CNUR 202 part 2

B- adrenergic drugs: Beta blockers

"olol's" - atenolol, metoprolol, acebutolol Mechanism of Action ¡block beta-adrenergic receptor sites located on the heart and the smooth muscle of the bronchioles and vessels. ¡Cardioselective (beta1): ¡Reduce myocardial stimulation - ¡Non-selective (beta1 & 2): ¡All the above plus.......constrict the bronchioles and dilate vessels - NOT a first line agent for those over age 60 years

Patient education for antianginal drugs

- Proper technique and guidelines for taking sublingual (SL) nitroglycerin for anginal pain Never to chew or swallow the SL form- PO has high first pass effect A burning sensation felt with SL forms indicates that the drug is still potent Keep a fresh supply of nitroglycerin on hand - Keep the medication away from moisture, light, heat -cotton filter, keep in original package Proper application of nitrate transdermal forms - take off old patch, rotate sites To reduce tolerance of topical ointment; allowing for a nitrate-free period- older form of medication Take nitrates as needed at the first hint of anginal pain- Monitor vital signs frequently during acute exacerbations of angina, keep fresh nitroglycerin on hand if drug isn't working- check expiration date and when it was opened- write on bottle- only good for 3 months after- monitor headaches, hypotension, dizziness,A patient taking sublingual nitroglycerin who experiences chest pain should lie down to prevent or decrease dizziness and fainting that may occur due to hypotension If anginal pain occurs, the patient should: Stop activity and sit or lie down Take an SL tablet, and wait 5 minutes If no relief in 5 minutes, take a second SL tablet/spray If no relief in 5 minutes, take a third SL tablet/spray After three tablets, or 15 minutes, if no relief of chest pain, call 911 immediately Not try to drive to the hospital, A patient taking sublingual nitroglycerin who experiences chest pain should lie down to prevent or decrease dizziness and fainting that may occur due to hypotension If anginal pain occurs, the patient should: Stop activity and sit or lie down Take an SL tablet, and wait 5 minutes If no relief in 5 minutes, take a second SL tablet/spray If no relief in 5 minutes, take a third SL tablet/spray After three tablets, or 15 minutes, if no relief of chest pain, call 911 immediately Not try to drive to the hospital- IV- note PVC tubing, not blue, green, red, monitor BP and pulse before giving dose, contact if BP > 100 mm Hg, HR <60, >100, CCB Constipation is a common problem - BB Monitor pulse rate daily Dizziness or fainting Constipation is a common problem These medications should never be abruptly discontinued b/c of risk for rebound hypertensive crisis Inform patients that these medications are for long-term prevention of angina, not for immediate relief

ASA

Acetylsalicylic acid •Mechanism of Action: •Irreversibly inhibits cyclooxygenase, ultimately preventing thromboxane A formation •Result: prevents vasoconstriction and platelet aggregation •Effects last the lifetime of the platelet = 7 days •Indications: •Immediate treatment of acute events: •Suspected or actual myocardial infarction •Transient ischemia attacks •Evolving thromboembolic stroke •Prevention of MI and stroke in patients with prosthetic heart valves- 81 mg- do not need a prescription, used for anywhere on the cardiac spectrum, •Route and Dose: •Acute events: Chew an uncoated aspirin tablet •Maintenance: 81 mg EC tablets- not for pain, sit up after taking to prevent reflux •Adverse effects: •Bruising, bleeding, GI upset, drowsiness, dizziness, flushing, thrombocytopenia •Nursing Considerations: •Administer with food and a full glass of water •Instruct patient to remain upright for 30 min to prevent GI irritation •Teach patient that he may bruise easily •Prepare to hold pressure longer to sites following invasive procedures

Cephalosporins

1-5 generations, AE- same as penicillins, the higher the generation-= the more difficult the infection

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) Hypotension

Which assessements is the most important indicator of an exacerbation of HF in a patient? A) Increased weight B) Hypokalemia C) Increased pulse D) Increased oxygen sat

A) Increased weight

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 B) Acetaminophen (Tylenol) C) Penicillin D) Theophylline

A) Lithium

What should the nurse include in the teaching plan for a patient receiving a sulfonamide antibiotic? A) Maintain a fluid intake of 2-3 L per day B) Avoid direct sun exposure and tanning beds C) Take the medication with dairy products, such as milk D) Report the presence of tinnitus to your HCP

A) Maintain a fluid intake of 2-3 L per day

A patient is experiencing chest pain while playing tennis. He has sublingual nitroglycerin spray with him. In this situation, which of the following actions are approrparite for the patient to take? Select all that apply. A) Stop the activity and lie down or sit down B) call 911 immediately C) Spray under tongue D) Spray nitro in the space between the gum and the cheek E) If chest pain is not relieved after 1 minute, take another spray sublingually F) Take another spray sublingually if chest pain is not relieved after 5 minutes G) call 911 if the pain is not relieved after taking 3 sublingual tablets in 15 minutes

A) Stop the activity and lie down or sit down C) Spray under tongue F) Take another spray sublingually if chest pain is not relived after 5 minutes G) call 911 if the pain is not relieved after taking 3 sublingual tablets in 15 minutes

A patient had been placed on a milrinone infusion as part of the therapy for end-stage HF. Which of the following risks should the nurse keep in mind while assessing this patient during the infusion? A) hypotension B) Hyperkalemia C) Hypertension D) Decreased urinary output

A) hypotension

Which statement indicates an understanding of drug action from a patient new to statin therapy? A) it may take several months to reach target blood levels B) I will take this medication with a small sip of water each morning C) This drug will counteract my high- fat dietary habits, so I can eat all my favourites again D) This drug replaces the need to exercise to reduce my lipid blood levels

A) it may take several months to reach target blood levels

For which condition(s) is anticoagulant therapy indicated? Select all that apply. A.Atrial fibrillation B.Thrombocytopenia C.Myocardial Infarction D.Presence of mechanical heart valves E.Aneurysm F.Leukemia G.Post-operatively following major surgery

A.Atrial fibrillation C.Myocardial Infarction D.Presence of mechanical heart valves G.Post-operatively following major surgery

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

A.Eggs Although eggs are a common dietary source of iron, they should be avoided when ingesting oral iron preparations. In addition, corn, beans, and many cereal products contain chemicals known as phytates, which may impair iron absorption. The other foods enhance iron absorption.

Captopril

ACE inhibitor, mimizes. prevents left ventricular dilation and dysfunction, shortest half life- given 3-4 times daily, PO, onset- 15 min, Peak plasma concentration- 1-2 hr, elimination half life 2 hr, duration of action- 2-6 hr

Clinical indications for diuretics

Adjunctive therapy in edema associated with: ¡Heart failure ¡Cirrhosis ¡Renal impairment Hypertension ¡Alone or in combination with other drugs Acute renal failure Reduces pressure: ¡ICP before and after neurosurgery ¡IOP

Atherosclerotic plaque formation

Atherosclerosis - repeated, subtle injury to the artery's wall through various mechanisms ÷including smoking, ÷elevated blood pressure ÷Diabetes Mellitus ÷Elevated cholesterol

Angiotension Converting Enzyme Inhibitors

ACE inhibitors - "prils" ramipril, lisinopril- newer, longer half life, one dose, prodrug needs to be activatedd in liver, captopril(capoten)- short half life, slow, how it affects pt(HF), q6h, low dose, liver dysfunction First line therapy for HTN and HF Often used in combination: ¡thiazide diuretics or calcium channel blockers, not for monotherapy in darker skinned individuals MOA- Cardiac and renal effects Inhibit the conversion of angiotensin I to angiotensin II Prevent the breakdown of bradykinin and substance P (vasodilators) Inhibit aldosterone secretion Results: ¡Decreased SVR ¡Decreased afterload - ¡Prevention of sodium and water resorption ¡Diuresis and reduced preload - filling pressure at the end of diastole, Indications- Hypertension (discussing today) Heart failure- slows LVHF after MI Post myocardial infarction Renal failure patients with diabetes, Contraindications- Allergy: especially a previous reaction of angioedema- laryngeal swelling Pregnant/Lactating women Used with caution in women of child bearing age Children Bilateral renal artery stenosis- proteinuria (aggrivate or contribtute to) Hyperkalemia*****, increased sodium and water secretion, K re absorption increase, Adverse Effects- Fatigue Headache Impaired taste Rash Blood dycrasias (neutropenia, thrombocytopenia) •Dizziness •Mood changes •Hyperkalemia •Pruritis ØDry, nonproductive cough, which reverses when therapy is stopped (10-20%) ØAngioedema: 0.1 - 0.68% incidence ØNOTE: first-dose hypotension may occur! Black individuals and women may have increase risk, Interactions- NSAIDS- increase afterload Lithium- toxicity Potassium supplements and potassium-sparing diuretics- hyperkalemia

Angiotension 11 Receptor Blockers

ARBs - "sartans": losartan, valsartan Newer class Similar to ACE-I - bp/ hemodynamic effects Well tolerated Less likely to cause hyperkalemia, Mechanism of Action: decrease BP, SVR Block binding of angiotensin II to receptors Blocks vasoconstriction Block secretion of aldosterone Used to treat hypertension and heart failure (adjunct) Used primarily in clients who cannot tolerate ACE-I, vascular smooth muscle- adrenal glands prevent sodium and water retention, May be used alone or with other drugs such as diuretics ¡Hyzaar is a combination of losartan (ARB)and hydrochlorothiazide (Diuretic) Combinations of an ACE I with an ARB: ¡do not reduce cardiovascular events more than the ACE-I alone ¡have more adverse effects therefore are not generally recommended- not on ACE-I and ARB, protein urea, nephropathy- caution with HF, Contraindications: •Most patients can take these drugs •Drug allergy ACE-I, renin inhibitors and ARBs are contraindicated in pregnancy and caution is required in prescribing to women of child bearing potential. Adverse Effects: Upper respiratory infections Headache May cause occasional dizziness, inability to sleep, diarrhea, dyspnea, heartburn, nasal congestion, back pain, fatigue Use with caution - renal impairment, liver disease, billary tract obstructions

Adjunctive Anti-anginal drugs

ASA 80 - 325 mg - antiplatelet effects Antilipemics - decrease serum lipid levels Antihypertensives

Antidiarrheal drugs and laxatives

Abdominal pain, n/v, diarrhea/passage of stools with abnormality, increased frequency, fluid, weight, stool water excretion, > 3 stools (loose/liquid) per day, acute/chronic, treatment- decrease stool frequency, alleviate abdominal cramps, replenish fluid and electrolytes, prevent weight loss/ nutritional deficits

Anti-diarrheals

Absorbents, antimotility (anticholinergic and opiates), probiotics, MOA/DE- adsorbents- coat wall of GI tract, bind bacteria/toxin to surface for elimination from the stool, chemical binding of substances (absorption is penetration into structure or across a surface), anticholinergic- slow peristalsis by decreasing the rhythmic contractions and smooth muscle tone, dry effect to reduce gastric secretions, probiotics- replenish bacteria to help restore normal flora and decrease growth of bacteria, opiates- decrease bowel motility= increase absorption of water, electrolytes, nurtrients

Spironolactone

Aldactone, synthetic steroid that blocks aldosterone receptors, monitor serum potassium levels, commonly used for children with HF, potassium-sparing diuretics,oral, combination with hydrochlorothiazide, may be used in pregnancy despite fetal risks, onset- 1-3 days, peak- 2-3 days, half life- 13-24hr, duration of action- 2-3 days

Types of antihypertensive drugs

Angiotensin-converting enzyme inhibitors (ACE-I) Angiotensin II receptor blockers (ARBs) Calcium channel blockers (CCBs) Adrenergic drugs (a-2 receptor agonists & beta blockers) Vasodilators (direct acting) Diuretics

Losartan

Angiotension 2 receptor blocker, dose- 50-100 mg once daily, contraindicated in hypersensitivity, use in caution with kidney or liver dysfunction and renal artery stenosis and breastfeeding, onset- 1 hr, peak plasma concentration- 6 hr, elimination half life- 6-9 hr, duration of action- 24 hr

Fibrates

Are derivatives of fibric acid Examples include: Gemfibrozil (Lopid) Fenofibrate (lipidil) Mechanism of action increase the oxidation of fatty acids in liver and muscle tissue, inhibit peripheral lipolysis decrease hepatic extraction of free fatty acids decrease hepatic production of triglycerides, increase cholesterol into body, changes in blood coagulation- decrease platelet adhesion, warfarin- blood thinner- lower doses of fibrates, Indications: Primarily used for reducing serum triglyceride levels Useful for patients with low HDL- by as much as 25% In patients with coronary artery disease see a regression of atherosclerotic plaques If no decrease in serum lipid response in 3 months, d/c drug, contraindications- drug allergy, liver/kidney disease, cirrhosis, gallbladder inflammation, Adverse effects Abdominal discomfort Diarrhea Nausea Increased risk of gallstones Prolonged prothrombin time, Warfarin- displaces albumin binding site- more free drug in blood

Nursing Implications Diuretic Drugs

Assessment Baseline labs: electrolytes, BUN, creatinine, glucose Blood pressure Weight; fluid balance Presence of edema: Dependent areas ¡Nausea & vomiting ¡Abd. pain & tenderness ¡Ascites ¡Pulmonary edema, subjective- tired, SOB, shoes not fitting, Administer diuretics ¡early in the a.m. Ensure that client is receiving a ¡potassium supplement- unless pt is on k sparing diuretic Monitor routinely ¡electrolytes, give meds with food Elevate limbs when sitting- put legs on pillows, compression stockings Administer blood products and IV fluids cautiously IV route: ototoxicity, Evaluation of Therapy: increase output, decrease edema, decrease BP, weight loss, compliance Monitor for adverse effects ¡Metabolic alkalosis, drowsiness, lethargy, hypokalemia- k depleting, tachycardia, hypotension, leg cramps, restlessness, decreased mental alertness Monitor for hyperkalemia with potassium-sparing diuretics, teaching- Take diuretic early in the day Warn patient that frequent urination is expected Explain therapeutic benefits Weigh self every other day and record levels Dietary modifications ¡Potassium depleting diuretics: client requires potassium rich foods such as bananas, OJ Change positions slowly b/c postural hypotension can occur Diabetes: thiazide and loop diuretics may elevate blood glucose levels, Patients who have been ill with nausea, vomiting, should notify their physician because dehydration may be dangerous Signs and symptoms of hypokalemia Regular physician follow up is required Notify the physician immediately if they experience rapid heart rates or syncope (reflects hypotension or fluid loss) Excessive consumption of black licorice can lead to an additive hypokalemia in patients taking thiazides, dehydration- electrolyte imbalance

