Exam 3 Flashcards
1
Q
Diuretics
A
Promote the elimination of Sodium (Na+) and water from the body.
2
Q
Types of Diuretics
A
- Thiazides: Hydrochlorothiazide or
HCTZ - Loop: Furosemide
- Osmotic: Mannitol
- K+ (Potassium) sparing:
Spironolactone
3
Q
Loop diuretic: Furosemide
Action:
A
Block reabsorption of Na+, Cl-, and water at the ascending loop of Henle. Also, inc excretion of K+, Mg+, and Ca+. cause RAPID diuresis.
4
Q
Loop diuretic: Furosemide
Uses:
A
o Treatment of edema
o Heart failure
o Liver disease (cirrhosis)
o Kidney disease
o Hypertension
5
Q
Loop diuretic: Furosemide
SEs/ADRs:
A
o Dehydration
o Hypotension
o Hyponatremia
o Hypokalemia
o Hypomagnesemia
o Hypocalcemia
o Potassium/Magnesium imbalances–> life-threatening dysrhythmias
o Ototoxicity (hearing loss, tinnitus) is more likely if the drug is pushed too fast.
o Hyperglycemia
o Rash
6
Q
Loop diuretic: Furosemide
Administration:
A
o Before 5 pm if possible
o IV: Administer SLOWLY. No faster than 20mg/min
7
Q
Loop diuretic: Furosemide
Contraindications:
A
o Pregnancy
o Avoid in gout.
o Lithium treatment
o Severe electrolyte imbalances
o Allergy to sulfa drugs
8
Q
Loop diuretic: Furosemide
Interactions:
A
o Anticoagulants- inc risk of bleeding
o Steroids- inc potassium loss
o Digoxin toxicity- inc risk due to potassium losses
9
Q
Thiazide: HCTZ (Hydrochlorothiazide)
Action:
A
Blocks reabsorption of Na+, Cl, and water at DCT. Inc excretion of potassium/magnesium
10
Q
Thiazide: HCTZ (Hydrochlorothiazide)
Uses:
A
o Treatment of hypertension
o Edema
11
Q
Thiazide: HCTZ (Hydrochlorothiazide)
SEs/ADRs:
A
o Dehydration
o Dec potassium
o Dec magnesium
o Dec sodium
o Orthostatic hypotension
o Dizziness
o Headache
o Weakness
o GI upset
o Photosensitivity
o Gout
12
Q
Thiazide: HCTZ (Hydrochlorothiazide)
Contraindications:
A
o Pregnancy
o Avoid in pts with gout or on lithium.
13
Q
Thiazide: HCTZ (Hydrochlorothiazide)
Interactions:
A
o Inc Digoxin toxicity with hypokalemia
o Steroids – inc potassium loss
o Anti-diabetics- dec effect
14
Q
Both thiazides and loop diuretics waste K/Mg
A
Dec K (Potassium)
S Skeletal muscle weakness
U u-waves (EKG changes)
C Constipation/cramping
T Toxicity (Dig)
I Irregular heart rate
O Orthostatic hypotension
N Numbness/tingling
Dec Mg (Magnesium)
S Seizures
T Tetany
A Anorexia/arrhythmias
R Rapid heart rate
V Vomiting
E Emotional liability
D DTRs (deep tendon reflex) increased
15
Q
Nursing actions/teaching (potassium wasting diuretics)
A
- Give IV furosemide SLOWLY.
- Daily weights
- Monitor electrolytes.
- Encourage pts to inc foods high in potassium ex/ dark leafy greens, cantaloupe, citrus, potatoes, bananas, tomatoes, and avocados.
- Replace potassium if low (oral/IV)
- Monitor blood pressure- teach pt to change positions slowly.
16
Q
Osmotic diuretics: Mannitol
Action:
A
The site of action is the entire tubule, but the major effects are in the PCT and descending loop. Inhibits water reabsorption. Promotes “aquaresis”- water excretion without loss of electrolytes. Reduces intracellular volume.
17
Q
Osmotic diuretics: Mannitol
Uses:
A
o reduces intracranial pressure (ICP)
o reduces intraocular pressure (IOP)
18
Q
Osmotic diuretics: Mannitol
Administration:
A
o Must be given IV for systemic effects (emergency settings)
19
Q
Osmotic diuretics: Mannitol
SEs/ADRs:
A
o Pulmonary edema (due to high doses or kidney failure)
o Tachycardia (due to fluid loss)
o Metabolic acidosis
o Acute kidney injury
20
Q
Osmotic diuretics: Mannitol
Contraindications:
A
o Anuria
o Severe hypovolemia
o Pulmonary edema (a complication of left-sided heart failure)
21
Q
K+ (potassium-sparing) diuretics: Spironolactone
Action:
A
o Aldosterone- Na+/water retention, potassium excretion
o Spironolactone does the opposite (blocks aldosterone)- Na+/water excretion, potassium retention.
