EXAM 2 Flashcards
Heart failure
(Pump failure)
The heart muscles (myocardium) weakens and enlarges causing decreased ability to pump the blood through the heart and into the systemic circulation.
Congested Heart failure
They have now become fluid volume overload (SOB, gain weight, edema) /
Compensatory mechanisms fail and the peripheral tissues and lungs become congested (fluid overload)
Left-sided heart failure
Left ventricle is not pumping
Pulmonary congested (SOB/shortness of breath), cough, oliguria (400ml output), weight gain
Right sided and left sided typically looks the same
Right-sided heart failure
Right ventricle is not pumping
Peripheral edema, jugular vein distention, and weight gain
They also can have pulmonary edema and crackles, fluid volume over load
Causes of Heart failure
- Chronic HTN (when the heart has to pump harder against the blood vessels that has high pressure in them. When the heart has to work harder, the heart grows
- MI (heart attack): causes damage to heart tissue
- Coronary artery disease (CAD)/atherosclerosis: that means that. The vessels that sits on top oF the heart are not feeding the heart muscles well; so if the heart is not getting enough blood flow into the muscle, then it will start to decline)
Valvular disease: stenosis of the valves; means the valves are tight and the heart has to work harder to push the blood through them; regurgitation means when the valves doesnt close all the way, now the blood flow goes back. So the heart has to pump harder and harder to push that blood forward
-Congenital heart disease
-Aging: as we get older, the heart has to work harder and harder to function
Not everyone gets HF when they get older.
Cardiac Glycosides
We use cardiac glycosides to help improve the contractility of the heart. Make the heart muscle contract more efficiently; they are considered +INTROPES. To increase cardiac output; we perfuse the tissues, & if we perfuse the tissues, our organs work better (in particular our kidneys). They are gonna slow the hR down,
3rd line treatment for pt with HF. /
Inhibit the sodium-potassium pump Increases intracellular sodium leading to increased influx of calcium Causing cardiac muscle fibers to contract more efficiently
Positive Inotrope Negative chronotrope Negative dromotrope Used when other modalities don’t control manifestations
**improve myocardial contractility improves cardiac, peripheral and kidney function due to Increased cardiac output Increased cardiac output decreases preload improving renal perfusion caused decreased edema and promoting fluid excretion
Ianoxin (Digoxin)
A cardiac glycoside
A 2nd line treatment for HF
Used for pt that had Atrial fibrillation/Aflutter rate control (Irregular & rapid Heart rate) or have a low blood pressure
Slows hr down and DOESNT decrease bp
(Ex: if someone has a rapid HR we need something that would lower their hr, but not their bp)
Route: PO/IV
Its a highly protein drug ; means it needs a protein to rest on, if it doesnt have a protein to rest on, they will have active meds floating around; will increase risk of toxicity. ; protein binding power 30%
Small therapeutic window 0.5-2.0ng/ml
When we start to see pts above 2.0, that is when we start to see some toxic side effects such as: bradycardia, anorexia (not eating), N/V, diarrhea, visual changes* (having yellow halos in their visions), confusion, delirium dysrhythmias (ventricular)
Antidote: digibind, ovine: helps reduce levels of digoxin.
Pregnancy category C
You need to Rember that it is excreted by the kidneys. So we may need to lower the dose if the kidney function is not good; can lead to toxicity & pts with thyroid disease alter the metabolism of digoxin so we need to decrease the dose in pt with hypothyroid.
Increases myocardial contraction, increases CO, which increases tissue perfusion and lower HR (decreases AV conduction decreasing HR)
Drug interactions: one of the things we worry about is when pts are on potassium wasting diuretics, they can lose potassium, if they are also on digoxin the digion can get absorbed more readily; which leads to toxicity if they have low potassium levs already. Check potassium levels first before administering.
- cortisones or steroids increases the loss of potassium as well; which increases toxicity
-antacids its gonna decrease the acidity in the stomach, which interferes with the absorption of digoxin. Best to separate the medications by at least an hour.
/
Potassium loss diuretics and increase risk of digoxin toxicity Cortisone solution taken systemically (po,IV) increases hypokalemia increasing risk of toxicity Antacids decrease absorption, stagger doses
Digoxin Nursing considerations
We know that it will decrease HR, so check Hr before
Obtain apical pulse prior to administration
Assess for signs of toxicity (abuses, vomiting, bradycardia ect. )
Monitor digoxin level
Monitor potassium level (why? Low potassium means that increases the absorption of digoxin , which leads to toxicity)
Phosphodiesterase inhibitors
Increase cardiac output
Lower hr & bp; for CHF
Primacor (milrinone)
Inocor
These are + inotropes
Which increase tissue percussions.
**Can use in CHF an improve contractility which increase tissue perfusion, in particular to the kidneys, which will allow th kidneys to get the fluid off.. to help get rid of all of the edema that they are experiencing with CHF.
IV only
For about 24-72 hours (call in a cardiac “tune up”)
Because theses are cardiac select meds, we might see an increase in hr ; watch out for tachycardia. These meds also cause vasodilation, we have a balance act to make sure their bp doesn’t get to low, we are lowering their bp but need to make sure it doesn’t get too low.
/
Primacor (milrinone) Inocor
Positive inotropes that increase stroke volume, cardiac output, vasodilation
IV only 48-72 hours Cardiac dysrhythmia may occur, monitor EKG
Vasodilators
Another agent for heart failure
Decrease venous blood return to the heart, decrease pre load/
**gonna open up the arteries so thats gonna help decrease the workload of the heart,so it doesnt have to work that hard. This will alos help the heart from filing too much (decrease preload)
Arteriolar dilators
Another agent for heart failure
Decrease after load (the heart doesnt have to pump header) increasing cardiac output, increased renal perfusion by dilating arterioles, improve circulation to muscles. ;
ACE inhibitors
Another agent for heart failure
Dilate venues, arterioles, improve renal blood flow, decrease blood fluid volume. Certain ARBS also (Diovan, Atacand)/\
Help improve renal blood flow
Diuretics
Another agent for heart failure
We know we can use to get extra fluid off then have better fluid balance. When there’s better fluid balance, the heart can pump efficiently.
Aldactone (spironolactone)
Another agent for heart failure
Its a potassium sparing diuretic
We use in pts with HF especially low ejection fraction hf.
Blocks the secretion of aldosterone causing decrease fluid retention.
Beta- blockers
Another agent for heart failure
As long as pt doesnt have decompensated HF we can use. Bb will help heart work more efficiently.
Natrecor
Another agent for heart failure
Inhibits ADH (prevents body from holding on to extra fluid) help with vasodilation, diuresis (Acute CHF),
BiDil (hydralazine and isorbide dinitrate) :thats a meds that help them with getting renal blood flow or blood flow to the kidneys to help get the fluid off .
Angina
Chest pain, tightness, radiating to left arm and or neck
Is when someone expernce chest pain (chest pain, burning). It means the heart is not getting sufficiently amount of blood flow, due to plague (ex: blood clot) being in the arteries or coronary spasm (arteries constrict and cause a temporally constriction of blood flow).
If restrict the blood flow in the arteries that are feeding the heart muscles, thats how it’ll get ischemia, which causes chest pain. (Then can lead to a heat attack.)
What are the 3 types of angina?
Classic (stable)
Unstable (preinfarct)
Variant (prinzmetal, vasospasm)
Classic (stable) Angina
Person knows what causes their angina; they can predict it.
Ex: person goes for a walk, gets to top of hill, he develops angina then he walk back home.
/
Occurs with stress or exertion (physical effort)
Unstable (preinfarct) angina
Occurs frequently with progressive severity unrelated to activity.
Progresses
Ex: the man that walks to the top of the hill, if the angina starts to happen before he gets to the top of the hill, that means something changed, its unstable; its gotten worst. He feels dizzy, SOB while walking.
Basically change in the symptoms
Now, if someone suddenly develops angina anaad never experienced it before, it is unstable because they went form nothing to something.
Variant (prinzmental, vasospasm)
Occurs during rest.
Typically the most alarming kind, because it can send someone into cardiac arrest because we have sudden blockage in the heart, usually caused by a vasospasm.
Nonpharmacologic measures to control angina
- avoid heavy meals: helps decrease the pressure on the heart, especially at night.
- avoid smoking & vaping: every puff causes vasoconstriction; then lead to angina
- avoid strenuous exercise: when we know someone who has angina or cardiac disease, we dont want to over do it
- avoid extreme temperatures: avoid being outside in less than 40-degrees for 20mins or so …or in 80 degree or more..puts workload on the heart and causes damage (ex: shoveling snow should be avoided)
- avoid emotional upset
- rest and relaxation techniques.
Antianginal drugs
Increase blood flow by increasing O2 supply (vasodilation) or decreasing O2 demand/ decreasing the heart’s need for oxygen.
Three types of antianginals
Nitrates
Beta-blockers
Calcium Channel Blockers
Beta-Blockers
An antianginal
Decreases the heart’s need for oxygen and the heart work more efficiently ; which in turn decreases angina.
/
Decrease workload, decrease O2 demands
/
Beta-blockers as antianginal decrease heart rate and myocardial contractility, reducing O2 demands and reducing angina.
Most useful in stable angina
Taper dose to avoid reflex tachycardia and recurrent angina pain
Remember it lower HR, if someone has heart block and we give them a beta-blocker, it can slow the conduction even more, so we need to be careful.
/
Avoid in 2nd and 3rd degree AV block
Calcium Channel blockers
An antianginal
Help decrease the workload and oxygen demand. Dilate those coronary arteries a lil bit to ease the angina
/
Used to treat both variant and stable angina
Calcium blockers would dialate those arteries to prevent those spasms in variant angina.
Prevent spams help decrease oxygen cardiac demand
Decrease contractility
Decrease after load
Decrease PVR (peripheral vascular resistance) basically decreasing BP
Decrease workload of the heart
*Remember the two groups of calcium channel blockers. But Remember all of them will help with angina.
Nitrates
An antianginal
Reduce venous tone, increase vasodilation, decrease workload.
/
Increase vasodilation and also lower blood pressure and lower preload; helps the heart work more efficiently
*Keep in mind that nitrates are potent dilators, so someone can have a rapid drop in their blood pressure
More info: dilate those coronary arteries on the heart and also dilate the arteries around the body and drop bp and decrease the work of the heart.
/
cause generalized vascular and coronary vasodilation increasing blood flow to coronary arteries, reducing ischemia
Forms of Nitrates: sublingual (SL), IV, ointment, patch, PO
Nitroglycerin
A type of nitrate
An antianginal.