Nursing process for antiemetic and antinausea drugs

Assessment- I/O, skin/ mucus membrane- colour/ turgor, cap refill, lab tests, health/medication hx, dehydration, electrolyte balance, VS

Nursing Process for acid controlling drugs

Assessment- past/ present med hx- GI tract, food/activities, bowel patterns, GI functioning/pain, liver/kidney function tests, cardiac hx, medication hx, swallowing capacity, GI assessment

Nursing Process for Antibiotics

Assessment- §What assessment data should the nurse collect before beginning antibiotic therapy? §Medication history - including OTCs; determine potential drug interactions, medical hx §Allergies §Vital Signs §Results of lab tests: CBC, coags, LFTs, Renal function, cardiac function, pregnancy tests §Immune status §Hydration status - including fluid restrictions §Physical assessment: CNS, respiratory, cardiac, GI, GU, oral mucosa, etc. §Culture and sensitivity results: It is essential to obtain cultures from appropriate sites before beginning antibiotic therapy Diagnoses- Nonadherence, knowledge deficit, risk for infection/sepsis, risk for n/v, risk for diarrhea, Implementation- §Administer medications on time!- IV! §Administer with food or fluids as indicated: §All oral antibiotics are absorbed better if taken with at least 180 mL of water- cup §Sulfonamides: take oral doses with food; take with 2 - 3 L of fluid daily while on therapy §Penicillins: §Take with water only; avoid juices because acidic fluids may nullify the drug's action §Monitor the patient for at least 30 min after drug administration- especially if new to drug §Cephalosporins: §Assess for penicillin allergy §Give oral forms with food, §Macrolides: §Highly protein bound; will cause severe interactions with other protein bound drugs §Oral erythromycin is absorbed better on an empty stomach § §Tetracyclines: §Avoid milk products, iron preparations, antacids, and other dairy products because of the chelation and drug binding that occur §Take all medications with at least 180 mL of fluid, preferably water §Because of photosensitivity, avoid sunlight and tanning beds, Teaching- §Most "colds" are viral and do not require antibiotics §Take antibiotics exactly as prescribed and for the length of time prescribed §Never take another person's prescription §All oral antibiotics are absorbed better if taken with at least 180 to 240 mL of water §Each class of antibiotics has specific adverse effects and drug interactions §Cephalosporins may cause a serious reaction if taken with alcohol, refer to social worker if cost is an issue, §Some antibiotics reduce the effectiveness of oral contraceptives & estrogen §Ampicillin, nitrofurantoin, pen V, sulfonamides and tetracycline §Use an alternative birth control method while on therapy §The most common adverse effects of antibiotics are nausea, vomiting, and diarrhea- GI effects §Report severe, watery malodorous diarrhea; fever, perineal itching, cough, lethargy or unusual discharge- C. diff §Wear a medical alert bracelet if severe allergy §Encourage vaccination, Evaluation- should improve quickly- call physician if not, fever spikes- more invasive interventions

The nurse is assessing a patient who is receiving IV digitalis and recognizes that the drug has a negative chronotropic effect. How is this drug effect made evident in the patient? A) Increased HR B) Decreased HR C) Decreased conduction D) Increased ectopic beats

B) Decreased HR

The nurse is assessing the patient before administration of a cardiac glycoside. Which condition can predispose a patient tot digitalis toxicity? A) Hypokalemia B) Hyperkalemia C) Hypocalcemia D) HF

B) Hyperkalemia

Which lab tests would the nurse monitor for adverse reactions to HMG- CoA reductase inhibitors? A) CBC B) Liver function tests C) Renal Function tests D) Serum cholesterol levels

B) Liver function tests

When is tetracycline contraindicated? Select all that apply. A) Adults over age 65 B) Pregnancy C) Children under 8 D) Chronic kidney disease E) Breastfeeding

B) Pregnancy C) Children under 8 E) Breastfeeding

Which location is the area where the highest percentage of sodium and water are reabsorped back into the bloodstream? A) Glomerulus B) Proximal Tubule C) Ascending loop of henle D) Distal Tubule

B) Proximal Tubule

The patient is ordered furosemide (lasix). Before administering furosemide, it is most important for the nurse to assess the patient for allergies to which drug class? A) Aminoglycosides B) Sulphonamides C) Macrolides D) Penicillins

B) Sulphonamides

A patient is about to receive his morning dose of digoxin (Lanoxin), has an apical impulse of 54. What should the nurse do? A) Administer the dose B) Withhold the dose and notify the physician C) Notify physician and monitor the patient's vital signs D) recheck the pulse, making sure to count for 1 full minute

B) Withhold the dose and notify the physician

The nurse has administered IV iron 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.30 minutes It is recommended that the patient remain recumbent for 30 minutes after an IV injection of iron, to prevent drug-induced orthostatic hypotension.

Nursing Implications for all anti-hypertensives

Before beginning therapy ¡obtain a thorough health history and do a head-to-toe physical examination Assess for contraindications - specific drugs Patient education - importance of not missing a dose, double dose, take as prescribed, monitor BP during therapy (journal)- BP cuff in stores- not accurate, assess how they are taking, Instruct patients that these drugs should not be stopped abruptly - rebound hypertension, stroke Oral forms should be given with meals - absorb faster and effective Administering intravenous (IV) forms Remind patients that medication is only part of therapy - lifestyle Avoid smoking and eating foods high in sodium Exercise - supervised Instruct patients to change positions slowly - orthostatic hypotension Patients should report - SOB, difficulty breathing, syncope, feet/ankle, face swelling, weight gain, chest pain, palpitations Impotence is an expected effect -men- adherence Contact physician immediately if - adverse effects, need dosage change Hot tubs, showers, or baths, prolonged sitting or standing, physical exercise, and alcohol ingestion - aggravate low BP, fainting, injury, sit/lie down until symptoms go away Patients should not take any other medications - OTC- need HCP approval, lifestyle, dizziness, fatigue, toxicity, OH, elevate therapeutic 130-139/ 80-89

Nursing Implications for Antilipemic drugs

Before beginning therapy, obtain a thorough health and medication history Use a risk assessment tool Assess dietary patterns, exercise level, weight, height, VS, tobacco and alcohol use, family history Assess for contraindications, conditions that require cautious use, and drug interactions, low fat diet, fiber/nutrition, decrease milk and eggs, Contraindications include biliary obstruction, liver dysfunction, active liver disease Obtain baseline liver function studies Clients on long-term therapy may need supplemental fat-soluble vitamins (A, D, K), Client must be counseled concerning diet and nutrition on an ongoing basis Instruct on proper procedure for taking the medications Powdered forms must be taken with a liquid Other medications should be taken 1 hour before or 4 to 6 hours after meals to avoid interference with absorption, Instruct clients to report persistent GI upset, constipation, abnormal or unusual bleeding, and yellow discoloration of the skin Monitor for side effects ¡Ie: liver enzymes Monitor for therapeutic effects ¡Reduced cholesterol and triglyceride levels, statin drugs- not used in liver disease, increase liver enzymes, BAS- powder- 120-180 mL of fluid, wait 1 min for medication to dissolve, low fat, low cholesterol diet- lifestyle change

Which of the following statements should indicate to the nurse that the patient requires further teaching regarding warfarin? A. "I will only shave with an electric razor." B. "I will take my medication in the early evening each day." C. "I will increase the dark green leafy vegetables in my diet." D. "I will contact my physician if I develop excessive bruising."

C. "I will increase the dark green leafy vegetables in my diet."

Stomach

Cardaic, pyloric, gastric glands- byspincters, gastric on spundus, highly specialized secretory glands- parietal, cheif, mucous, endocrine, enterochromaffin- parietal produce and secrete HCl (keeps pH 1-4), chief cells secrete pepsinogen (becomes pepsin when activated by exposure to acid), diseases occur when there is imbalance- acid hypersecretion- PUD, esophageal cancer, hyperacidity (heart burn), GERD, parietal cell is target- Ach, histamine, gastric targets- histamine- ATP-cAMP- energy for protein pump (hydrogen- K+, ATP- ATPase pump- transport H+ ions needed for production of HCl), H. pylori- stress related mucosal damage

Metoprolol

Beta blocker, blocks stimulation of beta 1 adrenergic receptors, po, onset- 15 min, peak- unknown, duration- 6-12 hr, contraindicated in HF, Pulmonary edema, Cardiogenic shock, bradycardia, AE- fatigue, weakness, erectile dysfunction

Ethnocultural considerations for hypertensive drugs

Black patients - ¡Calcium channel blockers and diuretics White patients - ¡b-blockers and ACE-I Asians - ¡Beta blockers have greater effects - smaller dose is effective African Canadians - ¡Diuretics are first drug of choice - usually more than 1 class Aboriginals- ¡higher incidence of CV and renal complications - due to HTN, SOD of health- diet, income, accessibility, weight in midsections, drugs are expensive

Regulation of blood pressure

Blood pressure is the pressure of blood in the arteries, two major determinants of arterial blood pressure are cardiac output- CO= HR x SV, peripheral vascular resistance (diastolic pressure)- Afterload, arterial BP, compensatory effects, Neural ¡Sympathetic nervous system Hormonal ¡Renin-angiotensin-aldosterone (RAA system) ¡Antidiuretic hormone (vasopressin) Vascular Substances released from endothelial cells Vasoconstriction Vasodilators Vascular Remodeling- endothelial dysfunction, thickened arterial walls- decreased lumen

A nurse is completing an admission assessment on a patient who reports being allergic to sulpha drugs What action should the nurse take first? A) Mark the allergy on the pt's medical chart B) Place a red allergy armband on the patient C) Ask the patient for more info about the nature of the allergy D) Notify the physician about the pt allergy

C) Ask the patient for more info about the nature of the allergy

Which statement of 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 side effect D) Overdose is usually manifested by hypertension and bradycardia

C) Chest pain is a common side effect

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

C) Hypokalemia

Which symptoms might indicate a serious adverse reaction to the drug Simvastatin (Zocor)? A)Fatigue B) Headache C) Muscle pain D) N/V

C) Muscle pain

Cardiac output and factors of stroke volume

Cardiac Output = HR X Stroke Volume- amount of blood ejected Stroke Volume determined by: Preload: blood volume available Afterload: the resistance or pressure against which the ventricle must pump Contractility: Strength of contraction

Which action does the nurse perform when administering a liquid oral iron? A.Administer with an antacid to minimize gastrointestinal upset. B.Administer the iron with Vitamin C as iron causes a decreased absorption of Vitamin C. C.Have patient take the medication with a plastic straw. D.Never dilute oral liquid dosages of iron.

C.Have patient take the medication with a plastic straw. Have the patient sip the medication through a plastic straw to avoid discolouration of tooth enamel. Instruct the patient to dilute liquid dosage forms of iron products according to manufacturer instructions. Drug interactions affecting the absorption of iron preparations include ascorbic acid (increased absorption), antacids (decreased absorption), as well as decreased absorption of other drugs such as tetracyclines and quinolones; these medications should be used cautiously in patients taking iron preparations. If antacids or milk products are used, schedule them at least 1 to 2 hours before or after the oral dosage of iron

Dyslipidemia (hyperlipidemia)

Can be primary ¡Genetic or familial Secondary ¡Diet ¡ Disease process- diabetes, alcoholism, obesity, hyperthyroidism, positive risk factors- Age ¡Male 40 years or older ¡Female 50 years or older, or postmenopausal Family history: strong history of premature CAD Current cigarette smoker Abdominal obesity Hypertension ¡BP 140/90 or higher, or on antihypertensive medication Diabetes mellitus Metabolic Syndrome - set of risk factors associated with obesity, including hypertriglyceridemia and low HDL, lifestyle changes- Prior to initiating drug therapy initiate lifestyle changes Use for 6 months prior to initiating drug therapy ¡Increase fruit and vegetable intake ¡Decrease saturated fats and trans-fatty acids to less than 7% of total calories ¡Increase intake of omega-3 fatty acids ¡Reduce intake of refined carbohydrates and sugar, increase fiber ¡Follow the Mediterranean diet ¡Stop smoking, lose weight, regular physical activity, should be implemented for 6 months before pharmacological interventions

B- adrenergic drugs

Cardio-selective Beta Blockers: in heart, increase HR and contractility, when stimulated increase BP, vasodilation decrease BP, decrease HR with less force ◦Agents which block only the Beta-1 receptors; ◦Drugs: Atenolol Metoprolol Esmolol Non-Selective Beta Blockers: ◦Agents which block BOTH beta-1 and Beta-2. ◦Drugs: Propranolol Sotalol Indications: ◦Angina, hypertension, tachycardia, arrhythmias, chest pain Contraindicated In: ◦Bradycardia, hypotension, heart block and Raynaud's disease- narrow blood vessels in fingers and toes due to cold ◦ Caution with non-selective agents for patients with asthma ◦Caution with diabetes: mask the signs of hypoglycemia, Adverse effects- most common: Postural hypotension Dry mouth Drowsiness/sedation Constipation Erectile dysfunction, other: Headaches Sleep disturbances Nausea Rash Palpitations, increase incidence of orthostatic hypotension, nursing considerations- Check v/s prior to administration. ¡HOLD if Heart rate __<50 Monitor fluid balance and electrolyte mbalance K DM check BG Vertigo may be normal initially(patient will adapt) Do not hold medication for low blood pressure if patient is asymptomatic- hypotension, mask hypoglycemic episodes, vertigo, <110-100, b blockers- <60, systolic <90 follow up with HCP

Dromotrope

Conductivity of electrical impulse, positive= increase speed of impulses through conduction system- SA, AN, Bundle of His, Purjinke fibers, negative= decrease speed

What is the priority assessment for a patient prescribed antibiotic therapy? A) Immunizations B) Hx of seizures C) Cardiac dysrhythmias D) Allergies

D) Allergies

A patient with a hx 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) Captopril

A patient has developed tolerance to transdermal nitroglycerin therapy. What is the nurse's best response to the patient? A) Omit one dose per week B) Leave the patch on for 2 days at a time C) Cut the patch in half for 1 week until the tolerance subsides D) Remove the patch at bedtime, and then apply a new one in the morning