22
Q
K+ (potassium-sparing) diuretics: Spironolactone
Uses:
A
o Heart failure
o Hypertension
o Cirrhosis
23
Q
K+ (potassium-sparing) diuretics: Spironolactone
SEs/ADRs:
A
o Hyperkalemia
o Amenorrhea (stops menstrual cycle)
o Gynecomastia
o Impotence
o Metabolic acidosis
o Stevens-Johnson Syndrome- really bad rash
24
Q
K+ (potassium-sparing) diuretics: Spironolactone
Contraindications:
A
o Severe renal failure
o Hyperkalemia
25
K+ (potassium-sparing) diuretics: Spironolactone
Interactions:
Both raise potassium levels.
o ACEI ex/ lisinopril
o A2RBs ex/ valsartan
26
K+ (potassium-sparing) diuretics: Spironolactone
Nursing action/pt teaching:
o Avoid salt substitutes and K+ supplements.
o Limit/avoid foods high in K+
o Monitor input and output.
o Monitor daily weight.
o Monitor blood pressure.
27
Diuretics’ effect on electrolytes:
Na K Ca Mg
Thiazide dec dec inc dec
Loop dec dec dec dec
Spironolactone dec inc dec dec
28
Hypertension
“The silent killer,” #1 cause of stroke, PAD (peripheral arterial disease), CAD (coronary artery disease), ESRD
29
HTN Guidelines:
* Normal blood pressure: 120/80
* Elevated: 120-129/<80
* Stage I: 130-139/80-89
* Stage II: less than or equal to 140/90
30
HTN Diagnosis:
Based on an average of greater than 2 readings on more than 2 occasions.
31
HTN when to treat:
* Greater than 130/80 in diabetic or with renal or vascular disease.
* Greater than 140/90 in pts more than 60 yrs.
* Greater than 150/90 if less than 60 yrs.
32
Types of hypertensions:
* Essential (primary) HTN: most common, related to risk factors.
* Secondary HTN: has identifiable cause.
* Clinical manifestations: usually asymptomatic
33
HTN: Lifestyle modification is the best initial treatment:
* Exercise
* Low stress
* DASH diet
* Smoking cessation
34
Antihypertensive Drugs:
* Diuretics
* Calcium channel blockers (CCBs)
* Beta blockers (BBs)
* ACEI/A2RBs
* Alpha blockers
35
Best initial therapy:
Black Non-black
Thiazide or CCB Thiazide, CCB, ACEI,
“dec Renin HTN” A2RB
36
Beta-blockers:
cardioselective: Metoprolol
non-selective: Propranolol
Action:
Dec heart rate/ blood pressure
37
Beta-blockers:
cardioselective: Metoprolol
non-selective: Propranolol
Uses:
o Especially used in hypertensive pts who also have a history of MI (heart attack)/CHF (congestive heart failure).
o Can also be used in certain arrhythmias.
o Propanol is also used for anxiety, tremors, migraine, and headache prophylaxis.
38
Beta-blockers:
cardioselective: Metoprolol
non-selective: Propranolol
Contraindications:
o Hypoglycemia
o Cardioselective may be used with caution in pts with asthma/COPD.
o Nonselective are contraindicated.
39
Beta-blockers:
cardioselective: Metoprolol
non-selective: Propranolol
Warning:
o DO NOT STOP ABRUPTLY! Will hyperadrenergic state:
o Angina/MI
o Sudden death
o Tachycardia
o Hypertension
o Arrhythmia
o Wean slowly. BID-->QD-->QOD…..
40
Alpha-adrenergic blocker: Prazosin
Action:
Inhibit alpha-adrenergic receptors on arteries--> vasodilation-->drop in blood pressure
41
Alpha-adrenergic blocker: Prazosin
Uses:
o Hypertension
o BPH (Benign prostatic hyperplasia- enlarged prostate)
o Not recommended as first-line therapy for treatment of hypertension
42
Alpha-adrenergic blocker: Prazosin
SEs/ADRs:
o Orthostatic hypotension- can cause dizziness, vertigo.
o Tachycardia
o Rash
o Urinary frequency
o Drowsiness
o Edema
o Weight gain
43
Alpha-adrenergic blocker: Prazosin
Contraindications, Interactions:
1. Contraindications:
o Orthostatic hypotension
2. Interactions:
o Other antihypertensives
o Alcohol
o Dec effects with NSAIDs (dec blood pressure)
44
Alpha-adrenergic blocker: Prazosin
Monitoring:
o May inc LFTS
o Monitor daily weights.
