Patho/Pharm Exam 1
manifestation and diagnosis
"to present or show itself" signs and symptoms: -signs are objective findings gathered during assessment (history, exam, lab testing) -symptoms are subjective findings gathered during the history diagnosis and classification: -acute (sudden onset, short course) -subacute: intermediate -chronic: long term or recurring
pharmacokinetics
"what the body does to the drug" -the movement of drug particles inside the body -absorption: movement of drug from the site of administration into the blood stream -distribution: the movement of drug into cells -metabolism: the conversion of the drug into another substance(s) -excretion: removal of drug
losartan
(-sartan=ARB angiotensin receptor blocker) blocks actions of angiotensin II PT: -HTN, diabetic nephropathy, left ventricle dysfunction PK: -first pass metabolism. peak 1 hour. T1/2 is 2 hours. P450 -excretion: urine 35% and stool 60% PD: selectively blocking the binding of angiotensin II to the angiotensin I receptors in many tissues. Results in vasodilation and excretion of sodium and water contraindications: -hyperensitivity, pregnancy, only one kidney black box warning: -fetal/neonatal morbidity and mortality adverse effects: -hypotension, diarrhea, asthenia, dizziness, and fatigue drug interactions: -anti-hypertensives, hyperkalemics and grapefruit juice Nursing administration: -orally -can be with or without food -if taken for heart failure monitor weight and edema
captopril
(PRIL=ACE-I) PT: -HTN, CHF, diabetic nephropathy, and left ventricular dysfunction PK: -administered: oral -metabolism: liver p-450 -excreted: kidneys. T1/2 is 2 hours PD: -inhibits the ACE needed to change the inactive angiotensin I to he active form angiotensin II and increasing the levels of bradykinin leading to vasodilation, excretion of sodium and water, and retention of potassium by action of the kidneys contraindications: -pregnancy and hypersensitivity black box warning: -fetal/neonatal morbidity/mortality adverse effects: -persistent nonproductive cough, angioedema, rash, hypotension, neutropenia, and dyspnea drug interactions: -other anti hypertensives, other agents that cause hyperkalemia Nursing administration: -BP is monitored after the first dose for at least 2hr to detect hypotension -take at least 1 hour before meals
pharm interventions for MI
-EKG within 10 mins of admission to ED -O2 + aspirin, nitroglycerin, morphine, beta blockers (MONA-B) -angiotensin-converting enzyme inhibitor within 24 hours -eval for percutaneous coronary interventions thrombolytic therapy with alteplase -as indicated: IV heparin or LMWH, clopidogrel -bed rest
atherosclerosis and CVD
-abnormal accumulation of lipid deposits and fibrous tissue within arterial walls and lumen -blockages and narrowing of the vessels reduce blood flow --CAD: myocardium --cerebrovascular- brain tissue --PVD: extremeties -CAD, coronary artery disease, is the most prevelent cardiovascular disease in adults
allergic and idiosyncratic effects
-allergic response is an immune system response -the Ag/Ab response occurs when the drug is taken again -symptoms may become more severe each time drug is given -all recorded allergies should also note the reported action -anaphylaxis is most severe -idiosyncratic responses are often the opposite of what is anticipated
placental membrane
-any drug that can pass through a membrane can pass through the placenta -drug must be lipophilic, not ionized, and not protein bound
therapeutic range
-blood levels of a drug are measured and compared to the therapeutic range to guide the dosage changes -as drug levels within a body increase, the patient is more likely to experience adverse drug effects -nurses need to monitor drug blood levels and notify the provider if necessary
cardiotoxicity
-conduction defects -heart failure -damage to myocardium
assessments