Sublingual
Nitroglycerin (SL) its 0.4mg and it is inserted underneath the tongue wait 5mins and if the pain doesnt relieve in 5 mins, can take another pill, and if it doesnt relieve in 5mins, can take a third pill. If the angina still there after 5mins, call 911.
Patients should NOT swallow it because GI will deactivate it.
The tablets should be kept in the dark and not exposed to the light
This is NOT in a child proof container (if a child take this can significantly reduce their bp and kill them)
/
Nitroglycerin (SL) 0.4mg or 1/150 gr Take on q 5mins x 3 no relief call 911 Tablets will decompose when exposed to light and heat Keep in dark, glass, airtight jar. Not a child proof jar for decreased elder dexterity DO NOT SWALLOW UNDER GOES 1ST PASS METABOLISM AND WILL BE INEFFECTIVE
Transdermal is absorbed slowly.
You dont want to put the patches where you put the defibrillator because it will cause burns
/
SL absorbed directly and rapidly into the internal jugular vein and right atrium. (40- 50% absorbed through GI are inactivated by liver metabolism)
Nitro-bid ointment (you dont want to get it on your hands because its a potent dialator and can pass out) and transdermal patch absorbed slowly through the skin Excreted primarily in the urine
Pharmacodynamics:
Causes the blood vessels of the blood vessels to relax and dialate
Decreases preload and after load, so the heart doesnt have to work as hard
Reduces myocardial oxygen demand
Onset action SL and IV: 1-3mins
Transdermal patches onset: 30-60 mins duration 24hrs
Sometimes pts can develop nitroglycerin tolerance. To help prevent this sometimes we would Remove patch for 8-12 hours to help pts not to become tolerance/ Remove patch 8-12hrs for nitrate free interval
Side effects: headache (very common; because of the potent dilation), hypotension, dizziness, weakness and faintness
Adverse reactions: taper dose to avoid REBOUND effect of severe pain due to myocardial ischemia, reflex tachycardia if given RAPIDLY.
Drug interactions: Remember, any medications that is going to lower bp, any other meds that also lower bp can cause a problem. Such as Betablockers, CA+ blockers, vasodialation and ETOH (alcohol) may cause hypotension
We want to make sure we are careful when we are utilizing these meds together
Nursing interventions of antianginals
-Monitor vital signs
*Check orthostatic hypotension (all antianginals lower blood pressure)
-offer a sip of water with the nitroglycerin; dont use fingers to apply ointment because it’ll cause a significant drop in blood pressure
- taper dose down; at risk of vasospasm and at risk of MI
Rotate patches, avoid dirty areas
Keep in storage containers
/
Monitor vital signs Check orthostatic hypotension Offer sips of H2O prior to SL NTG to wet mouth and increase absorption DO NOT USE FINGERS TO APPLY OINTMENT DO NOT APPLY NITRI-BID OINMENT or Patch IN AREA OF DEFIBRILLATOR PAD PLACEMENT AS EXPLOSION OR SKIN BURNS MAY OCCUR Do not discontinue meds abruptly Rotate skin locations for patches and ointment, avoid hairy areas Keep in storage container
Cardiac dysrhythmias
Basically slows down the conduction within the heart.
We look at the ECG
When we have any interruptions in the p-wave, QRS, T, etc., thats when we see dysrhythmia
What are the common factors that causes dysrhythmias?
MI (after someone has had an MI, leads to dysrhythmias),
Hypoxia, hypercapnia,
Thyroid dx, CAD (blockages or plaques in the coronary vessels, leads to dysrhythmias), electrolytes imbalances (ex: potassium is conductor of the heart)
There are different types of antidysrhythmics
(Dont worry about what are the differences btwn the classes for example, the difference btwn class 1C and 1B)
Class I
Class II
Class III
Class IV
Class I
Class I are Sodium channel blockers
They decrease the sodium rush into the cells, which decreases conduction, which
**slows the heart and decreases ectopy
There are different types of class 1
What are the 3 types of Class I
Class IA
ClassIB
ClassIC
Class IA
A type of antidysrhythmic that Slows conduction and PROLONGS repolarization (PAT, SVT)
(Dont have to. Knoww these.. just to give you an idea what it is used for): PAT= paraschsmal atrial tachycardia …use it for atrial tachycardia/ rapid beating
SVT= regular rhythm, but beating over 150bpm
Meds: Quinidine, procainamide, disopyramide
Class IB
A type of antidysrhythmic that Slows conduction and SHORTENS repolarization (VT, fib)
Medications: lidocaine, mexitiletine HCL
(Extra info for better understanding: use for ventricular dysrhythmias /tachycardia)
Just focus on what rhythm each class is use for.
Class IC
A type of dysrhythmias that Prolonged conduction (VT, fib)
Medication: flecainide
Class II
A type of antidysrhythmic
These are your BETA BLOCKERS. Notice that they end in ‘olol’
Slows down the conduction speed (velocity) of the heart, help improve automaticity ; help decrease afibs, tachycardia, dysrhythmias
Meds: propranolol (Inderal),
acebutolol (Sectral), esmolol (Brevibloc),
sotalol (Betapace)
What is automaticity of the heart?
Automaticity is the property of cardiac cells to generate spontaneous action potentials
Acebutolol (Sectral)
Is a betablocker use for antidysrhythmias (keep in mind most beta-blockers are used for dysrhythmias)
Drug class: beta-1 blocker
Contraindications: anyone with heart block, severe bradycardia, severe HF, cariogenic shock
We know that taking a beta blocker will further decrease their hr and vasodilation
Interactions: anyone who is on meds that decrease their hr or bp ex: diuretics, prolonged hypoglycemia, antagonist effect with albuterol (albuterol causes tachycardia; have to look out for that), terbutaline, metaproterenol
Wat are the indications for acebutolol (Sectral)?
Treatment for dyshrythmias, angina, HTN
What are the side & adverse effects for acebutolol (Sectral)?
Dizziness, nausea, headache, hypotension, diaphoresis, fatigue
Remember if anyone on beta-blocker, have them taper down the dose.
Adverse: bradycardia, life threatening agranulocytosis (low WBCs) and bronchospasm at higher doses (remember, even in cardio selective meds, the lungs have a lil bit of beta-1)
Class III
At type of antidysrhythmics
Increase refractory period and prolong action potential
Indications: mostly used in atrial fibrillation (afib)
Amiodarone (Codarone)
Is a class III antiadysrhytmic
Increase refractory period and prolong action potential
Indications: mostly used in atrial fibrillation (afib)
Make sure to monitor thyroid function by doing tests, because thyroid may decline. It can also cause pulmonary fibrosis, so do pulmonary function tests.
Class IV
Class IV are calcium channel blockers
(Remember there are only two calcium channel blockers that lower hr; and use as antiadysrhythmcs )
Meds:
verapamil (Calan,Isoptin)
diltiazem (Cardizem)
They work by blocking calcium influx, which decreases the cardiac response and conduction
& put them back in normal sinus rhythm.
Contraindication: someone who has AV block, HF and severe bradycardia
(Dont want to decrease hr even more)
What are the drugs to help treat a Hyperlipidemia?
Bile acid sequestrants
HMG-CoA inhibitors
Fibrates
Niacin
Cholesterol absorption inhibitors
The goal is to put them on the highest tolerable dose without side effects, if we can’t do that we usually add these other medications
Bile Acid Sequestrants
To treat hyperlipidemia
They are usually added to statin (HMG-CoA inhibitors) to reach their goal cholesterol level
Indications: reduce elevated serum cholesterol in patients with hypercholesterolemia
Side/adverse effects of Bile acid sequestrants
Headache, fatigue, and drowsiness
Direct GI irritation: nausea and constipation
Increased bleeding times
Vitamin A and E deficiencies
What are the drug-to drug interactions with Bile Acid Sequestrants?
Malabsorption of fat-soluble vitamins
Thiazide diuretics, digoxin, warfarin, thyroid hormones and corticosteroids
HMG-coA Inhibitors
Aka ‘statin’ .. HCPs call them this
Utilize to lower cholesterol levels
Inhibits HMG-CoA, decrease serum cholesterol levels, LDLs, ad triglycerides and increase HDL levels
These are the best, best lowering
Indications: hyperlipidemia, prevention MI, CVA
Medications: atorvastatin (Lipitor),
rosuvastatin (Crestor),
Simvastatin (Zocor),
Lovastatin (Mevacor),
Pravastatin (Pravachol)
notice that they all end in ‘statin’
Where is the HMG-CoA inhibitor mainly metabolized?
Through the main pathway in the liver ,
So if someone is an alcoholic, liver toxicity, taking other meds that are metabolize through that,..typically try not to use that statin.
What are the contraindications of HMG-CoA inhibitors?
Allergy, active liver disease and hxs of alcoholic liver disease, pregancy and lactation
Caution in impaired endocrine function because they can develop hyperglycemia.
Why pregnant women or women, who are lactating cannot take HMG-CoA Inhibitors/statin?
Because babies need fat and cholesterol to have normal brain development, so we should never never ever put a woman who is pregnant or breast feeding on any cholesterol lowering medications.
What are the adverse effects of HMG-CoA?
Myopathy (complain in muscle pain)
Liver failure
Rhabdomyolysis (break down of all the muscle tissue and lead to organ failure; deadly)
Do liver function tests to monitor
Drug-to-drug interactions with HMG-CoA inhibitors
Erythromycin
Cyclosporine
Gemfibrozil
*Niacin
Grapefruit juice (also metabolize in the same pathway)
Acetaminophen:
It takes the same pathway as the satin, so pt should limit use of taking acetaminophen
Rosuvastatin (Crestor)
Class: A HMG-CoA inhibitor
Which decreases lipid levels (especially LDL and triglycerides)
Commonly use
Side effects: HA, constipation, diahreah, myalgia (muscle pain)
Adverse reactions: rhabdomyolysis (break down of muscle tissue; lead to death), photosensitivity, hyperglycemia, elevated LFTs
Contraindicated: pregnant, lactation, liver dx
Caution with ETOH use, Tylenol use, hxs of liver disease
Monitor LFTs at 6-8wks, then 6 months and then yearly
Cholesterol Absorption Inhibitors
Used to treat hyperlipidemia
Work in the small intestines to inhibit the absorb of cholesterol
This is typically an additive treatment, (for example, if someone cant get to their LDL goal on a highest tolerated dose of statin or they cant tolerate statin, we put them on cholesterol absorption inhibitor)
Med: Zetia (ezetimbe)
What are the indications of cholesterol absorption inhibitors?