D) Remove the patch at bedtime, and then apply a new one in the morning

After receiving an infusion of vancomycin, a client begins to experience itching and flushing of the neck, face, and upper body. He denies having chills or difficulty breathing. What should the nurse suspect is happening? A) an allergic reaction has occurred B) An anaphylactic reaction is about to occur C) The medication will not be effective for the bone infection D) The IV dose may have infused too quickly

D) The IV dose may have infused too quickly

A nurse is caring for a 82 year old client with a history of COPD who is unable to take the influenza vaccine because of allergies. Although he is without symptoms, the client is concerned because he was exposed to the flu at a family reunion. Which treatment option should be provided? A) The patient should receive the flu vaccine as soon as possible B)The patient should receive zanamivir (Relenza) in the inhalation form C) The patient should begin oral oseltmivir (Tamiflu) therapy when symptoms begin D) The patient should begin oral oseltmivir (Tamiflu) therapy as soon as possible

D) The patient should begin oral oseltmivir (Tamiflu) therapy as soon as possible

A patient with diabetes has a new prescription of the ACE inhibitor lisinopril. The patient questions this order because the patient's health care provider has never said that the patient has hypertension. What is the best explanation for this order? A) The health care provider knows best B)The patient is confused C) This medication has cardio protective properties D) This medication has a protective effect on the kidneys for patients with diabetes

D) This medication has a protective effect on the kidneys for patients with diabetes

Which would the nurse include in discharge teaching for a patient receiving an antilipemic mediation? A) Stop taking the medication if it causes N/V B) It is important for you to double your dose if you miss one in order to maintain therapeutic blood levels C) This medication will take over for other interventions you have been trying to decrease your cholesterol D) You should continue your exercise program in order to increase you HDL serum levels

D) You should continue your exercise program in order to increase you HDL serum levels

A 53 yr old male patient has been prescribed sublingual nitroglycerin tablets for angina. What information should the nurse tell the patient about this medication? A) take up to 5 doses at 15 minute intervals after an anginal attack B) If the tablet does not dissolve quickly, chew the tablet for maximal effect C) If the chest pain is not relieved, go to the hospital immediately D) after taking a dose, lie down; change positions slowly to avoid falling or fainting

D) after taking a dose, lie down; change positions slowly to avoid falling or fainting

A nurse is caring for a patient receiving intravenous gentamycin. Which assessment finding should be the most concerning to the nurse? A) Nausea and upset stomach B) Blood pressure= 100/ 65 C) Rash over upper trunk D) urine output of 150 mL over shift

D) urine output of 150 mL over shi

How should the nurse respond when a patient asks why he is taking on oral anticoagulant while still receiving intravenous heparin? A. "Your concern is valid. I will call the doctor to discontinue the heparin." B. "Because you are now up and walking, you have a higher risk of blood clots and therefore need to be on both medications." C. "Because of your valve replacement, it is especially important for you to be anticoagulated. The heparin and warfarin together are more effective than one drug alone." D. "It usually takes about 3 days to achieve a therapeutic effect for warfarin, so the heparin is administered to prevent blood clots until the warfarin is therapeutic."

D. "It usually takes about 3 days to achieve a therapeutic effect for warfarin, so the heparin is administered to prevent blood clots until the warfarin is therapeutic."

Which laboratory value should the nurse assess to determine the effectiveness of intravenous heparin? A. International normalized ratio (INR) B. Prothrombin time (PT) C. Complete blood count (CBC) D. Activated partial thromboplastin time (aPTT)

D. Activated partial thromboplastin time (aPTT)

Vasodilators

Directly relax arteriolar and venous smooth muscle Drug Effects: ¡Decreased SVR ¡Decreased preload ¡decreased afterload ¡peripheral vasodilation ¡Increased renal and cerebral blood flow, Indications: NOT a first line agent Hypertension Can be combined with other agents inhibit vasoconstriction Examples: ¡hydralazine hydrochloride (Apresoline) ÷Oral and IV ¡sodium nitroprusside (Nipride)- ICU, very powerful ÷IV only: reserved for hypertensive emergencies acute MI, blood disease. Adverse Effects- hydralazine ¡Dizziness, headache, anxiety, tachycardia, nausea and vomiting, diarrhea, anemia, dyspnea, edema, nasal congestion sodium nitroprusside (only used in ICU) ¡Bradycardia, hypotension, possible cyanide toxicity (rare)

Diuretic drugs

Drugs that accelerate the rate of urine formation ¡First-line drugs in the treatment of hypertension and heart failure ¡Cause direct arteriolar dilation, decreasing peripheral vascular resistance These drugs reduce: ¡extracellular fluid volume ¡plasma volume ¡cardiac output, decrease BP, 1st line- HTN, HF

Antilipemic drugs

Drugs used to lower lipid levels: ¡Atherosclerosis- reduce development and preexisting clots ¡Vascular disorders ÷Coronary artery disease ÷Cerebrovascular disease ÷Peripheral arterial insufficiency

Antilipemic drugs

Established classes of drugs used to treat dyslipidema: 1.HMG-CoA Reductase Inhibitors (statins) 2.Bile acid sequestrants 3.Fibric acid derivatives (fibrates), Decrease blood lipids Prevent or delay development of atherosclerotic plaque Regression of atherosclerotic plaque Reduce morbidity and mortality from CV disease Initiated if lifestyle changes are not effective (6 months)

Stomach acid

Excessive acid production= gastric hyperacidity, hydrocholoric acid- aids in digestion and serves as a barrier to infection, bicarbonate- base that is a natural mechanism to prevent hyperacidity, pepsinogen- enzymatic precursor to pepsin (digests dietary proteins), intrinsic factor- glycoprotein that facilitates gastric absorption of vit B 12, mucus- protects stomach lining, prostanglandins antinflammatory and protective functions

Antiplatelet drugs

GP IIb/IIIa Inhibitors; ADP Inhibitors; Cyclooxygenase Inhibitors, •Prevent platelet adhesion and clumping at the site of vascular injury due to: •Reduced blood flow •Trauma •Plaque rupture •Antiplatelet drugs differ in where they act in the platelet activation cascade •Goal of Therapy: •Prevention of stroke, MI, and vascular death in patients at risk- fatty plaques are acquired in vessels- restore blood flow by clumping platelets, epinephrine causes platelets to stick- not so good with an occlusion, contraindications- •Known drug allergy •Thrombocytopenia •Active bleeding •Traumatic Injury •GI ulcer •Recent stroke •Vitamin K deficiency

Calcium channel blockers

First line therapy for the treatment of hypertension Causes smooth muscle relaxation Drug Effects: ¡Decreased systemic vascular resistance ¡Decreased blood pressure, prevent muscle contractions }Examples: diltiazem, nifedipine, Adverse Effects: Cardiovascular - ¡Hypotension, palpitations, tachycardia or bradycardia, heart failure Gastrointestinal - Constipation, nausea Other ¡Dermatitis, dyspnea, rash, flushing, peripheral edema, wheezing

Drug therapy for HF

First-line treatment (discussed in Unit 8) Lets review! ACE inhibitors- prevent Na/ H20 re absorption= diuresis, "prils" (lisinapril, enelapril, captopril) Prevents the conversion of angiotensin I to angiotensin II Decreases vasoconstriction; causes vasodilation decreases aldosterone levels and Na and H2O retention - all resulting in vasodilation Used for hypertension and management of symptomatic HF- slows progression of lf ventricular remodeling Angiotensin receptor blockers- decrease systemic resistance, decrease hospitalization but not mortality Beta blockers- decrease HR, delay Av node conduction, contractility, ols" (metoprolol, carvedolol, atenolol) Supress activation of the SNS Ventricular remodelling regresses and CO improves Low doses at first; careful monitoring; added after ACE inhibitors and diuretics, don't know which is most effective, decrease morbidity and mortality in MI, stable systemic HF- stage 2/3- treatment of angina Diuretics- Loop - reduce fluid overload (furosemide) Potassium-sparing usually used with another diuretic (spirolactone) Vasodilators- hydralazine, Isordil Decrease preload (volume) and afterload (resistance) Start low and slow Following first-line treatment fails Inotropes Cardiac glycosides Phosphodiesterase inhibitors New research

BP classification

Four stages based on blood pressure measurements: 1.Normal 120/80-129/89 2.Prehypertension 130/85-139/89 3.Stage 1 hypertension 140/90-159/99 4.Stage 2 hypertension 160+/100+ Unknown cause ¡Is called essential, idiopathic, or primary hypertension ¡Accounts for 90% of the cases Known cause ¡Called secondary hypertension- renal, endocrine, SNS ¡Accounts for 10% of the cases Masked hypertension- <140/90 at hospital and high at home White-coat hypertension- higher in hospital, anxiety, nerves

HF

Heart cannot pump sufficient amount of blood- or only do so at elevated pressure Best way to prevent HF is reduce risk factors- hypertension, CAD, obesity, Diabetes, age (>65 yr), Impaired cardiac functioning in which the heart is unable to provide a blood supply sufficient enough to meet the metabolic demands of the body. Characterized by: Dyspnea Fatigue Fluid retention Angina Lt= lungs, Rt= systemic, pathological condition when ventricles cannot pump enough blood, fluid volume overload, as disease progresses so do symptoms, decrease blood supply to certain organs- kidneys, brain and heart will be last to be oxygen depleted, complications- removal of waste is impaired= kidney failure

Chronotrope

Heart rate, positive= increased HR, negative= decreased HR

Bile Acid Sequestrants

Indication: To further reduce LDL cholesterol in clients who are already receiving a statin drug. ¡Inhibition of cholesterol synthesis by statin makes this class of drugs more effective ¡Combination also increases HDL, 2nd line, used in pregnancy, bind bile and prevent resorption in intestine- excreted in feces- more that is excreted= less in bloodstream/ circulation, AE- GI upset, diarrhea, gallstones, Not absorbed systemically Side effects ¡GI discomfort and diarrhea ¡Abdominal fullness, flatulence, constipation- impaction in elderly- monito, increase fiber/ fluids, fiber supplement, low doses take with meals ¡Decrease absorption of many oral meds - take other meds 1 hour before or 4 hours after, contraindications- drug allergy, bowel obstruction, PKU- drug interactions- drugs should be taken 1 hr before or 4-6 hr after bas, decrease absorption of fat soluble vitamins

Hypertension

Is defined as a SBP greater than140 mm Hg or a DBP greater than 90 mm Hg on multiple blood pressure measurements ¡in patients without renal disease, diabetes, or proteinuria A systolic pressure of 140 or less, with a diastolic pressure below 90, is called isolated systolic hypertension and is more common amongst older adults. is a significant risk factor for developing ¡cerebrovascular disease ¡coronary artery disease ¡congestive heart failure ¡renal failure ¡peripheral vascular disease ¡dementia ¡atrial fibrillation ¡erectile dysfunction, silent killer

Digoxin

Lanoxin, used for HF, a fib and flutter, contraindicated in hypersensitivity and ventricular tachycardia or fib, normal therapeutic drug levels should be between 0.5 -1 ng/ mL higher than 2.4 ng/mL, loading/ digitalizing dose is often given to bring serum levels up to a therapeutic level faster, PO- onset- 1-2 hr, peak- 2-8 hr, half life- 35-48 hr, action- 3-4 days, IV- onset- 5-30 min, peak- 1-4 hr, half life- 35-48 hr, action- 3-4 days Digoxin is the only cardiac glycoside currently available. Indicated for the management of: Heart Failure Reduces morbidity NOT mortality Dysrythmias: Atrial fibrillation & Atrial flutter, adjunct to ACE I, ARBs, B- blockers, diuretics, Heart Failure Positive inotropic effects Increases amount of intracellular Ca++ ® increased force of contraction Increases renal perfusion Diuretic effect Dysrythmias Negative chronotropic effect- decrease HR Negative domotropic effect-decrease speed of electrical conduction= prolonged conduction, increase SV and decrease heart size, decrease venous BP and venous enlargement, Contraindicated in: Drug allergy, second or third degree heart block, atrial fibrillation, ventricular tachycardia, or ventricular fibrillation- cardiologist can recommend it Use cautiously in clients with: acute MI heart block Wolff-Parkinson-White syndrome- extra electrical pathway between upper and lower pathways= rapid HR electrolyte imbalances renal impairment- kidney function, Route: PO or IV Digitalization Loading or digitalizing dose: PO: 0.5 - 0.75 - 1 mg in 3 - 4 divided doses over 24 h IV: 0.5 - 0.75 mg in divided doses over 24 h Maintenance dose 0.125 - 0.5 mg daily Drug elimination takes approximately 1 week (renal), low therapeutic index- toxic concentration: effective concentration is very small, adverse effects- CNS: headache, drowsiness, confusion GI: anorexia, nausea, vomiting, diarrhea Cardiac dysrhythmias*** Bradycardia; AV blocks Premature ventricular contractions (PVCs) Tachycardia Retinal effects*** Colored vision (seeing green, yellow or purple), halo vision, flickering lights toxicity- Narrow therapeutic index predisposes client to adverse effects Causes: Hypoxia, electrolyte imbalance, renal dysfunction, hypothyroidism, age extremes, rapid loading Poor drug tolerance, medication interactions Therapeutic serum digoxin levels: 0.5 - 2 ng/ml Electrolyte levels must be monitored Low potassium levels contribute to toxicity & increases the risk of dysrhythmias, treatment of toxicity- Discontinue drug Treat cardiac dysrhythmias Digoxin immune fab (Digibind) Antidote for serious toxicity Route: IV slowly; improvement seen within 30 min. Serum digoxin levels not reliable in determining efficacy of Digibind- IV, 30 min, draws digoxin out of tissue, increase risk for toxicity- Hypokalemia- diuretic induced Cardiac pacemaker Hepatic dysfunction Hypercaclemia Dysrhythmias Hypothyroid, respiratory or renal disease Advanced age- decreased kidney function, body mass, drug excretion= lower dose, polypharmacy, nursing considerations-Prior to administration of digoxin: Baseline ECG, BP, electrolytes, BUN, creatinine Correct abnormal electrolytes Expect lower dosage in setting of renal dysfunction Auscultate the apical pulse for 1 full minute Note the quality of the pulse, regularity/irregularity Hold drug if HR < 60 for adults or < 70 for children and notify physician Notify physician if new irregularity noted- rapid ventricular response, HR > 100, high alert. Drug interactions- increase effects- Adrenergics Antidysrythmics Anticholinergics Erythromycin Calcium Channel blockers Ginseng, Hawthorne, licorice supplements- increase cardiac toxicity, decrease digoxin levels decrease effects- Antacids Laxatives Phenytoin, evaluation of drug efficacy- Increased urine output Reduced edema Less SOB Slower HR Improved activity tolerance Minimal adverse effects. Patient teaching- Discuss therapeutic benefits Take only as prescribed Teach client how to take pulse Take drug at the same time every day Consult physician or pharmacists - other meds- even OTC Do not take extra dose if dose missed Limit dietary sodium intake Report adverse effects - or worsening effects Keep out of the reach of children Regular follow-up

