Administration: transdermal patch* -Low dose (6mg/24hr) not require tyramine restrictions -Avoid exposing patch to heat/direct sun; heat speeds absorption

Hydrochlorothiazide:

*Thiazide diuretic, aka HCTZ* Common, safe, effective diuretic *Combined with many drugs:* -spironolactone -betablockers -hydralazine -methyldopa -ACE inhibitors *Treatment:* -edema -HTN -HF -adjunct to loop diuretic *Administration: oral only* *-*dosages exceeding 50 mg/day rarely produce additional clinical results and may only increase drug toxicity this is called *ceiling effect* *Common Adverse effects: electrolyte imbalance* *-*Hypokalemia *-*elevated calcium *-*elevated lipids *-*elevated glucose *-*elevated uric acid

Thiazide and Thiazide-Like Diuretics:

*Thiazide diuretics* chemical derivatives of sulfonamide ABX -hydrochlorothiazide(Esidrix, HydroDIURIL) -chlorothiazide (Diuril) *Thiazide-like diuretics* -metolazone (Mykrox, Zaroxolyn) -chlorthalidone (Hydone, Thalitone) -indapamide (Lozol) *Mechanism of Action:* *-*Inhibit tubular resorption of sodium, chloride, and potassium ions in distal convoluted tubule -*Result:* water, sodium, chloride are excreted *-*Potassium also excreted to a lesser extent *-*Dilate the arterioles by direct relaxation *Drug Effects:* -Decrease peripheral vascular resistance -Deplete sodium, water (and potassium) *Indications: monotherapy, or adjunct* -Treatment of HF and HTN -Combination with antihypertensive drugs -Treatment of various edemas, hypercalciuria, diabetes insipidus, hepatic cirrhosis *Less effective with decreasing renal function* -Thiazides should not be used if creatinine clearance < 30-50 mL/min (normal=125 mL/min) *Adverse Effects:* *-CNS;* dizziness, HA, blurred vision *-GI;* Anorexia, n/v/d *-GU;* Impotence *-Hematologic;* Jaundice, leukopenia *-Integumentary;* Urticaria, photosensitivity *-Metabolic;* Hypokalemia, hyperglycemia, hyperuricemia, hypochloremic alkalosis *Metolazone;* dizziness, vertigo with fluid shifts *Overdose/toxicity:* -electrolyte imbalance/hypokalemia -anorexia -lethargy -confusion -muscle weak -low B/P *Drug Interactions:* *-*Antidiabetic drugs= reduced effect (hyperglycemia) *-*Corticosteroids= hypokalemia additive effect *-*Digoxin-toxicity d/t hypokalemia *-*Lithium—toxic levels *-*NSAIDs—decreased diuretic activity *Contraindication:* *-*allergy *-*hepatic coma *-*anuria *-*severe renal failure

Embolus:

*Thromboembolic events* *-Myocardial infarction (MI):* embolus blocks coronary artery *-Stroke:* embolus obstructs a brain vessel *-Pulmonary emboli (PE):* embolus in the pulmonary circulation *Deep vein thrombosis (DVT):* embolus lodges in leg vein *High risk conditions:* -A Fib (A-Fib patients are ALWAYS on anticoagulants) -unstable angina -mechanical valves -orthopedic surgery -immobilization

clonidine (Catapres):

*Treatment for HTN* Used for *opioid withdrawal*, chronic pain *Administration:* oral, *weekly transdermal patch* *Side effects:* -Dizziness -drowsiness -HA -orthostatic hypotension -xerostomia -hypotension *Drug Interactions: ↓ effect* -TCA (tricyclic antidepressants) -MAOI -appetite suppressants *Drug Interactions: Increased hypotensive effects* diuretics, nitrates, Beta-blockers Taper gradually to d/c -sudden d/c causes rebound HTN

cyanocobalamin (Vitamin B12):

*Treatment for:* pernicious anemia, other megaloblastic anemias *Vitamin B12 deficiency:* Oral or intranasal doses *Pernicious anemia:* Parental doses: Deep IM (Z-track) injection Treat to therapeutic levels, then monthly -if the deficiency is lack of intrinsic factor in the stomach (pernicious anemia) you then have to give doses parentally (IM) -lack of b12 (besides cause lack of RBC) can cause neurological system damage, numbness and tingling in extremities -neuropathy caused by lack of vitamin b12

Therapeutic Indications:

*Treatment of asthma and bronchitis* -Bronchodilators: drugs stimulate beta2-adrenergic receptors of bronchial smooth muscles -Cause relaxation, bronchodilation *nonselective, will affect beta AND alpha* ephedrine, epinephrine *maintenance inhalers, not for emergency use* metaproterenol, salmeterol, formoterol *Rescue inhalers, emergency acting topical agents* albuterol, levalbuterol, pirbuterol *Stop premature labor* -cause relaxation of uterine smooth muscle -Terbutaline (brethine) Prevent, slow contractions of uterus. may help delay birth for several hours or days. *Treatment of nasal congestion* -Intranasal (topical spray) causes constriction of dilated arterioles, reduction of nasal blood flow, decreased congestion -Alpha1-adrenergic receptors Ephedrine, naphazoline (Clear Eyes) , oxymetazoline (Afrin), phenylephrine, and tetrahydrozoline (Murine) *Temporary relief conjunctival congestion (eyes)* -Alpha-adrenergic receptors Epinephrine, naphazoline, phenylephrine, tetrahydrozoline *Treatment of open-angle glaucoma* -Reduction of intraocular pressure -Dilation of pupils Alpha-adrenergic receptors epinephrine and dipivefrin *Treatment Overactive Bladder* -Beta-3 agonist relaxes detrusor muscle -Increase bladder storage capacity -Mirabegrom (Myrbetriq) -Interacts with digoxin, metoprolol (They slow the HR down, so they will counteract) -Adverse effects: HTN, UTI, HA, nausea, dizzy, nasopharyngitis

Antidepressants:

*Treatment of choice: major depressive disorders* -Dysthymia (chronic low-grade depression), eating disorders, personality disorders, schizophrenia adjunct -Migraine, sleep disorders, chronic pain, hot flash -Increase levels of neurotransmitters in CNS serotonin, dopamine, norepinephrine -Trycycic antidepressants -Monoamine oxidase inhibitors (MAOIs) -2nd-generation antidepressants SSRIs, SNRIs

Psychotherapeutic Drugs:

*Treatment of emotional and mental disorders* Occasional depression/anxiety to constant emotional distress -Affect ability to carry out normal daily functions •3 main emotional and mental disorders -Anxiety -Affective disorders -Psychoses *Types of psychotherapeutic drugs* -Anxioltyic drugs -Mood-stabilizing drugs -Antidepressant drugs -antipsychotic drugs

Heparin-Induced Thrombocytopenia:

*Type I* -Gradual reduction in platelets -Heparin therapy can generally be continued *Type II (5-15%)* -Acute drop platelets >50% reduction from baseline -Paradoxical thrombosis can be fatal Tx: thrombin inhibitors lepirudin, argatroban -*Discontinue heparin*

Barbiturates: Four Categories

*Ultrashort acting* -Anesthesia for short surgical procedures -methohexital (Brevital), thiopental (Pentothal) *Short acting* -Sedation, control of convulsive conditions -pentobarbital (Nembutal), secobarbital (Seconal) *Intermediate-acting* -Sedation, control of convulsive conditions -butabarbital (Butisol) *Long acting* -Sleep induction, epileptic seizure prophylaxis -phenobarbital, mephobarbital (Mebaral)

sertraline (Zoloft):

*Used for:* -major depressive disorder -OCD -panic disorder -social anxiety disorder *Common side effects:* -diarrhea -sexual dysfunction -insomnia *Serious side effects:* -increased risk of SUICIDE in patients < 25 years old, -serotonin syndrome

verapamil:

*Uses:* -controlling overall heart rate in supraventricular tachycardia -migraine headache prevention -cerebral vasospasm -cluster headache *Common side effects:* -headache -low blood pressure -nausea -constipation -muscle pains *Contraindication:* -low heart rate -heart failure

captopril (Capoten):

*Uses:* -prevention of ventricular remodeling (minimizing or preventing the left ventricular dilation and dysfunction) after MI; reduce the risk of HF after MI -Shortest half-life of ACEIs -Must administer multiple times throughout day

Folic Acid:

*Water-soluble, B-complex vitamin, folate* -Essential for erythropoiesis, DNA/RNA synthesis -Primary uses PO, IV, IM, subcutaneous •Folic acid deficiency •NECESSARY during pregnancy to prevent neural tube defects (neurologic system that involves brain and spinal cord) -Malabsorption syndromes: most common deficit cause -Should not be used until actual cause of anemia is determined; may mask s/s of pernicious anemia, which requires treatment other than folic acid (Vitamin B12) •Untreated pernicious anemia progresses to neurologic damage (numbness and tingling of extremities) *Dietary sources:* -Dried beans, peas, oranges, green vegetables *Adverse reactions rare:* -allergy -yellow urine *Drug interactions: decrease in FA levels* -Oral contraceptives -corticosteroids -sulfonamides -methotrexate -Bactrim cause deficit Available OTC: single dose or multivitamin

Potassium-Sparing Diuretics:

*aka aldosterone-inhibiting diuretics* -amiloride (Midamor) -spironolactone (Aldactone) -triamterene (Dyrenium) *Mechanism of Action:* -Work in collecting ducts, distal tubules -Interfere with sodium-potassium exchange -Block resorption of sodium and water usually induced by aldosterone, prevent potassium excretion *Adjunct to thiazide treatment* -Thiazide diuretic cause loss of K, Cl, Mag -Potassium-sparing diuretic elevate K, Cl *Indications:* -Hyperaldosteronism -HTN -Reversing K loss caused by potassium-losing drugs -Certain cases of HF: prevention of remodeling *Contraindications:* -allergy, hyperkalemia (K>5.5mEq/L) -severe renal failure -(triamterene-liver failure) *Adverse Effects:* -*CNS;* Dizziness, HA, weakness -*GI;* Cramps, n/v/d -*Other;* Urinary frequency, hyperkalemia *Interactions:* *-*ACE inhibitors, K supplements can cause hyperkalemia *-*With NSAIDs diminished effect *-*Causes Lithium toxicity *-*Triamterene- Decreased folic acid level, kidney stones Little or no antihypertensive effect

Anticoagulants:

*aka antithrombotic drugs* -Inhibit clotting, prevent intravascular thrombosis by decreasing blood coagulability -Have no direct effect on blood clot already formed *Used prophylactically to prevent:* -Clot formation (thrombus) -An embolus (dislodged clot) -Oral and parenteral administration -Main risk = bleeding

Beta-Adrenergic Drug Effects: Stimulation of *beta1*-adrenergic receptors

*beta-1* myocardium, atrioventricular (AV) node, and sinoatrial (SA) node results in cardiac stimulation -Increased force of contraction positive inotropic effect -Increased heart rate positive chronotropic effect -Increased conduction through AV node positive dromotropic effect

Beta-Adrenergic Drug Effects: Stimulation of *beta2*-adrenergic receptors

*beta-2* -Effect on lungs (airways) Bronchodilation (relaxation of the bronchi) Other effects of beta2-adrenergic stimulation -Uterine relaxation -Glycogenolysis in liver (glucose release) -Increased renin secretion in kidneys (renin increases BP) -Relaxation GI smooth muscles (decreased motility)

Treatment for Alcoholism:

*disulfiram (Antabuse)*- not a cure, curbs desire -Acetaldehyde syndrome occurs -*Naltrexone* helps to curb desire for alcohol *Acamprosate (Campral)* -Newest treatment to maintain abstinence -Interact with GABA, glutamine CNS receptors (restores normal balance of neurotransmitters to the norma functioning prior to alcohol dysfunction, decreases craving of alcohol) Counseling -Individual -Alcoholics Anonymous

Adverse Effects:

*•Cardiovascular* -Vasodilation -hypotension *•CNS* -Drowsiness -lethargy -vertigo -hangover effect -Paradoxical restlessness *•Respiratory* -Respiratory depression -cough *•GI* -N/V/D -constipation -hypoglycemia *Hematologic* -Agranulocytosis (low WBC) -thrombocytopenia •Hypersensitivity reactions; Stevens-Johnson syndrome *-Reduced REM sleep, resulting in:* -Agitation -Inability to deal with normal stress IV; be careful, assess respiratory function vein irritant, has incompatibilities

flunitrazepam (Rohypnol):

-*Intermediate acting benzodiazepine* -*Aka "Roofies", date-rape drug* -Not legal in US -Uses Rx: short-term/occasional insomnia -Recreational use: drunken high, disinhibition, amnesia *Adverse effects:* -dependence -somnolence (drowsiness) -sedation -balance/speech impairment -respiratory depression to coma -known to induce dizziness, nausea, temp fluctuation, loss of consciousness, amnesia

Action Potential:

-A change in the distribution of ions causes cardiac cells to become excited. -Movement of ions across the cardiac cell membrane results in electrical impulse spreading across cardiac cells. -This electrical impulse leads to contraction of myocardial muscle -There are 4 phases of action potential -Sinoatrial (SA) node and Purkinje cells each have separate action potentials. -Action Potential Duration contains absolute/effective refractory period and relative refractory period

Comparison of ACE Inhibitors and Angiotensin II Receptor Blockers:

-ACE inhibitors and ARBs appear to be equally effective for treatment of HTN -Both are well tolerated -ARBs do not cause cough -*Evidence that ARBs are better tolerated*, associated with lower mortality after MI than ACE inhibitors -Not yet clear whether ARBs are as effective as ACE inhibitors in treating HF (cardioprotective effects) or protecting the kidneys, as in diabetes

Heart Failure Medications:

-ACE inhibitors,ARBs -Certain beta blockers (metoprolol, a cardioselective beta blocker; carvedilol, a nonspecific beta blocker) -Loop diuretics (furosemide) are used to reduce fluid overload symptoms of HF -Aldosterone inhibitors (spironolactone, eplerenone) are added as the HF progresses. -Only after these drugs are used is digoxin added -Dobutamine, milrinone: positive inotropic drugs -BNP

Muscle Relaxants:

-Act to relieve pain from skeletal muscle spasms *Majority are centrally acting (works in CNS)* -CNS is the site of action-sedative effects -Similar structure/action to other CNS depressants -Brainstem, thalamus, spinal cord *Direct acting = dantrolene* -Act directly on skeletal muscle -Closely resemble GABA at muscle fibers -Decrease response of muscle to stimuli (Ca+ flow) -*Treatment: malignant hyperthermia* decreases response of the muscle to any stimuli

levetiracetam (Keppra):

-Adjunct therapy for partial- seizures, secondary generalization -Off-label to prevent seizures associated with subarachnoid hemorrhages -Mechanism of action: unknown, oral and IV doses Contraindication: -drug allergy Adverse effects: -sleepiness -synergistic with sedative prescription -No drug interactions -Potential for agitation, depression, anxiety

Antihypertensive Drugs: Categories

-Adrenergic drugs -Angiotensin-converting enzyme (ACE) inhibitors -Angiotensin II receptor blockers (ARBs) -Calcium channel blockers (CCBs) -Diuretics -Vasodilators -Direct renin inhibitors

Local Anesthetics:

-Aka: Regional Anesthetics -Anesthetize specific portion of body -Disrupt nerve transmission at peripheral nerve site; rendering insensitivity to pain -Do not cause loss of consciousness *Topical* -Direct application to skin or mucous membranes *Parenteral* -Spinal column: Intrathecal, epidural -Peripheral: Nerve Block, infiltration, On-Q Pump

Neuromuscular Blocking Drugs:

-Also known as NMBDs -Prevent nerve transmission in skeletal and smooth muscle, resulting in muscle paralysis -Paralyze the skeletal muscles required for breathing: the intercostalmuscles and the diaphragm -Used with anesthetics during surgery When used during surgery, artificial mechanical ventilation is required -Patient cannot breathe on his or her own -They do not cause sedation or pain relief -The patient may be paralyzed yet conscious

Antiepileptic Drugs (AEDs):

-Also known as anticonvulsants Goals of therapy -Control or prevent seizures while maintaining a reasonable quality of life -Minimize adverse effects and drug-induced toxicity -AED therapy is usually lifelong -Combination of drugs may be used -Single-drug therapy is started before multiple-drug therapy is tried -Therapeutic drug monitoring: serum concentrations Phenytoin, phenobarbital, carbamazepine, and primidone = better seizure control and toxicity than valproic acid, ethosuximide, and clonazepam Antiepileptic drugs traditionally used to manage seizure disorders include: -Barbiturates -Hydantoins -Iminostilbenes plus valproic acid -Second- and third-generation antiepileptics

Angiotensin II Receptor Blockers:

-Also referred to as angiotensin II blockers -Well tolerated -Do not cause a dry cough -losartan (Cozaar) -eprosartan (Teveten) -valsartan (Diovan) -irbesartan (Avapro) -candesartan (Atacand) -olmesartan (Benicar) -telmisartan (Micardis) -azilsartan (Edarbi)

Lidocaine (Xylocaine):

-Amide class "caines" of local anesthetics Most commonly used anesthetic -Infiltration and nerve block -*Topical*: EMLA (cream mix of lidocaine and prilocaine) for IV insertions Lidoderm Patch for postherpetic neuralgia -IV administration for cardiac dysrhythmias

Korsakoff's Psychosis:

-Amnestic disorder caused by thiamine deficiency associated with prolonged ingestion of alcohol -Exacerbated by neurotoxic effects of alcohol *7 Major Symptoms* 1.) anterograde amnesia; memory loss after onset of syndrome 2.) retrograde amnesia; memory loss extends before syndrome onset 3.) amnesia of fixation; loss of immediate memory (past few minutes) 4.)Confabulation; invented memories, taken by patient as true d/t gaps in real memory, associated with blackouts 5.) minimal content in conversation 6.) lack of insight 7.)Apathy; lose interest in things quickly, appear indifferent to change

Dopaminergic Receptors:

-An additional adrenergic receptor -Stimulated by *dopamine* Causes *dilation* of the following blood vessels, resulting in increased blood flow -Renal *(KIDNEY)* -Mesenteric (gut) -Coronary (to increase BP and heart) -Cerebral (causes stimulation) -can use this drug with problems of the kidney In the state of hypotension -improve blood flow, kidneys will shut down if blood flow is low

modafinil (Provigil):

-Analeptic -treat narcolepsy, shift work sleep disorder -Improves wakefulness d/t daytime sleepiness -Schedule IV drug: Less abuse potential than amphetamines, methylphenidate -Lacks sympathomimetic properties -Similar Drug: Armodafinil (Nuvigil)

Moderate Sedation:

-Anesthesia that does not cause complete loss of consciousness and does not normally cause respiratory arrest (Aka: conscious sedation and procedural sedation) -Pt maintains own airway, responds to verbal commands -Combination of IV benzodiazepine (midazolam) and opiate (fentanyl or morphine). Can use propofol in certain settings -Used for diagnostic procedures, minor surgery not requiring deep anesthesia— outpatient procedures -Rapid recovery time and greater safety profile than general anesthesia; Anxiety and sensitivity to pain are reduced, and patient generally cannot recall procedure -Alcohol tolerance requires increased dosage benzodiazepine

Interactions:

-Anesthetic drugs: increase cardiac arrhythmias -MAOIs: life threatening HTN crisis -Antihistamines: synergistic effects -Thyroid preparations: synergistic effects Adrenergic antagonists -Will directly antagonize each other, resulting in reduced effects -Includes some antihypertensives

Drugs to Treat Obesity:

-Anorexiants -Stimulant CNS drugs to suppress appetite: -phentermine (Ionamin) -Amphetamines: benzphetamine (Didrex), methamphetamine (Desoxyn) -diethylpropion (Tenuate) Orlistat (Xenical): Nonstimulant drug -Works locally in small and large intestines, -Inhibits absorption of caloric intake from fatty foods -lorcaserin (Belviq) -Qsymia (phentermine and topiramate)

Nonbiologic DMARD: Methotrexate

-Anticancer drug (lower dose)used to treat RA -Antineoplastic, immunosuppressive, anti-inflammatory -GIVE ONLY ONCE PER WEEK, oral or injectable***** -Half life of medication is 3-10 hours -Main adverse effect: Bone marrow suppression -Discontinue if s/s bleeding, monitor CBC

Monoclonal Antibodies (-mab):

-Antineoplastic, anti-TNF, immunosuppressant -Treatment of cancer, rheumatoid arthritis (RA), MS, and organ transplantation -Specifically target cancer cells and have minimal effect on healthy cells -Fewer adverse effects than traditional antineoplastic meds: flu—fever, dyspnea, chills -Risk for acquiring infection, malignancies (with TNF blocking agents), BBW

haloperidol (Haldol):

-Antipsychotic, actions like phenothiazines *Indications: long-term treatment of psychosis* low dose for nausea -Treat schizophrenia patients who are non-adherent with their drug regimen *Contraindications:* -hypersensitivity -Parkinson's Disease (due to its antidopaminergic effects) -Patients taking large doses of CNS depressants *Administration: Oral, IM, IV*

Hemostasis:

-Any process that stops bleeding -Coagulation Cascade: physiologic blood clotting -Mechanical compression of bleeding site -Surgery/cautery of bleeding vessels -Pharmacologic *-Thrombus:* technical term for a blood clot *Embolus:* dislodged thrombus travels in bloodstream *Complex relationship between substances that:* -Promote clot formation -Inhibit coagulation or dissolve a formed clot *Promote coagulation:* -Platelets, von Willebrand factor -activated clotting factors, tissue thromboplastin *Inhibit coagulation:* -Prostacyclin, antithrombin III, proteins C&S *Dissolve formed clots:* -tissue plasminogen activator; a natural substance

atomoxetine (Strattera):

-Approved for treating ADHD in children older than 6 years of age, adults -Not a controlled substance -Nonstimulant drug--SNRI -FDA warning (2005): cases of suicidal thinking and behavior in adolescent patients Adverse effects: -HA -abdominal pain -vomiting -anorexia -cough

Nursing Implications:

-Assess for allergies, asthma, and history of HTN, cardiac dysrhythmias, and other CVD -Assess renal, hepatic, and cardiac function before treatment. -Perform baseline assessment of vital signs, peripheral pulses, skin color, temperature, and capillary refill; postural b/p and pulse. -Follow administration guidelines carefully Titration of IV Drips, ACLS, anaphylaxis -Overuse of nasal decongestants may cause rebound nasal congestion or ulcerations. -Avoid over-the-counter and other medications because of possible interactions. -Administering two adrenergic drugs together may precipitate severe cardiovascular effects such as tachycardia or hypertension Monitor for therapeutic effects (CV uses) -Return to normal vital signs -Increased LOC -Improved skin color and temperature -Decreased edema -Increased urinary output Monitor for therapeutic effects (asthma) -Return to normal respiratory rate -Improved breath sounds, fewer crackle, wheeze -Increased air exchange -Decreased cough -Less dyspnea -Improved blood gases -Increased activity tolerance

Nursing Implications:

-Assess for drug allergies, food allergies to egg proteins, allergy to Immunoglobin G -Assess for conditions that may be contraindications. -Assess baseline blood counts; perform cardiac, renal, and liver studies. -Assess for presence of infection -Follow specific guidelines for preparation and administration of drugs. -Monitor the patient's response during therapy -Teach patients to report signs of infection immediately: -Sore throat, Diarrhea, Vomiting -Fever of 100.5° F (38.1° C) or higher -Monitor for therapeutic responses: -Decrease in growth of lesion or mass -Improved blood counts -Absence of infection, anemia, and hemorrhage -Monitor for adverse effects.

Nursing Implications:

-Assess history, drug allergies, contraindications. -Assess BP, apical pulse for 1 full minute, ECG -Heart sounds, breath sounds -Weight, I&O measurements -Labs: K, Na, Mag, Ca, renal & liver function tests For an apical pulse < 60 or >100 beats/min: -Hold dose, Notify prescriber *-Immediately report weight gain of 2 lb in 1 day or 5 lb in 1 week* Assess for s/s toxicity: Hold dose, notify MD -Anorexia, n/v/d -Visual disturbances (blurred vision, green or yellow halos) -Avoid giving digoxin with high-fiber foods (fiber binds with digitalis), dairy -Assess for adverse effects/synergistic effects of ACEI/ARB, diuretics, beta-blockers, spironolactone Nesiritide or milrinone -Use IV pump, monitor I&O, HR/rhythm, BP, daily weights, respirations... *Monitor for therapeutic effects:* -Increased urinary output -Decreased edema, SOB, dyspnea, crackles, fatigue -Resolution of paroxysmal nocturnal dyspnea -Improved peripheral pulses, skin color, temperature -Monitor for adverse effects

Nursing Implications:

-Assess patient history, med history, drug allergies -Assess for potential contraindications -*Baseline lab values: Hgb/ Hct, reticulocytes* -Obtain nutritional assessment -Ferrous salts are contraindicated in patients with ulcerative colitis, peptic ulcer disease, liver disease, and other GI disorders oral iron products are very harsh on the stomach, can aggravate these diseases -*Keep away from children because oral forms may look like candy* -Iron dextran is contraindicated in all anemias except for iron-deficiency anemia -For liquid iron preparations, follow the manufacturer's guidelines on dilution and administration -Instruct the patient to take liquid iron preparations through a straw to avoid staining tooth enamel -Oral forms of iron should be taken between meals for maximum absorption, *but may be taken with meals if GI distress occurs* -Give oral forms with juice but not with milk or antacids -Patients should remain upright for 15-30 minutes after oral iron doses to avoid esophageal corrosion -Patients should be encouraged to eat foods high in iron and folic acid -For IV iron dextran, small test dose should be given •if no reaction after 1 hour, give remainder of IV dose •Have resuscitative equipment available in case of an anaphylactic reaction •Administer IM using Z-track method to large muscle -Determine the cause of anemia before administering folic acid -Administer oral folic acid with food -Folic acid may be given IV, added to TPN -Monitor for therapeutic responses: •Improved nutritional status •Increased weight, activity tolerance, well-being •Absence of fatigue -Monitor for adverse effects

Nursing Implications:

-Assessments: include nonjudgmental and open-ended questions about substance abuse -Be observant for clues to substance abuseso as toavoid withdrawal symptoms -The most dangerous substances in terms of withdrawal are CNS depressants such as barbiturates, benzodiazepines, and alcohol -Establish therapeutic rapport and use empathy toward the patient Assessment tools for substance abuse -CAGE Alcoholism Screening Test Adapted to Include Drugs (CAGE-AID) -Substance Abuse Subtle Screening Inventory (SASSI) -Michigan Alcoholism Screening Test Geriatric version (MAST-G) -Problem Oriented Screening Instrument for Teenagers (POSIT) -Patient safety is of utmost importance at all times during patient care but especially when the patient is experiencing the signs and symptoms of withdrawal -Provide monitoring and support as needed throughout the withdrawal process -Educate patient, family members, significant others about the recovery process -*Emphasize that recovery is lifelong*

Benzodiazepines Interactions:

-Azole antifungals, verapamil, diltiazem, -Protease inhibitors (HIV meds), macrolide antibiotics, grapefruit juice -CNS depressants (alcohol, opioids) -Olanzapine (increased benzo effect) -Rifampin (decreased benzo effects)

Common Muscle Relaxants:

-Baclofen (Lioresal) common in hospital can be IV if necessary -Cyclobenzaprine (Flexeril) common in hospital -Dantrolene (Dantrium) -Metaxalone (Skelaxin) -Tizanidine (Zanaflex) -Carisoprodol (Soma) use is diminished due to street use high abuse -Chlorzoxazone (Paraflex) -Methocarbamol (Robaxin) very common in hospital can be IV if necessary -patients might need to bring meds from home because hospital won't have them (skelaxin, zanaflex)

Nursing Implications:

-Before beginning therapy, assess physical and emotional status of patients, baseline VS, postural B/P -Obtain liver, renal function tests -Assess potential for injury to self and others -Emphasize combination drug and psychotherapy: patients need to learn, acquire effective coping skills -Provide simple explanations about the drug, its effects, length of time before therapeutic effects can be expected -Advise patients to change positions slowly to avoid postural hypotension and possible injury (esp. elderly) -Only small amounts of medications should be dispensed at a time to minimize risk of suicide -Check patient's mouth; make sure oral doses swallowed -Simultaneous alcohol & CNS depressants: -Advise patients to avoid abrupt withdrawal *Antianxiety drugs:* -Monitor elderly for oversedation, CNS depression *Antidepressants:* -Many cautions, contraindications, and interactions -Inform patients: It takes weeks to see therapeutic effects -Monitor patients closely during this time, assess for suicidal tendencies, and provide support -Drowsiness, postural hypotension increases risk for falls in elderly or weak patients -Tricyclics may need to be weaned and d/c before surgery to avoid interactions with anesthetic drugs -Monitor for adverse effects and discuss with patients. -Encourage patients to wear medication ID badges naming the drugs being taken -Caffeine and cigarette smoking may decrease effectiveness of medication therapy -With MAOIs, instruct patients to avoid tyramine-containing foods, s/s crisis *Antipsychotics—phenothiazines* -Wear sunscreen because of photosensitivity -*Avoid antacid/antidiarrheal within 1 hr. of dose* -Avoid alcohol and other CNS depressants -*Long-term haloperidol therapy may result in tremors, n/v, or uncontrollable shaking of small muscle groups; report these symptoms to the physician* -Take oral forms to decrease GI upset -These drugs may cause drowsiness, dizziness, fainting -Patients should change positions slowly *Monitor for therapeutic effects* -Monitor mental alertness, cognition, affect, mood, ability to carry out ADLs, appetite, sleep patterns. -Monitor potential for self-injury during the delay between the start of therapy and symptomatic improvement. *For anxiolytics* -Improved mental alertness, cognition, and mood -Fewer anxiety or panic attacks -Improved sleep patterns and appetite -Less tension/ irritability; less feelings of fear, doom, stress -More interest in self and others *For antidepressants* -Improved sleep patterns and nutrition -Increased feelings of self-esteem, less hopelessness -Increased interest in self, appearance, daily activities -Fewer depressive manifestations or suicidal thoughts. *For antipsychotics* -Improved mood & affect, decreased psychotic episodes -Decreased hallucinations, paranoia, deulsions, garbled speech -Improved ability to cope *For lithium* -Less mania -*Therapeutic serum lithium levels of 0.6 to 1.2 mEq/L*