To lower serum cholesterol levels,
Treat homozygous familia hypercholesterolemia
What are the pharmacokinetics of cholesterol absorption inhibitors?
Absorbed in the GI tract,metabolized in the liver, excreted in urine and feces
Adverse/Side effects of cholesterol absorption inhibitors?
Abdominal pain and diarrhea
Headache
Dizziness
Fatigue
URI (upper respiratory infection)
Back pain
Muscle aches and pain
What are the drug-to-drug interactions of cholesterol absorption inhibitor?
Not significant but soemthing to keep in mind
Cholestyramine
Fenofibrate
Gemfibrozil
Antacids
Cyclosporine
Vibrates
Warfarin
Wha are the contraindications of cholesterol absorption inhibitors?
Allergy
And remebr pts who are pregnant or breast feeding if combined with a statin.
Niacin
Another lipid lowering agent
Vitamin B3, inhibits release of free fatty acids from adipose tissue.
Increase rate of triglyceride removal from plasma.
With this, they sometimes develop redness in chest or head; NOT an allergic reaction; its a known reaction
Fenofibrates
Used to treat hyperlipidemia
An additive to statin
Inhibits triglyceride synthesis in the liver, which decreases LDL
Increase Uric acid secretion and may stimulate triglyceride breakdown
Gemfibrozil
Another lipid lowering agent
Inhibits peripheral breakdown of lipids
Reduces production of triglycerides and LDL
Increases HDL
If combine with statin, we need to watch the LFT because both goes through same metabolic pathway.
Think of the gem’FIBR’ozil in FenoFIBRates
PSK9 Inhibitors
Help reduce LDLs and triglycerides
Not metabolized by the liver, and does not cause muscle aches and pains
Meds:
alirocumab (Praluent)
Evolocumab (repatha)
“PSK9 Ihibits CUM”
Injectable lipid lowering therapy (PSK9 Inhibitors) are only used when
When patients CANNOT tolerate statins
Or
Pts not at a goal at highest tolerable statin dose (ex: still had muscle aches and pains)
Or
They have liver toxicity and cannot be put on a statin
Can also use as a Addive
Patient education of PSK9 Inhibitor
Kept in the refrigerator take out fridge 30mins before taking dose
Make sure to hold down pen until windows fills with yellow tube.
Peripheral Vasodilators
Class: peripheral vasodilator
For those who have peripheral vascular disease.
Dilates those lil arteries in the extremities to improve blood flow to the tissue.
Indications: pts who have clottictaion/ angina in the legs
/
Increase blood flow to the extremities in older adults with PAD and PVD
Also effective in Raynaud’s disease, and Buergers disease
Meds:
cilostanzol (Pletal)
Trental
(Think of petals from roses look like platelets 🌹…”tal” ending in peripheral vasodilators)
Pletal
Class: peripheral vasodilator
Trade name: cilostazol
Therapeutic effects: Prevent platelets from sticking together/ Inhibits platelet aggregation and causes vasodialation
Use for peripheral vascular disease; it increases circulation.
Treats Raynaud’s disease, and cerebral vascular insufficiency.
PO
Interactions: hypotension, with anti-hypertensives
Never use Pletal for ___?
For patients who have. Stents
Contraindications in Pletal
Pts that have heart failure, arterial bleeding (you’re increasing secretions/ increase blood loss), severe hypotension, postpartum, tachycardia
Caution: bleeding disorder & tachycardia.
Side/adverse effects of Pletal
N/V
Dizziness
Syncope(fainting)
Blood in the eye
HA
Abdominal pain
Abnormal stools
Peripheral edema
Adverse: tachycardia, palpitations
Nursing considerations for Pletal
Obtain baseline vitals
Asses their extremities and observe for signs of inadequate blood flow to the extremities: pallor, coldness, and pain …see any improvement
Monitor for tachycardia & hypotension.
Thrombosis
Formation of a clot
What are the different types of blood clots?
Arterial (WBC & RBC)
Blood stasis (the blood is not moving; form clots ; thats why we have compression stockings on)
Platelet aggregation (if there’s plaque on the arteries; platelets can build up and form a clot)
Blood coagulation
Venous (RBC and PLT) happens in the veins
Blood stasis of slow flow
Occur rapidly
Can cause DVT and can lead to a Pulmonary embolism
Anticoagulants
Help prevent blood clots form forming
Ex: if someone is just sitting around, and the blood is just sitting there, it will help the blood clot from forming.
If someone already HAS a blood clot, it will prevent the clot form getting bigger. (It does not break up the clots; thrombolytics does) Alow THE BODY to break down the clot.
Indications for anticoagulants
Pts with both arterial and venous clots or pts who are at risk for clot formation
DVT
Pulmonary embolisms
MI (can be caused by blood clots
Artificial valves(the body doesnt recognize that surgery is good; the body see it as an injury; increase risk of forming clots; thats why its ideal to give Heparin during surgery)
CVA (stroke;
What are the different types of anticoagulant medications?
Heparin
Lovenox (LMWH)
Coumadin (LMWH)
Fragmin(LMWH)
Innohep (LMWH)
Heparin
used for RAPID anticoagulation for thrombosis such as DVT, PE, CVA (cerebral vascular accident)
Mostly used via IV
Used during surgery it is given to prevent thrombosis.
We use it as a bridge (ex: if someone is using another agent such as Coumadin and coming into a hospital for a procedure, we would take them off and then put them on heparin)
What is the mode of action of Heparin?
Combines with antithrombin III and *prevents thrombin formation
Inhibits the conversion of fibrinogen to fibrin *prevents fibrin clot formation
Prolongs clotting time Partial thromboplastin time (PTT)
How you measure heparin?
By looking at the PTT (partial thromboplastin time)
Ex: if the levels are too high, i need to lower dose of heparin)
Why Heparin is not given in other routes, besides IV and SQ?
Because heparin is poorly absorb through the GI mucosa
It is destroyed by heparinase in the Liver
Poor oral absorption
Not given IM due to pain and hematoma formation
How do you administer Enoxaparin (Lovenox)
2 inches away from umbilical
Maintain air bubble
What are the side/adverse effects of Heparin?
Bruising
Itching
Burning
Adverse Effects:
Beeding
Ecchymosis (bleeding under skin )
Thrombocytopenia (having an allergy to heparin; HIT: heparin induce thrombocytopenia)Increase risk of blood. Clot
Hemorrhage (can be life-threatening)
What are the contraindications of heparin?
Bleeding disorder
Peptic ulcer (increase risk of GI bleed)
Severe hepatic or Renal disease
Hemophilia
Hemorrhagic CVA/stroke: means they are already bleeding;it’ll increase tremendously with heparin)
What are the drug and food interactions of Heparin?
Taking another drug that is also an anticoagulant, there is going to be a higher increase of bleeding.
Increase effect with ASA (aspirin), NSAIDS, thrombolytics and probenecid
Decresed effect of nitroglycerin and protamine (antidote)
If someone is hemorrhaging from heparin, and we want to reverse it, what antidote do we use?
Protamine
Nursing consideration with heparin
Obtain hxs of possible abnormal clotting or health problems affect clotting (i.e. ETOH, severe renal or liver disease)
PTT should be checked (usually we start them on heparin and check the PTT 4 hours later or anytime we change the dose check 4 hours later)
Check stool for melena (dark starry blood stool) and occult blood (do a guiac) to see if there is any GI bleed
Warfin (Coumadin)
An anticoagulant
Same indications as heparin
Only given PO
Inhibits vitamin K, which decreases the clotting of blood
Its given at home
We need to worry about what they are eating; vitamin K will counter interact with Warfin.
Warfin (Coumadin) is affected by high type of foods?
Foods with vitamin K: dark leafy greens
Decreases the effectiveness of Coumadin and lower INR
Pts on Coumadin, they need to eat the same amount of dark green veggies every week (ex: if they normally eat it 3xs a week, you can do so and be consistent ) & adjust the Coumadin based on how much dark green leafy veggies they eat and according to their Pt/INR
If someone has HIGH INR, the antidote is vitamin K
Antibiotics often increase INR; monitor closely
What happens when the INR is high?
Pt is at increase risk of bleeding
We also look at their INR to adjust what?
To adjust the Coumadin dose.
If INR is too low, and they are at risk for blood clots, will need to increase the dose of Coumadin
If their INR is too high an increase of bleeding; would lower the dose of Coumadin.
Therapeutic range for INRS
Therapeutic range means that the Coumadin is preventing the blood form clotting
Normal INR range (someone who is not taking Coumadin): <1.2
*AFIB (therapeutic range): 2-3
*DVT/PE (therapeutic range): 2.5-3.5
High INR
MEANS INCREASE RISK OF BLEEDING
LOW INR
INCREASE RISK OF CLOTTING
Therapeutic INR
What the disease process is and what we know that will prevent blood clots from working
Novel anticoagulants
Aka NOax
New to the market
No INR monitor (no blood tests)
No antidotes yet
Increased risk for bleeding but less than warfarin
Most dose adjusted for renal insufficiency
Utilize for pt that have atrial fibrillation, DVT /PE BUT NOT USED FOR PTS THAT HAVE a MECHANICAL VALVE
Oral
Medications:
Eliquis (apixaban),
Xarelto (rivaroxaban),
Pradaxa (dabigatran)
“Novel AN!”
Dabigatran etexilate (Pradaxa)
A NOax aka Novel anticoagulant
Think of “NO’axa’”
These help prevent blood clots from forming
Treatment for DVT/PE and prophylaxis, stroke prophylaxis (non-valvular atrial fibrillation)
We need to worry about if they have chronic kidney disease; have to adjust dose; because it is mostly excreted by the kidneys
Avoid in hemodialysis
What are the side/adverse effects of Dabigatran etexilate (Pradaxa) ?
Side effects: bleeding, bruising, gastritis
Adverse effects: hemorrhage, hematoma, thrombocytopenia
What is the black box warning for Dabigatran (pradaxa)?
If pts are taking off this medication they have an increase risk of a blood clot forming
If they are on this medication, they cannnot get epidural because it will cause a spinal hematoma risk
What is the antidote for Dabigatran etexilate (paradaxa)?
Praxibind
Apixaban (Eliquis)
&
Rivaroxaban (Xarelto)
Class: Novel Anticoagulants
Therapeutic use: thromboembolism (DVT/PE) treatment and prophylaxis, stroke prophylaxis (non-valvular artrial fibrillation)
It blocks one of the clotting factors “Xa”
Excreted by kidneys;; decrease dose in CKD; avoid hemodialysis
Side effects: bleeding, bruising, gastritis, anemia
Adverse effects: hemorrhaging, hematoma, thrombocytopenia
Black Box Warning: increase thrombotic event and stroke risk when discontinued prematurely, epidural and spinal hematoma risk
What is the black box warning for all novel anticoagulants?