-current medications that a patient is taking --subjective data: pt interview and history --objective data: physical examination --secondary source: medical record -interactions between medications -use of resources to identify drugs that are unfamiliar
Nephrotoxicity
-decreased urinary output -elevated BUN and creatinine -altered acid-base balance -electrolyte imbalances
therapeutic strategies to prevent illness
-dietary recommendations -nursing interventions -education and support -surgical interventions -medical interventions
nitrates
-dilate vascular smooth muscle and both venous and arterial vessels (although more relaxation occurs on the venous side) -venous dilation reduces systematic vascular resistance and arterial pressure (after load) -these effects decrease the workload on the heart and its oxygen needs -nitrates improve the circulation to the heart by redistributing blood flow to the collateral vessels -always administer medication slowly because rapid administration will cause severe BP drop -PK: --IV: immediate onset, immediate peak, 3-5 min duration of action. Sublingual: 1-3 min onset, 4-8 mins peak, lasts at least 25 mins. trans lingual spray: 1-3 min onset, 4-10 min peak, lasts at least 25 mins. Oral: 60 min onset, 2.5-4 hours for peak, lasts 4-8 hours. Ointment: 15-30 min onset, 60 min peak, lasts 7 hours. prototype drug: nitroglycerin (nitrostat)
statins
-drugs that lower blood cholesterol levels and thus decrease the uptake of modified lipoproteins by vascular cells -statin therapy can lower LDL cholesterol by 20% to 55% when given at their max recommended dose -also raise HDL levels between 5-15% and lower triglycerides between 7-33% prototype drug: lovastatin (mevacor)
drug classification
-drugs that share similar characteristics are classified as a pharmacologic group or family -allows for increased understanding of medications -classified by: --chemical, physiologic, or therapeutic classification
pathophys of hyperlipidemia
-elevated blood lipid levels -a risk factor for the following disorders: atherosclerosis, CAD, and thromboses -when the amount of cholesterol within cells builds up, the number of these receptors on cell surfaces is reduced, preventing all of the lipids from entering the ells -patients with narrowed arteries from atherosclerotic cardiovascular disease are more likely to have HTN ideal cholesterol levels: -total: less than 200mg/dL -LDL: 100mg/dL -HDL: 40-59 mg/dL
biliary excretion
-enterohepatic recirculation -drug molecules in bile are reabsorbed -prolongs time drug is in the blood stream
risk factors for disease
-genetic predisposition -environmental trigger -stress, age, gender, lifestyle -congenital condition -acquired condition: injury, exposure, malnutrition, hypoxia, neoplasia most diseases are multifactorial in origin
beta blockers
-grouped according to their specificity of action at the beta-1 and beta-2 receptors -stimulation of beta-1 only (tachycardia, increased lipolysis, intropy) -stimulation of both beta-1 and beta-2 receptors (vasodilation, decreased peripheral resistance, bronchodilation) prototype drug: metoprolol (oppressor toprol XL)
core patient variables
-health status -life span and gender -lifestyle, diet, and habits -environment -culture/inhertied traits
hepatotoxicity (liver)
-hepatitis -jaundice -elevated LFTs -fatty infiltration of the liver
schedule C-2 of controlled substances
-high abuse potential -severe dependence -amphetamines, some opioid narcotics -require tamper proof prescription, no telephone orders, refill not allowed
immmunotoxicity
-immunosuppression -increased incidence of infections (bacterial, viral, parasitic)
restoration of O2 balance
-increase O2 supply -decrease O2 demand
Blood brain barrier
-keeps toxins and poisons from reaching the brain -at times this mechanism will prevent treatment of a problem
schedule C-5 of controlled substances
-limited abuse potential -lowest dependence -antidiarrheals -can be obtained without prescription
P-450 system