Nursing Implications:

-Before beginning therapy, obtain health history including allergies, medications, baseline VS, orthostatic B/P -Assess for potential disorders and conditions that may be contraindications and for potential drug interactions. -Give hypnotics 30 to 60 minutes before bedtime for maximum effectiveness in inducing sleep (depends on drug's onset). -Most benzodiazepines cause REM rebound and a tired feeling the next day; use with caution in older adults. -Instruct patients to avoid alcohol and other CNS depressants -Check with the prescriber before taking any other medications, including over-the-counter medications. -Rebound insomnia may occur for a few nights after a 3- to 4-week regimen has been discontinued. *Safety in hospital is important:* -Keep side rails up or use bed alarms. -Do not permit smoking. -Assist patient with ambulation (especially older adults). -Keep call light within reach. *Monitor for hypnotic therapeutic effects:* -Increased ability to sleep at night -Fewer awakenings -Shorter sleep-induction time -Few adverse effects, such as "hangover" effects -Improved sense of well-being d/t improved sleep *Monitor for therapeutic muscle relaxant effects:* -decreased spasticity, decreased rigidity

midazolam (Versed):

-Benzodiazepine -A short-acting hypnotic-sedative drug with anxiolytic and amnestic properties -Used in dentistry, cardiac and endoscopy procedures -Preanesthetic medication, adjunct to local anesthesia -Short duration and cardiorespiratory stability allows use in poor-risk, elderly, and cardiac patients -Administration: usually IV injection, liquid for pediatric *flumazenil (Romazicon) reverses toxicity caused by benzodiazepines*

The Immune System:

-Biologic defense mechanism -Recognize/destroy foreign substances/antigens in blood & body tissues. HUMORAL IMMUNITY -Mediated by B-lymphocytes (antibodies) CELL-MEDIATED IMMUNITY -Mediated by T- lymphocyte cell functions

Opioid Drug Withdrawal: Treatment

-Block opioid receptors so that use of opioid drugs does not produce euphoria *Naltrexone—an opioid antagonist* -Maintenance of opioid free state, oral dosing -Vivitrol; injectable form of naltrexone Naloxone combined with buprenorphine (Subutrex) or used alone (Suboxone) -Pt need to be opioid free for 1 week prior to dosing to prevent withdrawal symptoms -Used for alcohol cravings -contraindicated in liver disease or hepatitis, goes through the liver pathway

Ethanol: Drug Effects

-CNS depression, intensify sedation -Respiratory stimulation (moderate alcohol) -Respiratory depression increased alcohol amounts -increased sedative effects -decrease in HR, BP, RR, level of consciousness when mixed with other sedative acting drugs (Benzo) -interacts with other meds that aren't sedatives but go through the liver pathway -Vasodilation warm, flushed skin -Increased sweating -Diuretic effects -Interaction with medications: warfarin

Dextroamphetamine sulfate (Dexadrine):

-CNS stimulant, treat ADHD and narcolepsy -Schedule II Drug, written Rx only -Adderall, Adderall XR (Dextroamphetamine saccharate, amphetamine sulfate, amphetamine aspartate)

Types of Diuretic Drugs:

-Carbonic anhydrase inhibitors (CAIs) -Loop diuretics -Osmotic diuretics -Potassium-sparing diuretics -Thiazide and thiazide-like diuretics -Most potent = loop, then mannitol, metolazone, thiazides, potassium sparing

Beta Blocker: atenolol (Tenormin):

-Cardioselective beta blocker (beta-1) -Commonly used to prevent future heart attacks in patients who have had one -Hypertension and angina -Management of thyrotoxicosis (hyperthyroid) to help block the symptoms of excessive thyroid activity hyperthyroid causes tachycardia and palpitations, so atenolol is given to slow it down -Atenolol is available for *oral* use.

atenolol (Tenormin):

-Cardioselective beta blocker; preferentially blocks the beta1-adrenergic receptors in heart. -Noncardioselective beta blockers block not only the beta1-adrenergic receptors in heart but also beta2-adrenergic receptors in lungs----can exacerbate asthma or COPD. -Uses: antidysrhythmic, HTN, angina *Contraindications:* -severe bradycardia -2nd- or 3rd-degree heart block -HF -cardiogenic shock -dyspnea -Metoprolol (Lopressor) similar toatenolol -Sotalol: Class II and Class III

atenolol (Tenormin):

-Cardioselective beta1-adrenergic receptor blocker -Negative inotropic effect -Indication: prophylactic tx of angina pectoris -Administration: oral dose -Use of atenolol after MI has been shown to decrease mortality -Do not abruptly d/c drug; taper dose over 1-2 wks

Mechanism of Action Adrenergic Receptors: Indirect-acting sympathomimetic

-Causes release of catecholamine from storage sites (vesicles) in nerve endings -Catecholamine then binds to receptors and causes a physiologic response

Affective Disorders (Mood Disorders):

-Changes in mood that range from mania to depression -Some patients may exhibit both mania and depression: bipolar disorder (BPD) -*Mania*: exaggerated emotions -*Depression:* feelings of worthlessness, loss of interest in normal activities, reduced energy/motivation, decreased appetite, sleep disturbances, thoughts of death, suicide -Reduction in quality of life

flecainide (Tambocor):

-Chemical analogue of procainamide *-First-line drug in treatment of atrial fibrillation* -Negative inotropic effect and depresses left ventricular function *AE:* -dizziness -visual disturbances -dyspnea *Contraindications:* -hypersensitivity -cardiogenic shock -2nd or 3rd degree AV block -non-life-threatening dysrhythmias -Dosage: well tolerated oral

3 Classifications:

-Chemical structural similarities: amphetamines, serotonin agonists, sympathomimetics, and xanthines -Site of therapeutic action in CNS -Major therapeutic uses -anti-attention deficit disorder -antinarcoleptic -anorexiant -antimigraine -analeptic drugs

doxazosin (Cardura):

-Commonly used alpha1 blocker for HTN -Reduces peripheral vascular resistance and BP -Dilates both arterial and venous blood vessels *Available in immediate, extended release* -ER shell of capsule expelled in stool -Titrate dose 1-16 mg /day -First-dose orthostatic hypotension may occur -when the drug is released from the extended-release form, the matrix of the capsule is expelled from the stool (educate patients that this will happen and the active drug has been absorbed and not to take another dose)

Heart Failure:

-Complex clinical syndrome resulting from any functional or structural impairment to the heart, specifically ejection of blood or ventricular filling -Heart is unable to pump blood in sufficient amounts from ventricles to meet body's metabolic needs *Symptoms depend on cardiac area affected* -"Left-sided" HF (L ventricle): pulmonary edema, coughing, shortness of breath, and dyspnea -"Right-sided" HF (R ventricle): systemic venous congestion, pedal edema, jugular venous distension, ascites, and hepatic congestion

Hypokalemia:

-Deficiency of potassium; serum K level < 3.5 mEq/L -Usually d/t excessive K loss (not poor dietary intake) -Vomiting, diarrhea, drains -Ketoacidosis, burns: cellular shifts in K -Malabsorption -Thiazide, thiazide-like, and loop diuretics -Steroids Manifestations -Mental confusion, lethargy, weakness, nausea -Hypotension, cardiac dysrhythmias, neuropathy, -Paralytic ileus

Topoisomerase 1 Inhibitors (Camptothecins):

-Derived from camptothecin, substance from Chinese shrub -Inhibit proper DNA function in S phase, prevent DNA relegation Indications -Ovarian and colorectal cancer -Small cell lung cancer Adverse effects -topotecan (Hycamtin): BMS, mild to moderate n/v, diarrhea, HA; rash; muscle weakness, cough -irinotecan (Camptosar): more severe hematologic effects than topotecan, cholinergic diarrhea, moderate n/v -Topotecan has milder side effects than irinotecan

Diuretic Drugs:

-Drugs that accelerate rate of urine formation -Result in removal of sodium and water via kidney -First line drug for treatment HTN (thiazides) *Used in heart failure (HF), renal failure* -Cause direct arteriolar dilation -Reduces extracellular fluid volume, plasma volume -Decreases cardiac output, B/P *Metabolic adverse effects:* -Excessive fluid, electrolyte loss

Epinephrine (Adrenalin):

-Endogenous, vasoactive catecholamine -Acts directly on alpha & beta adrenergic receptors; nonselective adrenergic agonist Primary ACLS emergency drug -Increase HR, force of contraction in cardiac arrest *-Alpha-1, Beta-1 vasoconstriction—increase B/P* -Treat acute asthma attack, anaphylactic shock *-Beta-2 potent bronchodilator* -Assessment VS, breath sounds, ECG, ABG IV use 1:1000, 1:10,000 strength be careful of the different strengths! leads to many medication errors*

Hyperkalemia:

-Excessive serum potassium over 5.5 mEq/L *Causes* -Potassium supplements -ACE inhibitors, Potassium-sparing diuretics -Renal failure -Excessive loss from cells -Burns -Trauma -Metabolic acidosis -Infections *Hyperkalemia manifestations* -Muscle weakness, paresthesia, paralysis, cardiac rhythm irregularities (leading to possible ventricular fibrillation and cardiac arrest) *Treatment of severe hyperkalemia* -IV sodium bicarbonate, calcium gluconate or calcium chloride, dextrose with insulin -Sodium polystyrene sulfonate (Kayexalate) Oral suspension, enema -Hemodialysis to remove excess potassium

Immunosuppressants: Fingolimod (Gilenya)

-Failed as an anti-rejection drug -Approved in 2010 for MS -Only oral drug for relapsing forms of MS Significant adverse effects: headache, hepatotoxicity, flulike symptoms, back pain, atrioventricular block, bradycardia, hypertension, and macular edema Action: blocks T-cell autoimmune activity against myelin protein, which reduces the frequency of the neuromuscular exacerbations associated with MS

diazepam (Valium):

-First clinically available benzodiazepine drug *Uses:* -treatment of anxiety -procedural sedation -anesthesia adjunct for balanced anesthesia -anticonvulsant (emergency drug for epileptic activity) -alcohol withdrawal -skeletal muscle relaxant; ortho injury *Administration:* -oral (2-3 mg, 3-4x a day for use of anti anxiety muscle relaxant) -rectal -IM -IV IV immediate action, plasma peak in 8 min -tend to give with food to avoid GI upset -assess at patient's other medications before giving dose -slow IVP, don't mix with other solutions when given IV

Barbiturates:

-First introduced in 1903; were the standard drugs for insomnia and sedation -Physiologically habit forming; low therapeutic index, few used now d/t benzodiazepine safety rarely used now because of it's safety hazard, Benzos are used *Contraindicated in:* -pregnancy -respiratory disorders -severe liver or kidney disease -elderly *-Site of action: brainstem (reticular formation)* -Potentiates action of GABA: nerve impulses traveling in cerebral cortex are inhibited decreases brain stimulation -Raise the seizure threshold—anticonvulsant -can be long-acting, so easier to dose but not used for sleep it's used for seizures

Drug Effects: Paralysis

-First, autonomic activity is lost -Then pain and other sensory functions are lost -Last, motor activity is lost -As local drugs wear off, recovery occurs in reverse order (motor, sensory, then autonomic activity are restored)

Herbal Product: Omega-3 Fatty Acids:

-Fish oil products -Used to reduce cholesterol- decrease triglycerides -May cause rash, belching, allergic reactions -Potential interactions with anticoagulant drugs

Herbal Product: Flax

-Flowering plant of Europe, US, Canada -Seed, oil of plant are used *Uses:* -atherosclerosis -hypercholesterolemia -hypertriglyceridemia -constipation -menopausal symptoms -May cause diarrhea, allergic reactions -Possible interactions: antidiabetic drugs, anticoagulants *Contraindication:* pregnancy

sevoflurane (Ultane):

-Fluorinated ether; inhaled anesthetic -Widely used: rapid onset and rapid elimination patients won't feel as drowsy when awakening -Especially useful in outpatient surgery settings -Nonirritating to the airway -Greatly facilitates induction of an unconscious state, especially in pediatrics patients Side effects: less PONV, respiratory irritation

Colony-Stimulating Factors: Sargramostim (Leukine)

-Granulocyte-macrophage CSF (GM-CSF) granulocytes, monocytes (phagocytic cells) -Promotes bone marrow recovery after bone marrow transplantation in leukemia and lymphoma patients -Subcutaneous or IV injection Granulocytes= basophils, eosinophils, neutrophils Neutrophils= most important to fight infection

Heparin: Nursing Implications

-Guardrail Drug: 2 RN check IV doses Rotate subcutaneous doses, site must be deep subcutaneous fat, 2 inch from umbilicus, wounds, scars, stomas, drains etc. Do not aspirate! -IV doses may be given IVP or infusion -Anticoagulant effects immediate; half-life 1-2 hr -Lab monitor: aPTT values toward therapeutic level, then daily *-Antidote= protamine sulfate 1mg for every 100 units heparin* -Drug interactions: ASA, NSAIDs, anticoagulants -Monitor for bleeding: hematuria, melena, epistaxis

Hematopoietic Drugs: Oprelvekin (Neumega)

-Hematopoietic drug and Interleukin (IL-11) -Enhances synthesis of platelets -Stimulates the bone marrow cells megakaryocytes eventually give rise to platelets -Prevent chemotherapy-induced severe thrombocytopenia and need for platelet transfusions -Subcutaneous injection

digoxin Toxicity:

-Hyperkalemia (serum K>5 mEq/L) in digitalis-toxic patient -Life-threatening cardiac dysrhythmias *-Antidote: digoxin immune Fab (Digibind) therapy* *Conditions That Predispose to Digoxin Toxicity:* -Hypokalemia -cardiac pacemaker -Hepatic dysfunction -Hypercalcemia -Dysrhythmias -Hypothyroid -Respiratory or Renal disease -Advanced age

Parenteral Iron: Iron dextran (INFeD, Dexferrum)

-IV use only, saline flush beforehand and pump monitor -*May cause fatal anaphylactic reactions* Severe hypotension, orthostatic hypotension Can Premedication with diphenhydramine, steroid, Tylenol -IV test dose of iron dextran 25mg is administered before injection of full dose, if no reaction is present then after one hour, remainder of dose is given -Replaced by newer *ferric gluconate, iron sucrose* because of the anaphylactic reactions

Cholesterol and Coronary Heart Disease:

-Increase risk of CHD with high cholesterol levels -Increased circulating cholesterol creates blood vessel changes leading to foam cells -Foam cells create fatty streaks = precursor lesion of atherosclerotic plaque -Present in coronary and systemic circulation -Risk for Cardiac event, disability, death -Antilipemic drug therapy decrease risk of CHD, first and subsequent heart attacks Cholesterol levels ≥ 300 mg/dL = 3-4X greater risk of heart attack (blockage in coronary artery d/t plaque blockages) compared to pts with levels <200 mg/dL Statistic 50% Americans—male & female will die of heart attack

Narcolepsy:

-Incurable neurologic condition -"sleep attacks" in middle of normal daily activities -sleep attacks are reported to cause car accidents or near-misses in 70% or more of patients -70% involve cataplexy (sudden acute skeletal muscle weakness) this may be a reaction to strong emotions (joy, anger, laughter, fear, surprise) -50% of patients with narcolepsy have migraine headaches

Immunosuppressants: Mycophenolate (CellCept)

-Indicated for the prevention of organ rejection as well as the treatment of organ rejection -U.S. Food and Drug Administration BBW: Increased risk of congenital malformations and spontaneous when used during pregnancy Common side effects: hypertension, hypotension, peripheral edema, tachycardia, pain, headache, hyperglycemia, hyperlipidemia, electrolyte disturbances, cough, dyspnea and others

Nursing Implications: Intravenous (IV) administration

-Infuse drug slowly; to avoid dangerous CV effects -Check IV site often for infiltration, extravasation *Antidote for adrenergic drugs; Phentolamine (Regitine)* -Use clear IV solutions -Use an infusion pump, monitor site -Monitor cardiac rhythm, VS, chest pain

MAOIs and Tyramine:

-Ingestion of foods/drinks with tyramine leads to hypertensive crisis, risk for cerebral hemorrhage stroke, coma, death *Avoid foods that contain tyramine!* -Aged, mature (cheddar, bleu, Swiss) -Smoked, pickled, or aged meats, fish, poultry (herring, sausage, corned beef, salami, pepperoni, paté) -Yeast extracts -Beer and red wines -Italian broad beans (fava beans)

Cardiac Cell:

-Inside a resting cardiac cell, there is a net negative charge relative to the outside of the cell -This difference in electronegative charge results from an uneven distribution of ions (Na, K, Ca) across the cell membrane -Resting membrane potential An energy-requiring pump is needed to maintain this uneven distribution of ions -Sodium-potassium ATPase pump

Nursing Implications:

-Instruct patients in proper technique and guidelines for taking sublingual nitroglycerin for anginal pain -Hold dose if BP < 90/60 or HR >100 -Never chew or swallow the sublingual form -Instruct patients: burning sensation felt with sublingual forms indicates that the drug is still potent -Patients to keep a fresh supply of sublingual NTG on hand; potency is lost in 3 months after bottle opened -To preserve potency, store medications in an airtight, dark glass bottle with a metal cap and no cotton filler -Instruct patient: proper application of nitrate topical ointments & transdermal forms, include site rotation and removal of old medication—nurses wear gloves to prevent absorption onto own skin, do not rub in ointment -To reduce tolerance: patient removes topical NTG at hs, applies new dose in AM, allowing for a nitrate-free period -Patients to take prn nitrates at first hint of anginal pain -Monitor VS frequently during acute exacerbations of angina and during IV administration -If experiencing chest pain, patient taking sublingual NTG should lie down to prevent/decrease dizziness and possible fainting d/t hypotension -If anginal pain occurs: -Stop activity and sit or lie down and take a sublingual tablet -If there no relief in 5 minutes, call 911 or emergency services immediately and take 2nd sublingual tablet -If there is no relief in 5 minutes, take a third sublingual tablet -Do not try to drive to the hospital -IV nitroglycerin must be given with special non-PVC tubing/bag -Discard parenteral solution that is blue, green, dark red -Follow specific manufacturer's instructions for IV administration

Nursing Implications: Patients with chronic lung disease

-Instruct patients to avoid exacerbation factors (illness, crowds, respiratory irritants) -Encourage fluid intake ≥ 3000 mL/day if permitted -Educate patients about proper dosing, use of equipment (metered-dose inhaler, spacer, nebulizer), and equipment care.

temazepam (Restoril):

-Intermediate-acting benzodiazepine -One of the metabolites of diazepam -Normally induces sleep within 20 to 40 minutes -Long onset of action, so it is recommended that patients take it about 1 hour prior to going to bed patients will sleep all night long -Still an effective hypnotic; however, it has been replaced by newer drugs -May cause daytime sleepiness due to disrupted sleep cycle (duration is 7-8 hours, don't take late if you need to wake up early)

Ketamine:

-Intravenous administration use for both general anesthesia and moderate sedation -Rapid onset of action highly lipid soluble, penetrates the blood-brain barrier quickly -Binds to opioid CNS and NMDA PNS receptors located in the dorsal horn and spinal cord -Low incidence of reduction of cardiovascular, respiratory, and bowel function -Bronchodilating effect-used for asthmatic patients -*Adverse effects*: disturbing psychomimetic effects, including hallucinations

Anticholinergic Contraindications:

-Known drug allergy -Angle-closure glaucoma -Acute asthma, respiratory distress -Myasthenia gravis -Acute cardiovascular instability -GI or GU tract obstruction (benign prostatic hyperplasia [BPH])

Contraindications to Cholinergics:

-Known drug allergy -GI or genitourinary (GU) tract obstruction (if there is obstruction, we don't want to increase peristalsis in the muscles against the obstruction, can be dangerous and painful) -CV: Bradycardia (causes slow HR, it can lower HR even more) -Defects in cardiac impulse conduction -Hyperthyroidism (already have increased GI motility) -Epilepsy -Hypotension -COPD, asthma (causes narrowing of airways, will narrow them even more) -Parkinson's disease

Angiotensin-Converting Enzyme (ACE) Inhibitors:

-Large group of safe and effective drugs -First-line drugs for HTN, HF -May be combined with thiazide diuretic or CCB -*captopril (Capoten)* -benazepril (Lotensin) -*enalapril (Vasotec)* -fosinopril (Monopril) -*lisinopril (Prinivil)* -moexipril (Univasc) -perindopril (Aceon) -quinapril (Accupril) -ramipril (Altace) -trandolapril (Mavik) *bolded medications have distinctions from the rest of the medications*

Extravasation:

-Leaking of IV antineoplastic drug into surrounding tissues during intravenous administration -Can result in permanent damage to nerves, tendons, muscles; loss of limbs--Skin grafting or amputation may be necessary Prevention/Continuous monitoring of IV site is essential. -If suspected, stop infusion immediately, contact doctor -leave the IV catheter in place, use with antidote -Apply cold packs, sterile occlusive dsg, elevate limb -Thoroughly document the extravasation incident. Consult facility protocol and guidelines.

Mood-Stabilizing Drugs:

-Lithium carbonate and lithium citrate -Treatment: acute mania, maintenance bipolar disorder -Potentiates serotonergic neurotransmission *Used in combination with other drugs:* -Benzodiazepines -Antipsychotic drugs -Antiepileptic drugs -Dopamine receptor agonists -NARROW therapeutic range; blood level monitoring *Antiepileptics: drugs of choice for BPD* -Valproic acid (Depakote) -lamotrigine (Lamictal) -Oxcarbazepine (Trileptal) -topiramate (Topamax) *Atypical antipsychotics: tx mania, hypomania* -Aripiprazole (Abilify) -lurasidone (Latuda) -risperidone (Risperdal) -olanzapine (Zyprexa) -quetiapine (Seroquel) -ziprasidone (Geodon)

Barbiturates: Drug Effects

-Low doses: sedative effects -High doses: hypnotic effects (decrease RR) *Enzyme inducers* -Stimulate liver enzymes that cause metabolism or breakdown of many drugs -Result in shortened duration of action *Indications:* -Sedatives (rarely) -Anticonvulsants -Surgical Anesthesia (balanced anesthesia)

enoxaparin (Lovenox):

-Low molecular weight heparin, synthetic -Anticoagulant: prophylaxis and therapeutic treatment -Specific for activated factor Xa—predictable response -No lab monitoring required, half-life 4-5 hr -Not to be given with heparin, other anticoagulants -Exception: Used to bridge warfarin *Nursing Implications:* -Subcutaneous injection only, pre-filled syringes: rotate sites -Protamine sulfate can be given as antidote -Not used with epidural catheter; cause epidural hematoma

Interleukins: Aldesleukin(Proleukin)

-Lymphokine IL-2 -Treatment of metastatic renal cell carcinoma metastatic melanoma -Off-label: HIV, AIDS, non-Hodgkin's lymphoma -Contraindications: drug allergy, organ transplant, abnormal pulmonary or cardiac stress tests, corticosteroids (reduced anti-tumor effect) -Associated with severe rxn: capillary leak syndrome -Potential drug interaction with antihypertensive drugs producing additive hypotensive effects -Has tendency to disrupt body fluids, so hold the drug if pt has any heart disorders -Tends to lower HTN

Miscellaneous Antineoplastics: Octreotide (Sandostatin)

-Management of a cancer-related condition called carcinoid crisis -Treatment of the diarrhea caused by vasoactive intestinal peptide-secreting tumors (VIPomas)

Humoral (Anti-body) Mediated Immunity:

-Manufactured in the bone marrow

Nicotine:

-Many smoke to "calm nerves." -Releases epinephrine, which creates physiologic stress rather than relaxation -Tolerance develops -Physical and psychologic dependency -Withdrawal symptoms occur if stopped -No therapeutic uses -200 known poisons present in cigarette smoke

amiodarone (Cordarone, Pacerone):

-Markedly prolongs action potential duration and effective refractory period in all cardiac tissues -Blocks alpha & beta-adrenergic receptors of SNS *Indications:* -sustained & nonsustained ventricular tachycardia -ventricular fibrillation (40-60% effective) -atrial tachydysrhythmia Advanced Cardiac Life Support guidelines: -Drug of choice for ventricular dysrhythmias *Contraindications:* -hypersensitivity -severe sinus bradycardia or 2nd or 3rd--degree heart block Many AE (75% of patients-dose related) -Hypo/hyperthyroid d/t iodine content -Corneal microdeposits within 6mo: halos, photophobia, dry eyes -Pulmonary toxicity (10%), need PFT dyspnea, cough leads to pulmonary fibrosis -Long half life, may take 2-3 months for effects to recede after d/c -Drug interactions: digoxin and warfarin Decrease doses by 50%

Class I:

-Membrane-stabilizing drugs -Fast sodium channel blockers (phase 0) -Divided into Ia, Ib, and Ic drugs, accordingto effects

Nursing Implications:

-Monitor for adverse reactions: allergic reactions, headache, lightheadedness, hypotension, dizziness -Monitor for therapeutic effects: relief of angina, decreased BP, or both -Patches may cause skin irritation

Nursing Implications: Alkylating Drugs

-Monitor for expected effects of BMS. -Expect stomatitis, n/v, diarrhea -Hydration is important to prevent nephrotoxicity. -Report ringing or roaring in ears—possible otoxicity -Report tingling, numbness, pain in extremities-peripheral neuropathies may occur.