Increase risk to form a blood clot and pt cant get epidural it is a hematoma risk
Antiplatelets
Are a lil different
Help to prevent platelets from sticking together or aggregating together
Indications: use for pts who have MI or CVA(blockage in coronary arteries) , Stroke (not hemological stroke)
What are examples of antiplatelet medications?
ASA (aspirin),
*Ticagrelor (Brilinta) must use with 100mg ASA or less (usually 81)
Effient (prasugrel)
Clopidogrel (Plavix)
*Pletal (remeber use it for peripheral vascular disease NOT CVA)
Agrylin
Reopro
Integrillin
What do you need to remember with Ticagrelor (brilinta)?
Its an antiplate
It doesnt work if a person is on aspirin for more than 100 mg a day .
The aspirin has to be less than 100mg. (Or just 81mg)
Clopidogrel (Plavix)
Class: Antiplatelet
Helps to prevent blood clots from sticking together
Indication: prevent recurrence of MI or stroke, and prevent vascular death
In order for Clopidogrel (Plavix) to work, what type of dose they need to be placed on?
Need to start off with loading dose in order for it to work. Its either 300 or 600 mg they would have to take all at once.. then taken 75mg everyday
Contraindication of Clopidogrel (Plavix)
We do not use it in someone who is bleeding (intracranial bleed or hemorrhage)
Peptic ulcer
you do NOT keep them on an antiplatlet medication if the had BRAIN or SPINAL surgery
Caution: anyone who is undergoing surgery going to be careful with;
Liver disease
GI bleeding
Bleeding from trauma
Side/Adverse effects of Clopidogrel (Plavix)
Side:
URI (upper respiratory infection)
Flulike symptoms
Dizziness, HA , fatigue, CP (cerebral palsy), diahrea,
*Bleeding, *bruising
Adverse reactions: HTN, bronchitis
WHat are the interactions with Clopidogrel (Plavix)
May increase bleeding with NSAIDs (like ibuprofen, Motrin; any anticoagulants)
Interferes the metabolism of:
Warfin
Phenytoin
Fluvastatin
Tamoxifen
Tolbutamide
Torsemide
Ginger, garlic, ginkgo, feverfew increase risk of bleeding
Remember meds that are anticoagulants increase risk of bleeding
What are the difference btwn Antiplatlets and Anticoagulants?
Anticouagulatnts prevent BLOOD CLOTS from forming they are only utilize for pts who has ATRIALFIBILLATION, DVTs or PEs
Antiplatlets medications prevent PATLETS from sticking together and use for pts who have HEART DISEASE or hxs of STROKE or PERIPHERAL VASCULAR DISEASE
Summary:
Anticoagulants, such as heparin or warfarin (also called Coumadin), slow down your body’s process of making clots. Antiplatelets, such as aspirin and clopidogrel, prevent blood cells called platelets from clumping together to form a clot
In general,
-Anticoagulants are used for conditions that involve stasis. Stasis can cause blot clots (thrombosis) to form. That’s why PCDs are used for DVT prophylaxis.
-Antiplatelets are used for conditions that involve endothelial damage and platelets sticking to the injured site. For example, in the heart, ischemia and MI are usually not due to stasis but to plaque formation with coronary vessels. So you use antiplatelets.
Thrombolytics
“These are clot busters”
Used to promote the fibrinOLYYTIC mechanism /ACTUCALLY BREAK UP THE CLOT
indications: Utilize it pts who are having a STROKE (remember, we have to make sure it’s a embolic stroke and not a hemorrhagic stroke),
MASSIVE MI
MASSIVE PE
MASSIVE DVT
CVA (embolic stroke only; not hemorrhagic)
Having an acute MI Breaks up the clot and and open up the arteries
Or
If someone has a very big PE, use a thrombolytic to break up the clot
The most potent and powerful; so the. HIGHEST risk of bleeding is with these medications
When does the thrombolytic starts to work or the onset of it?
Usually the thrombus or clot disintegrates Within 4hours of the disease process
What are the types of thrombolytics?
Streptokinase,
Urokinase,
Altepase
Reteplase (retevase)
Tenecteplase (THKnase)
“ pASE give me a thrombolytic!!!!)
Ateplase (tPA)
Class: Trhombolytic argent
It breaks up the clot
To help improve blood flow
Indications: dissolve clot following AMI (acute myocardial infraction), PE, acute ischemic stroke
Side effects: bleeding
Adverse: biggest risk is intracranial bleeding, stroke, atrial or ventricular dysrhythmias
This medication is short term
What are the contraindications of Ateplase (tPA)
Internal bleeding,
bleeding disorders,
recent CVA/Stroke (even if is is an embolic stroke, a lot of times it can lead to a hemmoragic/bleeding stroke)
Surgery or Trauma
Bacterial endocarditis
Sever liver dysfunction
Severe uncontrolled HTN
Drug-food interaction with Ateplase (tPA)
Increase bleeding when taken with oral anticoagulants, NSAIDS, cefotetan, pilcamycin
Sodium-Glucose Co-transporter 2
(SGLT-2) Inhibitors
Aka “SOG2”
Class: Antidiabetic medication
Decrease blood glucose levels; cause body to get rid of glucose through urine. Have to be careful because can increase fungal infections and UTIs
Use in pts who has HF and protect the heart from getting damaged,, while getting rid of glucose (especially those who has HF and diabetes)
Dont use it to treat type 1 diabetes; insulin would be the one to use for that
Medications:
Empagliflozin (Jardiance),
Canagliflozin (Invokana),
Dapagliflozin (Farxiga)
Ending in “gliflozin”
WHat are the things to worry about with pts on Sodium-Glucose co-transporter 2 Inhibitors?
A/E: Hyperkalemia, fungal infections, UTI, renal insufficiency and
could potentially develop Hypotension (because when the glucose is leaving the body by urine, sometimes increasing urine production, and cause pt to become dehydrated; leads to hypotension)
Sacubitril/Valsartan (Entresto)
“Sartan” is an ARB
Also used for pts who have HF, help to reduce the morbidity and mortality of HF
Indications: heart failure with reduced ejection fraction
Side effects: hypotension, dizziness, cough, Hyperkalemia, real failure
Adverse effects: hypersensitivity, angio edema, severe hypotension, renal failure
Black box warning: fetal toxicity
What are the drugs to treat COPD
Bronchodialators (sympathomimetics, Beta-2 adrenergic agonist)
Methylxanthines (xathines)
Leukotriene antagonists
Glucocorticoids
Cromolyn
Anticholinergics
Mucolytics
Beta2 adrenergic agonists
It is a sympathomimetic
Alpha and beta2 adrenergic agonists
They STOP the bronchoconstriction and help to relieve Sxs of asthma or COPD exacerbation
Examples:
albuterol (Proventil), Ventolin, Metaproterenol
Albuterol (Proventil)
Class: Beta-2 Adrenergic
Indication: used for acute asthma attack, control asthma, exercise induced asthma (when exercise triggers their asthma)
Rapid onset; thats why we can use it as a rescue medication
What do we worry about with albuterol (Proventil) medication?
Can potentially affect Beta 1 as well.. remember the heart has a bit of beta-2.. thats why they can have heart palpitations, tachycardia hen on this medication
What is an alternative for pts who have afib or tachycardia who is experiencing an asthma attack?
Xopenex
Less heart rate, and good for pts with afib or tachycardia
How to use an Aerosol inhaler? (MDI (meter dose inhaler) or DPI (dry powder inhaler)
Always test spray inhaler that hasn’t been used recently
Insert medication canister into plastic mouthpiece
Shake inhaler before using, remove cap from mouthpiece
Breath out through mouth, place mouthpiece 1-2 inches from mouth or in mouth
Take slow deep breath while pressing top of medication canister once
Hold breath for few secs, exhale slowly through pursed lips
Wait two minutes repeat starting from shaking again
Administer bronchodilator 1st, wait 5mins then steroid inhaler (the steroid can actually get into the lungs)
Ipratropium (Spiriva)
Class: Anticholinergic
Indications: for maintance treatment of bronchospasm associate with COPD
To relax the bronchotubes and prevent bronchoconstriction
Administer this before administering the steroid, because we want to dilate the airway, so the steroid can get in.
How long to administer steroid after administering the Spiriva?
Administer Spiriva 5 minutes before steroid or cromolyn (this allows the bronchioles to
dilate so the steroids or cromolyn can be deposited in the bronchioles
What are the side/adverse effects of Spiriva?
Side effects: dry mouth, hoarseness
Adverse effects: angioedema (allergic reaction), dehydration, hyperglycemia
What are the Contraindications of Spiriva?
Cannot use during pregnancy
If someone is allergic to peanuts or lactose
Glaucoma (remember increasing ocular pressure)
Breastfeeding
Methylxanthine (xanthine) derivatives
Used for treatment of asthma
Stimulated the CNS (think of sedative effect) and respiration
Examples are aminophylline, theophylline and caffeine
They all have “ine” endings
*Therapeutic range: 10-20 mcg/ml ; the higher above that 20, the more side effects they have
What are the contraindications of xanthines?
Prototype is Theophylline
GI problems
Coronary artery disease
Respiratory dysfunction
Renal or hepatic disease
Alcoholism
Hyperthyroidism
Adverse: related to theophylline lvls in the blood if >20mcg/ml, more side effects
Range from GI upset, nausea, irritability, and tachycardia to seizure, brain damage and even death
Leukotriene (LT)
A chemical that causes inflammation in the lungs
migrating the eosinophil (see this in asthma attacks; allergic reaction so we basically want to move the eosinophils away from lungs to decrease lung inflammation), mucous production, and airway wall edema resulting bronchoconstriction.
Leukotriene inhibitors
Blocking that Leukotriene from causing the inflammation in the lungs
Help decrease inflammatory response
NOT used for asthma attacks (albuterol is the true rescue inhaler)
Used for exercise induced asthma
Medications:
Zafirlust (Accolate),
Zileuton (Zyflo CR)
Montelukast sodium (singular)
Montelukast (singular)
Class: Leukotriene receptor agonist
Trade name: Singilair
Think of “LUK” in LeUKotriene inhibitor
Indications: to prevent and maintain treatment of asthma
PO (a pill)
Side effect: fatigue, fever, dizziness , nasal congestions, sore throat, cough, HA
Contraindications: hypersensitivity, severe asthma attack, status asthmaticus (prolonged asthma attack that nothing is making it better)
Caution: severe liver disease
BLACKBOX warning: suicidal thoughts and psychosis
Glucocorticoid (steroids)
Used to treat respiratory disorders, particularly asthma
Anti-inflammatory action
Used if asthma is unresponsive to bronchodilator, or asthma attack on maximum does of theophylline or adrenergic drug
Has a synergic effect hen given with Beta2 agonist they work very well together
What are the routes for glucocorticoid (steroids)?