-liver metabolism is achieved by specific liver enzymes called the cytochrome P-450 system -the enzyme CYP3A4 is the most common and is responsible for the metabolism of most drugs -some drugs and foods either induce or inhibit the P-450, altering metabolism of other drugs -when a large quantity of one of these enzymes is present, more metabolism can occur -this increase in metabolism rapidly decrease the amount of circulating drug (inducer) -a decrease in metabolism rapidly increased the amount of circulating drug (inhibitor)
environment
-living accommodations that impact self management of medication -location of home (city, industrial, suburban, rural)
schedule C-4 of controlled substances
-low abuse potential -limited dependence - muscle relaxants and sedatives, Benzos -governing same as C3
maintenance and loading doses
-maintenance= daily dose -loading dose- larger than usual dose to reach therapeutic effect quicker
nurse management of drug therapy
-maximize therapeutic effect -minimize adverse effect -provide patient and family education
schedule C-3 of controlled substances
-moderate abuse potential -moderate dependence -some opioids, some CNS stimulants, anabolic steroids -phone order ok, up to 5 refills
nursing management of drug therapy
-nurses are legally responsible for the drugs they administer -safe drug administration requires a thorough understanding of therapeutic drug actions and adverse drug reactions -in some clinical settings, nurses are allowed to modify drug regimens -application of the nursing process to the pharmacologic aspects of patient care is especially important because long term use of drug therapy is frequently necessary to control chronic disease processes -nursing management of drug therapy may be considered an applied science
lifestyle, diet, and habits
-occupation -fianances -exercise patterns -sleep and rest patterns -dietary patterns/supplements -CAM use -illicit drug use -alcohol use -nicotine product use -caffeine use
how drugs move
-occurs during all phases of pharmacokinetics -drugs cross cell membranes --pass between spaces or channels between the molecules in the membrane --pass through the membrane with help of transport system --penetrate the membrane directly -chemistry effects how the drug will move
metabolism
-occurs in the liver -when drugs are metabolized they are changed from their original form to a new form --sometimes referred to as biotransformation -drugs are generally metabolized from substances that are lipophilic into ones that are hydrophilic -drugs that are metabolized are generally changed not an inactive form -drug that are inactive until metabolized into an active form are called "prodrugs" -product of metabolism is a metabolite -an active metabolite may cause a different and potentially harmful effect
drug interactions
-occurs when two drugs have an effect on each other (drug-drug) -occurs when a drug and a food have an effect (drug-food) -may increased or decrease therapeutic effect -may create new effect -may increase the incidence of an adverse effect
factors effecting renal excretion
-pH of urine -overloaded transport system -two drugs are given together to slow the rate of excretion of one or both drugs
core drug knowledge
-pharmacotherapeutics -pharmacokinetics -contraindications and precautions -adverse effects -drug interactions
health status
-presence of acute or chronic diseases -drug history -sensory deficits (vision, hearing, speech) -ability to understand instruction -cognitive or memory deficits
culture/inherited traits
-shared values, beliefs, norms -social history -spirituality and religion -genetic variations -presence or absence of certain isoenxymes
therapeutic actions
-specific details on how to give medication --if oral: with food or empty stomach? --can pill be crushed or altered? --if IV: does it need to be diluted? how much? with what? --if IVP: given over how much time? --if inhaled: with spacer or directly to mouth?