Immunosuppressants: Basiliximab (Simulect), daclizumab (Zenapax)

-Monoclonal antibodies -Used to prevent rejection of transplanted kidneys -Also used in cancer treatment to target tumor cells and bypass normal cells -Generally used as part of a multidrug immunosuppressive regimen that includes cyclosporine and corticosteroids -Have a tendency to cause the allergy-like reaction known as cytokine release syndrome -Cytokine release syndrome: can be severe and even involve anaphylaxis. Patients are often pre-medicated with corticosteroids (IV methylprednisolone) in an effort to avoid or alleviate this problem. -Basiliximab: BBW-potential for lymphoproliferative disordersand opportunistic infections and severe hypersensitivity reactions, including anaphylaxis

alcohol (Ethanol):

-More accurately known as ethanol (ETOH) -Causes CNS depression by dissolving in lipid membranes of CNS, augment GABA -Few legitimate uses of ethanol/alcoholic beverages -Drug solvent, skin coolant, topical disinfectant (isopropyl) -Treatment of methyl alcohol, ethylene glycol intoxication (antifreeze solution toxicity) -Red wine CV benefits -Long term use of increased ethanol ingestion: -Serious neurologic, mental disorders

Potassium:

-Most abundant positive electrolyte inside cells -95% of body's potassium is intracellular *Potassium content outside of cells = 3.5--5 mEq/L* -Potassium levels critical to normal body function *Food Sources:* -Fruits (banana, orange, apricot, date, raisins, broccoli, green bean, potato, tomato), meats, fish, wheat bread, legumes *Excess dietary potassium excreted via kidneys* -Impaired kidney function leads to high K levels, possibly toxicity *Potassium is responsible for:* -Muscle contraction -Transmission of nerve impulses -Regulation of heartbeat -Maintenance of acid-base balance -Isotonicity

atorvastatin (Lipitor):

-Most common high/mod intensity statin -Lowers total and LDL cholesterol levels -Lowers triglyceride levels -Raises "good" cholesterol (HDL) *Administration*: -once daily, usually evening meal or bedtime to correlate with diurnal rhythm •Takes 6-8 weeks to effect serum cholesterol levels *Contraindication:* allergy, pregnancy(category X)

alprazolam (Xanax):

-Most commonly used as anxiolytic *Short acting benzodiazepine; 6 hr, valium 12 hr* *Indications:* -GAD -short-term relief of anxiety symptoms -panic disorder -anxiety with depression *Adverse effects:* -confusion -HA -sedation -ataxia (lack of muscle coordination) -drowsiness *Interactions:* -alcohol -oral contraceptives -azole antifungals -rifampin -phenytoin -theophylline Administration: oral route only

midazolam (Versed):

-Most commonly used preoperatively and for moderate sedation -Causes amnesia and anxiolysis (reduced anxiety) as well as sedation -Normally administered by injection in adults (onset= 1-5 minutes, half life is very short 6 hours) -Liquid oral dosage form is also available for children very cautious when given to young and old patients -adjunct for anesthesia

Status Epilepticus:

-Multiple seizures occur with no recovery between them Result: -hypotension -hypoxia -brain damage -death -True medical emergency -*Diazepam, lorazepam* = acute drugs of choice -Phenobarbital, phenytoin = maintenance therapy

Hyperlipidemia Treatment Guidelines:

-National Cholesterol Education Program -Adult Treatment Panel III of the National Institutes of Health *Lifestyle modification:* -Diet low in saturated fat, high fiber, sterols/stanols -AHA: fatty fish, omega-3 fatty acids -Weight reduction, exercise *Antilipemic drugs* -Drugs used to lower lipid levels -Used as an adjunct to diet therapy Drug choice based on: -Specific lipid profile of patient (phenotyping) -Total cholesterol, triglycerides, lipoprotein factions -Patterns of hyperlipidemia (I-V) -Other risk factors for CHD -Metabolic Syndrome = risk for CVD -All reasonable nondrug cholesterol-lowering methods (diet, exercise) should be tried for at least 6 months and found to fail before drug therapy start

Albumin:

-Natural protein normally produced by the liver -Responsible for generating approx. 70% of COP -Sterile solution of serum albumin: prepared from pooled blood, plasma, serum, or placentas obtained from healthy human donors -Pasteurized to destroy any contaminants, Administer at room temp, IV 5,25% conc -Monitor for s/s fluid overload *Contraindicated: HF, severe anemia*

dopamine (Intropin):

-Naturally occurring catecholamine neurotransmitter -Potent dopaminergic, beta1- and alpha1- adrenergic receptor activity -Low dosages: dilate blood vessels, increase flow to brain, heart, kidneys, and mesentery (dopaminergic receptor activity) -look at kidney output to know that the effected tissue is getting the response -dopamine in higher infusion rates act on the heart, which increases BP -too much vasoconstriction of alpha-1 can makes the vessels in hands and feet blue, alpha-1 vasoconstricts peripherally -very toxic, must be given usually in central IV or PICC line, because its so toxic to the peripheral sites, if pt has no BP and only has peripheral site you have to be careful for extravasation -Higher infusion rates: improve cardiac contractility and cardiac output (beta1-adrenergic receptor activity) Highest doses: vasoconstriction (alpha1-adrenergic receptor activity). Monitor IV site *antidote for extravasation= phentolanine (Regitine)* Contraindicated in Pheochromocytoma catecholamine secreting tumor of adrenal gland

Nicotine: Drug Effects

-Nicotine from tobacco plants: no therapeutic use -Transient stimulation of autonomic ganglia: nicotinic receptors -Significant addictive, toxic properties *Drug effects:* -CNS, respiratory stimulation--followed by CNS depression -Increased heart rate and BP -Increased bowel activity: n/v/d (parasympathetic stimulation)

eszopiclone (Lunesta):

-Nonbenzodiazepine -First hypnotic to be FDA approved for long-term use -Designed to provide a full 8 hours of sleep -Considered a short- to intermediate-acting agent -Patients should allot 8 hours of sleep time and should avoid taking hypnotics when they must awaken in less than 6 to 8 hours (last for 8 hours, if need to wake up in 6 hours it's not a good idea to take)

Over-the-Counter Hypnotics:

-Nonprescription sleeping aids often contain antihistamines (have CNS depressant effect) -Doxylamine (Unisom) and diphenhydramine (Sominex), acetaminophen/diphenhydramine (Extra Strength Tylenol PM) -As with other CNS depressants, concurrent use of alcohol can cause respiratory depression/ arrest

orlistat (Xenical):

-Nonstimulant drug, lipase inhibitor -Binds to gastric and pancreatic enzymes -Reduces fat absorption by 30% -OTC drug: Alli Adverse effects: -Flatulence -fecal/oily incontinence (20-40% of patients) (leakage of stools) (to prevent this AE, patients can decrease their dietary intake of fat) -Decreases Vitamin A, D, E, K, beta carotene Contraindications: -chronic malabsorption syndrome (Crohn's ds, colitis)

Nursing Implications:

-Obtain H&P, drug history, baseline VS, I&O, BP, pulse, I&O, ECG, K level -Monitor cardiac rhythm, HR, BP, general well-being, skin color, temp, heart/lung sounds -Assess plasma drug levels as indicated -Patients to take meds as scheduled, do not skip doses or double up for missed doses -Contact physicians for instructions if dose missed -Instruct patients not to crush or chew oral sustained-release preparations -Monitor ECG for prolonged QT with antidysrhythmic, (amiodarone, procainamide, quinidine, dofetilide, bepridil, sotalol, and flecainide) -Administer IV infusions with an IV pump -Solutions of lidocaine containing epinephrine should not be given IV; ONLY used as local anesthetics -Patient should know to notify HCP if worsening of dysrhythmia or toxic effects -SOB, Edema, Syncope, Chest pain, GI distress, blurred vision -Assess for potential drug interactions, adverse effects -Teach patients taking beta blockers, digoxin, cardiac drugs how to take own radial pulse for 1 full minute and to notify physician before taking next dose if pulse is < 60 beats/min -Monitor for therapeutic response: -Decreased BP in HTN patients -Decreased edema, Decreased fatigue -Regular pulse rate without major irregularities -Improved regularity of rhythm -Improved cardiac output -Assess for knowledge deficit

Nursing Implications:

-Obtain baseline H&P, medication history, VS, weight -Assess baseline fluid volume status, I&O, serum electrolyte values, postural blood pressure) -Assess for disorders that may contraindicate or necessitate cautious use of these drugs. -Take diuretic in morning if possible, to avoid interference with sleep patterns -Monitor serum potassiumlevels during therapy -Monitor for digitalis toxicity if taking diuretics along with digoxin -Teach patients to maintain proper nutritional and fluid volume status -Diet therapy: Increase potassium-rich foods unless taking potassium-sparing drugs (Aldactone) -Potassium rich foods: bananas,oranges,dates, apricots, raisins, broccoli, green beans, legumes, potatoes, meats, fish -Diabetics taking thiazide/ loop diuretics should monitor blood glucose, watch for elevated levels -Patients should keep log of daily weight -Patients who have been ill with n/v/d should notify PCP d/t fluid, electrolyte imbalances -S/S of hypokalemia include muscle weakness, constipation, irregular pulse,lethargy -Notify their PCP immediately if rapid HR or syncope (reflects hypotension or fluid loss) -Excessive consumption of licorice can lead to additive hypokalemia when taking thiazides. -Monitor for hyperkalemiawith potassium-sparing diuretics -Remind patients to return for f/u visits, lab work *Monitor for adverse effects:* -Metabolic alkalosis -drowsiness -lethargy -hypokalemia -tachycardia -hypotension -leg cramps -restlessness -Patients should change positions slowly after sitting/lying to prevent dizziness, fainting *related to orthostatic hypotension, increased fall risk* *Monitor for therapeutic effects:* -Reduction of fluid volume overload/edema -Improvement in s/s HF, Reduction of HTN -Return to normal intraocular pressures

Tolerance:

-Occurs in patients taking nitrates around the clock or with long-acting forms -Prevented by allowing a regular nitrate-free period to allow enzyme pathways to replenish -Transdermal forms: remove patch at bedtime for 8 hours, then apply a new patch in the morning

citalopram (Celexa):

-One of the most commonly used SSRIs -*Treatment of depression and OCD* -Discontinuation syndrome because this drug has a very short half-life (24-48 hours) *Adverse effects:* -anxiety -dizziness -drowsiness -insomnia

enalapril (Vasotec):

-Only ACEI available in oral, parenteral forms -IVP Enalapril does not require cardiac monitor -Oral enalapril: prodrug -Improves chances of survival after an MI -Reduces the incidence of HF -oral form of enalapril differs from captopril in that is it a prodrug, and the patient must have a functioning liver for the drug to be converted into its active form

Blood Products:

-Only class of fluids that are able to carry oxygen -Increase tissue oxygenation Increase Colloid Osmotic Pressure and PV -Pull fluid from extravascular space into intravascular space (plasma expanders) -Red blood cell products also carry oxygen -Increase body's supply of various products (e.g., clotting factors, hemoglobin) -Most expensive and least available fluid because they require human donors

isosorbide dinitrate (Isordil):

-Organic nitrate -Available in rapid-acting sublingual tablets, immediate-release tablets, and long-acting oral dosage forms both rapid and long acting Isosorbide mononitrate (Imdur) -Common use sustained release form—steady response

bupropion (Zyban):

-Originally for depression; now smoking cessation -Dopaminergic, noradrenergic -Adjunct antidepressant for patients experiencing sexual adverse effects d/t SSRI *First nicotine-free Rx to treat nicotine dependence* -Zyban = SR formula (sustained release) -*Contraindicated:* seizure disorder (lowers threshold), MAOI medications *Adverse effects:* -dry mouth -dizzy -confusion -tachycardia -tremor -agitation

Nursing Implications:

-Patients taking beta blockers should monitor their pulse rates daily and report any rate < 60 beats/min or symptoms of relative bradycardia -Instruct patients to report dizziness or fainting -These meds should never be abruptly d/c -Inform patients: These meds are for long-term prevention of angina, not for immediate relief

Opioid Drug Withdrawal:

-Peak period: 1 to 3 days -Duration: 5 to 7 days *Signs* -Drug seeking -mydriasis (dilation of pupil) -diaphoresis -rhinorrhea (runny nose) -lacrimation (teary eyes) -diarrhea -elevated B/P -tachycardia -anxiety *Symptoms* -Intense desire for drug -muscle cramps -arthralgia (joint pain) -n/v with abdominal cramping -malaise -fever -insomnia Treatment—formal detoxification program -*Clonidine, methadone initially routinely when the pt is withdrawing, then naltrexone* *Medical detox:* -Withdrawal is associated with many acute physical reactions. Some can be severe but treated with medications to prepare the individual for long-term recovery -With medical detox, clients are monitored until withdrawal is over, so their safety and comfort can be prioritized -*Opiate withdrawal symptoms generally abate in a week, but may last up to a month* -Emotional symptoms, such anxiety, insomnia, and low energy can last for a few months, especially for those used to high opiate doses -Common physical symptoms include runny nose, teary eyes, and hot and cold sweats -A person withdrawing from opiates may yawn a lot -Other symptoms include muscle aches and pains, nausea, vomiting, diarrhea, and abdominal cramps

Stimulant Withdrawal:

-Peak period: 1 to 3 days -Duration: 5 to 7 days (depends on how much dosage a person was taking a day) *Signs* -Social withdrawal -psychomotor retardation -hypersomnia -hyperphagia (increased appetite) *Symptoms* -Depression -suicidal thoughts and behavior -paranoid delusions -No specific pharmacologic treatments to reduce cravings, reverse toxicity, *no antidote* -Supportive Care sometimes requires sedation to bring HR and BP down, fluids for dehydration

Drug Therapy for Heart Failure:

-Positive inotropic drugs: increase the force of myocardial contraction -Negative chronotropic drugs: decrease heart rate -Negative dromotropic drugs: delay cardiac conduction -Phosphodiesterase inhibitors- milrinone -Cardiac glycosides-digoxin -B-type natriuretic peptides- nesiritide -ACE inhibitors, ARBs -Beta blockers -Diuretics

Cardiac Glycosides: Drug Effects:

-Positive inotropic effect: Increase force, velocity of myocardial contraction (without increase in O2 need) -Negative chronotropic effect: Reduced heart rate -Negative dromotropic effect: Decreased automaticity at SA node and decreased AV nodal conduction -Increased stroke volume, coronary circulation -Increased perfusion, diuresis -Decrease in exertional and paroxysmal nocturnal dyspnea, cough, and cyanosis -Improved symptom control, QOL, exercise tolerance

Immunosuppressants: Cyclosporine (Sandimmune, Neoral, Gengraf)

-Prevention of organ rejection -May be used for other autoimmune disorders -May cause hypertensive crisis -Avoid grapefruit juice due to absorption disruption, avoid foods high in potassium (bananas, tomato) -When administered with allopurinol, cyclosporine level may become toxic -Available under different brand names; although they contain the same active ingredient (cyclosporine), they cannot be used interchangeably ***The patient needs the brand name, if patient is in the hospital and needs a script it has to be EXACTLY what they're taking at home****

Nursing Implications:

-Prior to therapy, obtain H&P, medication hx, family hx -Assess diet, exercise level, VS, tobacco, alcohol use -Contraindications include biliary obstruction, liver dysfunction, and active liver disease -Obtain baseline liver function studies (ALT, AST, bilirubin), assess for drug interactions, monitor labs -Patients on long-term therapy may need supplemental fat-soluble vitamins (A, D, K) -Prevent constipation and GI upset, increase fiber and fluids, fruit and vegetable intake -Refer to guidelines: administration times and meals -Powder forms (bile acid sequestrants) must be taken with food or liquids, mixed thoroughly to dissolve completely (in 4-6 oz. fluid) for 1 minute, and never taken dry. Other meds should be taken 1 hour before or 4-6 hours after meals to avoid interference with absorption -To minimize adverse effects of niacin, start on low initial dose and gradually increase it, and take with meals -Small doses of aspirin or NSAIDs may be taken 30 minutes before niacin to minimize cutaneous flushing -Instruct patients to report persistent GI upset, constipation, abnormal or unusual bleeding, yellow discoloration of the skin (jaundice) -Monitor for adverse effects, including increased liver enzyme studies Inform patients that antilipemic drugs may take several weeks to show effectiveness -Monitor for therapeutic effects: •Reduced cholesterol and triglyceride levels

Nursing Implications:

-Prior to treatment: obtain H&P -Assess for contraindications/cautious use of specific antihypertensive drugs. -*Educate patient: importance of not missing a dose and taking BP meds exactly as prescribed* -Instruct pt as to physician guidelines on what to do if med dose is missed; *never double up on doses* -*These drugs should not be stopped abruptly*; may cause a rebound hypertensive crisis and perhaps lead to stroke -Monitor BP: *keep journal of regular BP checks* -Promote lifestyle changes -Weight loss, stress management, *diet & exercise* -Smoking cessation, decrease sodium intake -Moderate alcohol consumption -Oral BP meds should be given with meals so that absorption is more gradual and effective. -*Infuse IV forms with extreme caution*, use IV pump -Get physician approval to take OTC drugs -Change positions slowly to avoid syncope from postural hypotension -Inform male patients that impotence is an expected effect, (this may influence compliance) -Hot tubs, hot showers/baths; hot weather; prolonged sitting/standing, physical exercise, and alcohol ingestion may aggravate low BP, leading to hypotension or syncope; patients should sit/lie down until symptoms subside -Monitor for adverse effects (dizziness, orthostatic hypotension, fatigue) and for toxic effects (SOB; dyspnea; swelling of feet, ankles, face, or around eyes; weight gain/loss; chest pain, palpitations) -Monitor for angioedema -If patient experience serious adverse effects or if pt believes the dose or medication needs to be changed, patient should contact physician immediately -Monitor for therapeutic effects

Nursing Implications:

-Prior to treatment: perform H&P, determine presence of contraindications, conditions requiring cautious use -Obtain baseline vital signs, respiratory patterns and rate -Assess for drug interactions -Check with physician before taking OTC medications -Limit caffeine intake *Patients should report:* -Blurred vision -persistent HA -dry mouth -edema -fainting episodes -weight gain of 2 lb in 1 day or 5 lb in 1 wee -pulse rate < 60 beats/min -Dyspnea -Alcohol consumption and spending time in hot baths or whirlpools, hot tubs, or saunas will result in vasodilation, hypotension, and possible fainting -*Patients should change positions slowly to avoid postural BP changes* -Patients to keep a record of anginal attacks, including precipitating factors, amount of pills taken, therapeutic effects

mirtazapine (Remeron):

-Promotes presynaptic release of serotonin and norepinephrine in the brain, histamine receptor -sedation, given at bedtime *Indications:* -depression -BPD -reduces sexual dysfunction adverse effects in males receiving SSRI, stimulant *Contraindication:* drug allergy, MAOIs *Adverse effects:* -drowsiness -abnormal dreams -dry mouth -constipation -increased appetite -asthenia *Drug interactions:* -additive CNS depressant -alcohol -CYP inhibitors

Immunosuppressants: Azathioprine (Imuran)

-Prophylaxis of organ rejection concurrently with other immunosuppressant drugs, such as cyclosporine and corticosteroids. -Decreased response to vaccines -Adverse effects: lymphoma and other malignancies hepatosplenic T-cell lymphoma, leukopenia, thrombocytopenia, hepatotoxicity, bone marrow suppression

Colloids:

-Protein substances -Increase COP -Move fluid from interstitial compartment to plasma compartment (when plasma protein levels are low) -Albumin 5% and 25% (from human donors) -Dextran 40, 70, or 75 (a glucose solution) -Hetastarch (synthetic, derived from cornstarch) *Adverse effects:* -Usually safe -May cause altered coagulation, resulting in bleeding -Have no clotting factors or oxygen-carrying capacity -Rarely, dextran therapy can cause anaphylaxis or renal failure

phenobarbital:

-Prototypical barbiturate -Long-acting drug, enhances the action of GABA *Uses:* -prevention of generalized tonic-clonic seizures -fever-induced convulsions -treatment of hyperbilirubinemia in neonates -Causes deprivation of REM sleep -May cause inability to deal with normal stress -Rare use as sedative, not used as hypnotic *Administration:* -oral -IV

Nonpharmacologic Treatments:

-Psychotherapy -Mental Health support groups -Social, family, spiritual support -Healthy lifestyle Good nutrition, exercise -Meditation, visualization -Patient reporting of improved symptoms determines of treatment

naloxone hydrochloride (Narcan):

-Pure opioid antagonist, blocks opioid receptors -Drug of choice for complete/partial reversal of opioid-induced respiratory depression -*Indicated: cases of suspected acute opioid overdose* -Failure of drug to significantly reverse effects of opioid OD indicates that condition may not be related to opioids

Class II: beta blockers

-Reduce or block SNS stimulation -Reduces transmission of impulses in the heart's conduction system -Cardioprotective: decrease HR, workload -Depress phase 4 depolarization -General myocardial depressants for both supraventricular and ventricular dysrhythmias -Also antianginal, antihypertensive drugs *Esmolol: IV short acting, Beta1 heart selective Used in anesthesia*

Cell-Mediated Immune System:

-Referred to as T cells because they mature in the thymus 3 different types of T cells: Cytotoxic: directly kill their targets by causing cell lysis or rupture T helper cells: considered the master controllers of the immune system; they direct the actions of many other immune components, such as lymphokines and cytotoxic T cells Cytokines: non antibody proteins that serves as chemical mediators of various physiologic functions

Herbal Products: Valerian

-Relief of anxiety, restlessness, sleep disorders *May cause:* -CNS depression -hepatotoxicity -n/v anorexia -restlessness -insomnia *Many interactions including:* -CNS depressants -MAOIs -phenytoin -warfarin -alcohol *Contraindicated in:* -cardiac and liver disease -use with muscle relaxants -anticonvulsants -other sedation and anxiolytics -Patient should not operate heavy machinery during use.

Parental Iron: Ferric gluconate (Ferrlecit)

-Repletion of total body iron content in renal pts with iron-deficiency anemia who have hemodialysis -Risk of anaphylaxis much less than iron dextran, test dose is not required. -*Doses >125 mg associated with adverse events:* •abdominal pain •dyspnea •cramps •*itching*

Iron Toxicity:

-Reported to CDC, US Poison Control Center -GI corrosive effects, metabolic and hemodynamic *Symptomatic and supportive measures* -Suction and maintenance of airway -give oxygen -correction of acidosis -control of shock and dehydration with IV fluids or blood -vasopressors -Severe iron intoxication s/s: coma, shock, seizures Need immediate: Chelation therapy with *deferoxamine* -Iron Overload treatment: *Deferiprone* Serum iron > 300mcg/ dL

Stimulants: Adverse Effects on CNS

-Restlessness -Syncope (fainting) -Tremor -Hyperactive reflexes -Talkativeness -Irritability -Insomnia -Fever -Euphoria -Confusion -*Aggression* -Increased libido -Anxiety -Delirium -*Paranoid hallucinations* -Suicidal or homicidal tendencies

Immunosuppressants: Muromonab-CD3 (Orthoclone OKT3)

-Reversal and prevention of graft rejection -Monoclonal antibody: differs from human antibodies in that it comes from mice -Action: specifically targets binding sites on T-cells that recognize foreign invaders (transplanted organ) Adverse effect: chest pain -Contraindicated in patient with fluid overload -Can cause cytokine release syndrome, patients also given corticosteroids with dose available only in injection form***

Autonomic Nervous System:

-SNS is the counterpart to PNS -Together comprise Autonomic Nervous System -SNS & PNS provide checks-and-balances system -maintain homeostasis of autonomic functions PNS= cholinergic receptors -Neurotransmitter= acetylcholine SNS= adrenergic receptors -Neurotransmitters = norepinephrine, epinephrine, dopamine

Benzodiazepines: Indications

-Sedation -Sleep induction -Skeletal muscle relaxation -Anxiety relief -Anxiety-related depression -Treatment of acute seizure disorders -Treatment of alcohol withdrawal alcoholics have an increased tolerance to benzodiazepines -Agitation relief -Balanced anesthesia (usually an induction first to calm patient then, then general anesthesia is given) -Moderate or conscious sedation -Calming effect on the CNS -Useful in controlling agitation and anxiety -Reduce excessive sensory stimulation, inducing sleep -Induce skeletal muscle relaxation -Combines with anesthetics, , analgesics, NMBD in balanced anesthesia -Benzodiazepine receptors same as those for alcohol addiction; treat & prevent alcohol w/d *-USED SHORT TERM FOR SLEEP THERAPY TO AVOID DEPENDENCY*

clozapine (Clozaril):

-Selectively blocks the dopaminergic receptors in the mesolimbic region of the brain -Associated with minor or no EPS *Adverse effects: blood dyscrasias - monitor WBC count weekly for the first 6 months* -Clozapine is only available through the National Registry, the patient and prescriber must be registered

Cytotoxic Antibiotic: Doxorubicin (Adriamycin)

-Serious SE of Doxorubicin is decrease in the heart's pumping capability (heart failure) -There is a lifetime maximum on the amount of doxorubicin you can receive. Synergistic with other anthracycline neoplastics -Cytoprotective drugs (dexrazoxane) can decrease incidence of this devastating toxicity. -Echocardiogram indicated prior to chemo start -Dose-related heart problems can occur as late as 7 or 8 years after treatments have ended. -Injection only, can increase digoxin levels -If pt already has HF, this can be a problem -Can increase digoxin medication to toxic level

Psychosis:

-Severe emotional disorder that impairs mental functioning where the individual cannot participate in activities of daily living -Hallmark trait: loss of contact with reality *Primary psychotic disorders:* -schizophrenia -Depressive and drug-induced psychoses -*Dopamine hypothesis*: excessive dopaminergic activity in the brain (opposite Parkinson's Ds)

zolpidem (Ambien):

-Short-acting nonbenzodiazepine hypnotic -Lower incidence of daytime sleepiness compared with benzodiazepine hypnotics -Ambien CR is a longer acting form with two separate drug reservoirs formulated to release twice, in the beginning of taking Ambien then several hours later more of the drug is released so it's released throughout the night -May cause somnambulating (sleep walking) -For patients with frequent waking and difficulty in returning to sleep -FDA= female; 5 mg limit male; 5-10 mg dose limit -2nd FDA drug to be used long-term after Lunesta

zaleplon (Sonata):

-Short-acting nonbenzodiazepine hypnotic -Unique advantage of this drug stems from its very short half-life -Patients whose sleep difficulties include early awakenings can take a dose in the middle of the night as long as it is at least 4 hours before they must arise Peak 1 hr, duration 6-8hr

Crystalloids:

-Solutions containing fluids and electrolytes that are normally found in the body -Do not contain proteins (colloids) -No risk for viral transmission, anaphylaxis or alteration in coagulation profile -Better for treating dehydration rather than expanding PV Used as maintenance fluids to: -Compensate for insensible fluid losses -Replace fluids (blood loss, vomiting) -Manage specific fluid, lyte disturbances -Promote urinary flow -Normal saline (NS; 0.9% sodium chloride) -Half NS (0.45% sodium chloride) -Hypertonic saline (3% sodium chloride) -Lactated Ringer's solution -Dextrose 5% in water (D5W) *Indications include:* -Acute liver failure -Acute nephrosis -Renal dialysis -Burns -Cardiopulmonary bypass -Adult respiratory distress syndrome -Reduction of the risk for deep vein thrombosis -Shock *Adverse effects; may cause:* -edema -peripheral or pulmonary -May dilute plasma proteins, reducing COP -Effects may be short-lived -Prolonged infusions may worsen HF

Colony-Stimulating Factors: Filgrastim (Neupogen)

-Stimulates growth of WBC granulocytes basophils, eosinophils, neutrophils primary defense against bacterial, fungal infection -Must be administered 24 hr before or 24 hr after chemotherapy treatment** -Administer before patient develops infection -Subcutaneous or IV injection -Common SE: fever, muscle aches, bone pain, flushing Pegfilgrastim= longer acting form of filgrastim

Cataplexy:

-Sudden, uncontrollable muscle weakness/ paralysis often triggered by strong emotion, excitement/laughter -Without much warning, loss of muscle tone (slack jaw, broken speech, buckled knees or total weakness in face, arms, legs, trunk. -Person stays awake and aware, but cannot move -Episodes last 1-2 minutes, may sleep afterwards. -Frequency varies widely, -Individuals avoid emotions that trigger cataplexy

Common Dysrhythmias:

-Supraventricular dysrhythmias -Ventricular dysrhythmias -Ectopic foci -Conduction blocks

Drug Effects and Indications: Alpha Blockers:

-Sympathetic nervous system is blocked so heart rate and BP reduces -causes arterial and venous dilation Used to treat hypertension -Cause both arterial and venous dilation -reduce peripheral vascular resistance, lowers B/P Doxazosin, prazosin, terazosin -zosins are all alpha-blockers Affect receptors on prostate gland, bladder -decrease resistance to urinary outflow -reduces urinary obstruction -miosis (pupillary constriction) -relieves effects of benign prostatic hyperplasia(BPH) Tamsulosin, alfuzosin BPH= enlarged prostate - these drugs target systemically (arteries and ventricles) and GU tract -alpha blockers reduce smooth muscle contraction of the bladder neck and the probate portion of the urethra, which reduces urinary obstruction and relieves some of the effects of BPH

Phentermine (Ionamin):

-Sympathomimetic anorexiant -Related to amphetamines, less abuse potential -Schedule IV drug -Not monotherapy—used with diet, exercise -Used in high risk patients >30 BMI or BMI >27 with DM (diabetes), HTN, HLD (high cholesterol) -Wean drug to prevent rebound appetite increase Contraindications: -drug allergy -CVD -uncontrolled HTN -glaucoma -hyperthyroid -history of drug abuse -agitation -eating disorders -recent MAOI use

Toxicity and Overdose:

-Symptomatic and supportive therapy -Continuous electrocardiographic monitoring -Activated charcoal -Treatment of shock -Antidote; Physostigmine

nesiritide (Natrecor):

-Synthetic version of human B-type natriuretic peptide Used in ICU as final effort to treat severe, life-threatening HF, often with other cardiostimulatory meds *Effects* -Diuresis (urinary fluid loss) -Natriuresis(urinary sodium loss) -Vasodilation of arteries, veins -Indirect increase in cardiac output and suppression of neurohormonal systems (RAS) *Adverse Effects* Hypotension, Dysrhythmia, HA, Abd pain, Insomnia

Vaughan Williams Classification:

-System used to classify antidysrhythmic drugs -Based on electrophysiologic effect of particular drugson the action potential Class I -Class Ia -Class Ib -Class Ic -Class II -Class III -Class IV

Biologic DMARD: Etanercept (Enbrel)

-TNF-blocking drug -Treatment: RA (including juvenile RA) & psoriasis -Administered as subcutaneous injection -Screen patients for latex allergy(some dosage forms may contain latex) -Onset of action: 1 to 2 weeks -Contraindicated in presence of active infections •Reactivation of hepatitis and tuberculosis -Heart failure, injection site reaction, URI -Caution with MS, CHF, hematologic abnormalities

Beta-Blocking Drugs: Nursing Implications

-Take apical pulse daily for 1 minute -Rebound hypertension or chest pain may occur if medication discontinued abruptly. -These medications should never be stopped abruptly Inform patients to report: -Weight gain of > 2 lb in 1 day or 5 lb in 1 week -Edema of the feet or ankles -Shortness of breath -Excessive fatigue or weakness -Syncope or dizziness -Apical pulse < 60 beats per minute

Monoclonal Antibodies & DMARD: Adalimumab (Humira)

-Targets tumor necrosis factor in synovial fluid -Modulates inflammatory responses controlled by TNF -Indicated for treatment of severe RA (failure to respond to other meds)** -Contraindicated with active infections -Adverse effects: injection site rxn, URI, UTI -Treatment for Crohn's Ds, ulcerative colitis, psoriasis Don't take if you've had active TB or recurring chronic infections

diltiazem (Cardizem):