Inhaled route (preferred; because not getting a full systemic reaction)
PO route (for exacerbation)
IV route (significant exacerbation; rapidly reduce inflammation in lungs)
How long does it take for inhaled steroids to take effect?
1-4 weeks for full effect, not ideal for severe asthma attack
Inhaled glucocorticoid (steroids)
Inhaled glucocorticoids help improve symptom control, and decrease attacks
Inhaled is the current preferred treatment
Inhale reduced risk of adrenal suppression associated with systemic glucocorticoid
*Inhaled is preferred over oral, unless inhaled doesn’t work
Make sure they take it with food when PO because risk of ulcers
Adair (fluticaspone propionate and salmeterol) combination used to alleviate constriction
Side effects of glucocorticoid
Can develop thrush* (rinse mouth out with water after each dose, wash the apparatus daily with warm water)
Throat irritation, hoarseness, dry mouth
Cromolyn (Intal)
Class: Glucocorticoid
It is only for prophylactic treatment of asthma
Need to be taken everyday for it to do their job and that goes for all the other medications (albuterol only acute asthma attacks)
Inhalation
Inhibits the release of histamine to prevent asthma reaction
Side effects: bad taste (decrease by drinking water after dose), rebound bronchospasm
DO NOT DISCONTINUE ABRUPTLY can cause rebound asthma attack
Nedocromil
Class: Glucocorticoid
Similar to Cromolyn
Think of the “CROM” in “CROMolyn:
Helps the stop of histamine
Indication: prophylactic treatment of bronchial asthma
Believe to be more effective than Cromolyn
Mucolytics
Utilize to make the secretions in the airway thinner; so it’ll be easy to cough out
Indication: hen pts with asthma or active airway disease, produce excess secretions, used as adjunct to bronchodilators
Medication:
Mucomyst (acetylcysteine)
What antidote is used for acetaminophen overdose?
Mucolytics if given within 12-24 hrs ex: mucomyst (acetylcysteine)
Mucomyst (acetylcysteine)
Utilize to liquify and loosen thick mucous secretions in airways, so it can be coughed out
Administered by neubilizer, or orally diluted by after or juice.
Take 5 minutes after bronchodialtors
Side effects: N/V, stomatitis (oral ulcers), and runny nose
Acute Rhinitis
Acute inflammation of mucous membranes of nasal passages , secretions; common cold.
Antihistamines
Help alleviate of symptoms of common colds, rhinitis, acute rhinitis or pharyngitis, sinusitis
H1 blockers or H1 antagonist; blocks nasal secretions
There are two types of histamine receptors
H1: when stimulated, extravascular smooth muscle in the nasal cavity are constricted
H2: when stimulated, increase gastric secretions
What are the types of antihistamines
1st generation (older)
2nd generation (newer is better; less side effects)
1st generation of antihistamine
Can cause dry mouth, drowsiness and other anticholinergic symptoms.
OTC
Ex: Benadryl
2nd generation of antihistamines
Non-sedating antihistamines, fewer anticholinergic effects.
Examples:
Loratadine (Claritan)
Zyrtec (cetirizine)
Allegra (fexofenadine)
Diphenhydramine (Benadryl)
Class: antihistamine
Indications: to treat allergic rhinitis (decrease secretions, and inflammations by inhibiting histamines) and itching, prevent motion sickness
Use as a sleep aid
Help prevent coughing by preventing post nasal drip (drying up the secretions)
What are the contraindications of Diphenhydramine (Benadryl)
Cannot use during acute asthma attack (because it can cause constriction)
Lower respiratory disease (because we do not want to have dried up secretions it will make them thicker, and it’ll be harder to expel)
Severe liver disease
Neonate (babies that ar <1 years old)
MAOIs
What are the drug interactions with Benadryl?
Anyone who is using another CNS depression (alcohol,sleeping pill ect.) not the best choice;
Narcotics and hypnotics
Barbiturates
Avoid MAOI
What are the side/adverse effects of Benadryl?
Drowsiness, dizziness, fatigue, urinary retention (not good for pts with BPH), constipation, dry mouth and throat. Decreased secretions and excitation in children (paradoxical effect)
Its like a anticholinergic.
Adverse: life-threatening agranulocytosis, hemolytic anemia, thrombocytopenia (basically breaking down the blood)
Antitussives
To control nonproductive cough. (We dont want to always prevent the cough because coughing can be a good thing; but if they have abdominal surgery or intracranial pressure or trachs wont be good)
Antitussive work in the cough center in the brain; decreases the cough reflexes
What are the contraindications of Antitussive medications ?
Pts who NEED to cough to maintain the airway (ex: so they wont develop pneumonia)
Head injury and impaired CNS (because the med causes sedatition; so if someone already has a decreased CNS, its not ideal for them to take an Antitussive)
Caution:
in those who has hxs of narcotic diction (ex: if a cough med has codeine in it, not used alcohol for the drug abuser to use)
Hypersensitivity
Adverse effects of antitussives
Drying effect on the mucous membranes (because of the decreased secretions)
CNS effects: drowsiness and sedation
GI upset (ex: codeine causing constipation)
Dextromethorphan Hydrobomide (Robitussin)
Trade names: Robitussin, Benylin
Sucrets cough control
Vicks 44
Inhibits the cough center
PO
Therapeutic effects: temporary suppression of non-productive cough
What are the contraindications of Dextromethorphan Hydrobomide (Robitussin)?
Keep in mind, Robitussin work by constricting blood vessels; which decrease secretions. So pts who have HTN or cardiovascular disease shouldn’t take this OFC
Pts who have COPD (if holding on to those secretions, increase of risk of developing pneumonia)
Chronic productive cough
Hypersensitivity
MAOIs
Children <2
What are the side/adverse effects of Dextromethorphan Hydrobomide (Robitussin)?
Side:
Nausea
Dizziness
Drowsiness
Sedation
Adverse: hallucinations at high doses
What are the drug interactions of Dextromethorphan Hydrobomide (Robitussin)?
Increased toxicity/effect with MAO, narcotics, sedative hypnotics, sedative hypnotics, barbiturates, antidepressants and ETOH
Topical nasal decongestants
These are nasal sprays
They work by constriction of blood vessels in the nose and decrease secretions.
Relieve the discomfort that accompanies the common cold, sinusitis, and allergic rhinitis
Sympathomimetic (not really gonna have sympathetic effects, but still use with caution)
Adverse effects: local stinging and burning, rebound congestion, sympathomimetic effects
Medication: Ephedrine
What are the contraindications of topical nasal decongestant ?
If a pt has lesion or erosion (cuts) in the mucous membranes
Caution: may cause stroke, HTN, renal failure
What happens when you overuse topical nasal decongestion?
Get re-bound congestion (rebound vasodilation)
Ephedrine
Topical nasal decongestion
Think about DRaINE in EphiDRINE, but with EPHInphrine (constricting blood vessels)
Oral decongestion
Indication: Someone who has significant secretions in the sinus
Same action as topical/Oral decongestion work by constricting blood vessels and decrease secretions and inflammation to alow sinuses to drain better.
The contraindications are the same as topical nasal decongestion
Adverse effects are the same as topical
What type of drug is contained in oral decongestion OTC drug?
OTC oral decongestion ma contain pseudoephedrine
An cause serious Sid effects.
Topical nasal STEROID Decongestion
Indications:
used for seasonal allergic rhinitis
Inflammation after the removal of nasal polyps
We use this short term
Generally not absorbed systemically because its in the nose
Contraindication: acute infections
Cautions: active infection, avoid exposure to airborne infections
Steroid decreases what?
Steroids decreases the immune response
What are the Adverse effects in topical nasal STEROID decongestion ?
Local burning, irritation, stinging, dryness of the mucosa, and headache
Suppression of healing can occur in pt who has had a nasal surgery or trauma.
What is Flunisolide ?
A topical nasal steroid decongestant
Think of “flu…slide in nose”
“S” for steroid
Expectorants
Indications: relief of respiratory conditions conditions characterized by a dry, non-production cough
Decrease the thickness of the mucous; make it easier to cough up. To clear their lung
Hydration is the best natural expectorant
What is Guaifenesin?
A type of expectorant medication
Think about “Guafin up mucus”
Mucolytics
Work to break down mucous
&
Causes bronchospasm to cough up mucous
What are the indications of Mucolytics?
Pts who have difficulty coughing up secretions
Patients who develop atelectasis (collapsed lungs)
Patients undergoing diagnostic bronchoscopy (to be able to see through the mucous when its thin out by the Mucolytics )
Postoperative patients (we dont want them to have a huge cough reflex to avoid using abdominal muscles)
Patients with tracheostomies tend to have thicker secretions; use mucolytics to thin them out
What route are mucolytics?
Nebulization
Direct installation into the trachea
What are the adverse effects of mucolytics
GI upset
Stomatitis
Rhinorrhea (runny nose)
Bronchospasm
Caution: acute bronchospasm (ex: asthma), Peptic ulcer, and esophageal varices (abnormal dilated vessels in throat)
Acetylcysteine
A type of mucolytic
Emetics
Medications that Causes vomiting
(No longer reccomeded for at-home poison control)
Dont want to use if they are unconscious; would se an absorbent (ex: charcoal)
think about “emesis”
Antiemetics
Medications that decrease or prevent n/v
These meds are centrally acting (sedation occurs)
What are the groups of centrally acting antiemetics
Antihistamines
Dopamine agonists
Anticholinergics
Serotonin antagonists
Benzodiazepines
Glucocorticoids
Cannabinoids
Miscellaneous
Phenothiazines (Phenergan)
Class: antiemetic
Trade name: Phenergan
Indication: used to treat and prevent motion sickness and nausea and diarrhea
Blocks H1 receptor sites.
Meds:
chlorpromazine (Thorazine)
Prochlorperazine edisylate (comparing),
Promethazine (Phenergan)
They all end in “azine”
Think of “AZINE (Iseen) antiemetics, i need it”
What do you usually see with pts on antiemetic and what does it causes?
