Pharmacology Week 13 Concept Map Notes

Alpha 1 Blockers Additional Notes

1.

Alpha 2 Agonists Additional Notes

1.

Bile Acid Sequestrants Additional Notes

1.

Class 1A Antiarrhythmic Agents Additional Notes

1.

Class 1B Antiarrhythmic Agents Additional Notes

1.

Class 1C Antiarrhythmic Agents Additional Notes

1.

Direct Vasodilators Additional Notes

1.

Fibrates Additional Notes

1.

Niacin Additional Notes

1.

Statins Additional Notes

1.

Bile Acid Sequestrants Patient Teachings

1. Mix powder with water or other fluids for administration (choking hazard if swallowed dry) 2. Do not take with other drugs 3. Take other drugs 1 hour before or 4-6 hours after bile acid sequestrants

ACE Inhibitors Patient Teachings

1. Monitor blood pressure and pulse on a regular basis 2. Move from lying to standing slowly 3. Report cough if intolerable 4. Report any swelling of lips or tightness in the throat

Alteplase/Reteplase/Urokinase Additional Notes

1. Most deadly 2. Can go in existing peripheral IVs, not in central line 3. Massive bleed risk 4. No IVs, subcutaneous, IMs, or ABGs 5. Only taken 3-4.5 hours of onset of symptoms 6. Avoid giving to active bleeding (peptic ulcers), uncontrolled hypertension 180/110+, and recent surgery within 2 weeks 7. Clarify with the provider Accidents (recent trauma) Aneurysm (hx of hemorrhagic CVA) AV malformation

Alpha 2 Agonists Nursing Implications

Can be used in pregnancy

Fibrates Uses

High triglycerides, most effective, and increased HDL

Alpha 2 Agonists Uses

Hypertension

Alpha 1 Blockers Uses

Hypertension and BPH

ARBs Uses

Hypertension and heart failure

ACE Inhibitors Additional Notes

1. ACE and ARBs act to lower the BP (not HR) 2. Prils add potassium 3. Prils puff up the tongue 4. "Chill pril" 5. Need a cardiac monitor 6. Potassium pumps muscles 7. High potassium, high pump 8. Peaked T wave, ST elevation 9. Avoid pregnancy Angioedema (ACE) Cough (ACE) Elevated K+

Alpha 2 Agonists Patient Teachings

1. Apply clonidine patch to hairless area on upper arm/torso 2. Rotate sites 3. Do not stop aburptly as rebound hypertension can occur

Class 1A Antiarrhythmic Agents Nursing Implications

1. Black box warning: prodysrhythmic properties 2. Prolong QT interval

ACE Inhibitors MOA

1. Blocks the enzymes that converts angiotensin II 2. Prevents the breakdown of bradykinin 3. This has a vasodilating effect and reduces retention of sodium and water

Warfarin Additional Notes

1. Blocks the formation of fibrin 2. WH- With Holding Clotting Factor 3. Slow acting (weaker) 4. Eat vitamin K consistently and in moderation 5. Lasts a long time 6. INR= 2-3 therapeutic range and 2.5-3.5 with heart valve replacement 7. Vitamin K Kills warfarin 8. Not increased, not decreased, and not avoid vitamin K totally 9. Antibiotics increase the risk of bleeding by increasing INR by killing vitamin K 10. Warkin: is it working? 11. INR of 4-5? Assess for bleeding and get the antidote ready 12. Life-long 12. Frequent blood tests to check INR therapeutic range

Alpha 1 Blockers Nursing Implications

1. Can lead to sodium and fluid retention 2. Elderly are more prone to orthostatic hypotension

Bile Acid Sequestrants Nursing Implications

1. Cautions: Biliary obstruction and impaired GI function 2. Can decrease absorption of many drugs and fat soluble vitamins 3. Vitamin supplementation may be required

Heparin Nursing Implications

1. Classified as high-alert drug due to major adverse events 2. Monitor platelet levels for HIT and discontinue immediately if HIT occurs 3. Contraindicated in risk for bleeding: GI ulcer, aneurysms, severe hypertension, and intracranial bleeding 4. Monitor aPTT for therapeutic response 5. Antidote is protamine sulfate