Furosemide

Lasix, loop diuretic,used in managing pulmonary edema, edema from HF, liver disease, nephrotic syndrome, ascities, contraindicated in hypersensitivity to it or sulfonamides, anuria, hypovolemia, electrolyte depletion, solution or tablets, benefits may cause use in pregnancy despite potential fetal risks IV- onset- 5 min, peak plasma concentration- 15 min, elimination of half life- 1-2 hr, duration of action- 2 hr, PO- onset- 30-60 min, peak- 1-2 hr, half life- 1-2 hr, duration- 6-8

Classifications of Diuretic drugs

Loop diuretics Potassium-sparing diuretics Thiazide and thiazide-like diuretics Other Classes of Diuretics (not used to treat hypertension) ¡Carbonic anhydrase inhibitors- gluacoma, edema, high altitude sickness ¡Osmotic diuretics- cerebral edema, promote secretion of toxic substance

Potassium- sparing diuretics

MOA- Act at distal tubule to decrease Na+ reabsorption and K+ excretion Amiloride & triamterene- do not bind to the aldosterone receptors ¡ decrease the exchange of Na+ for K+ in the distal tubule- pediatrics, HF ¡Used to treat HF Spironolactone is an aldosterone antagonist ¡Blocks Na+ retention ¡Indications: to help with hormonal alpha one ÷Hyperaldosteronism ÷Hypertension, Weak diuretics when used alone Usually given in combination with K+- depleting diuretics ¡Benefits: better diuretic effects with less K+ loss ¡Apo-Triazide is a combination of triamterene & hydrochlorothiazide Contraindications ¡Renal insufficiency ÷Inhibition of aldosterone causes K+ retention ¡Hyperkalemia, spironolactone (Aldactone) ¡Gynecomastia ¡Amenorrhea ¡Irregular menses ¡Postmenopausal bleeding Significant drug interactions with: ¡lithium ¡angiotensin-converting enzyme (ACE) inhibitors ¡potassium supplements- k sparing- do not give = Hyperkalemia

Adrenergic drugs

MOA- Centrally acting a2 receptor agonists ¡Stimulate a2 -adrenergic receptors in the brain ¡Decrease sympathetic outflow from the central nervous system (CNS) ¡Reduces renin activity in the kidneys ¡Decrease norepinephrine production Examples: Clonidine and Methyldopa NOT a first line agent! Add-on therapy" for treatment of hypertension- when other ones don't work or severe adverse effects, pregnancy decreases sympathetic output, migraine, withdrawal

Loop diuretics

MOA- Inhibit Na++ and Cl- reabsorption in the ascending loop of Henle Increase kidney prostaglandins- blood vessel dilation, decrease pressure, preload Versatile and effective! kidney, cardio, metabolic, single dose, early in the day- increase urination, do not want to be up all night urinating, Examples: ethacrynic acid (Edecrin) and furosemide (Lasix) Onset & Duration of Action ¡Oral: effects occur within 30 - 60 min.; peak in 1-2 h; last 6-8 h. ¡IV: effects occur within 5 min.; peak in 30 min.; last 2h, Indications- Edema associated with heart failure or hepatic or renal disease, hepatic disease Hypertension Hypercalcemia Heart Failure When rapid fluid removal is required, Contraindications: ¡Known drug allergy ¡Allergy to sulfonamide antibiotics ¡Hepatic coma ¡Severe electrolyte abnormalities- hepatic coma Adverse Effects ¡Hypokalemia- k depleting ¡Tinnitus; ototoxicity, lithium concurrent use- increase lithium toxicity, Post-diuresis: ¡ Na++ reabsorption begins quickly Patient Teaching: ¡Dietary sodium restriction important to achieve therapeutic drug benefits ¡High sodium intake can obliterate the effects of the drugs

Thiazide and thiazide- like diuretics

MOA- Inhibit tubular resorption- DCT- excretion of all water, dilate arterioles- direct relaxation ¡sodium, chloride, and potassium ions Act primarily in the distal convoluted tubule Result in excretion of ¡water, sodium, and chloride, and potassium to a lesser extent Dilate the arterioles by direct relaxation, hydrochlorothiazide, metolozone- not if creatinine is less than 30-50 mL(normal is 120), Thiazide diuretics ¡hydrochlorothiazide Thiazide-like diuretics ¡metolazone (Zaroxolyn) Thiazides should not be used if ¡creatinine clearance is less than 30 to 50 mL/min (normal is 125 mL/min) metolazone remains effective ¡to a creatinine clearance of 10 mL/min, Indications- Hypertension (first line agent) Edematous states Heart failure due to diastolic dysfunction As adjunct drugs in treatment of edema related to: ¡heart failure ¡hepatic cirrhosis ¡corticosteroid ¡estrogen therapy, increase idopathic hypercalcuria, contraindications- Known drug allergy Hepatic coma (metolazone) Anuria- failure of kidney to produce urine Severe kidney failure

Calcium channel blockers

Mechanism of Action Block the calcium from binding to the receptors - Relaxation of the smooth muscles that surround the coronary arteries causes them to dilate - Verapamil & Diltiazem - êHR due to affects on contractility Treatment for HTN, SVT, angina (artery spasms). Used short term for A.fib/Flutter

Beta blockers

Mechanism of Action: b1-adrenergic receptors on the heart are blocked Decrease the heart rate Decrease myocardial contractility- increase oxygen delivery to heart Indications Cardioprotective effect after an MI a high level of circulating catecholamines irritate the heart- imbalance in supply and demand- life threatening arrythmias b-blockers block the harmful effects of catecholamines Angina Antihypertensive Cardiac dysrhythmias, migraines, stage fright- not Health Canada approved, AE- dizziness, fatigue, altered metabolism, dyspnea, wheezing

Nitrates

Mechanism of Action: •Dilate all blood vessels •Arterial vasodilator effect = relaxation in smooth muscle cells of veins and arteries •Potent dilating effect of nitrates on the coronary arteries- redistributes blood decrease preload and afterload, decrease venous return= decrease afterload and preload, all types of angina, Nitropaton- long acting- prevent angina, baseline, long acting SL tablet/spray- acute, treat angina episodes IV drip, contraindications- hypotension- could bottom them out, Nitroglycerin: Has large first-pass effect with oral forms - IV, Sublingual spray or tabs- never PO Used for symptomatic treatment of acute angina IV form for BP control in perioperative hypertension, heart failure, ischemic pain, pulmonary edema associated with MI, hypertensive crisis. Isosorbide: Prophylaxis - management- anticipated angina attacks Available in extended release oral forms, tolerance- long acting or taking continuous, have break from medication to allow enzymes to recover (patch on at 8 am and off at 8 pm), Indications •Used for stable, unstable and vasospastic (Prinzmetal's) angina •Used for prevention of anginal episodes (transdermal patch) •Rapid-acting - spray/tab or IV - used to treat acute anginal attacks Contraindications Severe anemia Glaucoma Hypotension Severe head injury, Adverse Effects Usually transient and involve the cardiovascular system •Most common = headache- Tylenol prophylactically •Tachycardia, postural hypotension* •Reflex tachycardia •Tolerance* •Interactions •Can produce additive hypotension effects when combined with: •Alcohol, beta blockers, CCB, phenothiazines, •Viagra = additive hypotensive effects when taken together.

Therapeutic regimens for hypertension

Most patients require more than one class of medication to achieve targets ¡75% of patients need two drugs ¡25% need three drugs The CHEP guidelines suggest ¡thiazide diuretics, beta-blockers, ACE inhibitors, ARBs, or CCBs as first-line therapy ¡Beta-blockers are not indicated as first-line therapy for hypertension in those over 60, If the initial drug (and dose) does not achieve target can- increase dose, change drug, add different group of drugs Studies support using lower doses of multiple drugs rather than higher doses and fewer drugs. Review other factors that may decrease therapeutic response - OTC appetite- suppressants, herbal products, nasal decongestants

Cardiovascular disorders

Most vascular diseases result from malfunction of endothelial cells or smooth muscle cells Major factor in atherosclerosis, acute coronary syndromes, hypertension, and thromboembolic disorders, capillaries media (muscle and elastic tissues), CT

Classification of HF

Stage A (I)- high risk but no structural disorders Stage B (II)- structural disorders with no symptoms Stage C (III)- past or current symptoms, underlying structural disease Stage D (IV)- end stage, specialized mechanical support, drug therapy is based on this and is individualized

Narrow spectrum- natural penicillin vs penicillinase resistant drugs

Natural- §Penicillin G (IV or IM)- strep throat, skin infections §Penicillin V (oral) §Penicillinase sensitive §Clinical indications: §Gram + bacteria §Drug of choice for treatment of streptococci, pneumococci and staphylococci bacteria that do not produce penicillinase §Gonorrhea and syphilis- gonorrhea resistant, Resistant- §Cloxacillin and Oxacillin §IM, IV, oral routes §Active against gram + cocci- manage/ destroy enzyme responsible for ARO §Advantageous because it inactivates penicillinase §Treatment of infections due to penicillinase producing staph aureus and staph epidermidis: §Respiratory tract infections §Sinusitis §Skin infections §NOT MRSA- methicillin resistant, need different antibiotics

Nausea/ Vomiting

Nausea- unpleasant feeling that precedes vomiting- vomiting (emesis)- forcible emptying or expulsion of gastric and intestinal contents, vomiting centre (VC)- area of the brain that is responsible for initiating the physiological events, neurotransmitter signals are sent to the VC from the chemorecptor trigger zone (CTZ)- alter brain to nauseating substances that need to be expelled form the body

Antacids

Neutralize stomach acid, OTC, tablets slower than liquid, MOA/DE- do not prevent overproduction of acid, promote gastric mucosal defensive mechanisms- stimulate secretion of mucus, prostaglandins, and bicarbonate, reduce pain, acute relief of PUD, gastritis, hyperacidity, reflex, AE- Mg+ causes diarrhea, Al/ CA+2= constipation, kidney stones, systemic alkalosis, rebound hyperacidity, interactions- absorption, chelation, increase stomach pH/ urinary pH

Other considerations for antihypertensives

Older adults- Start with diuretic (thiazide) Initial drug dosing- 1/2 of what you would give to a younger patient Older patients have more adverse effects due to ¡Decreased renal function ¡Less efficient homeostasis mechanisms, Renal disease- Antihypertensives may slow progression of disease, thiazide are uneffective in renal disease Use loop diuretic ACE inhibitors- caution with renal artery problems Beta blockers eliminated by kidneys- dose reduction, natural health products- ¡Significant interactions can occur ¡Non-prescription medications - ÷Can decrease the effectiveness of anti-hypertensive drugs or worsen hypertension- antihistamine, cold/cough, weight loss ¡Caffeine - ÷may increase blood pressure

Antivirals for influenza a and b

Oseltamivir phosphate (Tamiflu) and zanamivir (Relenza) §Indicated for treatment of uncomplicated acute illness in adults §Active against influenza types A and B §Prevent budding virions from escaping from infected cells §Reduces duration of illness- when given early §Oseltamivir: §Indicated for prophylaxis (3 months and older) and treatment (any age); oral use only, in home with exposure or long term care §Adverse effects: nausea and vomiting, skin reactions, and sporadic, transient CNS disturbances ("neuropsychiatric events"): insomnia, vertigo, confusion, seizures §Inhaled Zanamivir- Relenza §Indicated for prophylaxis (5 years and older) and treatment (7 years and older); route: inhalation powder §Not recommended in those with underlying respiratory disease; contraindicated if allergic to milk or protein §Adverse effects: diarrhea, nausea, sinusitis, CNS disturbances, bronchospasm Treatment should begin within 2 days of influenza symptom onset

Lipids and lipid abnormalities

Primary Forms of Lipids ¡Cholesterol -steroid hormones, bile salt ¡Triglycerides - energy source, adipose tissue, LDL- bad cholestrol- strong risk factor for CAD, longer half life than LDL- precursor to LDL, carriers LDL, HDL- good cholsterol, protective effects by transporting cholesterol from the liver, Cholesterol Homeostasis ¡Fats are taken into the body - ¡Triglycerides are incorporated into chylomicrons in the cells of the intestinal wall - into lymphatic system ¡Chylomicrons transport lipids obtained from dietary sources from the intestines to the liver - ¡Liver is the major organ where lipid metabolism occurs.