-Temporary control of a rapid ventricular response in patients with atrial fibrillation or flutter and PSVT: IVP, infusion -Drug of choice for new onset rapid rate A-fib *Contraindications:* -hypersensitivity -acute MI -pulmonary congestion -Wolff-Parkinson-White syndrome -severe hypotension -cardiogenic shock -sick sinus syndrome, or 2nd or 3rd-degree AV block

methylphenidate (Ritalin):

-Treat ADHD and narcolepsy -Sympathomimetic -Extended-release dosage forms Ritalin SR, Concerta, Metadate CD

Nicotine Withdrawal Treatment:

-Treatments provide nicotine without tobacco carcinogens -Nicotine transdermal system - Patch system uses a stepwise reduction in delivery, gradual decrease dose -Nicotine polacrilex (gum) - Acute relief from w/d symptoms; rapid chewing releases immediate dose of nicotine (1/2 dose of one cigarette) -Nicotrol inhaler, nasal spray -Nicotine *(Nicorette)* lozenges -Antidepressant *bupropion*—SR formula -*Varenicline (chantix); activates CNS nicotinic receptors*

Indirect-acting anticholinesterase drugs:

-Tx mild to moderate Alzheimer's disease -Neurologic disorder: decreased levels ACh -Enhance /maintain memory, learning capabilities -3 main Indirect-acting cholinergic drugs: •donepezil (Aricept) •galantamine (Razadyne) •rivastigmine (Exelon) -15-30% efficacy, may add Namenda -must be taken everyday with these drugs -progressing disorder, so Namenda can be added to drug therapy -Namenda is not a cholinergic drug but can work with these cholinergic agents

Transplants:

-Types: kidney, heart, liver, lung, pancreas, small bowel, bone marrow, and cornea. -Rejection: primary concern; an immune response targeted against the transplanted organ -Immunosuppressants are used to inhibit the immune system and prevent organ rejection. -Transplant patients are on immunosuppressant therapy for the duration of their lifetime. -Cost of therapy can average more than $2500 per month

adenosine (Adenocard):

-Unclassified Antidysrhythmic -Slows conduction through the AV node -ACLS: Used to convert PSVT to sinus rhythm -Very short half-life—less than 10 seconds -Only administered as fast IV push -May cause asystole for a few seconds -Other adverse effects are minimal

Herbal Products: Kava

-Used to relieve anxiety, stress, and restlessness and to promote sleep -May cause temporary yellow skin, hair, and nail discoloration (extended, continued intake) and visual disturbances -Potential interactions with alcohol, barbiturates, and psychoactive drugs *Contraindicated in:* -liver disease -Parkinson's disease -alcoholism -pregnancy -Patient should not operate heavy machinery during use -can interfere with vision, causes mydriasis

Biologic DMARD: Abatacept (Orencia)

-Used to treat RA, inhibits T-cell activation -Caution if patient has history of recurrent infections or chronic obstructive pulmonary disease -Immunizations up-to-date before starting therapy (may increase the risk for infections associated with live vaccines and may decrease the response to dead and/or live vaccines) -May increase risk of infections associated with live vaccines, decrease effectiveness of any vaccines -Adverse effects: HA, URI, hypertension -Do not give with Echinacea (Immunostimulants) Dose: according to weight, 4 weekintervals, IV infusion

Methadone (Dolophine):

-Used to treat opioid dependence -Methadone: Opioid Replacement Therapy •Initial dose to suppress withdrawal symptoms, may titrate hourly with eventual bid to daily dose •*Goal:* reduce the patient's dosage gradually so that eventually the patient can live permanently drug free •Taper strength of daily doses •Relapse rates are often high •Risk for abuse of this drug -when physical withdrawal symptoms diminish, methadone can be given once a day instead of titrating hourly -half life is long

procainamide (Pronestyl):

-Uses: atrial and ventricular tachydysrhythmias *Significant AE:* -ventricular dysrhythmias -systemic lupus erythematosus (SLE)-like syndrome (30%) -n/v/d -fever -blood disorders -leukopenia -maculopapular rash -flushing -torsades de pointes resulting from QT prolongation -Contraindications: known hypersensitivity, heart block and SLE -Dosage: IV, po

Adverse Effects:

-Usually limited *Adverse effects result if:* -Inadvertent intravascular injection (unintended injection of a large dose of local anesthetic into a blood vessel within the epidural space) -Excessive dose or rate of injection -Slow metabolic breakdown (decreased liver or kidney function can cause this) "Spinal headache" -70% of patients who have dural puncture during epidural anesthesia or undergo intrathecal anesthesia. -Usually self-limiting -Treatment: bed rest, analgesics, caffeine, blood patch (anesthetist injects a venous sample of the patient's own blood into the patient's epidural space)

Adverse Effects/Contraindications:

-Wide range, dose related *Tend to "speed up" body systems* -CV: HR, B/P, tachycardia, palpitations, angina -Nervous System: Anxiety, insomnia, HA, tremor -GI: Metabolism, n/v/d, -GU: urinary frequency Contraindications: -drug allergy -Cardiac abnormality, anxiety or agitation disorders -Recent MAOI therapy (can cause hypertensive crisis) -Glaucoma, HTN

Immunosuppressants: Glatiramer acetate (Copaxone)

-Works by blocking T-cell autoimmune activity against myelin protein, which reduces the frequency of the neuromuscular exacerbations associated with MS -Only available in an injectable form -Contraindicated if allergy to mannitol (sugar component)

Mechanisms for alpha-adrenergic competitive by alpha drugs:

-adrenergic blocking agent has an increased affinity for the receptor sites and works to compete to get to and fill the sites before the catecholamine reach the end tissue destination

Atypical Antipsychotics:

-clozapine (Clozaril) -risperidone (Risperdal) -olanzapine (Zyprexa) -quetiapine (Seroquel) -ziprasidone (Geodon) -aripiprazole (Abilify) -paliperidone (Invega) -iloperidone (Fanapt) -asenapine (Saphris) -lurasidone (Latuda) *Mechanism of Action:* *Block specific dopamine receptors:* -dopamine-2 (D2) receptors *Also block specific serotonin receptors:* -serotonin 2 (5-HT2) receptors -Improved efficacy and safety profiles.

Immunosuppressant Drugs:

-cyclosporine (Sandimmune) -azathioprine (Imuran) -muromonab-CD3 (Orthoclone) -daclizumab (Zenapax) -sirolimus (Rapamune) -basiliximab (Simulect) -glatiramer acetate (Copaxone) -tacrolimus (Prograf) -mycophenolate mofetil (CellCept) -fingolimod (Gilenya), 2010

Common Symptoms of Serotonin Syndrome:

-delirium -agitation -tachycardia -sweating -myoclonus (muscle spasms) -hyperreflexia -shivering -coarse tremors -extensor plantar muscle response *severe cases:* -hyperthermia -seizures -rhabdomyolysis -renal failure -cardiac dysrhythmias -disseminated intravascular coagulation

Mechanisms for noncompetitive blockade by alpha drugs:

-drug takes up all the receptors and specific drugs cause a situation where they block the ability of catecholamine or norepinephrine to bind with any of those receptors which increases the opposite effects

BP Management: Lifestyle changes

-smoking Cessation -Control blood glucose and lipids -Dash Diet (foods lower in sodium and high in potassium, magnesium, and calcium) -Moderate alcohol consumption -Reduce sodium intake (< 2,400 mg/day) -Physical activity : Moderate-to-vigorous activity 3-4 days/week averaging 40 min per session

Hypertension Guidelines based on BP:

1.) *Normal:* < 120/80 2.) *Prehypertension:* 120/80 to139/89 3.) *Hypertension:* age < 60 ≥ 140/90 age > 60 ≥ 150/90 DM/CKD ≥ 140/90

Case Study #5:

1.Nursing considerations for conversion of IV heparin to oral warfarin (Coumadin) therapy will include: A. immediate discontinuation of IV heparin and administration of oral warfarin therapy only B. overlapping therapy of IV heparin and warfarin are for at least 5 days C. monitoring the INR and stopping the IV heparin when the INR is 1.0 B.

Fluid Balance:

60% of adult human body is water Higher in infants, lower in elderly Total body water is composed of: -Intracellular fluid (ICF): within cell membranes -Extracellular fluid (ECF): •Interstitial fluid (ISF): spaces between cells Transcellular fluid: lymph, CSF, synovial, pleural •Intravascular fluid (IVF): inside blood vessels Blood, plasma, albumin Water freely exchanged within all fluid compartments -Solvent for electrolytes, glucose within cells -Medium for metabolic reactions -Movement via diffusion, filtration, active transport, osmosis Homeostasis: intake = output -Fluid & electrolyte balance -Thirst, antidiuretic hormone, aldosterone -Intake: Food, fluids, IV, parenteral -Output: urine, emesis, feces, insensible loss -Sudden change in weight= fluid indicator

Case Study:

A 58-year-old patient is recovering in the intensive care unit after a myocardial infarction (MI). The nurse notes an order for the beta blocker metoprolol (Lopressor). The purpose of this drug is to A. dilate the coronary arteries. B. inhibit stimulation of the myocardium by circulating catecholamines. C. provide a positive inotropic effect. D. maintain the patient's BP. B. Rationale: Studies have shown increased survival in patients given metoprolol after experiencing an MI. Metoprolol has a cardioprotective effect by decreasing the heart's response to circulating catecholamines resulting from the MI.

Case Study #4:

A 72-year-old woman is taking an OTC multivitamin that contains ginkgo. Her physician has recommended that she start taking low-dose aspirin as part of her treatment for transient ischemic attacks. The concern with taking these two drugs together is A. increased risk of gastric ulcer B. decreased action of the aspirin because of the interaction with ginkgo C. increased risk of bleeding because of the ginkgo D. antagonism of the action of the aspirin because of the multivitamins C.

Case Study #2:

A 75-year old man fell at home and hit his head on a table. His wife reports that he does not have any scratches but has a small lump on his upper scalp. She does not see any blood. He is taking warfarin and an antidysrhythmic as treatment for chronic atrial fibrillation. What is the main concern at this time? A. Pressure should be applied to the lump for 3 to 5 minutes B. He will need to take two doses of warfarin tonight to prevent blood clotting C. He needs to be examined for possible internal bleeding from the fall D. As long as there is no bleeding, there is no concern C.

Case Study #7:

A patient asks how to apply transdermal nitroglycerin. What is the nurse's best response? A. "Always apply the transdermal patch over the area of your chest where your heart is." B. "Keep the previous patch on for 1 full day so you always have two patches on at a time." C. "Apply the patch to hairless areas of the body." D. "First apply Vaseline to your body; then apply the transdermal patch." C.

Case Study #5:

A patient asks the nurse to tell her more about a new drug the patient has been prescribed called ranolazine (Ranexa). Which response by the nurse is accurate? A. "We do not know how Ranexa works." B. "This drug is the first medication your health care provider will use to treat your angina." C. "This drug must be given intravenously." D. "Ranexa is safe to use in patients with liver failure. A.

Case Study:

A patient has been ordered the powdered form of the bile acid sequestrant colestipol. Which of the following does the nurse identify as true? A. The nurse should have the patient swallow the dose of the colestipol powder one teaspoonful at a time. B. The powder should be dissolved and immediately administered. C. The colestipol should be administered 1 hour before or 4 to 6 hours after any other oral medication. D. The colestipol should be administered with meals. C.

Case Study:

A patient has received an IV dose of adenosine, and almost immediately the heart monitor shows asystole. What should the nurse do next? A .Check the patient's pulse. B. Prepare to administer cardiopulmonary resuscitation. C. Set up for defibrillation. D. Continue to monitor the patient. D.

Case Study 1:

A patient has two inhalers that are due to be taken at the same time. One is a bronchodilator; the other is a corticosteroid. Which inhaler should the patient take first? A. The bronchodilator B. The corticosteroid C. It does not matter which one is taken first. A. Taking the bronchodilator first will result in a more open airway and thus allow for better penetration by the inhaled corticosteroid

Case Study #7:

A patient in the ICU will be receiving an NMBD. Which piece of equipment is essential to have nearby when the nurse initiates this therapy? A. Defibrillator B. Sphygmomanometer C. Mechanical ventilator D. Oxygen source C.

Case Study:

A patient is in the ED with an unspecified supraventricular dysrhythmia. The physician orders a dose of diltiazem (Cardizem) IV push. While the nurse administers the medication through the IV lock, the patient says she feels something wet spilling on her arm. Her heart rate was unchanged. What will the nurse do next? A. Assess the patient for diaphoresis B. Check the IV lock to see if it is functioning properly C. Repeat the dose of diltiazem (Cardizem) D. Restart the IV in another location B.

Case Study:

A patient is in the emergency department with new-onset atrial fibrillation. Which order for digoxin would most likely have the fastest therapeutic effect? A. Digoxin 0.25 mg PO daily B. Digoxin 1 mg PO now; then 0.25 mg PO daily C. Digoxin 0.5 mg IV push daily D. Digoxin 1 mg IV push now; then 0.25 mg IV daily D.

Case Study 1:

A patient is mowing his lawn on a hot Saturday afternoon. He begins to noticechest pain. What should his first action be? A.Take his nitroglycerin tablet B.Stop mowing and sit or lie down C.Go inside the house to cool off and get a drink of water D.Call 911 B.

Case Study 3:

A patient is prescribed an anorexiant. Which statement will the nurse include in patient teaching? A. "Take the medication with your evening meal." B. "You will need to take this drug for at least 2 years." C. "If you develop a dry mouth, stop taking the drug immediately." D. "Avoid intake of caffeine." D.

Case Study #3:

A patient is receiving an IV infusion of a thrombolytic drug during treatment for an acute MI. The nurse notices that there is a slight amount of bleeding from the antecubital area where venous lab work was drawn. What will the nurse do first? A. Monitor the site for further bleeding B. Apply pressure to the site with a gauze pad C. Slow the rate of infusion of the thrombolytic drug D. Stop the infusion of the thrombolytic drug B.

Case Study #1:

A patient is receiving an IV infusion of heparin and was started on warfarin therapy the night before. Which statement is mostcorrect? A. The patient is receiving a double dose of anticoagulants B. The heparin therapy was ineffective, so the warfarin was started C. The heparin provides anticoagulation until therapeutic levels of warfarin are reached D. The heparin and warfarin work together synergistically to provide anticoagulation C.

Case Study:

A patient is receiving digoxin 0.25 mg/day as part of treatment for HF. The nurse assesses the patient before medication administration. Which assessment finding would be of most concern? A. Apical heart rate of 58 beats/min B. Ankle edema +1 bilaterally C. Serum potassium level of 2.9 mEq/L D. Serum digoxin level of 0.8 ng/mL C.

Case Study:

A patient is receiving oral quinidine. Which assessment finding is of most concern? A. Nausea B. Prolonged QT interval C. Diarrhea D. Occasional palpitations B.

Case Study 2:

A patient is scheduled to have lunch at 1200. The nurse will administer the pyridostigmine (Mestinon) at what time for optimal therapeutic effect? A. 1100 B. 1130 C. 1200 D. 1230 B. Rationale: The drug should be taken 30 minutes before a meal for maximal therapeutic effect.

Case Study #6:

A patient is to receive a NMBD while on mechanical ventilation. While the patient is receiving this medication, the nurse should expect the patient to be A. sedated B. resisting the ventilator C. awake but unable to move D. pain free C.

Case Study 2:

A patient on a dobutamine drip starts to complain that he feels a "tightness" in his chest that he had not felt before. What will the nurse do first? A. Check the infusion site for possible extravasation. B. Increase the infusion rate. C. Check the patient's vital signs. D. Order an electrocardiogram. C. Before anything else is done, the patient's vital signs should be checked for alterations. The dopamine rate should not be increased. Extravasation rarely causes chest tightness. Although an electrocardiogram would be prudent, it's not the priority until after the vital signs demonstrate that the patient is stable

Case Study 3:

A patient on a dobutamine drip starts to complain that her intravenous line "hurts." The nurse checks the insertion site and sees that the area is swollen and cool. What will the nurse do first? A. Slow the intravenous infusion. B. Stop the intravenous infusion. C. Inject the area with phentolamine. D. Notify the physician health care provider. B. Infiltration of an intravenous solution containing an adrenergic drug may lead to tissue necrosis from excessive vasoconstriction around the intravenous site. Phentolamine is often used for the treatment of infiltration, but the first thing the nurse must do is to stop the infusion of the adrenergic drug. Slowing the medication will not stop further tissue damage. The physician should be notified, but the infusion should be stopped first.

Case Study 2:

A patient wants to take Orlistat (Xenical) to assist in her weight loss program, but she is wary of its unpleasant adverse effects. What measure can be suggested to reduce these effects? A. Restrict dietary intake of fat B. Restrict dietary intake of fiber C. Increase intake of dairy products D. Avoid intake of carbonated beverages A.

Case Study:

A patient wants to take garlic tablets to improve his cholesterol levels. Which condition would be a contraindication? A. Hypertension B. Bowel obstruction C. Sinus infection D. Scheduled surgery D.

Case Study #4:

A patient who has had an MI is taking a beta blocker. What is the main benefit of beta blocker therapy for this patient? A.Vasodilation of the coronary arteries B.Increased force of cardiac contraction C.Slowing of the heart rate D.Maintaining adequate BP C.

Case Study 3:

A patient who was walking his dog developed chest pain and sat down. He continues to experience chest pain when sitting down. When should he call 911? A.Immediately B.If the pain becomes more severe C.If one sublingual tablet does not relieve the pain after 5 minutes D.If the pain is not relieved after three sublingual tablets, taken 5 minutes apart C.

Case Study:

A patient will be taking niacin as part of antilipemic therapy. The best way to avoid problems with flushing or pruritus would be to A. take the medication at bedtime B. take the medication with a small dose of a steroid C. take the medication with a full glass of water on an empty stomach D. start with a low initial dose and then increase it gradually D.

Case Study 4:

A patient with Alzheimer's disease accidentally took 2 weeks' worth of a cholinergic medication. He is brought to the emergency department, is going into shock, has severe hypotension and vomiting. The nurse will expect which initial treatment? A. Administration of physostigmine B. Administration of atropine C. Administration of epinephrine D. Cardiovascular support with dopamine B. Rationale: Atropine can be given to reverse the effects of an overdose of a cholinergic drug.

Case study #3:

A patient with a creatinine clearance of 20 mL/min is admitted to the medical-surgical unit. The patient is in need ofrapid diuresis. Which class of diuretic does the nurse anticipate administering? A. Potassium sparing B. Thiazide C. Osmotic D. Loop D.

Case Study #2:

A patient with a diagnosis of delirium tremens is admitted to the acute care facility. Which finding does the nurse expect upon assessment of the patient? A. Hyperthermia B. Hypotension C. Bradycardia D. Somnolence A.

Case Study:

A patient with a history of HF presents to the ED with difficulty breathing, cough, and edema of the lower extremities. The nurse anticipates administration of which type of medication? A. Positive chronotrope B. Negative chronotrope C. Positive inotrope D. Negative inotrope C.

Case Study #3:

A patient with a history of pancreatitis and cirrhosis is also being treated for hypertension. Which drug will most likely be ordered for this patient? A. Clonidine B. Prazosin C. Diltiazem D. Captopril D.

Case Study:

A patient with a new Rx for a statin drug is instructed to take the medication with the evening meal or at bedtime. The patient asks why it must be taken at this time of day. The reason is A. the medication is better absorbed at this time. B. this timeframe correlates better with the natural diurnal rhythm of cholesterol production. C. there will be fewer adverse effects if taken at night instead of with the morning meal. D. this timing reduces the incidence of myopathy. B.

Case Study #2:

A patient with diabetes has a new prescription for the ACE inhibitor lisinopril. She questions this order because her physician has never told her that she has hypertension. What is the best explanation for this order? A. The doctor knows best B. The patient is confused C. This medication has cardioprotective properties D. This medication has a protective effect on the kidneys for patients with diabetes D.

Case Study 2:

A patient with extremely high blood pressure (BP) is in the emergency department. The physician will order therapy with nitroglycerin to manage the patient's BP. Which form of nitroglycerin is most appropriate? A.Sublingual spray B.Transdermal patch C.Oral capsule D.IV infusion D.

Case Study:

A patient with type 2 diabetes is taking a beta blocker as part of treatment for hypertension. Which complication is most likely to develop? A. Hypertension B. Hyperkalemia C. Hypoglycemia D. Angina C. Rationale: Beta blockers may mask the signs and symptoms of hypoglycemia.

Case Study 1:

A teenage boy will be receiving atomoxetine (Strattera) as part of treatment for ADHD. Which statement about this drug therapy is accurate? A. Strattera is highly addictive. B. Psychotherapy is rarely helpful in cases of ADHD. C. The patient should be monitored for possible suicidal thoughts and behavior. D. Strattera is used to treat narcolepsy as well as ADHD. C.

Case Study 3:

A woman, age 60, asks the nurse about taking ginkgo to improve her memory. The patient has a history of arthritis, diabetes, thyroid disease, and HTN. She currently takes NSAIDs for arthritis, oral antidiabetic medications, a thyroid replacement hormone, and beta blocker for blood pressure. What potential adverse effect from gingko would be of most concern for this patient? A. Stomach upset B. Diarrhea C. Bleeding D. Drowsiness C. Rationale: Potential adverse effects of gingko = GI upset, headache, bleeding, and allergic skin reaction. Potential drug interactions include aspirin, NSAIDs, anticoagulants. *Ginkgo may interact with NSAIDs and cause increased bleeding*

Intravenous (IV) therapy is ordered for a patient with a serum sodium of 150 mEq/L. Which of the following does the nurse anticipate administering? A.0.45% NS B.0.25% NS C.3% NS D.5% NS

A.

Antilipemic Drugs:

ACC/AHAGuideline: Tx of Blood Cholesterol to Reduce Atherosclerotic CV Risk in Adults (2013) -Hydroxymethylglutaryl-coenzyme A (HMG-CoA) reductase inhibitors (HMGs, or statins) -Bile acid sequestrants -B Vitamin: Niacin (vitamin B3, nicotinic acid) -Fibric acid derivatives (fibrates) -Cholesterol absorption inhibitor (Zetia) -Combination drugs (Vytorin) -Hydroxymethylglutaryl-coenzyme A (HMG-CoA) reductase inhibitors = Statins *Indications for Statins:* -Clinical Atherosclerotic CVD -LDL cholesterol levels >190 mg/dL -Diabetics 40-75 yo with LDL levels of 70 to 189 mg/dL and without evidence of CVD -Patients without CVD or DM with LDL levels between 70 and 189 mg/dL and a 10-year risk for CVD >7.5%

Obesity:

According to NIH, CDC: -approximately 30% of Americans obese -2/3 of Americans (64.5%) overweight >women, minorities, young people (6-19 years old) *Overweight= BMI 25-29.9* *Obese= BMI ≥ 30* -Pathophysiology: metabolism disorder, excess calories -Health risks -HTN -Coronary artery disease -stroke -type 2 diabetes -Osteoarthritis -cancer -dyslipidemia -gallbladder disease -Stigma (even by health care professionals treating them)

Carbonic Anhydrase Inhibitors (CAI):

Acetazolamide (Diamox) -chemical derivative of sulfonamide antibiotic *Mechanism of Action:* *-*Reduces activity of carbonic anhydrase enzyme in the active transport mechanism of kidney proximal tubules: *Decreases resorption of water, bicarbonate, sodium, potassium* *-*for sodium and water to be reabsorbed back into the blood, hydrogen must be exchanged for it *-*without hydrogen, this can't occur, and the sodium and water will be eliminated with the urine *-*carbonic anhydrase makes hydrogen ions available for this changed, when its actions are inhibited by a CAI, little sodium and water can be resorbed into the blood and they are eliminated with the urine *-*CAIs reduce the formation of hydrogen and bicarbonate ions from carbon dioxide and water, results in a reduction in the availability of the ions, many hydrogen *-*Mild diuretic, can induce respiratory/metabolic acidosis -Acts on kidney (HF), eyes (IOP), brain (ICP), lungs -Administration oral, IV *Indications:* *-*Lower intraocular pressure, treat open-angle glaucoma Increase outflow aqueous humor *-*Treat signs and symptoms of Acute Mountain (Altitude) sickness Decrease edema brain, lungs *-*Edema in HF resistant to other diuretics *Contraindications:* -allergy -Hyponatremia -hypokalemia -Severe renal or hepatic dysfunction, Cirrhosis -Adrenal gland insufficiency *Adverse Effects:* -Acidosis -hypokalemia -Hyperglycemia -Glucosuria in DM -Drowsiness -Anorexia -hematuria (blood in urine) -Urticaria (hives) -Photosensitivity -Melena (blood in stool) *Interactions:* -hypokalemia increases in digoxin toxicity -Use with corticosteroids may cause hypokalemia. -Increase effects of amphetamines, carbamazepine, cyclosporine, phenytoin, and quinidine

lidocaine (Xylocaine):

Action: raises ventricular fibrillation threshold Decrease sensitivity of cell membranes to impulses *Significant AE:* *CNS toxicity* -twitching -convulsions -confusion -respiratory depression/arrest -hypotension -bradycardia -dysrhythmias -Extensive 1st Pass effect—only parental doses -Contraindications: hypersensitive, severe SA or AV block, Wolff-Parkinson-White syndrome -Reduce dosage for liver, renal disease

doxapram (Dopram):

Actions mimic Xanthines Greater CNS stimulation in respiratory center of brain -When high CO2; deeper, faster breathing -Improves oxygen exchange in COPD-induced hypercapnia -Treatment: respiratory depression d/t anesthesia and drugs of abuse (opioids, alcohol, barbiturates) Used with supportive measures -IV dose or infusion, titrate dosage/kg -Monitor deep tendon reflexes, VS, heart rhythm to prevent over-dosage of this drug. Neuro assessment for seizures -Contraindicated in newborns because of benzyl alcohol formulation

Herbal Product: Garlic:

Active ingredient allicin *Uses:* -antispasmodic -antihypertensive -antiplatelet -lipid reducer *Adverse effects:* -dermatitis -vomiting -diarrhea -flatulence -antiplatelet activity -Possible interactions with warfarin, diazepam -May enhance bleedingwhen taken with nonsteroidal anti-inflammatory drugs (NSAIDs) *-Contraindications:* HIV, DM, *surgical patients*

Nitrates and Nitrites:

Administration forms: -Sublingual* -Chewable tablets -Oral capsules/tablets -IV solutions* -Transdermal patches* -Ointments -Translingual sprays* Rapid-acting forms -Used to treat acute anginal attacks -Sublingual tablets; IV infusion Long-acting forms -Used to PREVENT anginal episodes *Bypass the liver and the first-pass effect

Nursing Implications:

Administration guidelines: -Give last daily dose 4-6 hours before bedtime (↓insomnia) -Take on empty stomach 30-45 minutes before meals -Extended release meds avoid school time doses -Drug "holidays" diminish addictive tendencies (holidays= don't give on holiday breaks or weekends) Monitor for therapeutic responses -Parents keep journal to monitor child's response -ADHD; decreased hyperactivity, increased attention span, concentration -Monitor child's physical growth (ht, wt), appetite -Narcolepsy: decrease in sleepiness

Nursing Implications:

Administration guidelines: -Dissolvable wafers, nasal spray, self-injectable forms -Provide specific teaching re: correct administration. Monitor for therapeutic responses: -Aborting of migraine HA -Improved daily function, performance d/t HA reduction Patient journal -Monitor migraine frequency, patterns, duration, and severity, exacerbating factors, successful tx, failures

Nursing Implications:

Administration guidelines: -Follow instructions for diet and exercise -Take in the morning -Avoid caffeine (for phentermine) -Frequent oral care for dry mouth, ice, water -Use with CAM: hypnosis, biofeedback, imagery -Fat-soluble vitamin supplementation Monitor for therapeutic responses: -appetite control and weight loss -Accurate weekly wt, food/progress journal

Nitrates:

Adverse effects: -HA: Usually diminish in intensity and frequency with continued use, dizziness -Reflex tachycardia, postural hypotension -Tolerance may develop Contraindications: -Severe anemia, closed-angle glaucoma -Severe head injury -Use of erectile dysfunction drugs sildenafil, tadalafil, vardenafil

Adverse Effects:

Adverse effects= result of overstimulation of PNS CV; Bradycardia, AV block and cardiac arrest hypotension, syncope, conduction abnormalities CNS; HA, dizziness, convulsions, ataxia GI; Abdominal cramps, increased secretions, n/v/d Respiratory Increased bronchial secretions, bronchospasms -Lacrimation, sweating, salivation, miosis

Case Study 3:

After administering oxybutynin (Ditropan) to a patient with spina bifida, the nurse is monitoring the patient for therapeutic effects. Which assessment finding indicates the therapeutic effect of this drug? A. Increase in heart rate B. Decrease in urinary frequency C. Absence of muscle rigidity and tremors D. Sudden urge to have a bowel movement B.