45
Calcium channel blocker: Amlodipine
Action:
Blocks entry of calcium into vascular smooth muscle -->vasodilation-->dec blood pressure
46
Calcium channel blocker: Amlodipine
Uses:
o Treatment of hypertension
o Vasospastic angina
o Raynaud’s disease
47
Calcium channel blocker: Amlodipine
SEs/ADRs:
o Dizziness
o Headache
o Flushing
o Peripheral edema
o Palpitations
o Abdominal pain
o Nausea
o Erectile dysfunction (rare <2%)
48
Calcium channel blocker: Amlodipine
Contraindications:
o Use with caution in pts with hepatic impairment.
o AVOID in pts with congestive health failure.
49
Calcium channel blocker: Amlodipine
Interactions:
o Other antihypertensives
o Cold medications (dec antihypertensive effect)
50
ACEI (end in “pril”): Lisinopril
Action:
Action: Blocks effects of angiotensin II (AT2- vasodilator) and aldosterone (salt and water retention and K+ excretion)
Effects: Vasodilation and less salt and water retention-->dec blood pressure
51
ACEI (end in “pril”): Lisinopril
Uses:
o Heart failure
o Hypertension
o Improves survival in pts post-MI (heart attack)
52
ACEI (end in “pril”): Lisinopril
SEs/ADRs:
o Hyperkalemia – due to aldosterone suppression
o Dry cough
o Angioedema
- Potentially fatal
- ACEIs are the leading causes of drug-induced angioedema.
- Signs & Symptoms:
--- Swelling of lips, tongue, face, and upper airway
- Incidence is 5x greater in people of African descent.
- Time course: swelling develops over mins to hrs., peaks, resolves over 24-72 hrs.
- Severity: may resolve without complications, incubation/tracheostomy may be necessary.
o Renal impairment
53
ACEI (end in “pril”): Lisinopril
Contraindications:
o Pregnancy
54
ACEI (end in “pril”): Lisinopril
Interactions:
o Spironolactone
o K+ supplements
o Salt substitutes
o NSAIDs (raise blood pressure)dec renal function.
55
ARBs (A2RB-angiotensin 2 receptor blocker): Valsartan
Does not cause dry cough or angioedema.
56
ARBs (A2RB-angiotensin 2 receptor blocker): Valsartan
Action:
Block AT2 (angiotensin 2) from binding to receptor sitesvasodilation, dec Na and water retention
57
ARBs (A2RB-angiotensin 2 receptor blocker): Valsartan
Uses:
o Heart failure
o Hypertension
58
ARBs (A2RB-angiotensin 2 receptor blocker): Valsartan
SEs/ADRs:
o Hyperkalemia
o Orthostasis
o Renal impairment
59
ARBs (A2RB-angiotensin 2 receptor blocker): Valsartan
Contraindications:
o Pregnancy
60
ARBs (A2RB-angiotensin 2 receptor blocker): Valsartan
Interactions:
o Spironolactone
o K+ supplements
o Salt substitutes
o NSAIDs
61
Nursing actions/teaching for antihypertensive drugs:
o Baseline vitals, recheck after administration.
o Monitor electrolytes: K+ --ACEI/A2RB
o Monitor renal function: ACEI/A2RB
o Daily weights: diuretics, alpha-blocker
o Monitor for edema: calcium channel blocker, alpha blocker.
o DO NOT STOP ABRUMPTLY – beta blocker.
o Low K+ diet for pts on ACEI/A2RBs
62
Tuberculosis (TB)
A contagious disease that generally affects the lungs but may affect other parts of the body.
63
Tuberculosis:
Organism, Transmission:
* Organism: Mycobacterium tuberculosis
* Transmitted through aerosolization (airborne route)
64
Tuberculosis:
At-risk groups:
o Immunocompromised
o Homeless
o Health care workers
65
Tuberculosis:
Signs & Symptoms:
o Fever
o Sputum production
o Productive cough
o Anorexia (lack of appetite)
o Fatigue
o Malaise
o Weight loss
o Night sweats
o Hemoptysis
66
Tuberculosis:
Drug treatment:
TB is usually curative. Four drug therapies. ALL TB DRUGS ARE HEPATOTOXIC
R Rifampin Causes red secretions; these are expected, and harmless.
Red urine, tears, sweat. May stain contact lenses.
I Isoniazide (INH) Injures neurons (depletes B6 levels) and hepatocytes.
P Pyrazinamide
E Ethambutol
67
TB DRUGS HEPATOTOXIC
Signs & Symptoms:
o Dark urine
o Jaundice
o Abdominal pain
o Nausea and vomiting
o Bruising
o Bleeding
o Inc LFTS
68
TB DRUGS HEPATOTOXIC
Nursing actions/teaching:
o INH/Rifampin- administer 1 hr. before or 2 hrs. after meals.
o Check LFTs, asses for signs of liver toxicity.
o Take with B6 to prevent peripheral neuropathy.
o Must complete full course of treatment (>6 months)
69
Upper respiratory tract infections (URIs):
o Common cold: mild URI, involves varying symptoms, usually uncomplicated, symptoms self-limiting.