Antitubercular drugs

Principles of Therapy §Mycobacterium is more difficult to treat than most other bacterial infections §Multi drug resistant TB is a public health crisis §Close contacts of patients with multidrug resistant TB need to be treated for 6-9 months §Antitubercular drugs treat all form of mycobacterium, meds may have not changed in decades First-Line Drugs §isoniazid (INH) §pyrazinamide §rifampin §ethambutol- initial 2 months

Lisinopril

Prinivil, Zestril, ACE inhibitor, hypertension, HF, acute MI, can cause injury or fetal death when used in pregnancy, hyperkalemia may occur, same with dry cough, PO- onset- 1 hr, peak- 6 hr, half life- 11-12 hr, action- 24 hr

Drug doses for hypertension

Start low and go slow Use lower doses of 2-3 agents versus maximum doses of one

Canadian Hypertension Education Program

Recommendations ¡Home blood pressure (BP) monitoring ¡Annual BP assessment for individuals with prehypertension (130-139/85-89 mm Hg) ¡Ongoing routine assessment of blood pressure at clinic visits ¡Assessment of overall cardiovascular risk, Lifestyle modifications ¡Healthy diet ¡Regular physical activity ¡Moderation in alcohol ¡Reduction in dietary sodium ¡Stress reduction, Treat to target ¡less than 140/90 mm Hg ¡less than 130/80 mm Hg in those with diabetes or chronic kidney disease Combinations of therapies Regular follow- up Focus on adherence- major focus for nursing care

HMG-CoA Reductase Inhibitors

STATINS" ¡Most potent for reducing plasma concentrations of LDL cholesterol and most prescribed ¡Inhibit an enzyme required for hepatic synthesis of cholesterol ¡Decrease the rate of cholesterol production- less is produced- liver produces more receptors ÷LDL within 2 weeks, max effect in 6-8 weeks ¡Reduce C-reactive protein - severe arterial diffusion- MI, stroke ¡Reduce incidence of CAD by 25-60% and risk of death by 30% ¡Reduce risk of angina and need for angioplasty, First-line drug therapy atorvastatin (Lipitor), lovastatin, pravastatin(Pravachol), simvastatin (Zocor), fluvastatin, rosuvastatin (Crestor) Side effects Mild, transient GI disturbances Rash Headache HDL- increases risk for cardiovascular disease,, monitor for effects, contraindications- drug allergy, pregnancy, liver disease, increase liver enzymes, muscle diease/ weakness, myopathy, decrease in muscle fibers, rabiomylosis- renal failure, Adverse Effects that may require cessation of medication Myopathy (muscle pain) ¡monitor CK levels Elevations in liver enzymes or liver disease- INR, aPTT, PTT ¡Monitoring LFT before and after 6 and 12 weeks of therapy and PRN, tea colored urine, fever, malaise, n/v, increase glucose levels

Thrombolytics

TPA- •Primarily indicated in the treatment of acute, embolic events •Myocardial infarction •Acute ischemic stroke- caused by embolism- scan to see what kind •Pulmonary embolism •Peripheral arterial thrombosis •Therapeutic Goal: Reestablish perfusion in order to minimize tissue necrosis •Other use: to restore patency of occluded central venous access devices, increased risk for bleeding, Mechanism of Action •Directly converts plasminogen to plasmin •Plasmin is a proteolytic enzyme which mimics the body's own process of clot destruction Important Thrombolytic Agents •Alteplase (t-PA) •Tenecteplase (TNK)- streoptoconase is caused by TNK •IV ONLY & weight based dosing •Short half life •No reversal agents!, adverse effects- general bleeding- •Epistaxis- nose bleed •Gingival bleeding •Hemoptysis- coughing up blood •Hemorrhage at IV site, critical site bleeding- •Intracranial hemorrhage •GI bleeding •Retroperitoneal bleeding •GU tract bleeding, contraindications- •Risk stratification prior to administration is imperative for patient safety •Thrombolytics are absolutely contraindicated in the presence of: •Active internal bleeding •Recent intracranial or intraspinal surgery or trauma within past 3 months •Intracranial neoplasm, AVM, or aneurysm •Known bleeding disorder •Severe uncontrolled HTN: SBP > 185 or DBP > 110 •Recent major surgery •Hemorrhagic stroke or evidence of intracranial hemorrhage •Recent stroke within past 3 months •Severe thrombocytopenia, significant risk for bleeding, treatment- •t-PA is the treatment of choice for acute embolic stroke •CT scan must be obtained prior to treatment in order to rule out hemorrhagic stroke •Assess neuro status •Determine time of onset of stroke symptoms •Alteplase must be administered within 3 - 4.5 hours of the onset of stroke symptoms •Must have a reliable witness as to when symptoms emerged •If the patient is older than 80 years, then drug must be administered within 3 hours of onset of stroke symptoms- know time, otherwise not effective •Target: eligible patients are treated with tPA within 60 min of hospital arrival- stroke alert, time is tissue, TNK- •Percutaneous coronary intervention (PCI) is the gold standard of treatment for acute STEMI •If no angiogram suite available, then patient with receive TNK •Maximum benefit is seen when medication is administered within the first hour of symptom onset- pain, etc, •Great for rural and remote areas that do not have access to tertiary care centers •Target: eligible patients are treated with TNK within 30 min of hospital arrival- door to needle time, time is muscle, nursing considerations- •Drugs are administered in critical care areas •Patient must be receive continuous ECG monitoring and nursing surveillance •Prior to initiation of therapy, place all invasive lines: • IV sites x 2, urinary catheters, etc. •Avoid all invasive procedures during therapy •Routine lab work is drawn from IV lines •No IM injections!

HF management

Treatment of Chronic Heart Failure focuses on reducing: The effects of renin-angiotensin-aldosterone system SNS stimulation Ventricular remodeling, increase blood volume, pressure in chambers, and improve symptoms, exercise tolerance and quality of life, alter compensatory mechanisms and prevent heart damage

A dislodged clot is referred to as an embolus. True or False

True

Anticoagulants can only prevent clots from forming. True or False

True

Most available B- blockers demonstrate antianginal efficacy. True or False

True

Thrombolytic drugs lyse clots that have already been formed. True or False

True

Warfarin and heparin both prevent clot formation. True or false

True

Antiemetic and Antinausea Drugs

block the site in vomiting pathway, MOA/DE- Ach- bind to and block Ach receptors on the vestibular nuclei, prevents signals from being transmitted to the VC, dry GI secretions, reduce smooth muscle spasms (anticholinergics), antihistamines inhibit vestibular stimulation similar to anticholinergics, bind to H1 receptors but potent antisecretory and antispasmodic effects- prevent stimulation in vestibular and reticular systems, antidopaminergic- block dopamine receptors in the CTZ, calm CNS, prokinetic- block dopamine receptors in the CTZ (desensitizes CTZ to impulses from GI tract, promote peristalsis), Serotonin blockers- block serotonin receptors in GI tract, CTZ and VC- 5HT3, THC- inhibits reticular formation, thalamus, cerebral cortex- alteration in mood and body's perception of pain

Angina pectoralis

chest pain, When the supply of oxygen and nutrients in the blood is insufficient to meet the demands of the heart, the heart muscle "aches" Oxygen demands are influenced by: Heart rate Contractility Caffeine Exercise Stress Chronic stable angina: (also called classic or effort angina)- atherosclerosis, cold, tobacco, alcohol, intense pain for 15 min Unstable angina:(also called preinfarction or crescendo angina)- most dangerous, no release of enzymes and biomarkers of cardiac necrosis, no pattern/ exertion criteria- 1: Angina at rest, 2: Recent onset, 3: increase intensity/ duration of angina in past 2 months Vasospastic angina:(also called Prinzmetal's or variant angina)- pattern, episodic chest pain- atherosclerosis, nonpharm management- nonmodifiable- Age Ethnicity- African and Asian- increased risk Gender- men and women after menopause Family History- increase risk if close family member has HF before 55/ menopause Modifiable- Sedentary lifestyle Smoking Hypertension Hyperlipidemia Obesity Stress Drugs that increase myocardial demand, antianginal drugs- Nitrates b-blockers Calcium channel blockers Therapeutic Objectives Minimize frequency of attacks Improve patient's functional capacity with few adverse effects Prevent or delay an MI Overall Goal: Increase blood flow to ischemic heart muscle and decrease oxygen demand

CAD

coronary artery disease, Ischemic heart disease Poor blood supply to the heart muscle Caused by: Atherosclerosis Coronary artery disease (CAD) MI Necrosis, or death, of cardiac tissue Ø Disabling or fatal Ø Acute result of CAD and of ischemic heart disease

Aminoglycosides

for hard to treat infections, "cin", §Bactericidal - prevent bacterial protein synthesis §Gentamicin, tobramycin, neomycin, amikacin, streptomycin (IV, IM, topical - gtt, ungt) §Potent with serious toxicities- to kidneys §Active against: §Serious gram - infections: Pseudomonas, enterobacter, E coli, proteus, klebsiella, and serratia §Some gram +: Enterococcus, staph aureus §Synergistic benefit when combined with other antibiotics §Clinical Use: §Bacterial endocarditis resistant to other antibiotics, prophylaxis for GI and GU procedures (prone to enterococcal infections), toxicities- §Nephrotoxicity- increase urea and creatinine- can reverse if identified early, protein in urine, permanent renal failure- permanent dialysis , CN 8 §Ototoxicity §Before therapy is initiated: §Estimated Creatinine Clearance is calculated to determine dosage §Renal function monitored during therapy §Therapeutic drug monitoring essential for safety: §Ensures that drug levels are sufficient to kill bacteria §Prevents toxicity §Serum Drug levels §Monitored initially and then once q 5 - 7 days §Obtain serum trough levels 30 minutes prior to the time the next dose is due- narrow therapeuticindex §Goal: trough(lowest serum concentration) level at or less than 1 mcg/mL, monitor urine output, ensure lab work is drawn and reported, §Contraindicated for known drug allergies; pregnancy; during breastfeeding §Adverse effects §Headache §Fever §Vertigo §Rash §Paresthesia- numbness or tingling §Interactions: §Increased risk for nephrotoxicity when used with: §vancomycin §cyclosporine §amphotericin- very critically ill patients §Use with loop diuretics increases the risk for ototoxicity §Aminoglycosides can potentiate warfarin toxicity

Metronidazole - Flagyl

for hard to treat infections, §Miscellaneous classification §Bactericidal §IV/oral forms §Spectrum of activity: anaerobic microorganisms §Bacteroides, Clostridium- drug of choice in treatment of children with C. diff, adults can be resistant §Indications: §Protozoal infections §Intra-abdominal and gynecological infections

Clindamycin

for hard to treat infections, §Miscellaneous classification §IV/IM/oral forms §Bactericidal or bacteriostatic - depending on the drug concentration §Spectrum: Gram + and gram - microorganisms §Indications: §Chronic bone infections §UTI §Intra-abdominal infections §Anaerobic pneumonia §Septicemia caused by strep or staph §Serious skin and soft tissue infection §May cause C. diff, not aminoglycoside!

Vancomycin

for hard to treat infections, §Miscellaneous classification §IV/oral forms §Oral formulations are poorly absorbed and distributed §Binds to bacterial cells wall - inhibits cell wall synthesis - resulting in cellular death §Indications: §Treatment of choice for... §Oral vancomycin is indicated for the treatment of antibiotic-induced colitis (C. difficile) and for the treatment of staphylococcal enterocolitis §Given to prevent SSI in patients allergic to cefazolin, used in adults with C. diff, §Adverse effects: §Ototoxicity §Nephrotoxicity - increased risk when used concurrently with IV contrast dye or other nephrotoxic drugs §"Red man syndrome" - flushing, itching of face, neck and trunk; occurs with rapid drug administration §Hypotension can occur with rapid IV administration §Muscle spasms; dyspnea §When given IV, must monitor serum trough levels to ensure therapeutic levels and prevent toxicity §Drawn immediately before administration of next dose- pump §Optimal trough levels = 15 - 20 mcg/mL, 60 min, 90 min, 120 min, IV contrast dye

Quinolones

for hard to treat infections, §Potent, bactericidal, broad-spectrum antibiotics - alter bacterial DNA §Ciprofloxacin,- common levofloxacin, moxifloxacin §IV; Excellent oral absorption §Spectrum of Activity: gram - and gram + microorganisms- community acquired pneumonia §Active against numerous microbial species §Clinical Uses: §Respiratory infections §Skin, soft tissue, UTI, prostate, bone/joint, and intraabdominal infections §Infectious diarrhea §Gonorrhea; meningococcal carriers §Anthrax, interacts with tube feed- hold before and after- decrease absorption, §Adverse effects- spontaneous: §CNS, GI, Skin, other (tendonitis, ruptured tendons, tinnitus, fever, chills, blurred vision) §Drug Interactions: §Oral quinolones: antacids, calcium, magnesium, iron, zinc preparations, or sucralfate §Patients need to take the interacting drugs at least 1 hour before or after taking quinolones §dairy products §Enteral tube feeding §probenecid-prevents acid by coating GI wall §nitrofurantoin §oral anticoagulants, dairy, Mg, Ca

Inotrope

force of contraction, negative= decreased force, positive= increased force

Health care associated infections

host defenses, community associated infections- immunizations, §What are common sources of HAI? Improper hand hygiene, central line associated blood infections, catheter associated UTI §What is the most common mode of transmission? Lack of cleaning hands §List the most common types of HAI in Canada. Post op wound infections, MRSA, VRE §Identify strategies to reduce the incidence. Handwashing, environmental cleaning procedure, surgical site pre/ post op care, no pre- infectious state- 48 hours after admission, immunocompromised, ICU

Nursing process for antidiarrheal and laxatives

hx, abdominal assessment- Bowel sounds, tenderness, contour, peristaltic waves= BM, pain, c. diff, VS, I/O, weight, fluid and electrolyte levels, n/v, health promotion and teaching

Proton Pump inhibitors

more powerful, bind directly to ATPase pumps and inhibit enzyme= total blockage of H+ secretion, MOA/DE- pump transport H+ ions out= increase acid content of the surrounding gastric lumen= decrease pH, drugs prevent movement of H+, does not affect food absorption

Atorvastatin

most commonly used, cholesterol lowering drug, lower total and LDL-C levels and triglyceride levels, raise HDL levels, once daily at bedtime or evening meal (can be dosed at any time), tablet, PO- onset- 0.5 hr, peak- 1-2 hr, half life- 7-14 hr, action- unknown

Nitroglycerin

prototypical nitrate, most important drug in treatment of ischemic heart conditions- angina, metabolized in liver before activation- sublingual tablets or pump sprays, IV for preop, sublingual- onset- 2-3 min, peak- unknown, half life- 1-4 min, action- 0.5- 1 hr

H2 antagonists

reduce but do not abolish acid secretion, MOA/DE- block H2 receptors of acid- producing parietal cells= less responsive to histamine, Ach, gastrin, decrease H+ secretion from parietal cells= increase stomach pH, GERD, PUD, erosive esophagus, GI bleed, watch for mental status changes

Beta- Lactam Antibiotics

ring- responsible for the antibacterial activity, MOA- inhibit the synthesis of bacterial cell wall- contents leak out and cell dies, §Penicillins §Cephalosporins §Carbapenems §Monobactams, antibiotic resistance- §Beta lactamase (penicillinase) are secreted by some bacteria §Action of this enzyme splits the Beta lactam ring §Result: drug resistance ESBL positive patients are isolated in hospital, B- lactames (enzyme) breaks a bond in the ring- pencillin to disable the molecule- resist the effects of penicillin and other bl antibiotics

Hydrochlorothiazide

safe, effective, diuretic, used in combination, doses over 50 mg/day rarely produce additional clinical results- ceiling effect, used in pregnancy, onset- 2 hr, peak- 4-6 hr, half life- 5-15 hr, duration- 6-12 hr