ARBs Nursing Implications

1. Combined with diuretic for African American hypertensive patients 2. Cough not common like with ACE inhibitor 3. Contraindicated in pregnancy 4. Use birth control if patient is a child bearing age female

ACE Inhibitors Nursing Implications

1. Combined with diuretic for African American hypertensive patients 2. Discontinue in pregnancy (black box warning) (use birth control) 3. Monitor potassium levels (avoid salt substitutes)

Statins Nursing Implications

1. Contraindicated in liver disease. Monitor liver function tests 2. Avoid in pregnancy (counsel childbearing aged women about risks) and lactation 3. Many drug interactions 4. Monitor for muscle pain, fatigue, cola-colored urine. If present, hold dose and notify 5. Monitor LDL response to therapy. Effects in 1-2 weeks, max effect at 4-6 weeks

Fibrates Nursing Implications

1. Contraindicated in severe renal impairment, liver disease, and history of gallbladder disease 2. Monitor liver function during the first year of treatment 3. Increased risk of myopathy when combined with statins

Class 3 Antiarrhythmic Agents Uses

1. Conversion of afib and aflutter to NSR 2. Maintainence of SR 3. Treatment of VT and vfib

Fibrates AE

1. Diarrhea 2. Formation of gallstones 3. Hepatotoxicity 4. Myopathies

Warfarin Patient Teachings

1. Do not change your intake of foods high in vitamin K (broccoli, brussel sprouts, dark leafy greens, and peppers) 2. Interacts with G-herbs 3. Routine blood testing is necessary to determine dosing 4. Notify provider if you suddenly stop smoking

Heparin Patient Teachings

1. Education related to bleeding risk 2. Self administration techniques

ACE Inhibitors Uses

1. First line of treating hypertension 2. Used for heart failure 3. Kidney protection in diabetes, kidney damage, and hypertension 4. Post myocardial infarction

Low-Molecular-Weight Heparin (Enoxaprin/Dalteparin) Nursing Implications

1. Fixed or weight-based doing without monitoring of blood coagulation 2. Less risk of thrombocytopenia but platelets should still be monitored 3. Protamine sulfate can be used, but not as effective of reversal

Bile Acid Sequestrants AE

1. GI (constipation and flatulence) 2. Can cause increased bleeding times by binding to vitamin K

Class 3 Antiarrhythmic Agents MOA

1. Has characteristics of sodium channel blockers, beta blockers, and calcium channel blockers 2. Slows down electrical activity in both atria and ventricles

Class 1B Antiarrhythmic Agents Nursing Implications

1. High risk alert: do not confuse lidocaine combined with epinephrine for local anesthesia use with IV lidocaine

Direct Vasodilators Uses

1. Hypertensive emergancy 2. Control of BP in surgery

Direct Vasodilators AE

1. Hypotension 2. Reflex tachycardia

ARBs AE

1. Less risk of angioedema than ACEs 2. Usually well tolerated 3. Hyperkalemia

Aspirin/Clopidegrol Additional Notes

1. Lowers platelet aggregation 2. Spreads platelets out 3. A.C. for anti-clogging 4. Used post-PCI (Percutaneous coronary intervention) 5. Less chance of them sticking together 6. Key numbers: Hgb less than 7= heaven Platelets less than 150,000= very iffy Platelets less than 50,000= very risky 7. Activated charcoal is the #1 drug for aspirin toxicity 8. Key signs of aspirin toxicity is tinnitus and hyperventilation

Class 1A Antiarrhythmic Agents Uses

1. Maintaining NSR after conversion of afib, SVT, and vtach 2. Prevention of vfib

Statins Patient Educations

1. Many manufacturers recommend taking at night (when cholesterol production is most active) 2. Do not take with grapefruit juice