It causes CNS depression, so you will mostly see confusion, dizziness, sedation as a side effects
& anticholinergic-like side effects
*What are anticholinergic-like side effects?
Decreased GIMotility (constipation) , dry mouth, urinary retention, orthostatic hypotension,
What are the side effects of Promethazine (Phenergan)?
Side effect: drowsiness, constipation, urine retention, confusion, anorexia, dry mouth and eyes, blurred vision, photosensitivity, hypertension, transient leukopenia
What are the contraindications of phenothiazine?
Hypersensitivity, narrow-angle glaucoma, severe liver disease, intestinal obstruction, bone marrow depression
Caution: cardiovascular disease, liver dysfunction, asthma, respiratory dysfunction, HTN, older adults and debilitated (weak) pts.
Adverse effects: parkinson-like-reactions
What are the drug interactions for Promethazine (Phenergan)?
Drugs that increases CNS depression and anticholinergic effects (ex: ETOH and other CNS depressants)
Phenothiazine gives false result on which test?
Pregancy tests
What are the non-pharmacologic antiemetics?
Weak tea (non-dark)
Flattened carbonated beverage (not too bubbly)
Gelatin
Gatorade (half Gatorade, half water; want to limit the consumption of sugar
Pedialyte
Crackers dry toast
IV fluids with severe hydration
Cool rag on forehead or neck
Lemon ice
Ginger
What are the non prescriptive/OTC antiemetic drugs?
These are mostly used for motion sickness
Dimenhydrinate (Dramamine)
Meclizine hydrochloride (Antivert): mostly used for vertigo
Diphenhydramine hydrochloride (Benadryl)
Antihistamine antiemetics
Used to prevent motion sickness, n/v and dizziness (vertigo)
(not effective treatment for severe vomiting R/T anticancer agents, radiation or toxins)
Also used to prevent or alleviate of allergic reaction to insect bite, allergens or foods
Blocks H1 receptors/ histamine receptors
Stabilizes the inner ear that causes motion sickness
What are the side effects of antihistamine antiemetics OTC?
Drowsiness, dry mouth, and constipation (think of anticholinergic effect)
Cant use during pregnancy
If pregnancy women cant use Benadryl as an antiemetic, what med can they use?
Trimethobenzoamide (Tigan)
Use if severe vomiting threatens mother or fetus
Think of
“TRIMEster antihistamine”
What is peptobismol
Help withh n/v
Acts directly on gastric mucosa to suppress vomiting, diarrhea
Pink solution
Chewable tabs
Has subsalicylate (asprin)
If someone has an allergy to subsalicylate, not ideal to use
Can give a false pos guiac test.
What are the indications of using emetics?
To induce vomiting when toxic substance have been ingested, prior to absorption
What are the reasons to avoid inducing vomiting?
Avoid inducing vomiting when caustic (able to burn or corrode tissues) are absorbed
Ex: chlorine bleach, ammonia, Lye, toilet cleaners, battery acid
Avoid inducing vomiting to prevent aspiration if petroleum are ingested; because if thrown up they can aspirate on it and die
(Gasoline, kerosene, paint thinners, lighter fluid)
If we cant induce vomiting we can use _____ to absorb
Charcoal
Activated charcoal is used when emesis is contraindicated.
Ipecac
Is a type of emetic
Induces vomiting when pt is alert, conscious and within 60 minutes oof poisoning
Thank of “I” for “I”nduce vomiting
Acts directly on the gastric mucosa
Should be taken with a glass of water
Use only the SYURP form of medication.
Onset 15-30 minutes, if not successful use absorbent (charcoal)
What do we have to be careful with Ipecac?
People who has Anorexia and Bulimia usually abuse this drug because of the induce vomiting
Losing electrolytes (particularly potassium ; leading to ventricular dysrhythmias/v fib )
How many bowel movements in a day is considered diarrhea?
More than 3 BM and loose stools
Different types of. Antidiarrheals
We use opioids or opiod-related (remember they slow down the GI motility; constipation)
Ex: camphorated opium tincture (paregoric), deodorized opium tincture, *Lomotil, Motofen)
Somatotatin analogue
Ex: *octreotide acetate (Sandostatin)
Adsorbents
Bismuth Subsalicylate (*Pepto-Bismol, kapectolin, kaopectate)
Miscellaneous
Rifaximin (Xifaxan)
Diphenoxylate (Lomotil)
Class: antidiarrheal
Think of
“LOwMOTILity is antidiarrhea”
Treat diarrhea by slowing intestinal motility
Inhibits gastric motility
Wht are the “ingredients” in the Lomotil med?
It is diphenoxylate with atropine
Remebr atropine is an anticholinergic ; use it to help slo down GI motility AND DEREASE diarrhea
What are the side/ adverse effects of Diphenoxylate (Lomotil) ?
Depresses the CNS; Think of anticholinergic side effects
Drowsiness, dizziness, constipation, dry mouth, weakness, flush, rash, blurred vision, urine retention
Adverse: angioneurotic edema
Life threatening: Becreful.. can cause paralytic illeus can occur if used too much.
What are the drug/fod interactions of Diphenoxylate (Lomotil) ?
Any med that depresses the CNS (ex: ETOH),
Antihistamine,
Narcotics,
MAOI’s may enhance hTN crisis
Octreotide (sandostatin)
Class: Antidiarrheal
Antidiarrheal class: Somatatostatin analogue
Inhibits gastric secreations
Help to. Decrease the diarrhea
Used a lot in cancer pts
Pesto-bismol
Class: Antidiarrheal
Class of Antidiarrheal:
Adsorbent
Absorb the toxins that are causing the diarrhea high will help with preventing the diarrhea.
Remember it has ASA (aspirin) in it; not ideal for those who as aspirin allergy.
Normal bowel movement range ?
1-3 per day
3 per week
Different types of Laxatives/Cathartics
*Osmotics (saline
Ex: glycerin, lactulose, magnesium citrate, MOM, sodium biphosphate
*Stimulants. (Contacts or irritants)
Ex: *biscodyl (Dulcolax),
*Caster oil (Neolithic, Purge),
Senna (senekot)
*Bulk forming
Ex: polycarbophil (Fibercon)
Methylcellulose (Citrucel)
Emollients (stool softeners)
Ex: docusate sodium calcium (Colace, Surfak, Dialose)
Osmotic Laxitives (Hypersmolar Laxitives)
They pull water into the stool, which increases water into the stool , which increases the size of stool, make them softer, which stimulates peristalsis and the urge to defecate
Utilize for pts who undergo a GI procedure (colonoscopy)or GI surgery; want to make sure the bowel is cleaned out
Must have good renal function
Since it has sodium in it, dont ant to give it to a HF pt; use Goltely.
Since we cant use osmotic Laxatives for heart failure pts, we can use ____ instead.
We can use Golytely in heart failure patients to stimulate bowel movements and clean them out before a procedure.
Biscadyl (Dulcolax) (OTC)
Class: stimulant
Increases peristalsis; it is a short term treatment of constipation and bowel prep for diagnostic tests (ex: colonoscopy ) or after surgery
Route: PO, PR (per rectum)
Can be abused by anorexics and bulimia pts
Think of “—lax” ending for laxative
What are the contraindications of Biscadyl (Dulcolax)
Someone who has hypersensitivity, fecal impaction, intestinal/biliary obstruction, appendicitis, abdominal pain, N/V, rectal fissure.
What are the side/adverse effects of Bisacodyl (Dulcolax)?
Side: N/V/D, cramps
Adverse reactions: Dependence, Hypokalemia
Adverse:
dependence (body will rely on med to stimulate peristalsis)
Hypokalemia (risk for losing potassium)
Life threatening: tetany
Concerned about dysrhythmias
What are the drug-food interactions (Bisacodyl (Dulcolax)
Antacids decreases effect of laxitive and histamine2 blockers, milk
Castor Oil
Class: Stimulant
It is used to make stool softer aand increase peristalsis
Don’t use castor oil during ____
Early pregnancy because it will stimulate uterine contractions & cause spontaneous abortion
Senna
Class: Stimulate
Increases peristalsis as well
Dont want to overuse cause dependence and need it for rest of their life.
Psyllium (Metamucil)
Class: Bulk-forming Laxitive
To control constipation
Acts as a bulk forming laxative by drawing in water into intestine.
Has fiber in them
Side/ Adverse effects of Psyllium (Metamucil)
Anorexia, N/V/D, cramps
Adverse: we are worried about esophageal or intestinal obstruction, due to not drinking adequate amount of water.
Life threatening: bronchospasm, anaphylaxis
Nursing considerations for laxatives
• Encourage increased water intake if not contraindicated
• Avoid over use of laxatives can lead to electrolyte imbalances, dependence
• Encourage exercise to increase peristalsis
• Store suppositories in less than 86º F (30 º C)
• Take with water to increase absorption
• Do not take with in 1 hr of any other drugs
• Discontinue if rectal bleeding, N/V or cramping occurs
What increases development of ulcers?
Aspirin
Steroids
Advil (NASIDA
H.pylori
Aluminum hydroxide (amphojel)
Class: Anatcids
Neutralizes gastric activity
Indications: treat hyperacidity, peptic ulcer, reflux esophagitis,
↓ hyperphosphatemia
Shouldnt use long term; could cause constipation
What you should keep in mind with other medications vs antacids?
Keep in mind that antacids lower the acidity in the stomach and interfere with absorption of most medications ; separate meds an hour or two
Side/adverse effects of Antacid?
Side: constipation
Adverse: hypophosphatemia, long term use can cause GI obstruction
Nursing considerations for antacids
• AVOID ADMINSTERING WITH OTHER ORAL DRUGS
MAY ANTACID MAY DELAY ABSORPTION
• GIVE ANTIACID 1-2 HOURS AFTER OTHER
MEDICATIONS
• SHAKE SUSPENSION WELL BEFORE
ADMINISTERING, DRINK H2O AFTER DOSE
• TELL PT TO REPORT PAIN, COUGHING OR
VOMITING OF BLOOD
• ALERT HEATHCARE PROVIDER IF TAKING > 2
WEEKS (something else is going on and e need to find out)
• AVOID TAKING WITH MILK OR FOODS HIGH IN
VITAMIN D
• STOOLS MAY BECOME SPECKLED WHITE
Ranitidine (Zantac)
Class: Histamine 2 blocker
To prevent and treat peptic ulcers, GERD, stress ulcers
Inhibits gastric acid secretions by inhibiting histamine at H2 receptors.
PO
“—idine” endings are H2 blockers
Think of “IDINE freely”
What are the side effects of RANITIDINE (ZANTAC)?