Etiology of Cancer:

Age- increase risk -Male>female -Genetic, Ethnic factors Oncogenic viruses -HPV humanpapiloma virus—anal, cervical CA -Occupational and environmental carcinogens -Radiation-ionizing, nonionizing -Immunologic factors- health of immune system Lifestyle factors -Smoking, Alcohol, Obesity

tamsulosin (Flomax):

Alpha blocker used primarily to treat BPH; is exclusively indicated for *male* patients *Effects:* -relaxation smooth muscle of bladder; helps with dilation Improved urine flow *Contraindications:* -known drug allergy -concurrent use of erectile dysfunction drugs -synergistic with other antihypertensive meds *Adverse effects:* -hypotension, not as severe as the other drugs -Get up slowly from a sitting or lying position -headache -abnormal ejaculation -rhinitis

Midodrine (ProAmatine):

Alpha-1 adrenergic receptor stimulant -Active form desglymidodrine *Causes constriction arterioles and veins* -Peripheral *vasoconstriction*, INCREASE blood pressure *Treatment for orthostatic hypotension* Dosages 2-3X daily, start early AM -Prevent orthostatic intolerance during day -Give with fluids -Don't give after 6pm, at least 4hr prior to bedtime -prevent insomnia, supine hypertension *oral*

dexmedetomidine (Precedex):

Alpha-2 adrenergic receptor agonist Dose-dependent sedation, decreased anxiety analgesia without respiratory depression *Use:* procedural sedation, short duration surgery Short half-life; patient awakens quickly upon withdrawal of the drug -Sedation of mechanically ventilated patients (ICU) Side effects: -hypotension -bradycardia -nausea

Vasoactive Adrenergics (Pressors, Inotropes):

Also called cardioselective sympathomimetics -Treat the heart during cardiac failure or shock -Various alpha and beta receptors affected -Increase HR, B/P, improve cardiac output, stroke volume -epinephrine, norepinephrine, dopamine, dobutamine

Drugs for ADHD and Narcolepsy:

Amphetamines; Schedule II Drug First-line drug: 65-75% symptom improvement -Stimulate areas of brain to increase mental alertness -Mood elevation, increase energy, task performance -Prolong wakefulness, decrease fatigue/drowsiness -Respiratory: relax bronchioles, increase RR -Methylphenidate= synthetic amphetamine derivative -Nonamphetamine stimulants modafinil- narcolepsy -Atomoxetine (Strattera): nonstimulant ADHD drug, SNRI -(norepinephrine reuptake inhibitor) -not an amphetamine -low incidence of insomnia and has low abuse potential

Case Study #2:

An older adult patient taking multiple medications has a barbiturate added to his medication regimen. When administering a barbiturate to an older adult, the nurse should expect A. a decrease in dosages of the other medications. B. the patient will experience increased amounts of REM sleep C. to administer half of the usual dose of the barbiturate D. total relief of anxiety C *Rationale:* Barbiturates are associated with an increased incidence of falls when used in older adults; therefore, the usual dose is reduced by half whenever possible. Because barbiturates stimulate the action of enzymes in the liver, drugs are usually broken down more quickly, sometimes requiring the dose to be increased. Patients taking barbiturates have decreased amounts of REM sleep and often experience paradoxical restlessness or excitement.

Analeptic-Responsive Respiratory Depression Syndromes:

Analeptics :doxapram, methylxanthines, caffeine Stimulate areas of brain controlling respiration -Medulla, spinal cord Inhibit enzyme phosphodiesterase: allows cAMP accumulation: -CNS stimulation -bronchodilation -pulmonary arteriole dilation Treatment for: -Neonatal apnea -Bronchopulmonary dysplasia -Post anesthesia -drug abuse -respiratory depression

Nursing Implications:

Analeptics: CNS respiratory stimulant Patients in ICU, PACU -Close monitoring VS, heart rate & rhythm, B/P -Thorough neurologic assessment

Opioids:

Analgesics aka narcotics Schedule I opium, heroin -Binds opioid receptors in brain-creates euphoria then relaxation -Schedule II opioids, narcotics, oxycodone -Intended drug effects: relieve pain, reduce cough, relieve diarrhea, and induce anesthesia -Narcosis (drowsiness, unconsciousness) state of stupor= reduced sensory response, decrease pain *CNS:* -miosis -convulsion -n/v *CV* -hypotension -Large doses can stop respirations—cause death -*Affect areas outside CNS:* -skin -GI -GU (flush, diaphoresis (sweating), urticarial (hives, skin rashes), pruritus (itching), urine retention, n/v, constipation) -*Administration: oral, injection, inhale, sniff* Heroin: IV "mainlining", subcutaneous "skin popping", smoke, snort -IM injection; effect within 5-8 minutes (longer than subcutaneous) -"Snort or sniff"; effect in 10-15 minutes -IV; effect in 7-8 seconds

Anesthesia:

Anesthetics -Drugs that reduce or eliminate pain by depressing nerve function in CNS and PNS Anesthesia State of reduced neurologic function -*General anesthesia:* complete anesthesia, loss of body reflexes, paralysis of respiratory muscles. -*Local anesthesia:* elimination of pain sensation in the tissues innervated by anesthetized nerves, no paralysis of respiratory function

Caffeine:

Antagonizes adenosine receptors= stimulant effects -Treat newborns with neonatal apnea less tachycardia, CNS stimulation, feeding intolerance -*2 forms of IV* caffeine citrate (neonatal) caffeine sodium benzoate (adults) (caffeine sodium benzoate cannot be given to babies) -Potentiate effects of migraine analgesics Use with caution in patients with a history of: -Peptic ulcer -recent myocardial infarction -dysrhythmias Contraindicated in known hypersensitivity Found in: •OTC drugs: NoDoz, foods and beverages •Combination Rx drugs: Fioricet, Fiorinal

Interactions:

Anticholinergics, antihistamines, sympathomimetics -Antagonize cholinergic drugs, resulting in decreased responses Other cholinergic drugs -Additive effects (increased sweating, increased salivation, etc.)

Adrenergic-Blocking Drugs: Nursing Implications

Assess for: -allergies -history COPD -hypotension -cardiac dysrhythmias -bradycardia -heart failure Any preexisting condition that might be exacerbated by use of these drugs = contraindication to their use *Alpha blockers may precipitate hypotension* -Some beta blockers may precipitate bradycardia, hypotension, heart block, heart failure, bronchoconstriction. *-ECG monitoring for IV drug administration* -Report constipation or urinary hesitancy, bladder distention -Teach patients to change positions slowly to prevent or minimize postural hypotension. -Avoid caffeine (excessive irritability). -Instruct patients to avoid alcohol ingestion and hazardous activities until blood levels become stable. -Instruct patients to notify their physicians if palpitations, dyspnea, nausea, or vomiting occurs. -Monitor for adverse effects. -Monitor for therapeutic effects: -Decreased chest pain in patients with angina -Return to normal BP and heart rate

Nursing Implications:

Assess past history, allergies, medications. -Attention to past surgery, responses to anesthesia -Assess use of alcohol, illicit drugs, and opioids. -Assess during Preop, Intraoperative, Postop phases -Vital signs, -oxygenation -*ABCs* -Baseline lab work -ECG -Monitor all body systems -Preop teaching: informed consent, baseline labs -Intraop: Be alert for s/s Malignant Hyperthermia -Postop: CV, resp complications from anesthesia -Safety risk d/t motor, sensory loss, confusion

Nursing Implications:

Assessment -Health history, current medications, allergies -Liver function studies, CBC -Baseline VS Oral drugs -Take regularly, same time each day. -Take with meals to reduce GI upset. -Do not crush, chew, or open extended-release forms. -If NPO, contact prescriber regarding AED dosage. AEDs should not be discontinued abruptly -Cause rebound seizures Intravenous forms -Follow IV administration protocols. -Monitor vital signs during administration. -Avoid extravasation of IV fluids. -Use only normal saline with IV phenytoin (Dilantin) Teach patients to keep a journal to monitor: -Seizure occurrence and descriptions -Response to AED and adverse effects -Instruct patients to wear a medical alert tag or ID -Follow driving recommendations -Teach patients that therapy is long term and possibly lifelong (not a cure) Monitor for therapeutic effects: -Decreased or absent seizure activity Monitor for adverse effects: -Mental status, LOC, or mood changes -Eye problems, visual disorders -Sore throat, fever -Blood dyscrasias may occur with hydantoins

Cholinergic Drug Effects:

At recommended doses: -cholinergics primarily affect muscarinic receptors At high doses: -cholinergics stimulate nicotinic receptors -crossover to the SNS Desired effects = muscarinic receptor stimulation. Undesirable effects are caused by stimulation of nicotinic receptors -increase in HR/BP, increase in contraction of musculoskeletal muscle

A patient is hypokalemic and will be receiving IV potassium. The patient is not on a heart monitor. How should the nurse administer the potassium replacement? A.IV push B.No more than 10 mEq/hr C.No more than 20 mEq/hr D.40 mEq/hr

B.

A patient is taken to the trauma unit after a motorcycle accident. It is estimated that he has lost 30% of his blood volume and he is in hypovolemic shock. The nurse anticipates a transfusion with which blood product? A.PRBCs B.Whole blood C.Cryoprecipitate D.FFP

B.

Phenobarbital and Primidone:

Barbiturates -Primidone (Mysoline) metabolized to phenobarbital -Treatment: Tonic-clonic, partial, secondary seizures -Most common adverse effect: sedation -Slow process through kidneys allows once daily dose -Therapeutic drug level: 10 to 40 mcg/mL -has a long half life, so patients only need once a day dosing -interacts with many drugs because it is a major inducer of hepatic microsomal enzymes, including the cytochrome P-450 system enzymes Contraindications: -known drug allergy -porphyria -liver/kidney impairment -respiratory illness Adverse effects: -CV -CNS-sedation -GI -dermatologic reactions -can be fatal with alcohol

Case Study #3:

Barbiturates have a low therapeutic index. This means A. low doses are not therapeutic. B. the toxic range is narrow. C. they are habit forming. D. the effective, safe dosage range is narrow. D. *Rationale:* Drugs with a low therapeutic index have only a narrow dosage range within which the drug is effective; above that range, they are rapidly toxic. Barbiturates are habit forming, but this is not related to the therapeutic index.

Case Study 4:

Before administering a serotonin agonist, it is most important for the nurse to assess the patient for a history of A. hypertension B. allergy to penicillin C. chronic bronchitis D. cataracts A.

Case Study #1:

Before administering epoetin alfa to a patient in renal failure, it is most important for the nurse to assess which laboratory result? A. Blood urea nitrogen B. WBC count C. Hemoglobin level D. Urine specific gravity C.

Case Study #1:

Before administering lithium to a patient, it is most important for the nurse to assess which laboratory value? A. Blood sugar B. Sodium C. Urine osmolality D. Hematocrit B.

Case Study:

Before administering niacin, it is most important for the nurse to assess the patient for A. allergy to erythromycin B. gout C. coronary artery disease D. hypothyroidism B.

Case Study 4:

Before administering tolterodine (Detrol), it is most important for the nurse to assess the patient for a history of which condition? A. Angle-closure glaucoma B. Cataracts C. Hypothyroidism D. Hyponatremia A. Rationale: Tolterodine (Detrol) may worsen preexisting angle-closure glaucoma and urinary retention, so its use should be avoided in patients with these conditions.

dobutamine (Dobutrex):

Beta1-selective vasoactive adrenergic drug -Structurally similar to natural occurring dopamine -Stimulates beta1 receptors on heart muscle (myocardium); increases cardiac output by increasing contractility (positive inotrope), which increases the stroke volume, especially in patients with heart failure -Intravenous drug; titrated continuous infusion *HAS TO BE MONITORED IN THE ICU*

Mechanism of Action Adrenergic Receptors: Direct-acting sympathomimetic

Binds directly to the receptor and causes a physiologic response

Beta Blockers: Adverse Effects

Blood -Agranulocytosis -thrombocytopenia Cardiovascular -AV block -bradycardia -heart failure (can aggravate HF, the heart is failing and beta blockers lower the oxygen which makes it worse) CNS -Dizziness -depression -unusual dreams -drowsiness Gastrointestinal -Nausea -vomiting -constipation (constipation is more common than diarrhea) -diarrhea Other -Impotence (erectile dysfunction) -alopecia -wheezing -bronchospasm -dry mouth -delay the recovery from hypoglycemia in patients with type 1 diabetes --------------- *Nonselective beta blockers may interfere with normal responses to hypoglycemia* -Block glycogenolysis: glucose production -Impedes secretion of pancreas insulin May mask s/s hypoglycemia: -tremor, tachycardia, nervous/irritable feelings -have to routinely check blood sugar because pts with type 2 diabetes won't feel the symptoms of their BS dropping -May cause hyperglycemia -Increases level of triglycerides *Use with caution in diabetic patients with diabetes mellitus 2*

Which condition does the nurse identify as a late manifestation of hypokalemia? A.Muscle weakness B.Hypotension C.Palpitations D.Lethargy

C.

Which of the following statements regarding colloid administration does the nurse identify as being true? A.Colloids enhance the oxygen-carrying capacity of the blood. B.Colloids increase the coagulation properties of blood. C.Dextran therapy can cause anaphylaxis or renal failure. D.Colloids are contraindicated in the treatment of hypovolemia.

C.

Alpha-Adrenergic Adverse Effects:

CNS -HA, restlessness, excitement, insomnia, euphoria Cardiovascular -Palpitations (dysrhythmias), tachycardia, vasoconstriction, HTN Other -Loss of appetite, dry mouth, n/v, -taste changes (rare)

Beta-Adrenergic Adverse Effects:

CNS -Mild tremors, HA, nervousness, dizziness Cardiovascular -Increase HR, palpitations (dysrhythmias), -fluctuations in blood pressure Other -Sweating, n/v, muscle cramps

Antipsychotics: Adverse Effects

CNS effects; drowsiness, dry mouth *Tardive dyskinesia* -Involuntary contractions of oral and facial muscles -Choreoathetosis; wave- like extremity movements -Occurs: long-term antipsychotic therapy *EPS; Extrapyramidal symptoms* -Involuntary muscle symptoms similar to Parkinson's Ds -Akathisia (distressing muscle restlessness) -Acute dystonia (painful muscle spasms) -Rx: benztropine (Cogentin), trihexyphenidyl (Artane) Agranulocytosis, *hemolytic anemia* *NMS; Neuroleptic malignant syndrome* -Potentially life threatening -High fever, unstable B/P, myoglobinemia *Metabolic syndrome* -Insulin resistance, weight gain , increased serum lipids *Additive:* hypotensive, CNS depressant effects -*No grapefruit juice* *Black Box Warning:* -Increased risk for death in elderly dementia patients -Risk for suicidal thinking—child, adolescent -Pregnancy: newborns with EPS, w/d symptoms

amlodipine (Norvasc):

Calcium Channel Blocker: dihydropyridine -Indicated for both angina and HTN -Administration: oral dose only -Adverse effect: tachycardia, hypotension -Causes several drugs to increase in effect: cyclosporine, simvastatin, and tacrolimus -Toxicity: Dilate blood vessels, severe low BP, fast HR -Treatment: fluid replacement, monitor ECG, VS, respiratory status, glucose levels, kidney function, electrolytes, urine output -Used off label for migraines

Class IV:

Calcium channel blockers -Inhibit slow-channel (calcium-dependent) pathways -Depress phase 4 depolarization -Reduce AV node conduction -Used for paroxysmal supraventricular tachycardia (PSVT); rate control for atrial fibrillation and flutter

metoprolol (Lopressor, Toprol-XL):

Cardio-selective beta1-adrenergic receptor blocker *Indication:* prophylactic treatment of angina -Many of same characteristics as atenolol -Reduces mortality rate in patients after MI/ angina -Forms: oral (immediate release, long acting) and parenteral (injectable) forms -IV metoprolol is commonly administered to hospitalized patients after MI, used for tx of HTN in patients who are NPO

Drug Effects:

Cardiovascular -Small doses: may slow heart rate -Large doses: increase heart rate (the dose we're going to use, to increase HR) CNS -Small doses: decrease muscle rigidity, tremors (the response we want) -Large doses: drowsiness, disorientation, hallucinations Eye -Dilate pupils (mydriasis), -decrease accommodation (paralysis of ciliary muscles)= cycloplegia increases IOP Glandular -Decrease bronchial secretions, salivation, sweating Gastrointestinal (GI) -Relax smooth muscle tone of GI tract -Decrease intestinal and gastric secretions -Decrease motility and peristalsis -GI used in OR, GI procedures Genitourinary (GU) -Relaxed detrusor muscle -Increased constriction of internal sphincter -Result: urinary retention -GU treat incontinence Respiratory -Decreased bronchial secretions -Dilated bronchial airways

Theophylline:

Cause vasodilation by increasing levels of cAMP -Inhibit phosphodiesterase from breaking down cAMP Metabolized to caffeine—stimulate CNS -Medullary respiratory center--Increase respiratory drive -Maintain open airways (bronchodilator) in COPD -Therapeutic blood level 10-15mcg/mL Adverse effects: - n/v -anorexia -tachycardia -palpitations -dysrhythmias -increased urination -hyperglycemia -Interactions with macrolides, quinolones, rifampin Contraindication: -drug allergy -Peptic Ulcer Disease -seizure disorder -hyperthyroid -dysrhythmias

cyclobenzaprine (Flexeril):

Centrally acting muscle relaxant Structurally, pharmacologically related to tricyclic antidepressants, not controlled substance -Indicated for muscle spasms, spasticity disorders -Most common drug for musculoskeletal injury *Administration:* oral dosage--titrate to response 5mg, 10mg dosage, extended release= Amrix

baclofen (Lioresal):

Centrally acting muscle relaxant -Not controlled substance -Indicated for muscle spasms, spasticity disorders -Administration: oral dosage--titrate to response *Available as an injectable form for use with an implantable pump device* -Test dose administered initially to determine response -Restrict alcohol intake, benzodiazepines -can reduce hiccups

Substance Abuse: Leads to Dependence

Characteristics of substance abuse: -*Physical dependence* tolerance to the effects of the substance and development of withdrawal symptoms when the use of the substance is terminated -*Psychologic dependence* a condition characterized by strong desires to obtain and use a substance -*Habituation* pt becomes accustomed but without psychologic or physical dependence, for ex; pt has surgery and needs pain meds and needs a higher dose because of the pain -*Addiction* psychologic or physical dependance on a drug or psychoactive substance need counseling, group therapy, need to be careful of life-threatening side effects of withdrawal Addiction treatment strategy requires assessment, intervention, therapeutics, monitoring of recovery. -Prevention of life-threatening withdrawal symptoms: seizures, delirium tremens -Increase compliance of psychosocial treatment

Nursing Implications:

Cholinergic Drugs stimulate PNS, mimic action of ACh -Assess for allergies, baseline assessment, VS GI/GU obstructions, asthma, PUD, CAD -Take meds as ordered, spread evenly apart to optimize effects, not abruptly stop -Overdosing can cause life-threatening problems -Atropine is antidote for cholinergics, it should be available in patient's room for immediate use if needed -Patients should notify PCP if muscle weakness, abd cramps, diarrhea, or difficulty breathing -Encourage pt with myasthenia gravis to take med 30 min before meal to improve chewing/swallowing so easy for these patients to aspirate and die, can get pneumonia when food goes down the wrong pipe -When cholinergic drugs are prescribed for Alzheimer's disease, be honest with caregivers and patients: the drugs are for management of symptoms (not a cure) -Therapeutic effects of anti-Alzheimer's drugs may not occur for up to 6 weeks -Monitor for adverse effects -Monitor for therapeutic effects -Alleviate s/s of myasthenia gravis -In postop patients with decreased GI peristalsis •Increased *bowel sounds*, flatus (gas), bowel material -In patients with urinary retention or hypotonic bladder, *urination* should occur within 60 min of bethanechol (Urecholine) dose -In patients with Alzheimer's disease: •Improvement in symptoms: mood, *confusion*

Cholinergic Receptors:

Cholinergic drugs stimulate PNS receptors: *Nicotinic* receptors -Located in the ganglia of both PNS and SNS -Named nicotinic because they can be stimulated by nicotine -If given in high doses, undesired SE will occur *Muscarinic* receptors -Located post synaptically in effector organs of PNS •Smooth muscle, Cardiac muscle, Glands -Named muscarinic because they can be stimulated by the alkaloid muscarine

Types of Angina:

Chronic stable angina -aka classic or effort angina -Atherosclerosis = primary cause -Triggers: exertion, stress, cold, nicotine, coffee, alcohol Unstable angina -Aka preinfarction or crescendo angina -Pain, frequency of attacks increase -CAD progresses to MI Vasospastic angina -aka Prinzmetalor variant angina -Spasms occur in smooth coronary muscle -Occurs at rest, no precipitation

Beta-Blocker: propranolol (Inderal)

Classification: Nonselective sympatholytic beta blocker Used to treat: -HTN -irregular heart rhythms/rates -thyrotoxicosis -capillary hemangiomas -migraine -performance anxiety (stage fright) -essential tremors Adverse Effects: -Diabetes mellitus (S/S hypoglycemia may be masked) -worsening of Raynaud's syndrome Contraindication: -asthma (do NOT want vasoconstriction) *Available po and injectable (IV)*

Migraine:

Common recurrent HA, escalating pulsatile pain -Usually unilateral, may be bilateral -Lasting from 4 to 72 hours, may have aura -Associated signs and symptoms: n/v photophobia (light sensitivity) phonophobia (sound sensitivity) Women > men, Familial tendency -Begin after 10yo, peak 20-40, fade after 50 Precipitating factors: -stress, hypoglycemia, menses (menstrual period), exercise, alcohol, caffeine, MSG (monosodium glutamate), aspartame (artificial sweetener), cocaine, NTG Cause: 3 hypotheses -vascular, neurovascular, serotonin deficit

Herbal Products: Gingko

Common uses -Prevent memory loss -Vertigo -Tinnitus -May cause GI upset, HA, bleeding (acts like an anticoagulant) Potential interactions -Aspirin -NSAIDs -Anticoagulants -Anticonvulsants taken cautiously because it has drug interactions with antidepressants, antihypertensives, insulin, thiazide diuretics -increases circulation in brain and enhances brain function -inhibits platelet aggregation like anticoagulants

Normal Saline:

Concentrations 0.9% = physiologically normal concentration of sodium chloride (isotonic), referred to as NS 0.45% ("half-normal") 0.25% ("quarter-normal") 3% (hypertonic saline) 5% (hypertonic saline)

Warfarin (Coumadin): Nursing Implications

Coumadin dose started while pt on Heparin Drip -Loading doses until PT/INR indicates therapeutic -Full therapeutic effect takes 3-5 days -Monitor PT/INR regularly; keep follow-up appts -Antidote is vitamin K, maintain stable diet *Herbal interactions; increased bleeding risk* -Garlic, Capsicum pepper, Ginger, Ginkgo -St. John's wort, Feverfew -Wear Medical Alert bracelet, bleeding precautions, avoid injury

Blood Products Indications:

Cryoprecipitate and plasma protein factors -Management of acute bleeding (greater than 50% slow blood loss or 20% acute blood loss) Fresh-frozen plasma (FFP) -Increase clotting factor levels in patients with deficiency *Packed red blood cells (PRBCs)* -Increase oxygen-carrying capacity in pts with anemia, substantial Hgb deficits, or loss of up to 25% of total blood volume *Whole blood* -Same as for PRBCs except that whole blood is more beneficial in cases of extreme (greater than 25%) loss of blood volume -Contains plasma proteins, which help draw fluid back into blood vessels from surrounding tissues *Adverse effects:* -Incompatibility with recipient's immune system -Crossmatch testing -Transfusion reaction: Temp, flank pain, SOB, rash -Anaphylaxis -Transmission of pathogens to recipient (hepatitis, human immunodeficiency virus) Administration: -NS only with transfusion (D5W cause hemolysis)

Stimulant Overdose:

Death results from poisoning, toxic levels -Convulsions -Coma -Cerebral hemorrhage (from massive stroke) -May occur during intoxication or withdrawal -Overdose requires supportive care, sedation

Anxiolytic Drugs:

Decrease anxiety by reducing overactivity in central nervous system (CNS) -*Benzodiazepines* •Depress activity in brainstem, limbic system •Increase GABA--blocks nerve transmission in CNS •Additive effects with CNS depressants, alcohol •Also treat ethanol withdrawal, insomnia, muscle spasm, seizure disorder -*Miscellaneous drug: buspirone (BuSpar)* •Agonist to , serotonin receptors

Nursing Diagnoses:

Decreased cardiac output r/t adverse CV effects of hypotension, bradycardia Deficit knowledge of therapeutic regimen, adverse effects, interactions, precautions Risk of injury r/t possible adverse effects of bradycardia, hypotension with risk for falls, syncope

Pilocarpine (Pilocar):

Direct acting cholinergic drug: -Used for angle closure glaucoma decrease IOP until surgery can be performed -Decrease ocular hypertension -Management open angle glaucoma *-Cause constriction of pupil (following dilation)* -Onset of dosage ophthalmic drop effects: typically within 1 hour, lasts for up to a day -causes miosis

Bethanecol (Urecholine):

Direct-acting cholinergic agonist *(oral)* -Tx acute postop/postpartum urinary retention -Manage urinary retention with neurogenic bladder Contraindications: -known allergy -hyperthyroidism (causes increase of metabolism, already have an increase of GI motility and don't need that secreted for it to be activated more) -peptic ulcer disease -bronchial asthma (bronchioles are already constricted, don't want them to be constricted more) -CAD -epilepsy -Parkinsonism (already have problems with musculoskeletal, don't want to slow it down more) Adverse effects: -syncope -hypotension with reflex tachycardia -HA -seizure -GI upset -asthma attacks -Interactions: synergistic-- acetylcholinesterase inhibitors

Cholinergic Drugs: Mechanism of Action

Direct-acting cholinergic agonists -Bind to cholinergic receptors, activating them Indirect-acting cholinergic agonists -Also known as *cholinesterase inhibitors* -Inhibit enzyme acetylcholinesterase (breaks down ACh) -Results in more ACh available at the receptors

Mechanism of Action Adrenergic Receptors: Mixed-acting sympathomimetic

Directly stimulates the receptor by binding to it *AND* Indirectly stimulates the receptor by causing release of stored neurotransmitters from vesicles in the nerve endings

Alpha-Adrenergic Receptors:

Divided into alpha-1 and alpha-2 receptors differentiated by their location on nerves *Alpha-1 adrenergic receptors* *-Located on postsynaptic effector cells (tissue, muscle, or organ that the nerve stimulates)* *Alpha-2 adrenergic receptors* *-Located on presynaptic nerve terminals (the nerve that stimulates the effector cells)* -Control the release of neurotransmitters Responses: Vasoconstriction, CNS stimulation

Lithium:

Drug of choice: treatment of acute mania -Potentiate serotonergic neurotransmission *Narrow therapeutic blood level range:* -acute mania: 1 to 1.5 mEq/L -maintenance levels 0.6, 1.2 mEq/L -Toxicity: 1.5 to 2.5 mEq/L GI discomfort, tremor, confusion, somnolence, seizures, and possibly death *Keep sodium level WNL (135-145 mEq/L)* -helps maintain therapeutic lithium levels *Adverse effects: Serious = cardiac dysrrythmias* -Drowsiness -slurred speech -seizures -choreoathetotic movements -ataxia hypotension -Long-term tx causes hypothyroidism *Drug interactions:* -Thiazide diuretics -ACEI -NSAID—increase toxicity *Contraindications:* -CV -renal disease -dehydration -Overhydration; changes to sodium levels *Administration: oral only*

Cholinergic-Blocking Drugs:

Drugs that block or inhibit actions of acetylcholine (ACh) in the PNS aka anticholinergics parasympatholytics antimuscarinic drugs Mechanism of Action: -Competitive antagonists *-Compete with ACh binding at muscarinic receptors in PNS* Result: ACh unable to bind to receptor site/ will not cause cholinergic effect -When these drugs bind to receptors, they inhibit nerve transmission at these receptors -Allow SNS to dominate anticholinergics have many of same effects as SNS adrenergics they mimic SNS drugs -The major sites of action of the anticholinergics are the heart, respiratory tract, GI tract, urinary bladder, eye, and exocrine glands

CNS Stimulants:

Drugs that stimulate specific area of brain/spinal cord -Actions produced by excitatory neurotransmitters: norepinephrine (adrenergic drugs) dopamine (dopaminergic drugs) serotonin (serotonergic drugs) -Sympathomimetic drugs (mimic the SNS)

Adrenergic Drugs:

Drugs that stimulate sympathetic nervous system Also known as: -Adrenergic agonists -Sympathomimetics (Mimetic= relating to, simulate...mimics) Characteristics -Mimic effects of SNS neurotransmitters (catecholamines) -Norepinephrine (NE) -Epinephrine (EPI) -Dopamine

Cholinergic Drugs:

Drugs that stimulate the parasympathetic nervous system (PNS) -The PNS is the opposing system to the sympathetic nervous system (SNS). PNS = "rest and digest" SNS = "fight and flight" -Drugs also known as cholinergic agonists parasympathomimetics -Mimic effects of the PNS neurotransmitter acetylcholine(ACh)

Case Study #3:

During surgery, the anesthetist notes that the patient's heart rate is gradually increasing and becoming more irregular, the patient's blood pressure is becoming unstable, and the patient is starting to sweat profusely. What other assessment should the anesthetist note immediately? A. Pupillary reactions B. Respiratory effort C. Temperature D. Urinary output C.