Low-Molecular-Weight Heparin (Enoxaprin/Dalteparin) Additional Notes

1. Never aspirate/rub injection site 2. 25 G needle at 90 degree angle 2 inches from the umbilicus 3. Given for prevention of new clots and growth of existing clots 4. "Diet coke" compared to heparin 5. It's normal to have mild pain, bruising, irritation, and redness at the injection site 6. Doesn't need frequent blood tests, but assess hematocrit and hemoglobin and open fractures before giving 7. Open fractures/hematocrit and hemoglobin is low= enoxaprin is a no-go 8. Decreased hematocrit and hemoglobin with a drop in blood pressure means blood loss 9. Platelets should be 150,000-400,000, hold the drug if platelets are below 50,000 10. HIT= heparin induced thrombocytopenia and is seen as platelet count decreased by half in 24 hours of giving the drug 11. HIT is when Half the platelets are gone in 24 hours of giving Heparin

Aspirin/Clopidegrol Nursing Implications

1. No antidote for clopidogrel 2. Contraindicated in active bleeding 3. Assess for bleeding

ARBs Additional Notes

1. Normal range of potassium is 3.5-5.0 2. Look for big BP drop 3. Sartans spare potassium 4. ACE/ARBs decrease water 5. Adds sodium/water in 6. Lets potassium (K+) out 7. ACE and ARBs act to lower the BP (not HR) 8. Avoid pregnancy Angioedema (ACE) Cough (ACE) Elevated K+

Heparin Additional Notes

1. Quick acting (hella fast) 2. Administered IV or subcutaneous 3. Given with warfarin for several days 4. Doesn't dissolve clots 5. PTT=46-70 6. HePTT the frog: H=heparin, P=protamine sulfate, and PTT=46-70

ACE Inhibitors AE

1. Rare but serious: angioedema (deep swelling and welts in the face and neck) which could effect the airway 2. Common: persistent cough 3. First dose hypertension 4. Hyperkalemia

Bile Acid Sequestrants Use

1. Reduces LDL, little to no effect on HDL and triglycerides 2. Used adjunct to statins or niacin

ARBs Patient Teachings

1. Report any swelling of lips or tightness of throat 2. Monitor blood pressure and pulse on a regular basis 3. Move from lying to standing slowly 4. Avoid salt substitutes and potassium supplements may be needed

Niacin Nursing implications

1. Safety concerns when combined with statins 2. Typically combined with bile acid sequestrants or fibrates 3. Monitor for hepatotoxicity 4. Contraindicated in liver disease

Low-Molecular-Weight Heparin (Enoxaprin/Dalteparin) Patient Teachings

1. Self-administration: cleanse skin, inject around navel, upper thigh, or buttock, and rotate sites 2. Education related to bleeding risk (minimizing risk and reporting)

Alteplase/Reteplase/Urokinase Nursing Implications

1. Shouldn't be given with other anticoagulants 2. Contraindicated in severe hypertension, aneurysm, vessel malformations, internal bleeding, brain or spine surgery or recent trauma in the past 3 months, recent major surgery, and use of oral coagulants 3. For stroke- give within 4 hours of symptoms occurring 4. Rule out hemorrhagic stroke with CT can before starting therapy

Alpha 1 Blockers Patient Teachings

1. Take first dose or first increased dose at bedtime to prevent dizziness/fainting 2. Move positions slowly

Warfarin Nursing Implications

1. Takes 3-5 days to come into effect (bridge from heparin and warfarin) 2. Warfarin antidote= vitamin K 3. Monitor PT and INR for therapeutic effect 4. Assess for signs of bleeding

Niacin Patient Teachings

1. To reduce flushing, start with small doses and gradually increase 2. Take doses with meals and take 325mg of aspirin 30 minutes prior

Statins Use

1. Treatment for hypercholesterolemia 2. Most powerful drugs for LDL reduction

Class 2 Antiarrhythmic Agents Uses

1. Treatment of SVT and ventricular tachycardia 2. Reduces mortality after myocardial infarct 3. Control rate of afib

Class 1B Antiarrhythmic Agents Uses

1. Treatment of vtach 2. Prevention of vfib

Statins AE

1. Usually well tolerated (GI and headache) 2. Myopathies (muscle pain) should be reported and they can become severe (rhabdomyolysis); there is an increased risk when combined with a fibrate 3. Liver function should be monitored routinely