- Etiology: Rhinovirus
o Acute rhinitis: acute inflammation of mucus membranes of the nose, usually accompanied by the common cold.
o Allergic rhinitis-: allergic inflammation of nasal membrane, affects up to 20% of U.S. population. Understood as a major chronic respiratory disease of childhood.
o Sinusitis: inflammation of sinus cavities of the skull, results in blockage, buildup of fluid and pressure.
o Acute pharyngitis (sore throat): infection and inflammation of pharynx. Usually viral but can be bacterial (strep throat). Most common symptom is a sore throat, sometimes fever.
70
Antihistamines
A major class of medications used for allergies; exerts effects via inhibition of histamine receptors. H1 is most significantly implicated in allergic disease.
71
H1 receptors
Mediate inflammatory and allergic reactions.
H1 receptors are expressed on vascular endothelial (in vessels) cells, smooth muscle cells, brain and peripheral nerve endings.
72
When histamine binds to:
* Vascular endothelial cells: -->vasodilation, redness, edema
* Smooth muscle cells in bronchioles: -->bronchoconstriction
* H1 receptors in brain-->wakefulness, appetite suppression
* Peripheral nerve endings--> pain/itching
73
1st generation antihistamine: Diphenhydramine
Action:
Binds to H1 on target tissue—>inhibition of histaminic action
74
1st generation antihistamine: Diphenhydramine
Uses:
o Relief of allergy-related symptoms
o Also has anti-emetic and anti-nausea effects due to the blockade of central (in the brain) histamine and acetylcholine receptors.
75
1st generation antihistamine: Diphenhydramine
SEs/ADRs:
o Can cross the blood-brain barrier and cause sedation and impaired cognitive function.
o 1st generation antihistamines can occupy cholinergic, alpha-adrenergic, and serotonin receptors.
- Blocking cholinergic receptors causes dry mouth, blurry vision, and urinary retention.
- Blocking alpha-adrenergic receptors--> Hypotension and reflex tachycardia
- Blocking serotonin receptors--> inc appetite
76
1st generation antihistamine: Diphenhydramine
Contraindications/Cautions:
o Asthma/COPD: may thicken respiratory secretions-->airway obstruction.
Position statement: not contraindicated but not used in asthma treatment.
o Severe liver disease: Diphenhydramine undergoes extensive 1st pass metabolism, 50-60% metabolized by the liver before reaching systemic circulation.
77
1st generation antihistamine: Diphenhydramine
Interactions:
o Other CNS depressants
78
2nd generation antihistamine: Loratadine
Action:
Similar to 1st generation, more selective for H1 receptors involved in allergies. DO NOT readily cross the blood-brain barrier, so it is less likely to cause somnolence (sleepiness).
79
2nd generation antihistamine: Loratadine
Use:
o Relief of allergy related symptoms
80
2nd generation antihistamine: Loratadine
SEs/ADRs:
o Headache (10%)
o Palpitations
o Tachycardia
o Photosensitivity
o Skin rash, more likely in children
o Abdominal pain
o Constipation
o Diarrhea
o Bronchospasm (4% in children)
81
2nd generation antihistamine: Loratadine
Interactions:
o Amiodarone
o Clozapine
82
Nursing actions/teaching for antihistamines: Diphenhydramine and Loratadine
o Obtain baseline vital signs.
o Medical history/ medications
o Any signs and symptoms of urinary dysfunction
o Cardiac/ respiratory status
o Avoid other CNS depressants (diphenhydramine)
o Gum/candy/ice chips for dry mouth
o BEERS criteria- avoid in adults less than 65 yrs
o May cause excitation in children.
83
Nasal congestion
Due to dilation of blood vessels; dilation causes fluid to permeate tissues and cause swelling.
84
Decongestants: Pseudoephedrine (PO)
Action:
Stimulates Alpha 1 receptors of respiratory mucosa-->vasoconstriction. Also stimulates beta receptors--> bronchodilation.