Antidysrhythmics:

Dysrhythmia -Any deviation from normal rhythm of the heart Antidysrhythmics -Used for treatment, prevention of disturbances in cardiac rhythm -Causes: MI, cardiac surgery, CAD

Epilepsy:

Epilepsy: -Syndrome of CNS dysfunction, often detected by EEG -Chronic, recurrent pattern of seizures Seizure = Episode abnormal electrical activity in nerve cells of brain Convulsion = Involuntary spasmodic contractions of voluntary muscles throughout body (skeletal, facial, ocular) Primary (idiopathic); 50% of cases -No identifiable cause, genetic predisposition Secondary (symptomatic) -Distinct cause: trauma, fever, infection, cerebrovascular disorder

Drug Effects:

Exact mechanism of action is not known -Alter Na, K, Ca, Mag ion movements *Pharmacologic effects:* -Reduce nerve's ability to be stimulated -Increase threshold of activity in motor cortex -Suppress transmission of impulses from one nerve to the next -Decrease speed of nerve impulse conduction within a neuron -Increase GABA, enhance effects

Adjunct Anesthetics:

Fentanyl (Sublimaze); opioid analgesic Diazepam (Valium); benzodiazepine Atropine: glycopyrrolate (Robinul); anticholinergic Morphine, meperidine (Demerol); opioid Hydroxyzine (Vistaril); sedation, antiemetic Pentobarbital (Nembutal); sedative Dexmedetomidine (Precedex); sedation

diazepam (Valium):

First-line treatment for status epilepticus -Administration: 5-10mg dose IVP, rate 2mg/minute -Rarely used for long-term epilepsy treatment due to tolerance to anticonvulsant effects within 6-12 months *Adverse Effects:* -hypotension -amnesia -confusion -somnolence (drowsiness) -apnea Commonly used -anxiety disorders -alcohol withdrawal symptoms -muscle spasms

Methotrexate:

Folate (folic acid) antagonist -Interferes with the use of folic acid -As a result, DNA not produced, and cell dies Adverse effect -Bone marrow suppression (BMS) -given with Leucovorin (Wellcovorin)to reduce BMS -provides active folic acid to healthy cells -Stevens-Johnson syndrome (Life threatening rash covering entire body) Dosing: PO, intrathecal, IV

Calcium Channel Blockers:

For Chronic Stable Angina Amlodipine, diltiazem, nicardipine, nifedipine, verapamil *Mechanism of Action* -Cause coronary artery vasodilation -Cause peripheral arterial vasodilation, thus decreasing systemic vascular resistance -Reduce the workload of the heart -Result: decreased myocardial oxygen demand -Dysrhythmias: depression of the automaticity of and conduction through the sinoatrial and AV nodes *Indications:* -First line drug: Angina, HTN, SVT -Coronary artery spasms (Prinzmetal angina) -Short-term management of atrial fibrillation and atrial flutter -Migraine headaches -Raynaud's disease -Nimodipine: cerebral artery spasms d/t aneurysm rupture *Contraindications:* -Known drug allergy -Acute MI, hypotension -2nd or 3rd degree AV block (unless pacemaker) -Avoid consuming grapefruit *Adverse Effects:* -Overexpression of therapeutic effects -May cause hypotension, palpitations, tachycardia or bradycardia, nausea, dyspnea, fainting -Constipation is a common problem; instruct patients to take in adequate fluids and eat high-fiber foods

General Phase of the Cell Cycle:

G0: resting phase G1: first gap phase (enzymes necessary for DNA synthesis are produced) S: synthesis phase (DNA synthesis takes place, DNA strand separation to replication) G2: second gap phase (RNA and specialized proteins are made) M: mitosis phase (cell reproduction) (divided into 4 subphases; prophase, metaphase, anaphase, and telophase)

Indications:

General anesthetics are used during surgical procedures to produce: -unconsciousness -Skeletal muscular relaxation -Visceral smooth muscle relaxation -Rapid onset; quickly metabolized -Also used in electroconvulsive therapy treatments for depression *Contraindications:* -drug allergy -pregnancy -narrow-angle glaucoma -malignant hyperthermia

Hormonal Drugs:

Hormonal therapy -Used to oppose effects of hormones used by cancer cells: breast, prostate cancers -Block body's sex hormone receptors -Cause opposite hormone effects Used commonly as adjuvant, palliative therapy -Estrogen receptor modulators= tamoxifen -Aromatase inhibitors= anastrozole Side effects: -acne, HTN, rash, hot flash, menstrual irregularities -Weight gain, mood swings, depression Opposite hormone, like breast cancer can be given testosterone If men has testicular cancer, give chemo based female hormones

Types of Dehydration:

Hypertonic:Water loss > sodium loss -Results in concentration of solutes outside cells -IC fluid moves to extracellular space -Cell dehydration Hypotonic: Sodium loss > water loss -Results in higher concentration solutes inside cells -EC fluid (plasma, interstitial) pulled into cells Isotonic:Sodium & water loss -Results in decrease volume of EC fluid

carbamazepine (Tegretol):

Iminostilbenes -2nd most commonly prescribed antiepileptic drug in U.S. -*First line drug: partial and generalized tonic-clonic seizure* -May worsen myoclonic or absence seizure -Autoinduction of hepatic enzymes Within 2 months the drug stimulates production of enzymes that enhance its own metabolism; leads to lower blood levels Higher dose is needed after 2 months Adverse reactions: -Unusual eye movements -mood changes -Decrease in bone marrow function (rare) Drug interactions----*no grapefruit juice* -Antifungals -acetaminophen -barbiturates -hydantoins -CYP450 enzyme pathway drugs—macrolides, SSRI, MAOI

Nursing Implications:

In general: -Monitor closely for anaphylactic reactions. -Keep epinephrine, antihistamines, and anti-inflammatory drugs on hand. -Monitor closely for complications associated with BMS •Anemia, thrombocytopenia, neutropenia Cytoprotective drugs may be used to reduce toxicities:* -IV amifostine to reduce renal toxicity associated with cisplatin -IV or oral allopurinol to reduce hyperuricemia** Monitor for oncologic emergencies:*** -infections -Pulmonary toxicity -Allergic reactions -Stomatitis with severe ulcerations -Bleeding -Metabolic aberrations -Bowel irritability with diarrhea -Renal, liver, cardiac toxicity

Indirect-acting cholinergic drugs:

Increase ACh concentrations at receptor sites, which leads to stimulation of the effector cells -interfering with actions of acetyholinesterase, an enzyme that destroys ACh from receptor sites -if we block this enzyme we will have more ACh at the receptor sites Cause skeletal muscle contractions: -Dx & tx myasthenia gravis (progressive neuromuscular disorder due to decrease amount of ACh at the receptors for contractions and movement to the muscles that daily affect the upper body; diaphragm, chewing and swallowing) *•pyridostigmine* -Reverse neuromuscular blocking drugs -Reverse anticholinergic poisoning (antidote) insecticides *•physostigmine= ANTIDOTE*

Genitourinary:

Indications: -Reflex neurogenic bladder -Incontinence (overactive bladder) Adverse Effects: -Urinary retention -helps relax detrusor muscle so the bladder can hold in urine longer -vesicare is the #1 drug in its class for this problem ANTICHOLINERGICS HELP INCONTINENCE

Respiratory:

Indications: Block cholinergic stimulation of PNS: allow action SNS Results -Decreased secretions nose, mouth, pharynx, bronchi -Relax smooth muscles in bronchi and bronchioles -Decreased airway resistance, bronchodilation Cholinergic blockers are used to treat: -Common cold symptoms -Exercise-induced bronchospasms -Chronic bronchitis, Asthma, COPD Adverse Effects: Decreased bronchial secretions -dilates bronchioles

Cardiovascular:

Indications: Affects the heart's conduction system (the rate) -Low doses: slow the heart rate -High doses: block inhibitory vagal effects on sinoatrial, atrioventricular node pacemaker cells (what we want) •Result: increased heart rate Adverse Effects -Increased heart rate, dysrhythmias, palpitations, tachycardia

Indirect-acting cholinergic drugs: physostigmine (Antilirium)

Indirect acting drug: -Improves muscle strength; used to treat the symptoms of myasthenia gravis -Reverse the effects of depolarizing neuromuscular blocking drugs after surgery -Tx: severe overdoses of tricyclic antidepressants -An antidote after toxic chemical exposure Increase ACh at receptor sites

Indirect-acting cholinergic drugs: edrophonium (Tensilon)

Indirect-acting cholinergic drug -Used to diagnose myasthenia gravis -It can also be used to differentiate between myasthenia gravis and cholinergic crisis -we can quickly see after the dose is given an increase in muscle strength, that tells us that myasthenia gravis is present -if we give the same dose to someone in cholinergic crisis with already a lot of ACh, and we give this drug with more ACh we won't see any improvement, we're just increasing the ACh level and prolonging the symptoms

Indirect-acting cholinergic drugs: pyridostigmine (Mestinon)

Indirect-acting cholinergic drugs that work to increase ACh by inhibiting acetylcholinesterase Most common tx for myasthenia gravis -Improves muscle strength, spaced doses during day -30 min prior to meals (to improve muscles of eating and swallowing) -Reverse effects of nondepolarizing neuromuscular blocking drugs; (used for after anesthesia) -treat severe overdoses of tricyclic antidepressants; tricyclic antidepressants have anticholinergic properties in them -Antidote: toxic exposure to nondrug anticholinergic agents (chemicals), those used in chemical warfare available in oral and injectable forms

Phosphodiesterase Inhibitors: Milrinone

Inodilators (inotropic and dilator) Inhibits enzyme phosphodiesterase which results in positive inotropic response, vasodilation -Intracellular increase in cAMP -Increase calcium for myocardial muscle contraction Indications -Short-term management of HF for pts in ICU -AHA and ACC advise against long-term infusions

Drugs affecting cardiac function:

Inotropic drugs: affect force of myocardial contraction -Positive : increase force of contraction -Negative: decrease force of contraction Chronotropic drugs: affect heart rate -Positive: increase heart rate -Negative: decrease heart rate Dromotropic drugs: accelerate cardiac conduction -Positive: accelerate cardiac conduction -Negative: delay cardiac conduction

Interferons: Indications

Interferon Alfa-2a, 2b -Hepatitis C, hairy cell leukemia, Kaposi Sarcoma -Alfa 2a-Chronic myelogenous leukemia -Alfa 2b-Hepatitis B, malignant melanoma, genital warts Interferon Beta-1a,1b -Relapsing multiple sclerosis Interferon Gamma-1b -Chronic granulomatous disease, osteopetrosis Peg-interferon: stronger version, increase size of interferon with a longer half-life

Ischemia:

Ischemia -Damaged cells result from poor oxygenation -Poor blood supply to an organ Ischemic heart disease -Inadequate oxygen/blood supply to heart muscle -Atherosclerosis -Coronary artery disease Myocardial infarction (MI) = heart attack -Total blockage of coronary artery -Necrosis (death) of cardiac tissue -Disabling or fatal

Nursing Implications:

Keep in mind these drugs block the action of ACh in PNS. -Perform baseline assessment, VS, allergies -Assess for BPH, urinary retention, glaucoma, tachycardia, MI, heart failure, hiatal hernia, GI/GU obstruction, colitis -Medications should be taken exactly as prescribed to have the maximum therapeutic effect -Overdosing can cause life-threatening problems -Blurred vision causes problems; driving, operating machinery -Wear dark glasses/sunglasses for sensitivity to light if pupils are dilated, your eyes will be sensitive to light -For dry mouth: chewing gum, frequent mouth care, hard candy, water, chips of ice -For constipation: increase dietary intake of high fiber foods and fluids Ophthalmic solutions: apply pressure to inner canthus to prevent systemic absorption. -Anticholinergics in older adults may increase risk for heatstroke d/t effects on heat-regulating mechanisms decrease sweating, so our bodies won't cool off because of this effect -Teach pts to avoid high temperatures, strenuous exercise. -Emphasize importance of adequate fluid intake. -Patients should check with PCP before taking any other medication, including OTC products. cough and cold have anticholinergic ingredients -Patients to report: urinary hesitancy or retention, constipation, tachycardia, palpitations, tremors, confusion, sedation, hallucinations, decreased sweat (hot, dry skin) Monitor for therapeutic effects: -Parkinson's disease: fewer tremors and decreased salivation and drooling -Urologic problems: improved urinary patterns, less hyper-motility, decreased frequency -In bowel hyperactivity: decreased cramps, diarrhea -Often given preop to reduce oral, GI secretions -Antidote for atropine overdose is physostigmine

salmeterol (Serevent Diskus):

Long-acting β2adrenergic receptor agonist -used in maintenance & prevention of asthma symptoms and maintenance of COPD *-Indicated for prevention of bronchospasms, not management of acute symptoms* -BID dosing, use prior to other inhalers -Follow oral hygiene protocols with inhalers Prevent irritation, infection

Angiotensin II Receptor Blockers (ARBs):

Losartan, valsartan, olmesartan -Potent vasodilators; decrease systemic vascular resistance (afterload) -Used alone or combination with diuretics in treatment of hypertension or HF -Not as likely to cause cough or hyperkalemia associated with ACE inhibitors -Adverse effects on nursing infant, pregnancy category D

Interleukins:

Lymphokines: Natural part of immune system -Beneficial antitumor action -Stimulate or restore immune response -IL2 binds to receptor sites on T cells, which stimulates the T cells to multiply -Lymphokine activated killer (LAK) cells: recognize/destroy only cancer cells and ignore normal cells

Potassium:

Main indication -Treatment/prevention of K depletion when diet inadequate Other therapeutic uses -Stop irregular heartbeats -Management of tachydysrhythmias d/t cardiac surgery Adverse effects -Oral preparations: N/V/D, GI bleeding, ulcers -IV administration: Painat injection site, Phlebitis -Excessive administration: Hyperkalemia, Toxic effects

NMBD: Indications:

Main use: facilitating controlled ventilation during surgical procedures -Endotracheal intubation (short-acting) -Reduce muscle contraction in surgical area -Diagnostic drugs for myasthenia gravis Contraindication: -Drug allergy -hx malignant hyperthermia -narrow angle glaucoma -burns -CVA -crush injury

Beta Blockers:

Mainstay in the treatment of CVD Angina, MI, HTN, Dysrhythmias Antianginal Beta Blockers: atenolol metoprolol propranolol nadolol

Nicotine Withdrawal:

Manifested by cigarette craving -Irritability, restlessness, *decreased heart rate and BP* -Cardiac symptoms resolve in 3 to 4 weeks, but cigarette craving persists for months/years -Ask hospitalized patients about smoking history, present habits, assess for s/s w/d -Offer *smoking cessation* materials -*Nicotine replacement* products

CCNS: Cytotoxic Antibiotics

Mechanism of Action -Produced by mold Streptomyces -Active in all phases of cell cycle. Intercalation, blocks DNA synthesis. Generate free radicals-break DNA strands Indications: -Combination chemotherapy regimens -Treat variety of solid tumors, hematologic malignancies -Leukemia, ovarian, breast, bone cancers, others -Squamous cell carcinomas -AIDS-related Kaposi's sarcoma (intolerant to other tx) Adverse Effects: -All produce BMS except bleomycin (pulmonary fibrosis) -Hair loss, n/v, myelosuppression -Heart failure (daunorubicin) -Cardiomyopathy, Acute L ventricular failure (doxorubicin) -Pulmonary fibrosis, pneumonitis (bleomycin) -Liver, kidney, CV toxicities—dose related Monitor cardiac ejection fraction, MUGA scan -Many drug interactions**

Nitrates and Nitrites:

Mechanism of Action and Drug Effects -Cause vasodilation d/t relaxation of smooth muscles -Potent dilating effect on coronary arteries -Result: oxygen to ischemic myocardial tissue -Reduction of preload, LVED volume -Used for prevention and treatment of angina -Reduce exercise induced spasms

Anorexiants:

Mechanism of Action: -Suppress appetite control centers in brain -Increase body's basal metabolic rate -Mobilize adipose tissue stores -Enhance cellular glucose uptake -Reduce dietary fat absorption Adverse Effects: -Possible elevated b/p, heart palpitations -Anxiety -Agitation -Dizziness -HA

CCNS: Alkylating Drugs

Mechanism of Action: -prevent cancer cells from reproducing by using Alkyl groups to alter chemical structure of cell DNA -Developed from nitrogen mustard Indications: -Combined with other drugs to treat solid, hematologic tumors: -Lymphomas, Leukemias, Brain tumors -Recurrent ovarian cancer Breast, bladder cancer Adverse Effects -Dose-limiting -N/V, Alopecia, ototoxicity, myelosuppression Interactions -Caution against administration of agents with similar toxicities -cisplatin & gentamycin are both nephrotoxic Severe Adverse Effects: -Nephrotoxicity neuropathy, pulm fibrosis, BMS -Extravasation causes tissue damage and necrosis. -specific antidotes Know kidney functions beforehand Therapeutic prophylactic measures -Prior administration of antiemetics -Hydration can prevent nephrotoxicity Cisplatin, cyclophosphamide (Cytoxan), mechlorethamine

Antimetabolites:

Mechanism of action -Antagonize actions of key cellular metabolites. S phase of cell cycle, when DNA synthesis is most active. -Used in combination with other chemo drugs Indications -Solid tumors, some hematologic cancers -Acute and chronic lymphocytic leukemias, -Colon, rectal, breast, stomach, lung, pancreatic cancers -Oral and topical forms may be used for low-dose maintenance and palliative cancer therapy. Adverse Effects -Hair loss, n/v, myelosuppression -Neurologic, CV, pulmonary, hepatobiliary, GI,GU, dermatologic, ocular, otic, and metabolic toxicity Tumor lysis syndrome Nephrotoxic--may result in hemodialysis -Palmar-plantar dysesthesia (hand-foot syndrome) -Stevens-Johnson Syndrome -Toxic epidermal necrolysis

Marijuana:

Medical uses: -chronic pain, n/v from chemo, appetite stimulation (legal in 24 states) -*Dronabinol, Marinol* prescription names -Effects last few hours, self limiting -schedule III -calmative, anti-anxiety, mildly sedative -often used in patients with AIDS

Analeptic Drugs:

Methylxanthine Analeptics: *Aminophylline*= prodrug to theophylline *Theophylline* metabolizes to caffeine *Caffeine* = inherently strong CNS stimulant -Antagonist (blocks) adenosine receptors in brain that are associated with sleep (caffeine blocks adenosine receptors) Doxapram: similar actions to xanthines but more potent stimulant reaction to CO2 levels in blood Adverse effects: stimulate vagal, vasomotor brain centers -Increase gastric secretions -diarrhea -flushing -sweating -tachycardia -increased muscle tension -tremors -reduced deep tendon reflexes Contraindication: -peptic ulcer -CV conditions

Benzodiazepines: Adverse Effects and Contraindications

Mild and infrequent: -Headache -Drowsiness, lethargy -Cognitive impairment (patients may become confused) -Dizziness, vertigo -Fall hazard for older adults -"Hangover" effect or daytime sleepiness *Contraindicated:* -do not mix with alcohol (respiratory depression) -known allergy -narrow-angle glaucoma -pregnancy -Fall hazard elderly -rebound insomnia (long-term hypnotics can cause dependent, if stopped insomnia can occur. Short-term hypnotics are best way)

gabapentin (Neurontin):

Miscellaneous Chemical analogue of GABA, a neurotransmitter that inhibits brain activity -Increases synthesis, accumulation at nerve synapse -Adjunct drug: partial seizure treatment, prophylaxis -Single drug therapy for new onset seizures *Contraindication:* -known drug allergy -interacts w/alcohol *Adverse effects:* -drowsy -vision/speech changes -nausea *Common use* -neuropathic pain -migraine Don't have to take with food

ranolazine (Ranexa):

Miscellaneous Antianginal Drug Mechanism of action is unknown -Antianginal, antiischemic -Known to prolong the QT interval on ECG -Does not reduce HR or BP -Reserved for patients who failed to benefit from other antianginal drug therapy. *Contraindications:* -preexisting QT prolongation, hepatic impairment *Drug interactions:* -diltiazem -verapamil -ketoconazole

buspirone (BuSpar):

Miscellaneous Anxiolytic -Unknown mechanism of action -Non-sedating and non-habit forming -*Administer on a scheduled basis, not PRN* *Adverse effects:* -Paradoxical anxiety -blurred vision -HA -nausea *Drug interaction:* -CYP3A4 inhibitors -azoles -diltiazem -Rifampin -SSRIs (serotonin syndrome) -Do not administer with MAOIs; causes (HTN)

Vincristine (Vincasar):

Mitotic Inhibitor -An alkaloid isolated from the periwinkle plant -Treat acute lymphocytic leukemia -Significant neurotoxin, less BMS effect -Drug interaction with phenytoin reduces phenytoin blood levels with consequent enhanced risk of seizures For IV use only— -Extravasation antidote hyaluronidase (Wydase)

Paclitaxel (Taxol):

Mitotic Inhibitor Isolated from the Pacific yew tree -Treat lung, ovarian, breast CA, others -Water insoluble, administered in solution of caster oil Same hypersensitivity as with cyclosporine -Pre-medicate with a steroid (dexamethasone), H1 receptor antagonist (Benadryl), and H2 receptor antagonist (ranitidine) prior to infusion Abraxane= albumin bound form Hard to treat cancers Oil based administration, oil based solution which many people are allergic to, pre-medicate with steroid***

Disease-Modifying Antirheumatic Drugs:

Modify the disease of RA -Exhibit anti-inflammatory, antiarthritic immunomodulating effects -Inhibit movement of inflammatory cells neutrophils, monocytes) into an inflamed, diseased joint -Slow-acting antirheumatic drugs: onset of action (several weeks) versus minutes to hrs for NSAIDs -Nonbiologic: methotrexate, leflunomide, hydroxychloroquine, sulfasalazine -Biologic: adalimumab, abatacept, etanercept

Nursing Implications:

Monitor for complications GI mucous membranes: -stomatitis, inflammation and ulcerations of GI mucosa altered bowel function, poor appetite, n/v, diarrhea Alopecia: -address psychosocial concerns Bone Marrow Suppression: -baseline blood counts before administering antineoplastic drugs -Monitor low (life-threatening) blood cell counts Increased risk for infection -Neutropenic precautions Monitor for thrombocytopenia and anemia. -prevent bleeding in patients with low platelets -Anemia may result in severe fatigue Anticipate n/v, implement measures to reduce -Give antiemetics 30 to 60 minutes before chemotherapy is started **no flowers, no raw fruits/veggies, no raw foods (may have bacteria on them)

Attention Deficit Hyperactivity Disorder (ADHD):

Most common psychiatric disorder in children, -Boys > girls, can extend to adulthood Primary symptoms: -inappropriate ability to maintain attention span presence of hyperactivity and impulsivity -Diagnosis begins at age 4-7 -Symptoms in 2 or more settings (school, home) -Same drug therapy for childhood & adult ADHD

Statins:

Most potent LDL reducers -atorvastatin (Lipitor)* -rosuvastatin (Crestor)* -pitavastatin (Livalo)* -simvastatin (Zocor) -lovastatin (Mevacor) -pravastatin (Pravachol) -fluvastatin (Lescol) *Mechanism of Action:* -Inhibit HMG-CoA reductase, enzyme used by liver to produce cholesterol--Lower rate of cholesterol production -Increase liver LDL receptors—reduces plasma LDL *Indications:* First-line drug therapy for hypercholesterolemia Treatment of types IIa and IIb hyperlipidemias -Reduces LDL levels by up to 50% -Increases HDL levels by 2% to 15% -Reduces triglycerides by 10% to 30% *Adverse Effects:* -Mild, transient GI disturbances, Rash, HA -Elevations in liver enzymes, liver disease -Myopathy(muscle pain), can progress to rhabdomyolysis -Breakdown of muscle protein -Myoglobinuria: myoglobin (muscle protein) in urine -Can lead to acute renal failure and even death -Early recognition-- reversible with d/c statin -Increase risk= >65yo, renal ds, HOTH, gemfibrozil -Patients should immediately report s/s toxicity (muscle soreness, changes in urine color) *Interactions:* -Oral anticoagulants (warfarin) -Drugs metabolized byCYP450,CYP3A4 •azole antifungals, verapamil, diltiazem, amlodipine •EMycin, HIV protease inhibitors •amiodarone, gemfibrozil -Grapefruit juice -Therapy Intensity: High, moderate, low Dose equivalents between statin drugs, dose dependent

darifenacin (Enablex):

Muscarinic receptor blocker Uses: -urinary frequency -urgency -urge incontinence caused by bladder overactivity -Has much lower incidence of dry mouth than other anticholinergic meds used for this purpose -May produce constipation and blurred vision

tolterodine (Detrol):

Muscarinic receptor blocker Uses: -urinary frequency -urgency -urge incontinence caused by bladder overactivity Newer drugs for this purpose: -solifenacin (Vesicare) -darifenacin (Enablex) -trospium (Sanctura) -fesoterodine (Toviaz) -some won't be in hospital and have to bring from home -much lower incidence of dry mouth d/t pharmacologic specificity for bladder as opposed to salivary glands Avoid: -angle closure glaucoma -urine retention -decreased hepatic function (give 1/2 dose reduction) this drug goes through p450 pathway, and these drugs interact with -azole, anti-fungal drugs, and some antibiotics like emyacin -these drugs target smooth muscle of the bladder without affecting other cholinergic sites like dry mouth

Heparin:

Natural anticoagulant obtained from pigs -Inhibit clotting factors IIa (thrombin), Xa, IX -Unfractionated heparin *Dose: 10 to 40,000 units/mL; Medication Alert* -DVT prophylaxis: 5000 units subcutaneously 2-3X daily no monitoring -Catheter flush (10-100 units/mL): no monitoring -Therapeutic IV infusion: monitor aPTT (activated partial thromboplastin time) every 6 hours daily -Weight based dosing, adjusted to aPTT -Not given IM d/t risk for large hematoma *Risk for HIT (heparin induced thrombocytopenia)* thrombocytopenia= low blood platelets

Mitotic Inhibitors:

Natural products obtained from plants Mechanism of Action -Retard cell division before or during mitosis, in various phases of cell cycle (late S phase, throughout G2phase, and M phase) Each subclass inhibits mitosis in a unique way. -Vinca alkaloids (dissolve mitotic spindles -Taxanes form nonfunctional microtubules Combination chemotherapy-overall cytotoxic effect Vincristine, etoposide, paclitaxel Indications -Combination chemotherapies -Treat variety of solid tumors, some hematologic malignancies Small cell lung, Non-small cell lung cancers Testicular, breast, ovarian, Kaposi's sarcoma Acute leukemia Adverse Effects Hair loss, n/v, myelosuppression, convulsions Liver, kidney, lung toxicities Extravasation

Atropine:

Naturally occurring belladonna alkaloid antimuscarinic Indications: -CV: severe sinus bradycardia (ACLS) *-Antidote for anticholinesterase inhibitor toxicity and poisoning* -Preop to reduce salivation, GI secretions prevent aspiration, nausea, vomiting -Medication action: increases HR & B/P, slows GI Adverse effect: tachycardia, constipation *Antidote for overdose; physostigmine* *AVAILABLE IN ORAL, INJECTION, OR TOPICAL, OR OPHTHALMIC SOLUTION* -Lamotil; (Atropine combined with opiate diphenoxylate) for severe diarrhea -be careful giving, very potent

Scopolamine:

Naturally occurring cholinergic blocker and one of the principal belladonna alkaloids Uses: -prevention of motion sickness (patch 24-36hr) put right behind the ear on the scalp area -prevent postop, post-anesthesia n/v Contraindications: -angle-closure glaucoma -advanced hepatic and renal dysfunction -hiatal hernia with reflux esophagitis -intestinal atony -GI/GU obstruction -severe ulcerative colitis Adverse effects: -drowsiness -dry mouth -blurred vision *Scopolamine + CNS depressants/alcohol= increase sedation* dries up secretions *AVAILABLE IV OR IM*

Kidney Function:

Nephron= main structural unit of kidney -Elimination of toxins, retention essential chemicals and water -Glomerular filtration dependent on blood flow -Active transport of sodium, potassium from glomerular filtrate back to blood causes passive resorption of water and chloride via osmosis

nitroglycerin:

Nitrate -Most important drug used in symptomatic treatment of ischemic heart conditions (angina) -Routes: PO, SL, metered-dose aerosol that is sprayed under tongue, IV infusion, topical -Large first-pass effect with oral forms -Both rapid and long acting -IV form used for BP control in peri-operative HTN, heart failure, ischemic pain, pulmonary edema associated with acute MI, HTN emergencies

Drugs for Angina:

Nitrates or nitrites, Beta blockers Calcium channel blockers (CCBs) Therapy objectives: -Minimize frequency of attacks -Decrease duration, intensity of anginal pain -Improve patient's functional capacity with as few adverse effects as possible -Prevent or delay MI Overall goal: increase blood flow to ischemic myocardium, decrease myocardial O2 demand

digoxin (Lanoxin):