Class 1A Antiarrhythmic Agents AE

1. Vision changes 2. Dysrhythmias 3. GI 4. Liver toxicity

Aspirin/Clopidegrol Patient Teachings

1. When combined with anticoagulants, there is a high risk for bleeding 2. Safety precautions to prevent injury/bleeding 3. Report bleeding 4. Take aspirin with food and water to decrease stomach irritation

Bile Acid Sequestrants MOA

Binds to bile in GI tract, causing liver to use cholesterol to make more bile, pulling cholesterol from serum into the liver

Class 1C Antiarrhythmic Agents AE

Black box: new or worse dysrhythmias

Alteplase/Reteplase/Urokinase AE

Bleeding and brain hemorrhage (3% mortality rate)

Class 1C Antiarrhythmic Agents Nursing Implications

Continuous ECG monitoring when starting treatment

Class 1B Antiarrhythmic Agents MOA

Decreases cardiac tissue irritability in ventricles (does not impact AV conduction)

Alpha 1 Blockers MOA

Dilate blood vessels

Direct Vasodilators MOA

Directly relaxes smooth muscle in blood vessels (vasodilation)

Low-Molecular-Weight Heparin (Enoxaprin/Dalteparin) MOA

Inactivate factor Xa via antithrombin

Heparin MOA

Inactivates clotting factors to inhibit conversion of prothrombin to thrombin

Alpha 1 Blockers AE

First dose hypotension (dizziness and fainting)

Class 1A Antiarrhythmic Agents Patient Teachings

Frequent follow up and blood work required

Direct Vasodilators Nursing Implications

Given IV

Class 1C Antiarrhythmic Agents MOA

Greatly decreases conduction in ventricles

Warfarin AE

Hemorrhage (Contraindicated in bleeding risk)

Heparin AE

Hemorrhage and heparin induced thrombocytopenia (HIT)

Low-Molecular-Weight Heparin (Enoxaprin/Dalteparin) AE

Hemorrhage and heparin induced thrombocytopenia (HIT)

Fibrates MOA

Increase oxidation of fatty acids in liver and muscle tissue

Aspirin/Clopidegrol MOA

Inhibit ADP receptors on platelet cell surface and prevents aggregation

Statins MOA

Inhibits enzymes required for the liver to make cholesterol

Warfarin Use

Long-term prevention or management of DVT, PE, Afib, and prosthetic heart valves

Alteplase/Reteplase/Urokinase Use

Lysis of acute thromboembolism in evolving MI, PE, and ischemic stroke

Alteplase/Reteplase/Urokinase MOA

Lysis of clots- converting plasminogen to plasmin

Niacin Uses

Most effective for increasing HDL

Heparin Use

Prevention and management of thromboembolic disorders (DVT, PE, and Afib)

Low-Molecular-Weight Heparin (Enoxaprin/Dalteparin) Use

Prevention and management of thromboembolic disorders (DVT, PE, and Afib) after surgery

ARBs MOA

Prevents binding to angiotensin II to receptor sites, leading to a vasodilating effect and reduction of sodium and water retention

Aspirin/Clopidegrol AE

Pruritis, rash, hemorrhage, severe neutropenia, and thrombotic thrombocytopenia purpura

Alpha 2 Agonists AE

Rebound hypertension if stopped aburptly

Fibrates Patient Teachings

Periodic blood tests needed

Alpha 2 Agonists MOA

Reduces production of norepinephrine and epinephrine

Aspirin/Clopidegrol Use

Reduction of MI and stroke in patients with atherosclerosis or after coronary stents

Niacin AE

Skin flushing, pruritus, GI irritation, tachycardia, hypotension, and dizziness

Class 1A Antiarrhythmic Agents MOA

Slows electrical impulses and conduction

Class 1C Antiarrhythmic Agents Uses

Treatment of vtach, vfib, or SVT not responding to other treatments

Class 1B Antiarrhythmic Agents AE

Uncommon

Warfarin MOA

Works in the liver to prevent synthesis of vitamin K dependent clotting factors