pharmacotherapeutics
-the achievement of the desired therapeutic goal from drug therapy -the study of the clinical purpose (the indication) for giving the drug -the desired pharmacotherapeutics can be to induce a cure or prevent a problem -nurses need to use clinical reasoning and clinical thinking if the intended Pharma-therapeutics of a drug do not correlate with the reason for receiving drug therapy
etiology
-the cause of disease -cellular injury is the start of most disease --biological agents such as bacteria, parasites --physical forces: mechanical, electrical, extremes of temperature --radiation injury: ionizing, non-ionizing, ultraviolet --chemical agents: pollution, drugs, tobacco/food preservatives, lead/mercury --nutritional excess or deficit
therapeutic index
-the difference between an effective dose and a toxic dose -when the effective dose and the toxic dose do not differ by much, drug has a "narrow therapeutic index"
potency and efficacy
-the level of the drug needed in the body to proceed an effect -minimum effective concentration
steady state
-the point at which the amount of drug being administered and the amount of drug being eliminated are equal -steady state is achieved based on the amount of the time required for 4-5 half lives to occur
excretion
-the process of removing drug, or its metabolites from the body -primary organ of excretion is the kidney --glomerular filtration --passive tubular reabsorption --active tubular secretion -diseases and pathophysiologic changes in the kidney decreases the effectiveness of the kidney in drug excretion
clearance
-the rate at which drug molecules disappear from circulatory system -factors effecting clearance include gender, renal excretion, and hepatic metabolism
Ototoxicity
-tinnitus -hearing loss -vertigo -N/V
protein binding effects on distribution
-unable to pass through capillary walls -bonds dissolve in time, and the drug molecules will then become free and active -drug dosages are calculated on the protein-binding characteristics of the drug -when the patient has a lower than expected protein level, the distribution is altered
adverse effects
-undesirable effect other than the intended one -may occur even with normal dosing -may be the result of too much therapeutic effect or other pharmacodynamic effect
schedule C-1 of controlled substances
-very high abuse potential, severe dependence -no medical use -heroin, LSD
pharmacodynamics
-what the drug does to the body -the biologic, chemical, and physiologic actions of a particular frug within the body -responsible for its therapeutic effects and sometimes adverse effects -drugs cannot create new responses in the body; they can only turn on, turn off, promote or block a response that the body inherently capable of producing
patient and family education
-who will be administering the medication in the home setting -what is their developmental level -what is their preferred method of learning
stage 1 HTN
140-159 OR 90-99
distribution
3 factors: -blood flow through tissues -drug's ability to leave blood -drug's ability to enter cell
stage 2 HTN
>160 OR >100
pathophys of atherosclerosis
Fatty material deposited on artery walls--> that enlarges and becomes fatty tissue--> fatty tissue calcified into plaque--> plaque infiltrates arterial wall and reduces elasticity; growing plaque also reduces blood flow
controlled substances
Harrison narcotics law of 1914 1970 comprehensive drug abuse prevention and control act
potassium replacement
PT: -essential electrolyte replacement PK: -administered orally or slow IV via IVPB, excreted in urine PD: -major intracellular cation involved in physiological processes such as nerve impulse conduction, cardiac, skeletal, and smooth muscle contraction contraindications: -hyperkalemia, renal impairment or failure, cautious use in acidosis and dehydration, use of K+ sparing diuretics adverse effects: -dysrhythmias, oral administration: N/V, abdominal pain and flatulence. IV administration: phlebitis and discomfort at IV site drug interactions -any drug such as anticholinergics which may slow GI transit time
metoprolol
PT: -treatment of hypertension, angina, and controlled CHF PK: -administered: parenterally and orally. -metabolism: liver -excreted: urine and breast milk -onset and duration: varies with route of administration PD: -decreased cardiac output and blood pressure -slowing of atrioventricular conduction and suppression of automaticity contraindications *only effect heart RATE -severe bradycardia, cariogenic shock, airway diseases, Raynaud syndrome, and use of antidepressents adverse effects: -cognitive dysfunction, hypoglycemia, diarrhea, and severe hypertension several drug interactions Nursing administration: -orally, usually once or twice a day -take with food to increase absorption -do not crush or chew extended release tablets -effectiveness results in: absence of chest pain, dysrhythmias, Normal BP, controlled heart failure manifestations