No longer used as first-line treatment -Digitalis plant origin, foxglove -Use: HF, control ventricular response to atrial fib -Increases myocardial contractility -Slows electrical conduction between SA and AV nodes, prolongs refractory period -Increases vagal tone (PNS stimulation) decreases HR -Administration: IV, oral, not given IM (necrosis) -Narrow therapeutic window: 0.5 to 2 ng/mL Monitor drug levels, s/s toxicity, potassium level -Low potassium levels increase toxicity *Adverse effects:* -CV: dysrhythmias brady/tachycardia with toxicity—heart block, Ventricular arrhythmia -CNS: HA, fatigue, malaise, confusion, convulsions -Eyes: colored vision (green, yellow, purple), halo vision, flickering lights -GI: anorexia, n/v/d

ramelteon (Rozerem):

Nonbenzodiazepine- not CNS depressant -used as hypnotic -Not classified as controlled substance **Structurally similar to hormone melatonin agonist at melatonin receptors in the CNS** -Used to regulate circadian rhythm, day-night sleep cycles *-Indicated for patients with sleep onset difficulty rather than sleep maintenance—short duration* -Contraindicated: -liver dysfunction -azoles -rifampin (speeds up rozerem and makes it less effective) Hormone melatonin Not classified as controlled substance—no dependency risk Rifampin speeds ramelteon metabolism, decreases efficacy

Beta Blocker: carvedilol (Coreg):

Nonselective beta blocker, an alpha1-blocker, a calcium channel blocker, and possibly an antioxidant *Uses:* -heart failure, hypertension, and angina -Decreases heart rate, force of contraction, control arrhythmia -Slows progression of heart failure -decreases frequency of hospitalization in pts with mild to moderate (class II or III) heart failure Heart failure treatment: add to digoxin, furosemide, and angiotensin-converting enzyme inhibitors a weak heart has difficulty managing fluid balance, so diuretics are given with Coreg this is the #1 drug prescribed for patients with HF *oral only*

Effects of Chronic Ethanol Ingestion:

Nutrition, vitamin deficiencies (B vitamins) (particularly thiamine) -*Wernicke's encephalopathy* (syndrome including increased confusion, gait dysfunction, vision dysfunction, immediate need of thiamine IV) -*Korsakoff's psychosis* (impairment of the memory centers of the brain) -*Polyneuritis* -*Nicotinic acid deficiency encephalopathy* (niacin deficit) -Seizures -Alcoholic hepatitis, progressing to cirrhosis (can lead to losing function of the liver) -Cardiomyopathy -Alcoholic hepatitis, cirrhosis, hepatotoxicity with Tylenol -Fetal alcohol syndrome (FAS) -Craniofacial abnormalities, CNS dysfunction, growth retardation Fetal alcohol syndrome babies-alcohol withdrawal growth retardation in womb and after birth

milrinone (Primacor):

Only available phosphodiesterase inhibitor -IV administration (not mix furosemide in tubing) *Adverse effects:* -cardiac ventricular dysrhythmias -HA -hypokalemia -tremor -thrombocytopenia -elevated liver enzymes -hypotension -angina *Interactions* -Diuretics (additive hypotensive effects) -Administer in a separate intravenous line -digoxin (additive inotropic effects)

diltiazem (Cardizem):

Only benzothiazepine CCB -Very effective for treatment of angina pectoris resulting from coronary insufficiency and HTN -Used in tx of atrial fibrillation/flutter, paroxysmal supraventricular tachycardia -Administration: oral, SR forms, IVP, infusion -Adverse effects: dyspnea, palpitations, hypotension, HF, edema, constipation

ezetimibe (Zetia):

Only cholesterol absorption inhibitor available *Mechanism of action:* -Selectively inhibits absorption of cholesterol, related sterols from small intestine *Indications:* -Reduces total cholesterol, LDL, triglyceride levels -Also increases HDL levels -Enhanced effects with statin, use with CKD *Adverse effects:* abd pain, diarrhea, HA *Administration:* monotherapy or with statin -Not recommended with Fibrates: increases Zetia level -Reduced levels with bile acid sequestrants -May be taken with/without food *Contraindication:* -allergy, active liver disease, -↑LFT

Nitrous Oxide:

Only inhaled gas currently used as general anesthetic *-Aka "laughing gas"* -Weakest of general anesthetic drugs -Used primarily for dental procedures or as a supplement to more potent anesthetics -*Adverse effects*: PONV if used for > 1hr used with other inhaled agents in surgery setting desflurane, sevoflurane

Toxicity and Overdose; Barbiturates:

Overdose leads to respiratory depression, arrest -CNS depression (sleep to coma and death) *Can be therapeutic* -Anesthesia induction -Uncontrollable seizures: use this to put them into a coma if pt has seizure after seizure "phenobarbital coma" *Overdose treatment: symptomatic, supportive* -Maintain adequate airway -Assisted ventilation or oxygen therapy -Fluids, pressor support, ECG -Activated charcoal (if we know pt has just swallowed it, if we don't catch it right away it won't be affected) Anesthesia induction---not used for sleep aid Overdose: Charcoal shown to be ineffective

Cholinergic Crisis:

Overdose of cholinergic drug -Circulatory collapse, hypotension, bloody diarrhea, shock, and cardiac arrest *SLUDGE:* -salivation -lacrimation -urinary incontinence -diarrhea -GI cramps -emesis (vomiting) Early signs -Abdominal cramps, salivation, flushing of skin, n/v, syncope, transient heart block, dyspnea, orthostatic hypotension Tx early phase: *atropine, a cholinergic antagonist* *Tx for severe CV reactions or bronchoconstriction:* *epinephrine, an adrenergic agonist*

Fluid Imbalance;

Overhydration: -Water gained exceeds water lost -Edema: fluid accumulation in interstitial spaces -Sudden weight gain Dehydration -Water lost exceeds water gained—deficit -Imbalance between ECF, ICF -Sodium= principle EC electrolyte affects water concentration

Drug Effects on PSNS:

PNS = *"rest and digest"* system *Stimulate intestine and bladder* -Increased gastric secretions, GI motility -Increased urinary frequency *Stimulate pupils* -Constriction (miosis), reduced intraocular pressure Exocrine glands *-Increased salivation and sweating* Cardiovascular effects *-Decreased heart rate, vasodilation* Respiratory effects *-Bronchial constriction, narrowed airways*

Propofol (Diprivan):

Parenteral general anesthetic: Induction, maintenance of general anesthesia Sedation for mechanical ventilation in ICU Administration protocols Lower doses: sedative-hypnotic for moderate sedation Administration: Lipid based emulsion Monitor triglycerides (lipids) if given with TPN (triglycerides will go up if given with TPN)

Nursing Implications:

Perform thorough assessment before administering immunosuppressants: -Renal, liver, and cardiovascular function studies -Central nervous system baseline function -Respiratory assessment -Baseline vital signs -Baseline labs: hemoglobin, hematocrit, white blood cell (WBC) count, and platelet count -Assess contraindications, drug allergies/interactions. -Monitor WBC during therapy if count drops below normal range, contact prescriber. -Monitor for therapeutic responses, adverse effects and signs of drug toxicity. -Oral immunosuppressants should be taken with food* to minimize gastrointestinal upset. -Oral forms are used when possible to decrease risk of infection that may occur with parenteral injections. -Note all possible drug interactions -Grapefruit juice interacts with some of these drugs. -Oral anti-fungal drugs are usually given to treat oral candidiasis that may occur. -Assess oral cavity often for white patches on the tongue, mucous membranes, and oral pharynx. -Mix oral cyclosporine solution in a glass container. Do not use Styrofoam containers because the drug adheres to the inside wall of the container. -Follow guidelines for parenteral administration carefully -Inform patients that lifelong therapy with immunosuppressants is indicated with organ transplantation. -Encourage patients taking immunosuppressants to take measures to reduce the risk of infection: -Avoid crowds. -Avoid people with colds or other infections. -Immediately report fever, sore throat, chills, joint pain, fatigue, or other signs of a severe infection.

Fluid Balance:

Plasma proteins exert constant osmotic pressure -Colloid oncotic pressure (COP) -Normally 24 mm Hg ISF exerts hydrostatic pressure -Normally 17 mm Hg -Edema -Dehydration and fluid loss -Acid-base balance

Interferons:

Proteins that have 3 basic properties -Antiviral: enable enzymes to prevent viral replication -Antitumor: prevent cancer cell division -Immunomodulating: increase activity NK cells, macrophages, cancer cell markers 3 different groups of interferon drugs 1.) alfa 2.) beta 3.) gamma -interferons protect human cells from virus attack by enabling the human cells to produce enzymes that stop viral replication and prevent viruses from penetrating into healthy cells -they prevent cancer cells from dividing and replicating and also increase the activity of other cells in the immune system such as macrophages, neutrophils, and natural killer cells -Restore, amplify immune defenses -Inhibit dysfunctional immune system Autoimmune Disease (MS)

Mercaptopurine(Purixan):

Purine antagonists -Interrupts metabolic pathway of purine nucleotides -Interruption of DNA and RNA synthesis Adverse effects -Tumor lysis syndrome with build up of uric acid -Give allopurinol to reduce uric acid levels Mercaptopurine, thioguanine po dosing leukemia, Crohn's Ds, ulcerative colitis fludarabine, pentostatin inject leukemia, lymphoma kidneys will recover once the drug goes through the body

Immune System:

Purpose of Immune System: distinguish self from non-self, protect body from foreign material (antigens), including cancer -Humoral immunity: mediated by B lymphocytes -Cellular immunity: mediated by T lymphocytes -Participates in anaphylactic reactions -Responsible for rejection of kidney, liver, heart transplants -Can cause "autoimmune diseases" or immune-mediated diseases

Fluorouracil (Efudex):

Pyrimidine antagonists -interrupts metabolic pathways of pyrimidine bases -Results in interruption of DNA and RNA synthesis -used on the skin to treat cancerous skin growths Administration precautions -Use non-metal applicator or fingertips to apply cream** -Use care when applying around eyes, nose, and mouth -Wash hands immediately after applying -Avoid sun exposure-- Wear SPF 15 (or higher) sunblock and protective clothing.

Direct-acting cholinergic drugs:

Reduce intraocular pressure -Useful for glaucoma and intraocular surgery •Pilocarpine, echothiophate, carbachol Increases tone/motility of bladder and GI tract -Relaxes sphincters in bladder and GI tract -allow to empty •Bethanechol (Urecholine) -Helpful for postop atony of bladder, GI tract -Increase salivation: Sjogren's syndrome, xerostomia •Cevimeline (Evoxac) -Decrease IOP with ophthalmic drops; topical application -Bethanecol affects detrusor muscle -Xerostomia; excessive dry mouth

Indications:

Relief of painful musculoskeletal conditions -Muscle spasms -Management of spasticity of severe chronic disorders (multiple sclerosis, cerebral palsy) -Work best when used with Physical therapy *Adverse Effects:* -Extension of effects on CNS, skeletal muscles -Dizziness, drowsiness, fatigue, confusion, weakness -Grow tolerant over time -Less common; n/v/d, HA, slur speech, constipation

Rivaroxaban (Xarelto):

Rivaroxaban(Xarelto): First oral factor Xa inhibitor Apixaban(Eliquis),edoxaban (Savaysa) *Indications:* -Prevention of strokes with nonvalvular A-fib -DVT, PE postop prophylaxis ortho surgery -No routine monitoring *Contraindication:* -allergy -active bleeding *BBW: spinal hematoma w/ spinal epidural catheter* *Adverse Effects:* -Peripheral edema -HA -hematuria -diarrhea *Drug Interactions:* -grapefruit juice -phenytoin -rifampin -CYP34A -No routine monitoring

Rivaroxaban (Xarelto):

Rivaroxaban(Xarelto): First oral factor Xa inhibitor Apixaban (Eliquis), edoxaban (Savaysa) *Indications:* -Prevention of strokes with nonvalvular A-fib -DVT, PE post-op prophylaxis ortho surgery *-No routine monitoring* *Contraindication:* -allergy -active bleeding *BBW: spinal hematoma w/ spinal epidural catheter* *Adverse Effects:* -Peripheral edema -HA -hematuria -diarrhea *Drug Interactions:* -grapefruit juice -phenytoin -rifampin -CYP34A

sumatriptan (Imitrex):

SSRAs= selective serotonin receptor agonists Abortive therapy of acute migraine HA -not preventative, does not reduce # of attacks -May be taken during aura Effective within 2 hour, non-oral 10-15min -Oral, sublingual, subcutaneous, nasal spray Used with preventive migraine therapy -Propanolol, amitriptyline, valproic acid, topirimate -used for acute migraines -oral cannot be taken sometimes as patients experience n/v

Benzodiazepines:

Schedule IV controlled substance -Habit forming, addictive Largest, most common prescribed anxyiolitc -Alprazolam (Xanax), diazepam (Valium), chlordiazepoxide (Librium) -Lorazepam (Ativan), clonazepam (Klonopin) *Interactions* -Alcohol/CNS depressants result in additive CNS depression/death -Drug interactions with renal/hepatic compromise *Adverse Effects* Overexpression of therapeutic effects -Decreased CNS activity -sedation -hypotension -drowsiness -loss of coordination -dizziness -HA -confusion - n/v -dry mouth -constipation *Overdose* -Dangerous with other sedatives or alcohol -Treatment generally symptomatic, supportive -Flumazenil (Romazicon) = reversal agent *Contraindication* -Allergy -narrow-angle glaucoma -pregnancy

Beta-Blocker: metoprolol (Lopressor)

Selective β1 receptor blocker -used to treat HTN -chest pain due to CAD -abnormally fast HR dysrhythmias -given after an MI -prevent migraines Cardioprotective improves survival after MI Adverse Effects -bradycardia *Contraindication:* -known allergy -worsening heart failure -cardiogenic shock -bradycardia -pregnancy -severe pulmonary disease -Raynaud's disease Taper dose to discontinue, do not stop abruptly

Antimigraine Drugs: First Line Therapy

Serotonin receptor agonists (SSRA) *First-line therapy: triptans* -Sumatriptan (Imitrex), almotriptan (Axert), naratriptan (Amerge), zolmitriptan (Zomig) Mechanism of Action -Stimulate 5-HT (serotonin) receptors in cerebral arteries -Cause vasoconstriction, reduce headache symptoms -Reduce production of inflammatory neuropeptides Adverse Effects -Vasoconstriction (can cause extremities to be very cold) -tingling -flushing -injection irritation Contraindication: severe CV disease (these drugs cause vasoconstriction, will make CV disease worse)

Case Study #5:

Several months later, the patient returns to the PCP's office for follow-up regarding use of the SSRI. The patient tells the nurse that he is feeling better and stopped taking the SSRI yesterday. He doesn't plan on taking the medication again. When talking with the patient, which knowledge should guide the nurse's response? A. Drug dependency will develop, so it is appropriate to stop therapy after a few months. B .Drug therapy must be stopped as soon as the patient feels better to avoid serotonin syndrome. C .The patient is the best person to determine when the drug therapy should end. D. a 1- to 2-month taper period is indicated to prevent adverse effects of abrupt drug discontinuation. D.

Interleukins: Capillary Leak Syndrome

Severe toxicity of IL-2 (aldesleukin) therapy ●Capillaries lose ability to retain colloids in the blood; these substances are "leaked" into surrounding tissues ●Result: massive fluid retention (20-30 lbs) -Respiratory distress, heart failure -Myocardial infarction, Dysrhythmias ●Reversible after IL therapy is discontinued ●Other adverse effects: fever, rash, fatigue, myalgia, hepatotoxicity, HA

Ethanol Withdrawal:

Signs and symptoms -Elevated B/P > 150/90, P> 110, Temp>100*F -Insomnia, Tremors, Agitation -Classified as mild, moderate, and severe *Increasing to severe B/P> 200/, P> 140, Temp>101F* *Benzodiazepines are treatment of choice* -Diazepam (Valium), lorazepam (Ativan), or chlordiazepoxide (Korsakoff's psychosis) -Dosage and frequency depend on severity -Restraints for safety, fluids, lytes, nutrition, Bi vitamin replacement -For severe withdrawal: monitor in ICU -CIWA scale, group of symptoms we can rate our patients on degree of symptoms

varenicline (Chantix):

Smoking cessation drug -Stimulates nicotine receptors, nicotine agonist decreases cravings for nicotine, decreases pleasurable effects -Reduces cravings for, decreases pleasurable effects of cigarettes/tobacco products *Common side effect:* -n/v -HA -flatulence -insomnia -nightmares -disturbed taste Use caution when driving due to drowsiness -Improved success compared to bupropion *FDA warning: if you have psych symptoms this drug can exacerbate agitation, depression, suicidality, aggravation of psych disorder*

Aldosterone Antagonists:

Spironolactone and eplerenone -Useful in severe stages of HF -RAS system causes increased aldosterone production leading to sodium and water retention (edema) worsening HF; aldosterone antagonists block aldosterone receptors. -Monitor for hyperkalemia -Spironolactone is potassium-sparing diuretic eplerenone (Inspra) selective aldosterone blocker blocks aldosterone at receptors in kidney, heart, blood vessels, brain

American College of Cardiology Foundation/ American Heart Association (ACCF/AHA)Stages of Heart Failure:

Stage A: At risk for Heart Failure but no symptoms or structural heart disease Stage B: Structural heart disease but no symptoms Stage C: Structural heart disease with symptoms Stage D: Refractory Heart Failure requiring interventions Initially asymptomatic, increase in symptoms and dysfunction as disease progresses, decreased ejection fraction EF (ejection fraction)= % blood ejected in relation to LV end diastolic volume. Decreased EF indicates decreased L ventricular function

norepinephrine (Levophed):

Stimulates alpha-adrenergic receptors -Causes vasoconstriction, *increase BP* Direct-stimulating beta-adrenergic effects on heart (beta1-adrenergic receptors) -- *increase HR* -No stimulation to beta2-adrenergic receptors of lung -Directly metabolized to dopamine -Treatment of hypotension and shock *-Administered by continuous infusion titration (IV)* ER or ICU *-Oral drug Droxidopa* -Treatment: neurogenic orthostatic hypotension BBW: supine HTN—give last dose 3 hr prior to bedtime -pt must sleep with head and upper body elevated

Alpha-Adrenergic Drug Effects:

Stimulation of alpha-adrenergic receptors on smooth muscles results in: -Vasoconstriction of blood vessels -Relaxation of GI smooth muscles (decreased motility) -Constriction of bladder sphincter -Contraction of uterus -Male ejaculation -Contraction of pupillary muscles (dilated pupils) -Increased glycogenolysis

Catecholamines:

Substances that produce sympathomimetic response Endogenous -Epinephrine, norepinephrine, dopamine Synthetic -Dobutamine, phenylephrine Utilize adrenergic receptors throughout body Alpha-adrenergic receptors Beta-adrenergic receptors Dopaminergic receptors: respond only to dopamine

Key Concepts:

Sympathetic Nervous System Adrenergic receptors; Alpha, Beta-1 and 2 Vasoconstriction Beta-2; Bronchodilation in the lungs Mydriasis in the pupils -Chronotropic (increase HR) -Dromotropic (transmission of the electric circulatory in the heart to increase the HR) -Inotropic (Increase and stimulate the cells in the heart chambers, increased force of contraction)

Toxicity and Overdose:

Synergistic with other CNS depressants (opioids, alcohol, muscle relaxants) to cause hypotension, respiratory depression -Confusion, Somnolence, Coma -Diminished reflexes, RR, and B/P Treatment: symptomatic and supportive *-IVP Flumazenil as an antidote (1-4hr duration)* -has a short half life -if pt has a long acting benzodiazepine or a lot of it, might have to repeat this antidote -if compounded with other opioids, will give Narcan too *Sedation reversal* .2mg IVP over 15 sec x2, (every 60 sec) up to 1mg -if the patient has had too much benzodiazepine and won't wake up after a procedure, this is how much you'd give If patient has had an *overdose* give .2mg, .3mg, .5mg over 30sec (every 60 sec) up to 3mg -you'd give higher dosage

oxybutynin (Ditropan):

Synthetic antimuscarinic drug Indications: Overactive bladder and antispasmodic for neurogenic bladder associated with spinal cord injuries and congenital conditions (spina bifida) Contraindications: -drug allergy -urinary or gastric retention (Don't give it patient has hx of urinary retention) -if males have large prostate, don't give drug because pt already has urinary retention -uncontrolled angle-closure glaucoma -half-life: 2-3 hours -BID -take half hour before eating, or 2 hours after eating for better distribution, *oral form* -drug comes in a patch called Oxytrol, can be bought OTC

Glycopyrrolate (Robinul):

Synthetic antimuscarinic drug: blocks receptor sites in ANS that control secretion production -Uses: preop to reduce saliva, decrease respiratory and GI secretions, Hospice drug (patients that are hospice are too weak to control their secretions, exhibit death rattle which is a congestive and pooling of secretions in the back of their throat) -Contraindicated in glaucoma, myasthenia gravis, GI/GU obstruction, tachycardia, MI, ulcerative colitis, toxic megacolon -patient is already tachycardia, we don't want to increase HR -Ulcerative colitis, we don't need to slow down secretions - Megacolon: severe constipation, we don't want to make that worse -Obstruction: we don't want to make it worse by slowing it down -Glaucoma: it will increase intraocular pressure -Myasthenia gravis: we NEED acetylcholine *Injectable, oral forms* dries up airway secretions

dicyclomine (Bentyl):

Synthetic antispasmodic cholinergic blocker -Uses: functional disturbances of GI motility such as irritable bowel syndrome (slow it down) -Contraindications: -known hypersensitivity to anticholinergics -angle-closure glaucoma -GI obstruction -myasthenia gravis -paralytic ileus (GI atony) (if the bowel has no tone for ex after anesthesia, we won't give this drug to someone that has no tone, it will make it go even slower than it is) -toxic megacolon (already constipated with slow bowel movement)

Case Study #1:

The nurse anesthetist is planning to use balanced anesthesia during a surgical procedure. A characteristic of this type of anesthesia is the A. administration of minimal doses of multiple anesthetic drugs B. administration of inhaled anesthetics C. intravenous (IV) administration of anesthetics D. administration of anesthetics to cause muscle relaxation A.

Case Study #5:

The nurse has administered iron intravenously to a patient. To prevent orthostatic hypotension, it is recommended that the nurse have the patient remain in the recumbent position for how long? A. 10 minutes B. 30 minutes C. 60 minutes D. 90 minutes B.

Case Study 1:

The nurse is assessing a patient who has been taking a cholinergic drug for 3 days. The patient has flushed skin and orthostatic blood pressure changes and is complaining of abdominal cramps and nausea. The nurse recognizes that the patient is most likely experiencing A. early signs of a cholinergic crisis. B. late signs of a cholinergic crisis. C. an allergic reaction to the drug. D. expected adverse effects. A. Rationale: The items listed are early signs of a cholinergic crisis, which can become more severe and lead to hypotension, circulatory collapse, bloody diarrhea, shock, and cardiac arrest

Case Study:

The nurse knows that the adverse effects of a nonselective beta blocker are likely to be the most immediately life threatening in which patient? A. Patient with type I diabetes B. Patient with asthma C. Patient with gastroesophageal reflux disease D. Patient with hypertension B. Rationale: Although beta blockers may mask signs and symptoms of hypoglycemia, nonselective beta blockers may cause bronchoconstriction, which would be detrimental to the patient with asthma.

Case Study 2:

The nurse monitors a patient prescribed dicyclomine (Bentyl) for which therapeutic effect? A. Decrease in sweating B. Dilation of the pupils C. Reduction in urinary frequency D. Decrease in GI motility D.

Case Study:

The nurse notes an order for the patient to receive an IV dose of methylprednisolone prior to administration of basiliximab. The nurse understands the rationale for this therapy as: A. decrease pain at infusion site. B. enhanced suppression of immune system. C. prevention of fluid retention. D. prevention of cytokine release syndrome. D.

Case Study #8:

The patient accidentally takes too much of the prescribed warfarin (Coumadin) and is readmitted to the hospital with bleeding. The nurse anticipates administration of A. protamine sulfate B. alteplase (Activase, Cathflo Activase) C. reteplase (Retavase) D. vitamin K D.

Case Study #5:

The patient asks, "Is there anything I have to worry about when taking Kava?" The best response by the nurse is: 1. "Kava is a natural product which has no side effects." 2. "You need a prescription to take Kava." 3. "No worries, Kava is recommended for patients with depression." 4. "It is best to inform you health care provider of any additional medication or supplements you plan to take to check for interactions that may be harmful." 4 *Rationale:* Even natural products have side effects. Side effects of Kava include skin discoloration, possible accommodative disturbances and pupillary enlargement, and scaly skin (with long-term use). Kava and other supplements are available without a prescription. Kava is contraindicated in patients with Parkinson's disease, liver disease, depression, or alcoholism; in those operating heavy machinery; and in pregnant and breastfeeding women. As with all medications and supplements, it is best to inform the health care provider to evaluate possible interactions among drugs and supplements taken.

Case Study 4:

The patient improves within the first 3 months of treatment with methotrexate. Six months later, the patient experiences worsening of symptoms. The prescriber will most likely order which monoclonal antibody for the treatment of RA? A. adalimumab (Humira) B. trastuzumab (Herceptin) C. rituximab (Rituxan) D. cetuximab (Erbitux) A.

Case Study #5:

The patient is being discharged home with furosemide (Lasix). When providing discharge teaching, which instruction will the nurse include? A. Avoid prolonged exposure to the sun B. Avoid foods high in potassium content C. Stop taking the medication if you feel dizzy D. Weigh yourself once a week and report a gain or loss of more than 1 pound A.

Case Study:

The patient is discharged home and returns to the ED 4 days later. The patient is admitted to ICU with acute decompensated HF with dyspnea at rest. The nurse anticipates administration of which medication? A. atropine B. carvedilol (Coreg) C. lisinopril (Prinivil) D. nesiritide (Natrecor) D.

Case Study:

The patient is prescribed an ACE inhibitor. The nurse understands the primary mechanism by which the ACE inhibitors exert their therapeutic effect in a patient in HF is A. to inhibit catecholamine release. B. to inhibit acetylcholine release. C. to inhibit aldosterone secretion. D. to prevent vagal stimulation. C.

Case Study 1:

The patient is scheduled for discharge. Which information does the nurse include when teaching the patient about methotrexate therapy? A. You can expect to develop mouth sores that will improve with time when taking this medication. B. Administer the methotrexate injection daily in the early morning. C. Mix the methotrexate with sterile saline before administration. D. Administer the methotrexate subcutaneously into the thigh, abdomen, or upper arm, rotating injection sites D.

Case Study #6:

The patient tells the nurse that his friend has been taking valerian for a long period of time and that he isn't feeling so well. The patient asks the nurse what the adverse effects of valerian are. The best response by the nurse is that adverse effects of valerian include 1. insomnia. 2. yellow skin. 3. bruising. 4. increased appetite. 1. *Rationale:* Adverse effects of valerian include CNS depression, hepatotoxicity, nausea, vomiting, anorexia, headache, restlessness, and insomnia.

Case Study #4:

The patient was admitted to the hospital for observation and has now recovered. Which information will the nurse include in patient teaching about SSRIs? A. It usually takes 4 to 6 weeks until you will experience benefits from the medication. B. The patient must avoid foods that contain tyramine. C .If the patient develops an upset stomach when taking this medication, he should discontinue use. D. The patient should take the medication at bedtime to enhance sleep. A.

Case Study #6:

The use of folic acid to prevent fetal neural tube defects should be started: A. during a woman's adolescence B. at least 1 month before pregnancy C. when a pregnancy is first discovered D. at the beginning of the last trimester of pregnancy B.

Psychiatric Disorders:

Theory of Mental Disorders *Biochemical imbalance* -Abnormal levels of neurotransmitters -Catecholamines; dopamine, norepinephrine -Indolamines; serotonin, histamine -GABA; inhibitory transmitter -Acetylcholine -Electrolytes; Na+, K+, Mag -Psychotherapeutic drugs block or stimulate release of neurotransmitters -Often treat more than 1 disorder

Sleep:

Transient, reversible, periodic state of rest -Decreased state of consciousness, unaware of stimuli Normal sleep is cyclic and repetitive Sleep architecture -Rapid eye movement (REM) sleep -Non-REM sleep REM interference (decreased REM) -Due to prolonged sedative-hypnotic use -can cause day time fatigue, hangover feeling REM rebound (increased REM/vivid dreams) -With d/c of hypnotics

Chemotherapy:

Treatment Goal: Kill all neoplastic cells, produce cure -Factors affecting prognosis, survival: General health, health of immune system Stage of cancer at diagnosis Type of cancer, doubling time Efficacy of drug tx—narrow single therapeutic index Combination Drugs, differing action mechanisms Less drug resistance, no overlapping toxicities All Chemo harmful to rapid dividing cells-dose limiting -Healthy, normal cells: Hair follicles, GI tract, bone marrow -Hair loss, n/v, myelosuppression -IV chemo toxic to tissues-extravasation

chlorpromazine (Thorazine):

Treatment of acute and chronic psychoses -Schizophrenia, manic phase of bipolar disorder -amphetamine-induced psychoses -Off-label treatment of severe migraine *Side effects:* -movement problems -sleepiness -dry mouth -low B/P upon standing -weight gain -Photosensitivity (sensitivity to light) *Serious side effects:* -tardive dyskinesia -neuroleptic malignant syndrome -low WBC

Valproic Acid:

Treatment of generalized seizures -Tonic- clonic, myoclonic, absence, partial seizure *Contraindication:* -drug allergy -impaired liver -urea metabolism disorders (assess LFT prior to dosing) -Competes with protein-bound meds, drug interactions *Adverse effects:* -drowsiness -n/v -weight gain -tremor Serious effects: -hepatotoxicity -pancreatitis Available: XR, Depakote, Depakote Sprinkles Administration: -do not take with carbonated drinks -do take with snack to decrease GI upset

Case Study #4:

Two days after admission, the nurse is reviewing laboratory results of the patient. Which is the most common electrolyte finding resulting from the administration of furosemide (Lasix)? A. Hypocalcemia B. Hypophosphatemia C. Hypokalemia D. Hypomagnesemia C.