Laxatives

treat constipation (abnormally infrequent and difficult passage of feces, symptom), ingestion- digestion- absorption- storage and removal, regular time of defecation is 24-36 hr post ingestion, types depend on how long it stays in colon, BM- dietary, behavioral, pharmacological- long term use- dependence, damage to bowel, bulk forming, emollient, hyperosmotic, saline, stimulant, MOA/DE- affect fecal consistency, increase fecal movement, facilitate defecation, bulk forming- fiber in diet, absorb water into intestine= increase bulk and distends bowel to initiate reflex bowel activity= BM, emollient- stool softeners and lubricant laxatives- decrease surface tension of GI tract so more water and fat are absorbed into the stool and intestines- lubricate fecal matter- bowel distension and reflex peristaltic actias= defecation, hyperosmotic- increase fecal water content= distension= increase peristalsis and evacuation, large intestine, saline- increase osmotic pressure in small intestine by inhibiting water absorption and increase water and electrolyte secretions into lumen= watery stools, stimulant- stimulate nerves on intestines= increase peristalsis, fluid in colon= increase bulk and softens stool

Sulfonamides

widespread use over decades has led to large # of resistant strains §Mechanism of action: §Bacteriostatic - inhibits folic acid responsible for bacterial cellular biosynthesis §Effective against gram positive and gram negative bacteria- UTI §Enterobacter, E. coli, Klebsiella, Proteus, Staph aureus § Clinical Indications §Bactrim; Septra (trimethoprim-sulfamethoxazole) §Urinary tract infections §Opportunistic infections, i.e. Pneumocystis jiroveci pneumonia- cellulitis §Community acquired staph aureus, big drug allergy, lots of ARO strains, §Contraindications §Allergy! §Third trimester pregnancy and infants less than 2 months old §Several classifications are chemically related to sulfonamides and may cause allergic reaction: §Cyclooxygenase -2 inhibitors (Celebrex) should not be used- crossallergenicity §Use with caution: §Sulfonylureas (type II DM) §Thiazide and loop diuretics- Lasix §Carbonic anhydrase inhibitors- given for glaucoma, §Adverse effects §Because the drug is an antimetabolite, most reactions are immune mediated §Allergic reactions can begin with a fever/rash and lead to Stevens-Johnson Syndrome- skin sloughing §Photosensitivity §Sunburn §GI, liver, renal dysfunction, thrombocytopenia- take with food, consume 2-3 L of fluid per day §Drug Interactions §Sulfonylurea (severe hypoglycemia) §Phenytoin (toxicity) §Warfarin (hemorrhage) §Inhibit the immunosuppressive effect of cyclosporine and the likelihood of nephrotoxicity §Reduce the efficacy of oral contraceptives- use alternative birth control method

HIV and aids

§36.9 million people worldwide are infected with HIV §Where is the highest rate of HIV infection in Canada? §Retrovirus §Transmitted by sexual activity, intravenous drug use, perinatal transfer from mother to child §The risk for transmission to health care workers via percutaneous (needle-stick) injuries is currently calculated at approximately 0.3% §Universal precautions are imperative to prevent the spread of HIV

Pyrazinamide

§Action: converted to pyrazinoic acid in susceptible strains of Mycobacterium which lowers the pH of the environment §Bacteriostatic §Used in combination with other drugs for treatment of active TB §Route: oral only §Most common side effect is hyperuricemia- use in caution with gout, increase uricacid §Other: arthralgia, malaise, GI upset, dysuria §Life threatening adverse effect: hepatotoxicity §Must monitor LFTs §Used with caution in those with gout

Acyclovir

§Adverse effects: §Nausea, vomiting, diarrhea §Anorexia §Fatigue §Headache, dizziness §Burning with topical applications §Rash, urticaria §Nephrotoxicity: worse in IV route and high doses §Encephalopathy (rare) §Therapeutic benefits: §Lesions heal faster §Less pain & itching §Prophylaxis: fewer recurrences

Broad spectrum- aminopenicillins and extended spectrum- penicillin

§Ampicillin (IV, IM, oral) and Amoxicillin (oral) §Active against gram + and gram - bacteria: §Strep, listeria, pneumococci, enterococci, H. flu, E. coli, Enterobacter, Klebsiella, Proteus, N. meningitides, N. gonorrhea, Shigella, Salmonella §Treatment of the following infections: §Skin and soft tissue §Otitis media §Sinusitis §Respiratory infections §GU infections §Meningitis §Septicemia §Drugs of choice for prevention of bacterial endocarditis- in high risk pt- septal defects, hole in heart, implanted medical device, reconstruction, extended- §Piperacillin (IV, IM); Piperacillin - Tazobactam §Effective for gram - bacteria §Pseudomonas, proteus, E. coli §Note: pseudomonal infections require combinations of drugs

Antivirals

§Antiviral drugs §Used to treat infections caused by viruses other than HIV §Antiretroviral drugs §Used to treat infections caused by HIV NOTE: You do not need to know the antiretroviral drug classifications, only some general therapeutic principles, §Inhibit viral replication by: §Barring penetration of the virus into the host cell §Blocking replication, transcription, and/or translation of viral genetic material §Preventing the normal maturation of viral particles §Incapable of destroying the existing virus in infected cells, viral serology, §Toxic §Disrupting viral function often requires disrupting the metabolism of the host cell §Effective only for a limited number of viruses §Most effective if given as soon as possible after exposure §Chemoprophylaxis effective only when drug is taken- unprotected sex- partner has disease §Best therapeutic responses occur in patients with healthy immune systems §Expensive! Barrier, no treatments for some viruses- Ebola, §Viruses controlled by antiviral medications: §Cytomegalovirus (CMV) §Viral hepatitis §Herpes viruses §Human immunodeficiency virus (HIV) §Influenza viruses (the flu) §Influenza A and B §Respiratory syncytial virus (RSV)- peds, §Vaccines: §HPV §Hepatitis A & B §Measles, mumps, rubella §Diphtheria, tetanus, pertussis, polio, H. influenza B (1 needle x series of 5)- killed vaccination §Varicella §Shingles & chicken pox §Pneumococcal §Meningitis- not as serious as bacterial §Avian flu, herd immunity, §Limit the spread of the virus: §Provides protection; symptom control and reduction §Clients with a competent immune systems have the best responses to antiviral drugs, #1: Prevention §Vaccination §Cough etiquette and proper hand hygiene §Safe sex §Harm reduction programs for high risk individuals §Safe injection sites §PPE for health care providers §Isolation precautions §H. influenzae → droplet and standard precautions §Herpes zoster (shingles) with disseminated disease → airborne, contact, standard precautions §Noroviruses causing gastroenteritis → contact, standard precautions §Neutropenic patients are placed on protective isolation- neutrophils <1, Antibiotics are not appropriate for the treatment of viral infections, §Mechanism of action §Penetrate infected cells and block the activity of a polymerase enzyme that normally stimulates the synthesis of new viral genomes (DNA or RNA) §Interrupt the viral life cycle §Used to treat non-HIV viral infections §Herpes (HSV), varicella zoster virus (VZV) §Influenza viruses §Cytomegalovirus (CMV) §Hepatitis A, B, C § §Other classifications of drugs are also used to treat viral infections by stimulating the immune system, i.e. interferons; immunoglobulins

Tetracycline

§Bacteriostatic - inhibit protein synthesis §Tetracycline; Doxycycline §Broad spectrum of activity: §Gram-negative and Gram-positive organisms, protozoa, Mycoplasma, Rickettsia §Drug of choice for the treatment of: §Acne §Chlamydia §Mycoplasma pneumonia §Rocky mountain spotted fever; typhus (rickettsia infections) §Cholera, shigellosis §Lyme disease §Syphilis in those allergic to penicillin, treat acne,§Adverse Effects: §Vaginal candidiasis §GI upset §Maculopapular rash §Photosensitivity: avoid sunlight and tanning beds §Strong affinity for calcium precludes use in: §Children younger than 8 years of age and breast feeding mothers: §Discoloration of permanent teeth §May stunt fetal skeletal development if taken during pregnancy §Dairy products, antacids, & iron salts reduce oral absorption

Macrolides

§Bacteriostatic - prevents protein synthesis within bacterial cells §Azithromycin (ZithromaxÒ) - oral or IV §Clarithromycin (BiaxinÒ) - oral §Used in combination with omeprazole- proton pump inhibitor for treatment of active ulcer disease caused by Helicobacter pylori §Indications: §Streptococcus pyogenes - group A β-hemolytic streptococci §Mild to moderate upper and lower respiratory tract infections - H. influenzae §Spirochetal infections - syphilis and Lyme disease §Unique in that they are effective against bacteria that reproduce inside of cells: legionella; listeria, chlamydia, N. gonorrhea, bacteriostatic

Nursing process for antivirals

§Before beginning therapy, thoroughly assess underlying disease and medical history, including allergies §Assess baseline vital signs and nutritional status §Assess for contraindications, conditions that may indicate cautious use, and potential drug interactions §Monitor for dose-limiting toxicities §Monitor for signs of opportunistic diseases §Patients should be informed to start therapy with antiviral drugs at the earliest sign of recurrent episodes of genital herpes or herpes zoster- not take all the time- but may have constant prescriptions, teaching- §Prevention is the best medicine- condoms §Drugs do not cure or prevent the spread of infection §Take as directed by physician §Drugs vary with regards to interactions with food §Always wash hands before & after touching any lesions §Use gloves to apply ungt to lesions §Encourage vaccination §Particularly for high risk individuals

Opportunistic Fungal Infections

§Candidiasis- yeast infections can occur under folds- warm moist §Caused by C. albicans (usually) §Occur in healthy or severely immunocompromised hosts- oppurtunistic- when immunity/ normal flora is suppressed §Mucosal infections (mouth, vagina) §Result from antibacterial drug therapy §Mouth: thrush or oral candidiasis §Systemic, non-c. albicans species §Occur in HIV, cancer, organ transplants, long term IV therapy, implanted prosthetic devices, onkeymyosis- fungal infection of the nails, fungus can grow in blood

Antifungals

§Classified by chemical structure: §Polyenes - amphotericin B; nystatin- terribly toxic §Azoles: Imidazoles and Triazoles - fluconazole; ketoconazole §Echinocandins - caspofungin §Miscellaneous - griseofulvin- nails §Topical and systemic forms, IV, oral, cream, powder, MOA- binds the nonsterol lipids and alters cell membrane integrity, binds with ergosterol and disrupts memebrane integrity, inhibit the glucan biosynthesis pathway, inhibit the ergosterol, inhibits nucleic acid synthesis, contraindications- §Hypersensitivity §Liver failure §Renal failure §Pregnancy - Voriconazole, nursing implications- §Obtain baseline vital signs, complete blood count, liver and renal function studies, and electrocardiogram §Monitoring for intravenous antifungals §VS q15 - 30 minutes §Intake and output §LFTs, urea, creatinine §CBC §Adverse effects §Therapeutic benefits §Some oral forms should be given with meals to decrease gastrointestinal upset; others require an empty stomach. Be sure to check! §Monitor for signs of improvement, patient teaching- §Immunocompromised patients should avoid exposure to fungus (potted plants, flowers, damp environments), sterile water to flush §Topical skin preparations: wash & dry skin thoroughly prior to use; health care providers must wear gloves- inspect skin folds §Vaginal preparations: §insert high, wash & dry applicator after use §use during menstruation, avoid intercourse §wear clean, cotton underwear §Nystatin oral suspension §should be swished thoroughly in the mouth as long as possible before swallowing §Do not eat or drink for at least 30 min following ingestion

Beta lactamase inhibitors

§Clavulanic acid §Tazobactam §Bind with beta lactamase to prevent the enzyme from destroying penicillin- inactivates §Combined with penicillin to reduce AROs: §Amoxicillin trihydrate/clavulanic acid (ClavulinÒ) §Piperacillin/Tazobactam sodium ("Pip-Taz"; TazocinÒ) §Ticarcillin/clavulanic acid (TimentinÒ)

Properties of Fungi

§Diverse groups of microorganisms: §Yeasts §Unicellular §Reproduce by budding §Molds §Multicellular §Produce spores §Dimorphic fungi §As molds, thrive in cool temps §When inhaled, become yeasts that thrive in warmth §Exist in soil, plants, endogenous human flora (intestines, mouth, vagina)

Fluconazole (Diflucan)

§Drug of choice for localized candidiasis (UTI, thrush) §Other uses: systemic candidiasis, peritonitis, cryptococcal meningitis, prophylaxis in bone marrow transplant §IV or oral routes (well absorbed) §Adverse Effects: §n & v, diarrhea, skin rash, headache, abd. pain §Elevated liver enzymes, hepatic necrosis- LFT §Tolerance can develop in long term use

Anti- TB therapy

§Effectiveness depends upon: §Type of infection- latent vs acute §Adequate dosing §Sufficient duration of treatment §Drug adherence §Selection of an effective drug combination- special clinics §Problems include: §Drug-resistant organisms (MDR-TB) §Drug toxicity- liver §Patient nonadherence, contraindications- risk, benefit analysis §Severe drug allergy §Major kidney or liver dysfunction §Chronic alcohol use- liver dysfunction NOTE: The urgency of treating a potentially fatal infection may have to be balanced against any prevailing contraindications

Penicillin

§Generally a safe and well tolerated group of medications §Contraindicated for known drug allergy §Must obtain an accurate medication history prior to starting therapy §Those allergic to penicillins are very likely to be allergic to other Beta lactams cephalosporins) §Dose adjustments required in the setting of renal disease §Adverse effects: §Allergy: urticaria- hives, pruritus, angioedema §Rash occurs in 2% of patients §Anaphylaxis §GI upset §Drug interactions §NSAIDs; oral contraceptives, warfarin, dose adjust if renal insufficiency

How does hypertension alter cardiovascular function?