85
Decongestants: Pseudoephedrine (PO)
Uses:
o Rhinitis (stuffy nose)
o Nasal congestion
86
Decongestants: Pseudoephedrine (PO)
SEs/ADRs:
Due to adrenergic receptor stimulation
o Excitability
o Nervousness
o Headache
o Palpitations
o Tachycardia
o Hypertension
o Nausea and vomiting
o Urinary retention
o Arrhythmias
87
Decongestants: Pseudoephedrine (PO)
Contraindications/Caution:
o Cardiovascular disease
o Hypertension
o Ischemic disease
o Diabetics
o BPH (Benign prostatic hyperplasia- enlarged prostate)
o Thyroid dysfunction
88
Decongestants: Pseudoephedrine (PO)
Interactions:
o Caffeine
o Antihypertensives
o Antiarrhythmics
o MAOIs
89
Oxymetazoline- nasal spray
Action:
Stimulates alpha-adrenergic receptors in arterioles of nasal mucosa-->vasoconstriction
90
Oxymetazoline- nasal spray
Use:
Temporary relief of nasal congestion
91
Oxymetazoline- nasal spray
Caution:
o So effective that pts will overuse it. When they stop--> rebound rhinitis
o Limit to 3 days of consecutive use
92
Oxymetazoline- nasal spray
SEs/ADRs:
o “Rhinitis medicamentosa” which is rebound nasal congestion when the medication wears off.
- Treatment: withdrawal of medication
93
Intranasal glucocorticoid: Fluticasone
Action:
Directly inhibits inflammatory cells as well as many inflammatory medications
94
Intranasal glucocorticoid: Fluticasone
Use:
Allergic disorders
95
Intranasal glucocorticoid: Fluticasone
SEs:
o Dryness of nasal mucosa
o Headache
o Nasal irritation
o Pharyngitis (sore throat)
o Fatigue
o Insomnia
96
Cough
Protective reflex to clear the airways. regulated by the medulla.
97
Cough types:
* Nonproductive (dry cough)- should be suppressed- use antitussive (centrally acting)
* Productive cough (brings up mucous)- should NOT be suppressed- use expectants or mucolytics.
98
Centrally active antitussives:
Opioid antitussive: Codeine
Centrally acting cough suppressant.
o May cause:
- Sedation,
- Constipation.
99
Centrally active antitussives:
Non-opioid antitussive: Dextromethorphan
Centrally action.
o May cause:
- Sedation
- Hallucinations
100
Antitussive:
Expectorants: Guaifenesin
Action:
Muco-kinetic: dec viscosity of mucus so it becomes thinner and easier to cough up.
101
Antitussive:
Expectorants: Guaifenesin
Use:
Productive cough
102
Antitussive:
Expectorants: Guaifenesin
SEs:
o GI upset
o Dizziness
103
Antitussive:
Expectorants: Guaifenesin
Administration:
o Take with full glass of water.
o Adequate hydration is required for maximal efficacy (helps loosen mucus).
104
Nursing actions/teachings congestions: Codeine, Dextromethorphan, and Guaifenesin
* Check vital signs.
* Medical/medication history
* Cardiac/ respiratory status
* Teach proper use of nasal spray- longer than 3 days may--> rebound congestion.
* Inc fluids with Guaifenesin (expectorants)
105
Asthma
A chronic condition that results from inflammation and hyperresponsiveness of airways can-->bronchoconstriction.
Inhaled allergen-->inflammation of airway --> mucus production, constriction, swelling--> narrowed airways-->asthma symptoms (wheezing, shortness of breath, coughing)
106
COPD
Progressive, nonreversible obstructive pulmonary disease is characterized by two pathological processes: emphysema and chronic bronchitis.
107
Beta-2 adrenergic agonist: Albuterol
Action:
Stimulates Beta 2 receptors in lungs-->bronchodilation
108
Beta-2 adrenergic agonist: Albuterol
Uses:
o Treatment of bronchospasm in asthma
o COPD exacerbation
109
Beta-2 adrenergic agonist: Albuterol
Administration:
o Metered dose inhaler or nebulizer
- If it been more than 48 hrs since the last use, prime it (push the top of the medication)
- Inhale before using the medication.
- Hold breath for 10sec after inhaling the medication.
- Wait 1-2 mins between inhalations.
110
Beta-2 adrenergic agonist: Albuterol
SEs/ADRs:
o Mild tachycardia
o Cardia arrhythmias
o Nervousness
o Tremors
o Anxiety
o Insomnia
o Inc serum glucose
111
Beta-2 adrenergic agonist: Albuterol
Contraindications/Caution:
o Cardiovascular disease
o Diabetes
o Glaucoma
o Hyperthyroidism
o Hypokalemia
112
Beta-2 adrenergic agonist: Albuterol
Interactions:
o Other adrenergic drugs
o Dec effects of antihypertensives
o Dec effects of antiarrhythmic drugs
113
Muscarinic antagonist (inhaled anticholinergic): Tiotropium
Action:
Inhibits the effects of acetylcholine on M3 receptors-->airway smooth muscle relaxation
114
Muscarinic antagonist (inhaled anticholinergic): Tiotropium
Uses:
o Maintenance treatment of asthma
o Maintenance treatment of bronchospasm associated with COPD.
o Reduced COPD exacerbation
115
Muscarinic antagonist (inhaled anticholinergic): Tiotropium
Administration:
Oral inhalation- dry powder inhaler
116
Muscarinic antagonist (inhaled anticholinergic): Tiotropium
SEs/ADRs:
o Dry mouth
o Pharyngitis (sore throat)
o Upper respiratory tract infection
117
Muscarinic antagonist (inhaled anticholinergic): Tiotropium
Interactions:
Other anticholinergics
118
Long-acting beta agonist: Salmeterol
Inhaled corticosteroid: Fluticasone
Both together are: Advair
Long-acting beta agonist: Salmeterol-broncho dilates.