furosemide
PT: -treats peripheral and pulmonary edema and HTN PK: -administered: IV or oral. highly protein bound drug -metabolim: liver -excreted: kidneys PD: inhibits the reabsorption of sodium, chloride and water in the ascending loop of henle contraindications: -anuria or hypersensitivity black box warning: -profound diuresis with fluid and electrolyte depletion adverse effects: -hypokalemia (monitor cardiac status and K levels, report a decrease in K level less than 3.5, teach clients to consume high K foods, teach clients the manifestations of hypokalemia: nausea, vomiting, cramping, fatigue) and other electrolyte imbalances, ototoxicity (avoid use with other ototoxic meds, teach client to notify provider of tinnitus), alteration in blood glucose levels drug interactions: -many. do not give with digoxin (can cause ventricular dysrhythmias) or aminoglycoside Nursing administration: -get baseline data: BP, weight, electrolytes and location and extent of edema -weight clients at the same tune each day and monitor I and O and BP -usual dosing time is 0800 and 1400 -if K is lower than 3.5, monitor EKG and and notify provider
spironolactone
PT: -used as an adjunct to manage edema abd HTN PK: -absorbed incompletely after oral administration -metabolized: liver, CYP 450 -excreted: kidneys PD: -aldosterone antagonist- inhibits transport of sodium in the distal convoluted tubules, decreases sodium and water reabsorption but increases potassium retention contraindications: -hypersensitivity, hyperkalemia, renal or liver disease, pregnancy black box warning: -tumorigenic adverse effects -hyperkalemia, nephrotoxicity, thrombocytopenia, elevated liver enzymes, headache drug interactions: -potassium preparations or medications that cause hyperkalemia, anti hypertensives or other diuretics Nursing administration: - obtain baseline data, weigh at the same time everyday, monitor I and O and BP, periodically EKG, monitor K Client education: -reduce intake of potassium rich foods -keep a log of BP and weight -report cramps, diarrhea, thirst
HCTZ (hydrochlorothiazide)
PT: -used to treat HTN (usually first choice) PK: -administered: oral -metabolism: liver -excreted: kidney PD: -acts in the distal tubule -it increases excretion of sodium and chloride in the distal convoluted tubule by slightly inhibiting the ion pumps that work in sodium and chloride reabsorption contraindications: -severe renal impairment, anuria, hepatic coma, hypersensitivity, pregnancy adverse effects: -hypokalemia, hyponatremia, hypochloremia, hypomagnesemia, hypercalcemia, monitor for dehydration drug interactions: -additive effects with other antihypertensive agents Nursing administrations: -obtain baseline data, monitor K levels, alternate day dosing can decrease electrolyte imbalance, monitor BP and I and O Client education: -take med first thing in the morning and then no later than 1400 -consume foods high in K -if GI upset occurs take with or after meals
Nitroglycerin (Nitrostat)
PT: -uses of nitroglycerin vary by the route of administration, typically hypertensive crisis, sudden onset angina PK: -administered: IV, topical, oral, sublingual, nasal. kinetics vary with route of administration PD: relaxes vascular smooth muscle and dilates both arterial and venous vessels to decrease preload and after load contraindications: -hypersensitivity, severe anemia, closed-angle glaucoma adverse effects -headache (treat with Tylenol), hypotension, postural hypotension, tachycardia, syncope, vertigo, anxiety, weakness few drug interactions Nursing administration: -prepare medication by adding to diluent for IV infusion -solution usually light brown -protect IV container and tubing from light -discard med after 24 hours -monitor vitals continuously -should be maintaining normotensive BP, improved heart failure
neurotoxicity (CNS)
S&S: drowsiness, auditory and visual disturbances, and seizures
potassium sparing diuretics
Spironolactone (Aldactone)
prehypertension
Systolic: 120-139 Diastolic: 80-89
nosocomial/ healthcare associated
acquired in health care facility
lifespan and gender
age, physiologic development, reproductive stage, and gender
Drug incompatibilities
are drug interactions occurring when two or more drugs are mixed together that cause a chemical or physical deterioration of the drug.