Triglycerides and Cholesterol:

Two primary forms of lipids in the blood -Triglycerides -Cholesterol -Water-insoluble fats bound to apolipoproteins, specialized lipid-carrying proteins -Lipoprotein is the combination of triglyceride or cholesterol with apolipoprotein -Produced by liver to transport lipids to cells

Anxiety:

Unpleasant state of mind -characterized by sense of fear, dread -May be based on actual anticipated experiences or past experiences -May be exaggerated responses to imaginary negative situations *6 Major Anxiety Disorders* -Obsessive-compulsive disorder (OCD) -Posttraumatic stress disorder (PTSD) -Generalized anxiety disorder (GAD) -Panic disorder -Social phobia (social anxiety disorder) -Simple phobia

sodium nitroprusside (Nitropress):

Used in ICU for severe hypertensive emergencies; titrated to effect by IV infusion -Half life 10 minutes *Adverse Effects:* -bradycardia -hypothyroidism -rash -decreased platelets -severe hypotension -*cyanide toxicity* (rarely) -methemoglobinemia (a form of hemoglobin is high) *Contraindications:* -known hypersensitivity -severe HF -known inadequate cerebral perfusion (especially during neurosurgical procedures)

Drug Effects and Indications: Alpha Blockers (continued)

Used to control, prevent HTN with pheochromocytoma -Tumor on adrenal gland that secretes norepinephrine -Pt's with pheochryomocytoma, catecholamine is secreted and causes dangerously high BP to stroke level *phentolamine (Regitine)* is given Conditions that are treated; Treats vasoconstriction in: -Raynaud's disease (It causes the blood vessels to narrow when you are cold or feeling stressed) -acrocyanosis (blood vessels in skin constrict and turn hands and feet bluish), -frostbite -d/t increased endogenous alpha-adrenergic activity -phenoxybenzamine (drug used for these conditions) ---------------------------------- Prevent skin necrosis in extravasation from pressors -Antidote for skin damage: norepinephrine, epinephrine *Phentolamine (drug used for this situation):* -restores blood flow to ischemic tissue -*subcutaneous injections around the whole site of injury to reverse the vasoconstriction* (may save pt from limb amputation)

Lipoproteins:

Very-low-density lipoprotein (VLDL) -Produced by the liver -Transports endogenous lipids to the cells -Low-density lipoprotein (LDL) -Intermediate-density lipoprotein (IDL) -High-density lipoprotein (HDL) -Responsible for "recycling" of cholesterol -Also known as "good cholesterol"

Case Study #6:

What information will the nurse include when teaching the patients about taking beta2-blocking drugs for the treatment of angina? A. "Call your health care provider if you heart rate is 64 beats/min." B. "These drugs are safe to use in patients who have asthma." C. "Call your health care provider if you experience a weight gain of 2 lb or more in 24 hours or 5 lb or more in 1 week." D. "Avoid taking these medications with grapefruit juice." C.

Case Study #1:

When administering a loop diuretic to a patient, it is most important for the nurse to determine if the patient is also taking which drug? A. lithium (Eskalith) B. acetaminophen (Tylenol) C. penicillin D. theophylline A.

Case Study 1:

When administering an alpha-adrenergic drug for hypertension, it is most important for the nurse to assess the patient for the development of A. hypotension B. hyperkalemia C. oliguria D. respiratory distress A.

Case Study #2:

When administering erythropoiesis-stimulating agents, it is important for the nurse to: A. not administer the erythropoiesis-stimulating agent with any other product B. shake the vial prior to drawing up the medication C. avoid use of vitamin B12 supplements when patients are taking erythropoiesis-stimulating agents D. administer oral forms of iron with milk A.

Case Study #2:

When assessing a patient under general anesthesia, which change to organ systems does the nurse expect? A. Nystagmus B. Skeletal muscle contraction C. Hypertension D. Decreased intracranial pressure A.

Case Study #6:

When converting from IV heparin to oral warfarin (Coumadin) therapy, the prescriber monitors which of the following to determine the next appropriate dose of warfarin? A. Platelet levels B. aPTT C. Red blood cell count D. PT/INR D.

Interactions:

When given with other cholinergic blocking drugs, cause additive anticholinergic effects -Amantadine -tricyclic antidepressants -Antihistamines (like Benadryl), digoxin, phenothiazines Assess elderly for drug interactions -hyperthermia risk -dizziness -gait & balance changes - constipation

Case Study:

When handling and administering vesicant drugs, the nurse will: A. double flush patient's bodily secretions in the commode. B. use sterile towels to clean up after chemotherapy spills. C. mix chemotherapeutic drugs in the patient's room. D. teach the patient how to administer parenteral chemotherapeutic drugs. A. Vesicant drugs are drugs that cause extravasation and kill the normal cells Can be toxic to the skin

Case Study #2:

When patients are taking selective SSRIs for the first time for depression, which is most important to monitor for during the first few weeks of therapy? A. Hypertensive crisis B. Suicidal thoughts C. Convulsions D. Orthostatic hypotension B.

Case Study 1:

When providing education to the patient on the use of a benzodiazepine medication, the nurse will include which information? A. These medications have little effect on the normal sleep cycle B. Using this medication may cause drowsiness the next day C. It is safe to drive while taking this medication D. These drugs are safe to use with alcohol B. Rationale: Benzodiazepines interfere with REM sleep and may cause a "hangover" effect or next-day drowsiness. They should not be used with alcohol, and persons taking these drugs should not drive.

Case Study #3:

When providing teaching for a patient who is prescribed a selective SSRI, which statement will the nurse include? A. The SSRI will work faster than the older tricyclic antidepressants. B. The SSRI will have an immediate beneficial effect on the patient's depression symptoms. C .The SSRI will not work well for severe cases of depression. D. The SSRI may take several weeks to have a beneficial effect. D.

Angina Pectoris (Chest Pain)

When supply of oxygen and nutrients in blood is insufficient to meet demands of the heart, heart muscle "aches" (chest pain) -Angina: reduction of oxygen/demand ratio Situations that increase oxygen demand: -Increased HR, contractility -Caffeine, exercise, stress -Stimulation of SNS -Pain of angina caused by anaerobic metabolism, lactic acid

Case Study #5:

When teaching a patient about spinal headaches, which statement will the nurse include? A. Spinal headaches can be prevented with bed rest after the epidural procedure. B. Patients who have a spinal headache should have very limited fluid intake. C. A graft of skin from the patient's hand can be used to seal the leaking area causing the headache. D. High Fowler's positioning should be used for patients who have a spinal headache. A.

Case Study #4:

Which action does the nurse perform when administering iron intravenously? A. Premedicate the patient with an antihistamine to prevent anaphylaxis. B. Administer the iron with a running dextrose solution. C. Flush the IV line with 10 mL of normal saline. D. Have available Regitineto reverse vasoconstriction at the site should infiltration occur. C.

Case Study #1:

Which drug will the nurse anticipate administering to a patient experiencing benzodiazepine overdose? A. Flumazenil B. Naltrexone C. Vivitrol D. Flunitrazepam A.

Case Study 1:

Which finding would the nurse anticipate when assessing a patient with an atropine overdose? A. Moist skin B. Miosis C. Bradycardia D. Urinary retention D. Rationale: Atropine overdose is manifested by flushing, dry skin and mucous membranes, mydriasis, altered mental status, and fever. Other serious effects include sinus tachycardia, urinary retention, hypertension, hallucinations, and cardiovascular collapse. Activated charcoal is usually given along with supportive therapy.

Case Study #3:

Which food will the nurse teach the patient to avoid when ingesting an iron supplement? A. Milk B. Veal C. Orange juice D. Fish A.

Case Study #7:

Which of the following should the nurse include when providing dietary teaching for the patient receiving warfarin (Coumadin) therapy? A. Avoid drinking large amounts of green tea B. Cranberry juice will provide you with needed nutrients while taking Coumadin C. You must never eat spinach D. You can only eat lettuce once a month A.

Case Study #1:

Which patient is the best candidate to receive nesiritide therapy? A. A patient with atrial fibrillation who has not responded to other drugs B. A patient needing initial treatment for HF C. A patient with reduced cardiac output D. A patient with acutely decompensated HF who has dyspnea at rest D.

Case Study:

Which patient would benefit from administration of simvastatin (Zocor) 80 mg? A. A patient newly diagnosed with hyperlipidemia B. A patient with muscle aches who was taking another antilipidemic drug C. A patient who is taking verapamil D. A patient who has already been taking simvastatin (Zocor) for 12 months with no evidence of myopathy D.

Case Study #3:

Which statement about ARBs does the nurse identify as being true? A.) Hyperkalemia is more likely to occur than when using ACE inhibitors B.) Cough is more likely to occur than when using ACE inhibitors C.) Chest pain is a common adverse effect D.) Overdose is usually manifested by hypertension and bradycardia C.

Case Study #3:

Which statement does the nurse include when teaching a patient about disulfiram (Antabuse) therapy? A. "Disulfiram (Antabuse) will cure your alcoholism if you take it as directed." B. "If you drink alcohol after taking disulfiram (Antabuse), your blood pressure will get very high." C. "You cannot drink alcohol for at least 3 or 4 days after taking disulfiram (Antabuse)." D. "If you miss a dose of disulfiram (Antabuse), double the dose the next time it is due." C.

Case Study #4:

Which statement regarding conscious sedation does the nurse identify as being accurate? A. The IV route of drug administration is commonly used in pediatric patients to provide conscious sedation. B. Mild amnesia is a common effect of midazolam. C. Patients receiving conscious sedation must be intubated with an endotracheal tube. D. Effects of propofol include relief of anxiety and pain B.

Case Study #4:

Which statement regarding muscle relaxants does the nurse identify as being accurate? A. Baclofen (Lioresal) is available as an injectable form for use with an implantable pump device. B. Cyclobenzaprine (Flexeril) produces little sedation. C. Patients taking muscle relaxants are at high risk of developing hypertension. D. Patients taking muscle relaxants should be told to stop taking the medication if they feel sleepy. A. Rationale: Baclofen (Lioresal) is sometimes used in an injectable form. Cyclobenzaprine (Flexeril) often results in deep sedation and sleepiness. Patients taking muscle relaxants are at risk to develop hypotension; therefore, they should be taught safety measures to prevent falls. Sedation and sleepiness are common side effects of muscle relaxants; however, a patient should not abruptly discontinue use of the medication. Safety procedures should be followed to prevent accidents and falls.

Case Study #2:

While preparing an infusion of mannitol (Osmitrol), the nurse notices small crystals in the IV tubing. The most appropriate action by the nurse is to A. administer the infusion slowly. B. discard the solution and obtain another bag of medication. C. obtain a filter and then infuse the solution. D. return the fluid to the IV bag to dissolve the crystals. B.

B-Type Natriuretic Peptides:

aka BNP •Amino-acid secreted by heart ventricles in response to excessive stretching of heart muscle cells •Levels of BNP are elevated in patients with congestive heart failure •Correlates with severity of symptoms, prognosis •Used to regulate treatment medication dosages

niacin (Nicotinic Acid):

aka Vitamin B3 (OTC or Rx- Nicobid) -Lipid-lowering properties require much higher doses than when used as a vitamin -Effective, inexpensive, used with other lipid-lowering drugs, not first line therapy *Mechanism of Action:* -Inhibit lipolysis of adipose tissue -Increase lipase activity which breaks down lipids -Reduces metabolism/catabolism of cholesterol, triglycerides -Vasodilation of cutaneous vessels, increase gastric acid -Stimulates fibrolytic system to break down fibrin clots *Indications: (used alone or combination)* -Lowers triglycerides, total cholesterol, LDL -Increases HDL levels -Effective: hyperlipidemia types IIa, IIb, III, IV, and V -Max effect 3-5 weeks (triglycerides 1-4 days) *Adverse Effects:* -Flushing -vasodilation -minimize: aspirin/NSAID dose 30 minutes prior -Pruritus -GI distress (take with meals) *Contraindications:* -allergy -liver ds -peptic ulcer -gout -lactation

Fibric Acid Derivatives:

aka fibrates -gemfibrozil (Lopid), fenofibrate (Tricor) *Mechanism of Action:* -Activate lipase to break down cholesterol -Suppress free fatty acid release from adipose tissue, Inhibit triglyceride synthesis in liver -Increase secretion of cholesterol in the bile -Decrease platelet aggregation, increase fibrinolysis *Indications: (not first line drug)* -Treatment of types III, IV, and V hyperlipidemias -Decrease triglycerides, VLDL, LDL and increase HDL *Adverse Effects:* -Abd discomfort -n/v/d -risk of gallstones -Blurred vision -headache -hematuria -impotence -Prolonged prothrombin time -increase liver enzymes *Interactions:* -Oral anticoagulants (warfarin) -With statins: risk of myositis, myalgia, rhabdomyolysis -Fenofibrate raises level of ezetimibe *Contraindications:* -severe liver -gallbladder -kidney ds -cirrhosis

A patient with a serum potassium of 6.0 mEq/L is ordered polystyrene sulfonate (Kayexalate) via the nasogastric tube. When administering the medication, the nurse should administer the drug with? A.sorbitol B.water C.an antacid a laxative

b.

Class Ic:

flecainide, propafenone -Block Na channels (more pronounced effect) -Little effect on APD or repolarization -Slow conduction: atria, AV node, ventricles -Used for severe ventricular dysrhythmias, PVCs -May be used in atrial fibrillation or flutter, Wolff-Parkinson-White syndrome, supraventricular tachycardia dysrhythmias

Vasodilators:

hydralazine (Apresoline), minoxidil, nitroprusside (Nitropress), diazoxide (Hyperstat) *Mechanism of Action:* -Direct relaxation of arterial, venous smooth muscle -Results in: Decrease SVR, decrease afterload Peripheral vasodilation -Indications: Treatment of HTN -Used in combination with other drugs -*Sodium nitroprusside and IV diazoxide are reserved for the management of HTN emergencies* *Interactions:* -Hydralazine can produce additive hypotensive effects when given with adrenergic or other antihypertensive drugs *Contraindications:* -cerebral edema -head injury -acute MI -HF -hypotension *Adverse Effects of Minoxidil:* -ECG changes -angina -rash -tamponade thrombocytopenia

Miscellaneous Drugs for HF:

hydralazine/isosorbide dinitrate (BiDil) -First drug approved for HF specifically used for African Americans dobutamine (Dobutrex) IV only -Beta1-selective vasoactive adrenergic drug -Structurally similar todopamine -Inotropic -2.5-10 mcg/kg/min (48hr)

ACE Inhibitors:

lisinopril, enalapril, captopril Uses: hypertension, HF, acute MI -Prevent sodium and water resorption by inhibiting aldosterone secretion—causes diuresis -Diuresis decreases peripheral resistance, lowers blood volume, increases cardiac output -Cardioprotective: prevent remodeling post MI *Adverse effects:* -Hyperkalemia -dry cough -dizziness -decreased renal function -Pregnancy category D

Beta Blockers:

metoprolol- beta blocker Carvedilol- beta, alpha1, blocker, CCB, antioxidant slows progression of HF -Cardioprotective: prevent catecholamine-mediated actions by reducing/blocking SNS stimulation to the heart, conduction system -Reduce HR, delay AV conduction -Reduce myocardial contractility, automaticity

Class Ib:

phenytoin, lidocaine -Block sodium channels -Weak depressive effects: repolarization, ADP -Act preferentially on ischemic myocardial tissue -Lidocaine is used for ventricular dysrhythmias only -Phenytoin is used for atrial and ventricular tachydysrhythmias caused by digitalis toxicity or long QT syndrome

Class Ia:

procainamide, quinidine, disopyramide -Block sodium (fast) channels -Delay repolarization -Increase action potential duration (APD) -Used for atrial fibrillation, premature atrial contractions, premature ventricular contractions, ventricular tachycardia, Wolff-Parkinson-White syndrome

Cancer Treatments:

surgery, radiation, chemotherapy Chemotherapy: Pharmacologic treatment of cancer Antineoplastic drugs -Cell cycle-specific (CCS) -Cell cycle-nonspecific (CCNS) -Chemotherapy most effective when used in rapid dividing/proliferative tumor

Antiepileptic Drugs:

valproic acid gabapentin (Neurontin) lamotrigine (Lamictal) felbamate (Felbatol) levetiracetam (Keppra) topiramate (Topamax) zonisamide (Zonegran) tiagabine (Gabitril) pregabalin (Lyrica) permapanel (Fycompa) ezogabine (Potiga) vigabatrin (Sabril) Valproic acid= Depakote Gabapentin= antiseizure, combined with others to control their seizure Lamictal, Keppra, Topamax= newer generation that may be combined or used alone Zonegran= newer third generation drug, longer acting for seizure control

Sedative-Hypnotic Types: Benzodiazepines

•Long acting -Clonazepam (Klonopin) -diazepam (Valium) -flurazepam (Dalmane) •Intermediate acting -Alprazolam (Xanax) -lorazepam (Ativan) -temazepam (Restoril) (sleep aid) •Short acting -Midazolam (Versed) (short-acting procedures, conscious sedation, titrated to the dose, puts them to sleep where they don't remember but can easily wake up) -triazolam (Halcion) -eszopiclone* (Lunesta) -ramelteon* (Rozerem) -zaleplon* (Sonata) -zolpidem (Ambien) (hypnotic drug, sleep aid) *= miscellaneous drugs

pancuronium (Pavulon):

•Long-acting nondepolarizing NMBD •Used as adjunct to general anesthesia to facilitate endotracheal intubation and to provide skeletal muscle relaxation during surgery or mechanical ventilation •Commonly used for long surgical procedures that require prolonged muscle paralysis

succinylcholine (Anectine):

•Works similarly to neurotransmitter acetylcholine (ACh), causing depolarization •Metabolism is slower than ACh, so as long assuccinylcholine is present, repolarization cannot occur. •Result: flaccid muscle paralysis -Transient muscle pain is common Ties up receptors for 5-9 minutes, muscles cantcontract, after 5-9 minutes It comes back, very short acting

Case Study 3:

A 40-year-old female patient is seen in the clinic. She has been newly diagnosed with RA. Which medication does the nurse anticipate being ordered for the patient? A. methotrexate B. adalimumab C. infliximab D. etanercept A.

Cyclophosphamide (Cytoxan):

A nitrogen mustard derivative** -Treats bone, lymph cancers, solid tumors, anti-rejection organ transplants, severe RA Adverse Effects: -Bladder irritation, and bleeding (hemorrhagic cystitis) -Syndrome of inappropriate antidiuretic hormone secretion (SIADH) causing potentially fatal hyponatremia (compounded when IV fluids are given to treat cystitis) Monitor urine output, po fluids, labs*** Can irritate bladder, cause blood In urine, treat it with more hydration Be careful if sodium level is too low and give more hydration fluids

Case Study:

A patient is being discharged on cyclosporine therapy. Which statement by the patient indicates that more teaching is needed? "I will take the cyclosporine tablet with: A. water." B. milk." C. grapefruit juice." D. apple juice." C.

Case Study:

A patient who had a kidney transplant is receiving cyclosporine orally in maintenance doses. What action would decrease the potency of this drug? A. Taking it with green leafy vegetables B. Taking it with milk C. Using a Styrofoam container to administer the drug D. Mixing it with chocolate milk C.

Miscellaneous Antineoplastics: Hydroxyurea (Hydrea, Droxia)

Action similar to antimetabolites -CCS drug, interferes with synthesis of DNA -Treats squamous cell carcinoma, some leukemias Adverse effects: -drowsiness -HA -n/v -nephrotoxicity -edema -dysuria -rash -muscle -weakness -hyperuricemia myelosuppression -pulmonary fibrosi -peripheral neuropathy Interacts with HIV med zidovudine -Neurotoxic s/s with fluorouracil, reduce cytarabine -Works on the kidneys, kidney function can deplete

Interferons: Adverse Effects and Indications

Administered 1-3 times per week -Given IM or subcutaneously; rotate sites Adverse effects: -Dose-limiting adverse effect = fatigue -Flulike: fever, chills, headache, myalgia Other adverse effects: -Dizziness, anorexia, n/v/d Contraindications: -Immunosuppressant drugs, severe liver ds -Cytochrome P450 enzyme pathway, toxicity with zidovudine antiviral (HIV) drugs -These drugs use the p450 pathway of the liver, if patient has liver disease they cannot take this medication -Dosages are in mu unit

Case Study 2:

Before administering methotrexate, it is most important for the nurse to assess the patient for: A. allergy to eggs. B. congestive heart failure. C. latent tuberculosis. D. hypothyroidism C.

Adrenergic Blockers:

Bind to adrenergic receptors Inhibit/block stimulation of sympathetic nervous system Have the opposite effect of adrenergic drugs -*Adrenergic antagonists* -Sympatholytic (lyse/inhibit SNS response) Classified by type of adrenergic receptor they block -Alpha blockers -beta blockers, -alpha-beta blockers -Reverse of sympathetic response Will see bradycardia Hypoglycemia SE: -impotence (erectile dysfunction) -bronchoconstriction (have to think about this when pts have respiratory disorders like COPD or asthma)

Myelosuppression:

Bone Marrow Depression -Destroy precursors of WBC, RBC, Platelets Leukopenia, anemia, thrombocytopenia -Nadir= lowest level WBC post chemo 10-28 days following dose (shorter with recurrent chemo tx) -Prophylactic antibiotics, blood stimulants Contraindications to Chemotherapy: -WBC<500, infection, depleted nutrition, hydration -Pregnancy-fetal harm, reduced fertility, frailty in elderly -greatest risk of fetal harm or death is during the first trimester

Cell Cycle Nonspecific Antineoplastic Medications:

CCNS drugs -Cytotoxic during any cell-cycle stage -Alkylating drugs -Cytotoxic antibiotics -Miscellaneous antineoplastic (cell-cycle specificity unclear or novel drug mechanism) -Hormonal agents -Radioactive antineoplastics

Alpha Blockers: Adverse Effects

Cardiovascular Palpitations, orthostatic hypotension, tachycardia, edema, chest pain ---(alpha blockers are known to cause orthostatic hypotension, which then increases heart rate) CNS (central nervous system) Dizziness, headache, anxiety, depression, weakness, numbness, fatigue Gastrointestinal Nausea, vomiting, diarrhea, constipation, abdominal pain Other Incontinence, dry mouth, pharyngitis

Cancer:

Cellular transformation (genetic mutation) causing uncontrolled, rapid cellular growth. -Invasion into surrounding tissue (tumor/neoplasm) -Metastasis to other tissues or organs Cancerous cells lack: -Growth control mechanisms -Cell differentiation Tumors -Benign: uniform cells, similar to tissue of origin, slow growth, encapsulated -Malignant: cancer cells, rapid unpredictable growth, metastasize, recurrent

Rheumatoid Arthritis:

Chronic Autoimmune Disorder -Inflammation and tissue damage in joints -Diagnosis: blood rheumatoid factor pain, stiffness, joint swelling, decreased ROM hereditary, women>men -Treatment goal: alleviate pain, decrease damage -Initial: anti-inflammatory NSAIDs, corticosteroid -First line: DMARDS modify disease process

Nursing Implications:

Cytotoxic antibiotics -Expect bone marrow suppression, n/v/d, stomatitis, Monitor pulmonary status (pulmonary fibrosis) -Monitor for nephrotoxicity liver toxicity. -Monitor CV status. -Daunorubicin may turn the urine a reddish color.

Cell Cycle Specific Antineoplastic Medications:

Drugs cytotoxic during a specific cell-cycle phase treats variety of solid or circulating tumors •Antimetabolites •Mitotic inhibitors •Alkaloid topoisomerase II inhibitors •Topoisomerase I inhibitors Antineoplastic enzymes

Immunosuppressants:

Drugs that decrease/prevent immune response Immune-related disorders: Rheumatoid arthritis, systemic lupus erythematosus (SLE), Crohn's disease, multiple sclerosis (MS), myasthenia gravis, psoriasis, others -Prevent/treat rejection of transplanted organs -Act to suppress certain T-lymphocyte cell lines, thus preventing their involvement in immune response. -Pharmacologically immunocompromised state -Mechanisms of action vary according to drug -Adverse effects vary according to drugs and may be devastating. -All immunosuppressed patients have a heightened susceptibility to opportunistic infections. -Priority nursing outcomes for all immunosuppressant therapy: maximal comfort during drug therapy

Hematopoietic Drugs:

ERYTHROPOIETIC DRUGS -epoetin alfa -darbepoetin alfa COLONY-STIMULATING FACTORS (CSFS) -filgrastim -pegfilgrastim -sargramostin PLATELET-PROMOTING DRUGS -oprelvekin -romipliostim

Therapeutic Effects of Biologic Response-Modifying Drugs:

Enhancement of hematopoietic function Promote synthesis of major blood components -Red blood cell, platelet, neutrophil production Decrease the duration of chemotherapy-induced anemia, neutropenia, and thrombocytopenia -Enable higher doses of chemotherapy -Decrease bone marrow recovery time -Regulation/enhancement of immune response Cytotoxic activity against cancer cells Stimulate other cells in the immune system

Antineoplastic Enzymes:

Enzymesynthesized using cultures of bacteria and recombinant DNA technology -asparaginase (Elspar): used to treat acute lymphocytic leukemia -pegaspargase (Oncaspar)-decreased allergy Indication:treatment of acute lymphocytic leukemia Adverse effects: -impaired pancreatic function, hyperglycemia, severe or fatal pancreatitis -Dermatologic, hepatic, genitourinary, neurologic, musculoskeletal, GI, and CV effects can cause pancreas to stop working

Erythropoietic Drugs:

Epoetin alfa (Epogen, Procrit) -Promotes synthesis of erythrocytes in bone marrow -Synthetic form of natural hormone erythropoietin -Used to treat anemia -effectiveness monitored through hematocrit level -Contraindicated in uncontrolled HTN, Hgb>10g/dL -Adverse effects—HTN,HA, fever, n/v, pruritis, rash, arthralgia -natural hormone erythropoietin manufactured by kidney in response to low RBC -Kidney failing patients need erythropoietic drugs -Hematocrit IS THE PERCENTAGE OF RBC in blood

Hematopoietic Drugs:

Erythropoetic Drugs, Colony Stimulator Drugs Platelet Promoting Drugs

Alkaloid Topoisomerase II Inhibitors:

Etoposide -Used to treat small cell lung cancer and testicular cancer -Not used as much now because of significant toxicities without therapeutic benefit -Etoposide IV in hydralcoholic diluent Concentration toxicity cautions

Immunomodulating Drugs:

Interferons (IFNs), Monoclonal antibodies (MABs) Interleukin (IL) receptor agonists and antagonists Miscellaneous drugs

Immunosuppressant Therapy:

Major classes used to prevent organ rejection: -Corticosteroids: inhibit all stages of T-cell activation Chemotherapy induction, maintenance immunosuppression, and acute rejection -Calcineurin inhibitors: inhibit the phosphate required for interleukin 2 production Cyclosporine, tacrolimus, sirolimus -Antimetabolites: inhibit cell proliferation Azathioprine, mycophenolate -Biologics: inhibit cytotoxic T killer cell function Muromonab-CD3, basiliximab -Therapeutic use varies from drug to drug. -Primary indication: prevention of organ rejection -Muromonab-CD3, mycophenolate, and tacrolimus are indicated for both prevention of rejection and treatment of organ rejection** -Fingolimod, glatiramer used to reduce exacerbations of relapsing-remitting MS**

Neoplastic and Paraneoplastic:

Neoplastic cell characteristic- tissue of origin Determines tx, responses, prognosis -Carcinomas: epithelial tissue -Sarcomas-connective tissue -Lymphomas: lymphatic -Leukemias-blood, marrow Paraneoplastic Syndromes- Group of symptoms-may be 1st sign of malignancy Cachexia- general ill health, malnutrition Fatigue, fever, anorexia, weight loss Hypercalcemia, Endocrine disorders- Cushing's, Addison's, SIADH

Case Study:

Which potential problem is of most concern for a patient receiving immunosuppressant drugs? A. Orthostatic hypotension B. Increased susceptibility to infections C. Neurotoxicity D. Peripheral edema B.

Monoclonal Antibodies:

golimumab+++ ibritumomab tiuxetan infliximab+++ natalizumab rituximab trastuzumab adalimumab+++ alemtuzumab belimumab bevacixumab cetuximab certolizumab+++ +++ DMARD