Inhaled corticosteroid: Fluticasone- dec airway inflammation
Both together are: Advair
119
Long-acting beta agonist: Salmeterol
Inhaled corticosteroid: Fluticasone
Both together are: Advair
Use:
Maintenance treatment of asthma/COPD
120
Long-acting beta agonist: Salmeterol
Inhaled corticosteroid: Fluticasone
Both together are: Advair
Administration:
Oral inhalation
121
Long-acting beta agonist: Salmeterol
Inhaled corticosteroid: Fluticasone
Both together are: Advair
SEs/ADRs:
Upper respiratory tract infection/oral candidiasis (thrush)
122
Long-acting beta agonist: Salmeterol
Inhaled corticosteroid: Fluticasone
Both together are: Advair
Contraindications:
o Status asthmaticus (severe asthma attack)
o Acute symptoms of asthma/COPD
o Allergy to milk protein
123
Long-acting beta agonist: Salmeterol
Inhaled corticosteroid: Fluticasone
Both together are: Advair
Interactions:
Beta blockers
124
Long-acting beta agonist: Salmeterol
Inhaled corticosteroid: Fluticasone
Both together are: Advair
Instruction to pts:
Following administration rinse mouth with water after use- this is to dec risk of oral thrush. DO NOT SWALLOW!
125
Nursing action/teaching for inhalers: Albuterol, Tiotropium, Advair
* Baseline vital signs/ O2 stat
* Medical history/ medications
* Lung sounds before and after
* Inc fluid intake
* Teach proper use of inhaler.
* Bronchodilator 1st, then steroid
126
Leukotriene receptor antagonist: Montelukast
Action:
Blocks binding of leukotrienesbronchial smooth muscle contraction
127
Leukotriene receptor antagonist: Montelukast
Uses:
o Allergic rhinitis
o Asthma (maintenance therapy)
o Prevention of exercise induced bronchoconstriction.
128
Leukotriene receptor antagonist: Montelukast
Administration:
Oral
129
Leukotriene receptor antagonist: Montelukast
SEs/ADRs:
o Serious neuropsychiatric events!
o Agitation
o Aggression
o Depression
o Sleep disturbances
o Suicidal thoughts and behaviors
130
Leukotriene receptor antagonist: Montelukast
Contraindications:
NOT approved for reversal of bronchospasm or in acute attacks, including status asthmaticus.
131
Leukotriene receptor antagonist: Montelukast
Interactions:
Gemfibrozil
132
Leukotriene receptor antagonist: Montelukast
Nursing actions:
o Lung assessment
o Monitor for neuropsychiatric symptoms including suicidal thinking or behavior
133
Diabetes
* Type 1: due to autoimmune destruction of beta cells of pancreas. ALWAYS requires insulin.
* Type 2: due to insulin resistance. Cells stop responding to insulin.
* Role of insulin: transports glucose into cells so it can be used for energy.
* Glucose level: 70-110
134
Insulin Types
* Rapid
* Short
* Intermediate
* Long acting
135
Rapid acting: Lispro
Action:
o Onset: 15-30 min
o Peak: 30-90 min
o Duration: 3-5 hrs.
136
Rapid acting: Lispro
Use:
o Sliding scale regiment in hospitals. "Sliding scale" refers to the progressive increase in pre-meal or nighttime insulin doses.
137
Rapid acting: Lispro
Administration:
SQ (subcutaneous)
138
Short acting: Regular (clear)
Action:
o Onset: 20-30 min
o Peak: 1.5-3.5 hrs.
o Duration: 4-12 hrs.
139
Short acting: Regular (clear)
Use:
o Sometimes mixed with NPH (cloudy insulin)
o Insulin drip (IV) for endocrine energies
o Treatment for hyperkalemia
140
Short acting: Regular (clear)
Administration:
o SQ
o IV push
o IV drip
141
Intermediate acting: NPH (cloudy insulin)
Action:
o Onset: 1-2 hrs.
o Peak: 4-12 hrs.
o Duration: 14-24 hrs.
142
Intermediate acting: NPH (cloudy insulin)
Use:
o Given once or twice daily to improve glycemic control in pts with diabetes.
o May be mixed with rapid or short acting.