▫increasing the workload = thickening and sclerosis of arterial walls. ▫increased cardiac workload = myocardium hypertrophies = heart failure ▫endothelial dysfunction and arterial changes cause narrow arterial lumen, decrease blood supply to tissue, increase risk for thrombocytosis

Tuberculosis

§Highly contagious infectious disease caused by mycobacterium tuberculosis, an acid fast aerobic bacillus §Worldwide Incidence: §Considered a pandemic §In 2017, 10 million people worldwide fell ill with TB (World Health Organization, 2018) §1.6 million died §Globally, TB is declining by ~ 2% per year §TB is a leading killer of HIV positive people- opportunistic §Canada: §1600 new cases of active TB reported each year §Highest incidence is in Nunavut and amongst indigenous Canadians and new immigrants, §Most common sites of infection are the lungs and lymph nodes §Symptoms: §General feeling of sickness, weakness, weight loss, fever, night sweats §Coughing, chest pain, hemoptysis §Caused by inhalation of droplets and spread through blood and lymphatics Host response: §Bacteria are ingested by macrophages and walled off by proteins §Over time, these areas become fibrotic and calcified, forming tubercles §Tubercle bacilli may become dormant, or walled off by calcified or fibrous tissue, pockets seen on chest x-ray, bronchial erosions, forms tubercles contagious when virus is active, groups susceptible to TB- §Homeless individuals §Populations living in crowded and poorly sanitized housing facilities- immigrants §Undernourished or malnourished §Infected with human immunodeficiency virus (HIV) §Misusing illicit drugs §Living with cancer §Taking immunosuppressant drugs, transplant pt, §Diagnosis: §Pneumonia unresponsive to typical anti-infective agents §Positive acid fast bacillus sputum culture §Chest X-ray §TB skin test §+ if >10 mm §Two types of infections: §Latent TB §Active TB

Polyenes - Amphotericin B

§Highly toxic; reserved for serious systemic infections §Candidiasis, histoplasmosis §Fungicidal or fungistatic §Route: IV for several weeks, dose based on weight- very toxic §Long half life: initially 24h, then 15 days Adverse effects: §Nephrotoxicity §Cardiac dysrhythmias §Neurotoxicity §Fever, chills, tachypnea §Hypokalemia, hypomagnesemia §Anorexia, nausea, vomiting §Anaphylaxis, pharmacy monitors- active member of pt team

Carbapenems

§Imipenem/cilastin (PrimaxinÒ) - IV §Meropenem - IV §Broadest antibacterial action of all groups- important, common §Indicated for complicated infections in acutely ill, hospitalized patients §Examples: Intraabdominal infections, pseudomonas §Can cause seizures- IV meds, hospital acquired pneumonia

Principles of Anti-retroviral therapy

§Indicated for the treatment of active HIV infection §Prophylaxis may be administered to high risk infants, health care personnel with exposure §Treatment is complex and highly individualized- complex regimens way safer than before §Requires treatment by a specialist §Drug therapy should be initiated early §Viral load & CD4 counts measured q3-6mo. §Combinations of drugs is the standard of care §Choice of drug depends upon age, health status, drug interactions, ART for HIV §Contraindications: §Allergy §Severe intolerance to medications §Severe drug toxicity §Serious drug toxicities §Monitor liver function closely §Numerous drug interactions, teaching- §Success of therapy depends upon compliance §Non-compliance leads to drug resistance §Drug reduces symptoms; does not cure infection §Therapy is lifelong §Interruptions should be minimized §Adverse effects vary §Should be assessed at least twice during first month of therapy and every 3 months after, prevent opportunistic infections, immune states determines drug efficacy

Pathogenic Fungi

§Infections are also know as mycoses §Four types of infections §Cutaneous §Subcutaneous §Superficial §Systemic

Rifampin

§Inhibits RNA synthesis by blocking RNA transcription in Mycobacterium §Indicated for active TB §Routes: oral and IV §Adverse effects §Hepatitis, discoloration of urine- reddish- orange, stools, abd pain, diarrhea, nausea heartburn, thrombocytopenia §Drug Interactions §Increases the metabolism of many drugs §Decreasing the therapeutic effect of these drugs §i.e. beta blockers, close management

Isoniazid (INH)

§Inhibits mycobacterial cell wall synthesis and interferes with metabolism §Mechanism not well understood §Drug of choice for §treatment of active TB- liver §post exposure prophylaxis §INH is metabolized in the liver through acetylation—watch for "slow acetylators" Toxicity §Routes: oral and IM §Adverse effects §Peripheral neuropathies- n/t of fingers , hepatotoxicity §Abdominal pain and jaundice - - must monitor LFTs §Drug interactions §antacids (decreased INH absorption and serum levels) §Has additive effect with rifampin §Increases CNS and liver toxicity

Azoles - General Characteristics

§Largest group of anti-fungals §Prescription and OTC preparations §Oral agents §Better drug distribution §Less side effects §Fewer drug interactions §All azoles may cause hepatitis §Significant drug interactions, OTC Azoles- §Clotrimazole §Oral, vaginal candidiasis §Topically, intravaginally od X 3-7 days §Miconazole (Monistat) §Fungicidal §Vulvovaginal candidiasis §Topical cream: od x 3-7 days §Intravaginally: suppository od for 1 day, 3 days, or 7 days

Amphotericin B

§Management of Adverse Effects: §Pre-medicate: diphenhydramine, acetaminophen, hydrocortisone- immune suppress, prevent allergic reaction, decrease inflammation §Hydrate: bolus with NS intravenously- renal protection- less nephrotoxic §Administer lipid formulations, such as Fungizone, to decrease incidence of adverse effects and increase efficacy §Monitor and replace electrolytes §Life threatening adverse effects: §STOP the infusion STAT if signs of respiratory distress §Emergency measures for anaphylaxis: §Oxygen, epinephrine IV, IV steroids, airway management

Antibiotics

§Medications used to treat bacterial infections §Goals of therapy: prevent infections in high risk individuals (prophylaxis), eradicate cause of infection §Gram negative bacteria are much harder to eradicate than gram positive bacteria- tougher to treat §Drug selection depends upon causative microbe, severity of infection, age, host factors (pregnancy, age, comorbidities - renal/liver function) Best practice is to identify the causative organism and potential, §Broad Spectrum- large # of microogranisms- prevent surgical site infection and sepsis §Narrow Spectrum- short list of organisms that it is effective against §Bactericidal §Preferred in more serious infections §Bacteriostatic §Efficacy related to immune function of host- prevent growth, ideal drug is selectively toxic, high potent, stable, penetrate needed tissues, does not disrupt flora of host, is not resistant, mechanism of action- 1.Interference with bacterial cell wall synthesis 2.Interference with protein synthesis 3.Interference with DNA and RNA replication 4.Antimetabolite activity which interferes with bacterial cellular functions, §Antibiotic resistance is a significant healthcare concern §Each year, 220,000-250,000 Canadians are diagnosed with hospital-acquired infections, resulting in ~8,000-12,000 deaths §Occurs when microorganisms "defeat the drugs designed to kill them" (Centers for Disease control and Prevention, 2018) §Caused by: §Misuse and overprescribing of antibiotics §Failure of patients to adhere to drug regimen §Sharing unused antibiotics between individuals §Natural phenomenon of bacterial mutation - spontaneous changes to bacterial genes during replication; transfer of genetic material from one bacteria to another, mutate over time, misuse of antibiotics- strategies to limit the spread of ARO- §Basic infection prevention and control practices §Encourage vaccinations §Do not treat viral infections with antimicrobial medications §Antibiotic resistant organisms screening upon admission to health facilities (ARO) §Antibiotic stewardship programs §Saskatchewan Health Authority: Antimicrobial Stewardship Program §Accurate diagnoses leads to appropriate drug selection §Obtain cultures before administering the first dose of antibiotics §Surveillance by the Infection Control department §Isolation procedures §Expert consultation to an Infectious Disease physician for complex cases, identify cause, types of antibiotic therapy- empiric theory- experience, based on presenting symptoms, site of infection, s/s, high risk/ life threatening- bacterial meningitis, febrile, neutropenia, prophylactic therapy- within 60 minutes of incision time, prevent surgical site infection, dentist, bite, prevention of transmission, immunocompromised, administered prior- 3 doses, definitive theapy- based on culture and sensitivity results, combination therapy- Indicated for: §Infections that can potentially be caused by multiple organisms: §Abd or pelvis; nosocomial §Microbes that are difficult to treat §Synergistic effect beneficial §Tuberculosis §Signs of infection in the immunosuppressed- 38 degrees is very concerning, administration- §Routes: IV, IM- STI- cream, oral, topically, eye and ear gtt, intraventricular- of brain- physician §Duration of therapy dependent upon drug type and severity of infection §Must be given on time- specifically IV §Administered at equal intervals, adverse effects- **Nausea, vomiting, diarrhea- tough on gut- GI upset, diarrhea §Allergic reactions §Serum sickness- delayed allergy to antibiotics §Superinfection §Antibiotics reduce/eliminate normal flora §Candida albicans (thrush, vaginal yeast infections)- secondary infections §Pseudomembranous colitis (c. difficile) §Immune suppression from a primary infection leads to a new infection §Examples: bacterial pulmonary infections or cold sores develop following a viral infection (common cold), inspect mouth, Therapeutic Efficacy §What assessment findings should indicate to the nurse that a patient receiving antibiotics is improving? WBC normalizes, decreased fever, less pain, clear air entry- less reliance on 02, clear urine, less pain and inflammation What are the causes of a subtherapeutic response? Improper dose, wrong drug selection, poor drug penetration, ARO, insufficient serum drug levels

Herpes viral infections, antivirals

§Oral and genital herpes (HSV-1; HSV-2) §Highly transmissible through contact §Outbreaks occur with periods of latency §Incurable, painful, annoying, contact- outbreaks occur when immunosuppressed - sexual contact, topical agents, "vit" §Acyclovir: §Drug of choice for treatment of initial and recurrent HSV §Prescribed for treatment and prophylaxis §Decreases viral shedding, pain, & duration of genital herpes lesions §Start ASAP §Routes: oral, IV, topical §Valacyclovir (Valtrex®) §Oral preparation for recurrent genital herpes & varicella- zoster viruses §The prodrug of acyclovir: metabolized to acyclovir by an enzyme encoded in the virus §Indicated for less serious infections; more effective for relief of pain in herpes zoster §Greater oral bioavailability; therefore, less frequent drug dosing than acyclovir, GI upset- take with food

Nursing Process of Antitubercular drugs

§Patient education is critical §Inform patient that therapy may last for up to 24 months §Patient should take medications exactly as ordered, at the same time every day §Emphasize the importance of strict adherence to regimen for improvement of condition or cure §Directed observational therapy (DOT)- TB clinical, home care- watch pt take it §Remind patients that they are contagious during the initial period of their illness—instruct them in proper hygiene and prevention of the spread of infected droplets, cough etiquette, clinical determines home situation- to see if others need prophylaxis, §Patients should not consume alcohol while on these medications or take other medications, including over-the-counter (OTC) drugs before checking with their physician §Advise patient taking rifampin: §urine, stool, saliva, sputum, sweat, or tears may become reddish orange; even contact lenses may be stained- were glasses §Oral contraceptives become ineffective §Vitamin B6 may be needed to combat neurological adverse effects associated with INH therapy (peripheral neuropathies) §Oral preparations may be given with meals to reduce gastrointestinal (GI) upset, even though patients are recommended to take them 1 hour before or 2 hours after meals, §Monitor for adverse effects §Instruct patients on the adverse effects that should be reported to the physician immediately §Fatigue, nausea, vomiting, numbness and tingling of the extremities, fever, loss of appetite, depression, jaundice §Monitor for therapeutic effects §Decrease in symptoms of TB, such as cough and fever §Laboratory studies (culture and sensitivity tests) and chest X-ray should confirm clinical findings §Watch for lack of clinical response to therapy, indicating possible drug resistance, non adherence, drug resistance

Nursing Process for antibiotics used for hard to treat infections

§Patients requiring these anti-infective agents have serious infections, requiring hospitalization and IV administration §Must use the same assessments required for all antibiotics with greater surveillance Self Study: §Create a Nursing Care Plan for Patients Receiving Aminoglycosides, Quinolones, and Miscellaneous Antibiotics: §Identify specific assessments for each classification §Formulate relevant nursing diagnoses §Determine how to administer each classification of antibiotic §Identify key teaching points §Determine how to evaluate for adverse effects and drug efficacy

Viral infections

§Smallpox (poxviruses) §Sore throat and conjunctivitis (adenoviruses) §Warts (HPV) §Influenza: A (H1N1), B, C, D §Respiratory infections (coronaviruses, rhinoviruses) §Gastroenteritis (rotaviruses, Norwalk-like viruses) §Human immunodeficiency virus (HIV) / acquired immune deficiency syndrome (AIDS) (retroviruses) §Herpes (herpes viruses) §Hepatitis: A, B, C, D, E (hepadnaviruses), §Latent infections §The virus persists in an inactive form for months/years §Various stimuli can cause recurrent symptoms §i.e., HSV: cold sores, genital herpes §Oncoviruses §Viral nucleic acid becomes integrated with host DNA §Results in development of cancer §i.e., human papillomavirus → cervical cancer

Polyenes - Nystatin

§Used for candidiasis of skin and mucosa §Routes: §Oral suspensions (swish & swallow) §Topical (powders & creams) §Intravaginal §Poorly absorbed, excreted in feces §Adverse Effects: §Oral: nausea, vomiting, diarrhea §Topical: rash, urticaria §Vaginally: burning & irritation, cannot eat for 30 min after

Varicellas Zoster Viral infections

§Varicella zoster virus (VZV) §VZV is highly transmissible through contact or droplet inhalation §Primary infection with VZV causes varicella - chicken pox §Childhood vaccination is recommended §Once the illness resolves, the virus can remain latent in the dorsal root ganglia §Shingles are caused by the reactivation of VZV §Can occur at any age §Shingrix vaccine is recommended for adults 50 years and older: 2 doses 2-6 months apart- painful, unilateral §Treatment: §Antivirals should be initiated within 3 days of the onset of symptoms

Properties of virus

§Viruses are intracellular parasites §Ultramicroscopic §Not cellular §Basic structure of virions: protein shell, surrounding nucleic acid (RNA, DNA or both) §Inactive outside the host cell- take host hostage §Molecules on surface impart high specificity for attachment to host cell- hepatitis only affects liver, cardiac cells, etc §Multiply by taking control of host cell's genetic material & regulating the synthesis and assembly of new viruses §Most viruses kill the host cell, §Spread by inhalation, ingestion, inoculation: §Blood and body fluids §Ingestion of contaminated food/water §Organ transplantation §Blood transfusions §Sexual contact- Herpes §Pregnancy & breastfeeding §Animal and insect bites- mosquitoes §Viruses that cause human infections are found in 7 families of DNA viruses and 14 families of RNA viruses