Side: HA, *costipation, confusion, N/D, *vertigo, depression, rash, blurred vision, malaise, may increase oral anticoagulants.
Adverse: hepatotoxicity and blood dyspraxia both can be life threatening
Nursing consideration of H2 blocker
Decrease acidity in the stomach; administer drugs before meals to decrease acid secretions
Reduce dose for older adults
Instruct client to report pain, coughing, or vomiting blood
Avoid smoking because it may decrease effectiveness
Separate dose from antacid by 1 hr.
H2 blocker & antacids decreases what in stomach?
Decreases acidity; interferes with most drug absorption
Proton pump inhibitor
“PPI”
Utilized to treat and prevent gastric ulcers
Can be used as a prophylaxis
Decreases acidity in stomach
Esomeprazole (Nexium)
Class: PPI (proton pump inhibitor)
Used to treat and prevent gastric ulcers
Suppresses gastric acidic secretions
“AZOLE” ending
“PPI AZOLE!!!”
Side effects/adverse effects of (esomeprazole) Nexium
HA/dizziness, fatigue, appetite increased, N/D/C,
Adverse: may cause thrombocytopenia
Pepsin Inhibitor (Mucosal protective drug)
NON-ABSORBABLE AND COMBINE WITH PROTIEN TO FORM A VISCOUS
SUBSTANCE THAT COVERS ULCER AND PROTECTS IT FROM ACID AND
PEPSIN
Puts a coating around the stomach and protect the stomach and ulcer
Minimum drug interactions
Sulcrafate (Carafate)
Class: pepsin inhibitor
Coats the stomach, and protects the stomach and the ulcers
Indications: prevents gastric mucosal injury from drug induced ulcer; manage ulcers
Interfere with absorption of meds
ANTIULCER DRUGS interfere with absorption of what?
Most medications
Nursing considerations of sucralfate (carafate)
Administer on an empty stomach
Administer antacids 30mins before or after sucralfate
Allow 1-2 hours btwn sulcrafate and other drug
Avoid smoking, ETOH
Proper diet
Parkinson’s disease
Progressive disorder in the brain that causes abnormal movements and activities
No cure
Use medications are use to slow the progression and symptoms
Balance, coordination and locomotion problems
Three major features of Parkinson’s disease
Bradykinesia; slow movement and tremors
Rigidigity: increased muscle tone w/increased movement (so they are very stiff)
Posture: forward leaning, shuffle gait Also may have flat affect (not really having a face expressions), pill rolling (doing motions)
We are worried about risk of falls (especially if taking anticoagulants or Antiplatlets to bleed to death)
What do we what to do with Parkinson’s disease?
We want to balance the dopamine and acetylcholine
By decreasing the acetylcholine
Dopamine normally maintains control of
acetylcholine and inhibits excitatory
response, in Parkinson’s dopamine
production is inhibited, acetylcholine
increases and the movement disorder
progresses.
What are the non-pharmacological treatments of Parkinson’s disease?
We want to keep them mobile; to help them maintain normal movement activities (Therapeutic exercise)
Diet with fiber and adequate hydration: a lot of the Sxs of meds will causes constipation and orthostatic hypotension
Support groups
What drugs are used to treat Parkinson’s disease?
Anticholinergic: typically used to treat Parkinson’s but not the slow movements of the disease
(Meds: artane, *Cogentin, norflex, parsidol
Dominergics: convert to dopamine
(Meds: carbidopa-levodopa)
Dopamine agonists: stimulate dopamine receptors
(Meds: amantadine, bromocriptine, Mirapex requip) “MBA” or “MR. BA is Dope”
Mao b inhibitors :
(Eldepryl, azilect)
Comt inhibitors:
(Comtan, Tasmar)
Anticholinergic for parkinson
Help to decrease the rigidity and tremors, but it doesnt help with the slow movements (bradykinesia)
Inhibits the release of acetylcholine
Meds: Cogentin ,artane, akineton, parisdol, norflex, occasionally Benadryl
“Yo u caap’n B !”
What are the side effects of anticholinergics?
Dry mouth, dry secretions, urinary retention constipation, blurred vision, increased HR, restlessness, confusion, orthostatic hypotension
What are the contraindications of anticholinergics?
Glaucoma
What are the meds of anticholinergics of Parkinson’s disease?
Artane
Cogentin
Akineton
Parisdol
Norflex
Occasionally Benadryl
Dopaminergics
Class: antiparkinson dopaminergic
Carbidopa-levodopa (sinemet)
Class: antiparkinson dopaminergic
Use it to treat Parkinson’s disease; relieve the tremors and rigidity
This typically the gold standard
Helps block acetylcholine
W Hat drug we cant use carbidopa-levodopa (sinemet) with?
MAOIs; increase risk of hypertension crisis
Anticholinergics decrease the effects if taken with levodopa
High protein foods with vitB6 interferes with the medications
What are the contraindications of carbidopa-levodopa?
*Pts that have skin lesions; need to pay attention, because it might turn cancerous/ activate malignant melanoma,
Glaucoma
Severe cardiac
Renal/ hepatic disease
What are the side effects of Carbidopa-levodopa
*Anticholinergic-like side effects (dry mouth, urinary retention, orthostatic hypotension and constipation), *urine can become very dark, *sweat,
N/v, HA, twitching, blurry vision, insomnia, palpitations, psychosis, depression with suicidal ideation, hallucinations
What are the life-threating effects of carbidopa-levodopa
Agranulocytosis, hemolytic anemia, thrombocytopenia, cardiac dysrhythmias, neuroleptic malignant syndrome
Nursing considerations for carbidopa-levodopa
Not gonna see improvements in symptoms until 1-4weeks
Instruct pt to rise slowly to avoid orthostatic hypotension (remeber ALL anticholinergic drugs are all side effects of anticholinergics)
Vitamin B6 interfere with the absorption; so decrease the amount of protein intake
Avoid taking off med abruptly; rebound Parkinsonism can occur
Let the pts know the meds can change THE COLOR OF THEir URINE AND SWEAT
Dopamine Agents
Class: antiparkinson
Amantadine hydrochloride (symmetrel)
Class: antiparkinson dopamine agent
An antiviral dopamine agonist that help will help with decreasing the abnormal movements of Parkinson’s disease
You can either take it alone or with anti cholinergic medication
What is the problem with amantadine hydrochloride (symmetrel)?
Pt can develop a tolerance to the medication. The symptoms will return
What are the side effects with amantadine hydrochloride (symmetrel)?
Well tolerated side effects, but can develop tolerance to drug after awhile; may need to increase the dose, anticholinergic-like symptoms (orthostatic hypotension, urinary retention, constipation), confusion
Side effects increase with combination drugs (if taken with anticholinergics meds or carbidopa)
Mirapex and requip
Class: antiparkinson dopamine agonists
Less side effects than the older drugs: may cause nausea, dizziness, somnolence, weakness and constpation
Intensify hallucinations & dyskinesia (uncontrollable movements)
What is the problem with Mirapex and requip ?
It can be very sedating; pts can become very very tired
Even if dose at night, the pt is sleeping all day the next day
Bromocritpine (Parlodel)
Class: antiparkinson dopamine agonists
Acts on the dopamine receptors
It is more effective than Symmetrel , but not as effective as carbidopa-levodopa
*It is used when pts cant tolerate carbidopa-levodopa
Think of “PAR” for PARkinsons in PARlodel
Which drug is the gold standard or works the best for Parkinson’s?
Carbidopa-Levodopa
What. Are the side effects of bromocritpine(Parlodel)?
Similar side effects; anticholinergic-like side effects (orthostatic hypotension, palpitationect.), chest pain. LE edema, nightmares, delusions, confusions
MAO-B Inhibitors
ANTIPARKINSON MEDICATION
Help to keep levodopa acting longer; which helps to relieve the symptoms of Parkinson’s disease
What else does the MAO-B inhibitors inhibit?
Inhibits the metabolism of tyramine; pts need to limit foods that are high i tyramine (red wine, aged cheeses, bananas)
Because hypertensive crisis can occur.
What kind of pts the MAO-B inhibitor is common for?
Utilize for pts who are JUST been diagnosed with Parkinson’s disease because it is mild
Which drug you CANNOT use MAO-B inhibitors with?
TCA an SSRIs
Name a drug that is a MAO-B Inhibitor
Selegiline
“Selegiline MA” ;)
Comt inhibitor (catechol-O-methyltransferase)
Used for ADVANCED Parkinson’s disease
Increases the amount of levodopa in the brain
We are concerned about the liver hepatotoxic; monitor LFT
Tasmar
Class: antiparkinson
1st COMT inhibitor; used for advanced parkinson; monitor LFT
*May turn the urine bright yellow
Entacapone (Comtan)
Class: Comt inhibitor antiparkinson
NO effect on the liver
May turn the urine dark yellow to orange
Think of ‘COMT’ in ‘COMTan’ for ‘COMT-inhibitor”
Combination drug stalevo (carbidopa-levodopa)
Antiparkinsons
“Stalevo”
Good dosing flexibility; good side effects; still need to watch out for skin lesions
Alzheimer’s disease
Similar to parkinson; chronic. Progressive brain disorder, that decreases cognitive function.
No cure
Meds. Are used to slo the progression and minimize symptoms
What is the difference btwn Parkinson’s and Alzheimer’s?
With Parkinson’s, e want to decrease the acetylcholine levels,
however, with Alzheimer’s, we want to increase the acetylcholine levels
“AA” (Alzheimer’sAcetylcholine)
What are the drugs to treat Alzheimer’s
Ergoloid mesylate (hydergine); rare
Acetylcholinesterase inhibitors (ACHE):
Meds:
tacrine (cognex),
Donepezil (arciept)
*Rivastigmine (exelon)
Acetylcholinesterase inhibitor
Remember; the acetylcholinesterase breaks down acetylcholine….
However, the acetylcholinesterase inhibitors allows the acetylcholine lvls to increase; we want that for pts with Alzheimer’s disease.
Rivastigimine (Exelon)
Class: acetylcholinesterase inhibitor
Treat pts with Alzheimer’s
PO
“It will RIViVE the brain”
What are the contraindications of Rivastigimine (Exelon)?
Liver/renal disease, urinary tract obstruction ,
Pts who has orthostatic hypotension, bradycardia
What is the issue when Rivastigimine (Exelon) is taken PO?
Cant take with food;Food decreases absorption rate; have to take it 4x a day
Side effects with Rivastigimine (Exelon)?
Dizziness is the most common effect, dry mouth
Adverse: orthostatic hypotension
What are the life threatening side effects rivastigmine (exelon)?