143
Intermediate acting: NPH (cloudy insulin)
Administration:
SQ
144
Long acting: Glargine (Lantis)
Action:
o Onset: 1-1.5 hrs.
o Peak: none. It rises and stays consistent.
o Duration: 24 hrs.
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Long acting: Glargine (Lantis)
Use:
Basal insulin
146
Long acting: Glargine (Lantis)
Administration:
o SQ at bedtime
o CANNOT BE MIXED WITH ANY OTHER INSUIN TYPES.
147
Combinations: Novolin 70/30
70%NPH/
30%regular
148
Combinations: Novolin 70/30
Administration:
SQ
149
Insulin
SEs/ADRs:
* Hypoglycemia: normal level 70-110
o Signs and symptoms:
- SNS:
- Sweating
- Tremors
- Tachycardia
- Palpitations
- Anxiety
- Neuroglycopenic:
* Blurred vison
* Altered LOC (level of consciousness)
* Behavioral changes
* Slurred speech
* Others: tingling sensation, hunger
150
Insulin
Interactions:
* Alcohol, Beta-blockers--> dec B6
* Steroids, epi, B2 agonist--> inc B6
151
Insulin
Administration/other considerations:
* Refrigerate insulin not in use to maintain potency.
* May be kept at room temperature for 1 month or refrigerator for 3 months.
* Mixing: don’t mix any other type of insulin with Glargine
* Rapid/short may be mixed with NPH.
* Given SQ, Regular may be given IV.
* Rotate injection site- w/in one anatomic site.
* Don’t message injection site.
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Insulin nursing action/teaching:
* Teach pt how to recognize signs and symptoms of hyperglycemia.
* Monitor blood glucose and HGA1C.
* Instruct pt to report hyper/hypoglycemia, and that hypoglycemia is more likely during insulin peak.
* Advise pt to wear medic alert bracelet.
* Teach pt how to check blood glucose.
* Teach how to administer insulin.
153
Sulfonylureas: Glipizide
Action:
Stimulates insulin release from beta cells.
154
Sulfonylureas: Glipizide
Use:
Treatment of Type 2 Diabetes
155
Sulfonylureas: Glipizide
SEs/ADRs:
o Weight gain
o Hypoglycemia
156
Sulfonylureas: Glipizide
Contraindications, Interactions:
1. Contraindications:
o Type 1 diabetes
o Use with caution in pts with hepatic/renal impairment.
2. Interactions:
o Alcohol- may cause Antabuse type reaction.
o Beta-blockers-->dec blood glucose
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Biguanides: Metformin
Action:
Dec glucose production by liver, inc body’s response to insulin.
158
Biguanides: Metformin
Use:
Drug of choice for monotherapy in Type 2 Diabetes.
159
Biguanides: Metformin
SEs/ADRs:
o GI upset- especially diarrhea ----administer with food.
o Can cause lactic acidosis in pts with renal impairment.
o Should be withheld for 48 hrs. before and after administration of IV contrast. Pg 635
o Dosage adjustment may be necessary for altered kidney function.
160
Biguanides: Metformin
Contraindications, Interactions:
1. Contraindications:
o Severe renal impairment
o Hepatic dysfunction
2. Interactions:
o Levothyroxine- dec effectiveness of metformin and other diabetic medication.
o Metformin may alter TSH levels.
o Green tea- inc risk for hypoglycemia
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Incretin mimetic: Exenatide
Action:
Arguments post-prandial (after meal) insulin secretion.
162
Incretin mimetic: Exenatide
Use:
Treatment of Type 2 Diabetes, adjust to diet and exercise to help improve glycemic control.
163
Incretin mimetic: Exenatide
SEs/ADRs:
o Diarrhea
o Hypoglycemia
o Nodule at injection site
o Pancreatitis
164
Incretin mimetic: Exenatide
Contraindications:
o History of thyroid carcinoma
o Severe renal impairment
165
Incretin mimetic: Exenatide
Administration:
o SQ
o IR (instant release) forms are administered 60 minutes before morning/evening meals.
166
Incretin mimetic: Exenatide
Nursing Process:
o Medical/medication history
o Monitor blood glucose levels, A1C.
o Renal function
o Monitor SEs/ADRs
o Medical alert bracelet
o Teach how to administer.
167
Glucagon (hyperglycemic)
Action:
Promotes hepatic gluconeogenesis and glycogenolysis
168
Glucagon (hyperglycemic)
Use:
Raise blood glucose.
169
Glucagon (hyperglycemic)
Routes:
o SQ
o IM
o IV
o Intranasal
170
Glucagon (hyperglycemic)
SEs/ADRs:
o Nausea
o Headache
o Upper respiratory symptoms
171
Endocrine Drugs
Hypothalamus and Pituitary are at the base of the brain, key players in the endocrine system.
The pituitary is controlled by the hypothalamus, produces hormones.