Coagulation Modifier Drugs

•Aid in reversing or achieving hemostasis •Categories •Anticoagulants •Antiplatelet Drugs •Direct Oral Anticoagulants (DOAC)- new (NOAC) •Thrombolytics •Reversal Agents (antidotes), affect clotting systems- prevent clots or break up existing clots, some only given in acute settings

Heparin toxicity and overdose

•Antidote for heparin and LMWH is protamine sulfate IV •Indicated in the presence of severe bleeding- end of open heart surgery but not for post op- open heart surgery- heart is arrested for still field •Initial action is to immediately discontinue heparin •Collect serum coagulation profile and CBC STAT •Patient may require a blood transfusion •Mechanism of action: •Protamine binds with heparin to completely reverse its anticoagulant properties •Onset of action: 5 minutes •1 mg of protamine reverses the effects of 100 units of heparin •1 mg of protamine is administered to reverse the effects of 1 mg of enoxaparin, competitive

Nursing process for coagulation modifiers/ anticoagulant therapy

•Assessment: •PMH, medications, and baseline physical assessment •Bleeding - particularly signs of critical bleeding- risk not worth it if drug isn't working, want tissue perfusion •Labs - baseline CBC, coagulation times, INR •Nursing Diagnoses •Risk for bleeding •Risk for injury •Knowledge deficit •Risk for ineffective tissue perfusion, early mobilization, Interventions- •Strategies to prevent DVT in high risk patients •early ambulation, calf compressors, leg exercises •Provide adequate hydration to prevent hemoconcentration •Ongoing assessments to indicate drug efficacy and early identification of problems •Follow daily blood work •Ensure strict adherence to independent double check procedures •Avoid IM injections and invasive procedures, teaching- •Wear a medical alert bracelet or carry an identification card •If patient discharged on SUBCUT anticoagulation, then begin patient teaching for self administration early •Encourage the use of soft toothbrushes •Avoid straight blade razors and opt for electric razors •Do not take herbals, NSAIDS, or ASA before first discussing with a pharmacist or physician- increase bleeding risk •Avoid contact sports •Seek medical attention if decreased urine output, signs of bleeding, tinnitus, peripheral edema, rash or change in LOC, evaluation- How will we know if these medications are effective? •Must assess for signs of symptoms of new clot formation: •Dependent upon the clot location- DVT can be asymptomatic •Redness, swelling, hardened areas •Chest Pain •Shortness of Breath- PE •Neurological changes ***The drug is efficacious if none of these symptoms are present

Anemia Drugs

•Epoetin Alfa •Folic acid •Vitamin B12 •Folic Acid •Iron

Iron

•Essential mineral that is stored in the liver, spleen, and bone marrow •Oxygen carrier in hemoglobin and myoglobin •Dietary sources are normally sufficient to maintain normal levels •Deficiency results in anemia, common in childhod, grains, red meat, leafy green vegetables- need careful transition from meat to vegetarian, fatigue, broken hair, cracked lips, heartburn, anorexia, pale, dry skin, headache, immunodeficiency, indications- •Prevention and treatment of iron deficiency syndromes •Iron will alleviate symptoms, but not treat the underlying cause of the anemia •Supplemental iron may be administered in various formulations: •Single oral preparations: ferrous gluconate •Multivitamins •Parenteral formulations (IV or IM): iron sucrose- venofer: •Indicated for the treatment of iron deficiency anemia in patients with or without chronic renal failure •Route: Intravenous •Dose: Variable; depending upon cause •Adverse Effects: •Anaphylaxis! •Headache •Nausea/vomiting •Leg Cramps •Hypervolemia, know where emergency equipment is, monitor VS for 15 min and then hourly, less risk of iron phalaxis, contraindications- •Known drug allergy •Iron overload: hemochromatosis •Hemolytic anemia •Anemia caused by acute hemorrhagic events, oral iron preparations- •Ferrous sulphate is the most frequently used form •Route: tablets or syrup •Adverse effects •GI disturbances, including constipation! •Results in black, tarry stools (may mask GI bleeding!) •Syrups can stain teeth; advise patient to use a straw, •Administer with foods to enhance absorption: •OJ, veal, fish •Avoid foods that impair absorption: •Eggs, beans, corn, cereal- do not take iron with these •Do not administer with antacids or calcium because absorption is decreased •Dietary counselling is advised •Encourage ingestion of iron rich foods, such as eggs, dried fruits, beans, meat, dark green leafy vegetables, space drugs around iron, nursing care plan for IV iron- •Before beginning therapy, ensure that resuscitation equipment is readily available and functioning •Administer slowly •Monitor BP frequently during administration •Ensure that the pain remains in bed, laying down for at least 30 min to avoid orthostatic hypotension •Monitor liver function tests, Hgb, Hct, serum ferritin and transferrin levels prior to and periodically following therapy •Evaluation of drug efficacy: patient should feel less fatigue and express an increased activity tolerance!, takes a long time to feel better from infusion- but pt will feel better eventually

Anticoagulants

•Goal of Therapy •To prevent the formation of blood clots for patients identified to be at high risk •DO NOT exert any effect on blood clots that have already formed- DVT, PE •Mechanism of Action •Decrease blood coagulability by acting on different sites within the coagulation cascade •More effective in preventing venous thrombosis than arterial thrombosis •Narrow therapeutic index •Baseline labs must be drawn prior to initiating therapy ***High alert medications- independent double check , embolism- mortality and morbidity, better in veins than arteries, CBC- RBC, Hgb, hct, platelets, INR, PTT, •Drugs in this classification include: •Heparin •Low molecular weight heparin (enoxaparin, dalteparin) •Warfarin (Coumadin) •Direct oral anticoagulants (DOAC)- "ban" • apixiban, dabigatran, rivaroxaban •Differentiated by their site of action on the clotting cascade- indications and routes, contraindications- •Known drug allergy •Acute bleeding •Thrombocytopenia •Presence of high risk medical devices, i.e. epidural catheter

Direct Oral Anticoagulants

•Indicated for prevention of stroke in patients with non-valvular atrial fibrillation •Mechanism of Action: •Direct thrombin inhibitors •Factor Xa inhibitors •Favorable risk-benefit profiles: •when compared with warfarin in the management of atrial fibrillation •when compared with LMWH for prevention of DVT, prevent stroke in a fib- w/o valves, dabigatran- direct thrombin (11a) inhibitor,needs to be swallowed whole - it cannot be crushed, chewed or the capsule opened. You cannot sprinkle the pellets in food or mix in liquids, hygroscopic and the capsule should therefore only be removed from the manufactures packaging at the time of ingestion - this can impact the drugs storage options- comes in bottles or foil blisters- exposure to air- reduces efficiency Rivaroxaban/ Apixaban- ban or inhibit Xa inhibitors, advtages- •Standardized dosing •Easy to take •No frequent bloodwork required •Excellent for rural/remote patients or those who like to travel, disadvantages- •Expensive •Cannot be given to patients with mechanical valves •Dabigatran has no reversal agent!

Heparin

•Inhibits a pair of clotting factors: IIa (thrombin) and Xa •Routes of administration: IV or SUBCUT- replaced by enoxaparin- continuous bolus, IV push lines •Therapeutic Uses: •Acute thromboembolic disorders- formed clot has moved to somewhere •Acute coronary syndrome, thrombotic stroke, DVT, pulmonary embolism- spectrum of disorder in between chest pain and MI •Prevents further thrombus formation and embolization •Prevention of clot formation in high risk individuals •Disseminated intravascular coagulation (DIC)- critcally ill, secondary consequence, DVT dissolves on own •life-threatening condition, adverse effects- •Hematemesis - "Coffee Ground Emesis"- minor- hematuria, bruising, bleeding gums, nose bleed- is it worth altering dosages/ stopping medication- risk- benefit •Blood in stool - dark and tarry or frank red blood •VS Changes: •Tachycardia & hypotension •Severe headache or change in LOC- intra cranial pressure, hemodynamic instability, physiological response to hypovolemia. IV HEPARIN- •Intravenous Heparin •Continuous IV infusion at a dedicated site; dosed in "units" •Follows a nomogram: CVA, Cardiac, or DVT/PE- directions- safety, pre lab dosing •Dosing is determined by the serum aPTT level •Normal aPTT = 25 - 35 seconds •Therapeutic aPTT = 55 - 80 seconds- want to prolong aPTT •Advantages: •Acts immediately after infusion is initiated - excellent for acute thrombotic events •Short half life (90 minutes)- cannot wait for warfarin to regulate •Acts as "bridge therapy" to oral anticoagulation- cardio and neuro •Can be used in pregnancy - warfarin cannot •Disadvantages: •Short duration of action •Requires an IV- cannot be piggyback •Frequent laboratory monitoring required •Other adverse effects: hair loss, rashes, long term/high doses may result in osteoporosis- also affects osteoclasts, aPTT levels determine dosing

Enoxaparin

•Low moelcular weight heparin- synthetic, smaller than heparin •Route: SUBCUT; dosed in "mg" •Indications: •Used for prevention and treatment of thrombotic disorders •Higher doses used for treatment of PE, DVT, or ACS (I mg per kg BID) •Compared to heparin: •As effective as IV heparin in treating thrombotic disorders •Acts similarly to heparin, only has a greater affinity for factor Xa- takes longer •Longer half life, higher bioavailability, predictable dose response •Less risk of thrombocytopenia •Preferred in pregnancy - less incidence of HIT and osteoporosis, •Advantages: •More predictable anticoagulant response- works in 20-30 min •aPTT monitoring is not required •No IV required •Earlier discharge; patient can self administer at home •Disadvantages •Takes longer than heparin to leave the system •Can result in large, abdominal hematomas •Weight based calculations •Contraindicated in the presence of severe kidney disease, monitor risk for bleeding same way, in abdomen is the fastest absorption

Clopidogrel (Plavix)

•Oral tablets •300 mg initially X 1 dose •75 mg once daily for maintenance therapy •Mechanism of Action: •ADP inhibitor: inhibits platelet aggregation by altering the platelet membrane so that it cannot receive the signal to aggregate •"Platelet aggregation inhibitor" •Indications: •Superior to ASA in reducing the incidence of MI, stroke and vascular deaths in high risk patients •Often given with ASA for patients with established CV disease, including peripheral arterial disease •Acute coronary syndromes, including unstable angina •Prophylaxis against TIAs and reinfarction post-MI- with stents to provide stability to arteries, 6 mon- 12 mon- tissue will granulate, •Adverse Effects: major bleeding, chest pain, headache, fatigue, rash, edema •Nursing Considerations: •Administer once daily with or without food •Monitor closely for bleeding- decrease hgb of 21, neuro, GI bleed, hemostability •May interact with anticoagulants - increasing the potential for bleeding •NSAID use during therapy may increase the risk of GI bleeding •Patient should never double up on missed doses •Monitor CBC and platelets periodically during therapy •Discontinue 5-7 days before a planned surgical procedure, depends on situation- DR. decides

Warfarin

•Route: oral tablet taken once daily •Mechanism of Action: •Prevents the synthesis of vitamin K dependent clotting factors- antagonist •Acts in the liver as a competitive antagonist on vitamin K receptors •Has no effect on circulating clotting factors or on platelet function- only production of new ones •Narrow therapeutic index! •Highly protein bound- can become toxic •Excreted by the kidneys but can be taken with renal impairment, •Preferred for the long term prevention and treatment of thromboembolic disorders: •DVT •PE •Unstable angina- at rest, w/o activity •Atrial fibrillation •Prosthetic heart valves •After myocardial infarction, may reduce: •Risk of reinfarction •Incidence of ischemic stroke •Mortality The greatest therapeutic benefit of anticoagulants is the prevention of MI, stroke, pulmonary embolism, DVT, contraindications are the same as heparin, •Dosing dependent upon INR (international normalized ratio) •Serum lab test that determines the degree to which a patient's blood coagulability has been reduced •INR evaluates the extrinsic coagulation pathway •Normal INR: 0.8 - 1.2 •Therapeutic INR: •Diagnosis dependent •Typically, 2 - 3 •Prosthetic heart valves: 2.5 - 3.5 •Labs drawn daily when drug initiated and then periodically once therapeutic levels achieved •Physician will review the lab results daily and prescribe the dose- see how pt reacts •May take several days to achieve therapeutic range •Patient may need "bridge therapy" during this time- Heparin, toxicity and overdose- •The antidote for warfarin is Vitamin K- buys time •Route of administration depends on the acuity of the situation: •Oral is preferred but IV is necessary in the presence of acute bleeding •Initial action is to immediately discontinue the warfarin •May take up to 42 hours for the liver to synthesize enough clotting factors to reverse the effects of warfarin •High doses of Vitamin K may reverse the anticoagulation within 6 hours - can cause anaphylaxis •BUT...once Vitamin K is administered, warfarin resistance will occur for up to 7 days- could be unacceptable risk for pt •Current practice is to administer the lowest dose of vitamin K as possible •In the setting of acute and severe bleeding, clotting factors are administered to provide hemostasis (Fresh frozen plasma)- acute, unstable bleed, give platelets back, takes 30 min to administer, pt education- •Medication adherence- do not double up on doses •INR target- pt specific •Importance of lab monitoring •Diet Education: •Patient does not need to avoid foods rich in vitamin K, but must be consistent with consumption habits!- green leafy veggies, can drop to sub therapeutic range

Non-pharmacological managements of HF

•Smoking cessation •Fluid and sodium restrictions •Decrease cardiac work load, edema, etc. •Weight loss measures if overweight •Reduced physical activity in symptomatic HF •Moderate physical activity in stable patients •Oxygen PRN

Heparin-induced thrombocytopenia (HIT)

•The body creates antibodies against the drug- immune system, affects platelets (low) •Heparin binds to platelet factor 4 (protein) to create antibodies which then activate the platelets to clump •Results in platelet activation, clumping and new clot formation •Causes the platelet count to drop •Type I: Gradually reduction in serum platelet levels •Treat conservatively- not as urgent as type 2 •Type II: Acute reduction in serum platelet levels (more than 50% from baseline) •Discontinue all heparin products •Anticipate that physician may order a direct thrombin inhibitor (argatroban) to treat the coagulation that occurred from HIT, follow lab work of pt, protein- immune response and allergy