nursing process: HTN
assessment: -VS, edema for cardiac -urinary assessment: I and O planning/intervention -therapeutic actions for oral administration -therapeutic actions for IV administration evaluation: -expected/unexpected outcomes
nursing process for CAD
assessment: -cardiac: chest pain, edema, etc -respiratory: lung sounds, SpO2, dyspnea planning: -therapeutic actions for oral, topical, sublingual, IV administration evaluation: -expected/unexpected outcomes
trade name
brand or proprietary name ex: advil
pathophysiology
cellular and organ changes that occur with disease and the effects on function
drugs to reduce HTN
decrease cardiac output (decreases heart rate, decreasing force of contraction, and decreasing preload) -beta blockers decrease HR -beta blockers decrease force of contraction -diuretics, ARBs, aldosterone blockers decrease preload (systolic volume) decrease peripheral resistance -decreases afterload: diuretics, calcium channel blockers. ARBs, ACE inhibitors
iatrogenic
disease arose as a result of prescribed medicine -common in pharmacology -risk vs benefit
receptor theory
drug-receptor interactions -agonist causes cell to act -antagonist stops the cell from action. also called blockers -lock and key concept -most drugs create their effects in the body by attaching receptors occupancy theory -single-occupancy -modified occupancy receptor sensitivity: see photo
mechanisms of cellular injury
free radicals hypoxic cell injury impaired calcium homeostasis, disruption of the cellular membranes (reversible or irreversible, apoptosis, necrosis)
preventative care
health promotion and restoration: -acute care -long term care -rehab facilities -assisted living illness prevention: -first aid -safety -immunizations -screening
first pass effect
metabolism occurs at different rates for different drugs -the percentage of a drug that is metabolized and loses much of its effectiveness during the first pass through the liver is called the first pass effect -these drugs need a higher oral dose to achieve a therapeutic Lebel of circulating drug
generic name
nonproprietary name; identifies the drugs active ingredient ex: ibuprofen
pathogenesis
origin or development of disease due to: -structural abnormalities that are endogenous or exogenous -functional abnormalities that have no identifiable cellular changes that results in tissue abnormalities
diuretics not used for HTN
osmotic diuretics -mannitol/osmitrol -carbonic anhydrase inhibitors
sources of drugs
plants, animals, synthetic chemicals, genetically engineered chemicals
chemical name
precisely describes the drugs atomic and molecular structure ex: P-isobutylhydratopic acid
potassium chloride
principal intracellular cation in body tissues important in: transmitting nerve impulses, contraction of cardiac, skeletal, and smooth muscle, acid base balnce, and maintenanace of normal renal function
Lovastatin
prototype for -statins PT: -used for primary hypercholesterolemia and combined hyperlipidemia PK: -high first pass effect. P450 highly protein bound. excreted primarily through GI tract PD -competitively inhibits HMG-CoA reductase, which is the enzyme that catalyzes the early rate-limiting step in cholesterol biosynthesus contraindications -active liver disease and pregnancy adverse efffets -muscle and joint aches, weakness, cramps, muscle damage, liver damage, and rhabdomyolysis drug interactions: -anti fungal agents (azoles), antimicrobial agents (-mycin), anti viral agents (-vir) and grapefruit juice bc it suppresses CYP3A4 Nursing administration: -orally -administer with evening meal
absorption
rate influences: -route of administration (IV, IM) -speed at which drug dissolves orally (delayed) --> mucosal--> subcutaneous--> IM --> IV (immediate) surface area: -inhaler covers large area -topical agent covers smaller area blood flow/volume: -cream applied to area with vascular disorder will not be absorbed water vs lipid solubility: -water= quicker pH: -some absorbed in acidic environment -some drugs prefer alkaline
physiology
study of the functions of the human body
normal BP
systolic: <120 AND diastolic <80
half life
the amount of time required to remove half (50%) of the blood conc of a drug metabolism+ excretion= elimination
pathology
the study of structural and functional changes in cells, tissues, and organs of the body caused by disease
drug interactions: affecting pharmacokinetics
these interactions affect absorption, distribution, metabolism, and excretion
drug interaction: affecting pharmacodynamics
these interactions have additive, synergistic, potentiated, and antagonistic effect
potassium wasting diuretics
thiazide diuretics -hydrochlorothiazide (HCTZ) loop diuretics -furosemide
idiopathic
unknown etiology