Be careful with hepato-toxicity , sucidal ideation and Stevens-Johnson syndrome can occur
W Hat are the types of neuromuscular disorders?
Myasthenia gravis (autoimmune disorder)
Multiple sclerosis (autoimmune disorder)
Muscle spasms
Myasthenia Gravis
Affect younger women
Break down of acetylcholine recprtor site
Change is muscular contractions; its weaker
Our biggest concern is depression in respiratory (because diaphragm is a muscle)
Difficulty swallowing, respiratory weakness, dysarthria (difficulty speaking)
early Sxs: eyelids drooping, double vision,
Pryridostigmine bromide (Mestinon)
Class: cholinesterase inhibitor
Used to treat & control myasthenia gravis
Helps to keep the acetylcholine working and keep those muscle contracts sufficient.
Given PO, IM, IV
Think of “M” for MyaSTheNIa…MeSTINon
How many times a day Pryridostigmine bromide (Mestinon) is administered?
Several times. a day; via PO, IM/IV
What are the contraindications of Pryridostigmine bromide (Mestinon)?
GU and GI mechanical Obstruction, severe renal disease.
Caution in those with asthma, *hypotension, *bradycardia, peptic ulcer, cardiac dysrhythmias, renal dysfunction, hyperthyroidism and pregnancy
(Think about those cholinergic effects and what it does)
What are the side effects of the Pryridostigmine bromide (Mestinon)?
N/V/D, HA, dizziness, abdominal cramps, excessive saliva sweating, rash, miosis (constriction of pupils)
Adverse: *hypotension, *bradycardia
Life threatening: *respiratory depression, bronchospasm, seizures
What does overdosing on Pryridostigmine bromide (Mestinon) looks like?
The big thing to remember is symptoms of cholinergic crises:
Muscle weakness (extreme), excessive salvation, tears, sweating, miosis
- What is the antidote for overdosing on pyridstigmine bromide (Mestinon)?
Atropine
Multiple sclerosis (MS)
Autoimmune disease, where you start to see the break down of the myelin sheath in brain and spinal cord; causes. Weakness or spasticity and double vision
Typically in Caucasian women 20-40yrs old
Treatment is to decrease inflammation and help improve function of the demyelinating axons
What drugs to avoid when pt has multiple sclerosis?
H2 blockers
Indomethacin
Beta-blockers
Skeletal muscle relaxants for spascity
Relieve muscle spasms and pains associated with traumatic injuries and
spasticity from chronic disorders
Muscle spasm are typically *Treated with centrally acting muscle relaxants
Cyclobenzaprine (Flexeril)
Class: skeletal muscle relaxant for muscle spasm
Short term treatment for muscle spasms. (Tolerance can develop)
*Centrally acting
PO take its food
GI upset; avoid food
think of “relaxing the FLEX”
What are the side effects of Cyclobenzaprine (Flexeril)
Since its centrally acting: fatigue, drowsiness
Alos see anticholinergic effects: dizziness, HA, drymouth, tachycardia, urinary retention
What are the drug interactions of Cyclobenzaprine (Flexeril)?
Any drug that increases CNS depression
(ETOH, Narcotics, sedative-hypnotics,….)
What are the contraindications of cyclobenzaprine (Flexeril)?
Pts that has Acute MI , BBB&AV Block (block;That means the conduction in heart is slow, and we dont want to slow the conduction)
Paralytic ileus (its an opiod-like med; already slows the GI/cause constipation; not ideal to give them Flexeril)
MAOI use (if use within 14 days; high risk of HTN crisis)
What are the nursing considerations?
Do not stop abruptly, taper over 1 week to avoid
rebound spasm
• Do not drive or operate machinery
• Do not take for longer than 3 weeks
• Avoid alcohol and CNS depressants
• Contraindicated with nursing or pregnant mothers
• Take with food to avoid GI upset
Epilepsy
Chronic lifelong seizure disorder
What are the type of anticonvulsants?
Hydantoins: Phenytoin
Long-acting barbiturates:
Phenobarbital, mephabarbital, primidone
Benzodiazepines: Diazepam, clonazepem
Carbamazepine
Valproate (valproic acid)
What are the three ways anticonvulsants work?
- Suppressing the influx of sodium; which prevents the neurons from firing, so it decreases the electrical activity
- Suppresses the calcium influx, which slows the conduction in the brain activity; which will decreases seizure disorders
- GABA will increase which inhibit neurotransmitter, which will decrease seizure activity
Hydantoins
Are the 1st medications to treat seizures
Work by INHIBITING the influx of sodium, which will decrease the brain conduction; which will decrease seizure activity conduction
Therapeutic range: 10-20mcg/ml for it to be effective
Can pregnant women take Hydantoins?
NO
It is teratogenic to the baby!!
Pregnancy category D
Sometimes you will see them on it; but have to see neurologist to outweigh the risk and benefits.
But not supposed to be used
WHat happens if Hydantoins are not within the therapeutic range?
If not in between 10-20, too high it will end up having side effects
Phenytoin (Dilantin)
Class: anticonvulsant that is a Hydantoin
Look at ‘toin ending’
Used to treat or prevent seizure
Decreases sodium, which decrease s the brain conduction; which help decrease seizure activity
PO/IV
What are the contraindications of Phenytoin (Dilantin)?
*Do not USE IN pregnancy, hypersensitivity, heart block, psychiatric disorders
What do you need to remember with every single anti seizure medications?
They all will have the same side effects:
Remember it’s SLOWING DOWN brain activity
Slurred speech, drowsiness, confusion, dizziness, sedation, decreased coordination
Usually after a few months that they are used to it, but will come back again after increasing dose
What are the side effects of Phenytoin (Dilantin)
HA, diplopia (double vision), confusion, dizziness, sluggish, decreased coordination, ataxia (loss of muscle control), slurred speech, rash, anorexia, N/V, hypotension (after given IV form), pink-red/brown color of urine, fevers
Think of what happens when someone is drunk
Adverse reactions: gingival hyperplasia (overgrowth of gums), reduce WBC, depression because of decrease brain activity
What are the drug interactions with Phenytoin (Dilantin)?
All the GI meds (because of the decresed acidity in the stomach): antihistamines, PPI,
Dilantin decreases the efficiency of oral contraceptives
What are the onset in PO & IV version of Phenytoin (Dilantin)?
PO: takes longer *7-10days before it can actually work
IV: much more quick (1hr); not hat we go for, unless pt is having lots of seizures
What are the nursing considerations with Phenytoin (Dilantin)?
Always utilize seizure precautions (pad bed rails, suction that is ready to go, hieight of bed is low, move sharp utensils ou of the way ect.)
Advise females to use back up contraception if they are taking oral contraception
Monitor CBC
Shake suspension well before dispensing
Advise pt to avoid driving or other hazardous activities (what if they have. A seizure while driving? Not good)
Do not stop drug abruptly, obtain medic alert bracelet
Avoid alcohol and other CNS depressants
Phenobarbital
Class: an anticonvulsant that is a long acting barbiturate
Use it for seizures
It enhances GABA, which decreases the neuron activity, which will decrease seizures
Less side effects than Dilantin, less teratogenic effects (but it still is teratogenic)
What happens when we enhance GABA?
Decreases the neuron activity; which decreases seizures
Ethosuximide (Zarontin)
Class: an anticonvulsant that is a succinimide
To treat seizures
Decreases the CALCIUM influx
What is the therapeutic range of ethosuximide (Zarontin)?
40 - 100 mcg/ml
What are the adverse effect of ethosuximide (Zarontin)?
Break down of blood product (blood dyscrasia, renal and liver impairment, and SLE (systemic lupus)
Benzodiazephines
Is an anticonvulsant that treats seizures; tolerance may occur after 6mos
Use for less than 6mos
Remember it is CNS depressant; for all anti seizure meds, actually
Look at “BenzoDIAZEines”
Meds:
diazepam: DIAZEpam
clonazepam: clonaZEpam
Why would we want to limit the use of benzodiazepines?
Can develop addiction & tolerance
What is the therapeutic range for clonazepam?
20- 80ng/ml
Carbamazepine (Tegretol)
Class: iminostilbenes anticonvulsants
Treatment for seizures ; sometimes used for bipolar or ETOH withdrawal.
Metabolized by the main pathway in the liver; cant take grapefruit juice with it.
What is the therapeutic range for Carbamazepine (Tegretol)?
5-12
You cant drink ____ with Carbamazepine (Tegretol), because they are both metabolized in the same liver pathway.
Grapefruit juice; it will lead to toxicity.
Valproate (valproic acid)
Class: anticonvulsant
Use for seizures
Monitor LFT
*Cant use under 2 yrs and pts with liver disease
Always start at low dose and increase slowly
Levetiracetam (Keppra)
Class: anticonvulsant
Commonly used for seizures
Can use it in pregnant women and kids
Low teratogenic risk
What’s different about Levetiracetam (Keppra) than the rest of the anti-seizure meds?
There isn’t a lot of drug-to-drug interactions, and can use during pregnancy.
What sort of emotion that can occur as an adverse reaction in Levetiracetam (Keppra)?
Aggression; they be extremely angry
Have to lower the dose
Remember with ALL anti seizure medications, what common side effects?
CNS depression: slurred speech, dizziness, confusion, sedation
Remebr we are slowing down the brain conduction.
Anticonvulsants and pregnancy
• 25% of women with epilepsy experience ↑ seizures
while pregnant
• Hypoxia during seizure cause risk to fetus and
mother
• Dilantin and tegretol have been linked to cleft-lip and
palate
• Anticonvulsants inhibit vitamin K can cause
hemorrhage in infants, pregnant women usually given
vitamin k if on anticonvulsant during last week of
pregnancy and then 10 days later, also given to infant
after birth
Which antiseizure meds causes cleft left?
Dilantin and tegretol
Febrile seizures
Occur when theres a rapid change in the temperature; going from normal and high
Occur in children btwn 3mos- 5 years
Have higher chances of developing epilepsy later on
DONT USE VALPORIC ACID <2 BECAUSE OF LIVER TOXICITY
Most of the anticonvulsant drugs you dont take during what?
Pregnancy
Suffix: —dipine for calcium channel blocker
Think of “DECLINE” or DIP in BP; lowers BP
- Amlodipine
- Nicardipine
- Nifedipine
-Felodipine
SUFFIX: —zem for calcium channel blocker
Think of “ZEN”; getting a FULL treatment of lowering HR & BP
Cardizem (Diltiazem)
Verapamil
Just know that it lowers both BP and HR