Hormones: chemical messengers, tell the body what to do and when.
Hormonal imbalances can cause medical problems.
Pituitary:
* Anterior lobe: releases Thyroid Stimulating Hormone (TSH)--> stimulates thyroid to produce/release thyroid hormone.
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Thyroid hormones are responsible for:
* Metabolism
* Regulate body functions such as:
- Heart rate,
- Body weight
- Temperature
- Menstrual cycle
- Digestion
- Mental activity
- Breathing etc.
Thyroid hormones: T3 and T4
T3 is more active.
173
Hypothyroidism
Reduction of thyroid hormone
174
Hypothyroidism
Causes:
* Autoimmune (Hashimoto’s)
* Thyroiditis
* Drugs
* Iodine deficiency or excess
175
Hypothyroidism
Signs & Symptoms:
* Fatigue
* Cold intolerance
* Cramping
* Stiffness
* Carpal tunnel syndrome
* Weight gain
* Dec appetite
* Constipation
* Brittle hair
* Dry skin
* Edema
* Menorrhagia (heavy periods)
* Large tongue
* Pseudodementia
* Dec heart rate
* SOB (shortness of breath)
* Depression
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Complications of hypothyroidism:
* Hypercholesterolemia (a lipid disorder in which your low-density lipoprotein (LDL), or bad cholesterol, is too high)
* Myxedema - the result of having undiagnosed or untreated severe hypothyroidism. The term “myxedema” can mean severely advanced hypothyroidism. But it's also used to describe skin changes in someone with severely advanced hypothyroidism.
* Coma (emergency)
177
Levothyroxine (Synthroid): thyroid hormone replacement (synthetic version of T3)
Action:
o T4 is converted to its active metabolite, T3.
o Effect: inc basal metabolic rate
178
Levothyroxine (Synthroid): thyroid hormone replacement (synthetic version of T3)
Use:
Treatment of hypothyroidism
179
Levothyroxine (Synthroid): thyroid hormone replacement (synthetic version of T3)
Administration:
Take on an empty stomach 30-60 mins before breakfast and other meals.
180
Levothyroxine (Synthroid): thyroid hormone replacement (synthetic version of T3)
SEs/ADRs:
o CV: potentially life threatening
- Arrhythmias
- Elevated heart rate
- Hypertension
- Angina
o Endocrine:
- Cramps
- Diarrhea
o Nervous system:
- Anxiety
- Hyperactive behavior
- Heat intolerance
o Respiratory:
- Dyspnea
o Miscellaneous:
- Fever
181
Levothyroxine (Synthroid): thyroid hormone replacement (synthetic version of T3)
Contraindications:
o Acute MI (heart attack)
o Adrenal insufficiency
182
Levothyroxine (Synthroid): thyroid hormone replacement (synthetic version of T3)
Interactions:
Inc Effects:
Anticoagulants
TCAs
Vasopressors
Decongestions
Corticosteroids
Dec Effects:
Antidiabetics
Cardiac glycosides (Digoxin)
Beta-blockers
183
Hyperthyroidism
Elevation of thyroid hormone.
184
Hyperthyroidism
1# cause:
* Graves’ disease,
* Autoimmune origin, thyroid is active all the time.
185
Hyperthyroidism
Signs & Symptoms:
* Nervousness
* Emotional lability (mood swings)
* Tremor
* Insomnia
* Sweating
* Heat intolerance
* Wight loss
* Palpitations
* Arrhythmias
* Warm moist skin
* Amenorrhea (no menstrual cycle)
* Hypercalcemia
186
Hyperthyroidism
Treatment:
* Treatment of symptoms:
- Propranolol
* Treatment of disease:
- PTU (anti-thyroid drug)
187
Propylthiouracil (PTU): anti-thyroid agent
Action:
Inhibits synthesis of thyroid hormones.
188
Propylthiouracil (PTU): anti-thyroid agent
Use:
Hyperthyroidism
189
Propylthiouracil (PTU): anti-thyroid agent
Administration:
Oral
190
Propylthiouracil (PTU): anti-thyroid agent
SEs/ADRs:
o Bleeding
o Bone marrow suppression
o Dermatitis
o SEVERE liver injury
o Hypothyroidism
o Acute renal failure
191
Propylthiouracil (PTU): anti-thyroid agent
Interactions:
Anticoagulants
192
Parathyroids
One major function is to “sense” calcium.
Four parathyroid glands: on posterior aspect of thyroid- 2 superior, 2 inferiors.
Parathyroid hormone is released by parathyroid glands.
Functions:
* Promotes gut absorption of calcium and bone demineralization (activates osteoclasts-break down bone): inc calcium.
* Promotes conversion of inactive Vit D-->active form in kidney which result in an inc in calcium.
* Promotes renal excretion of phosphorus.
193
Calcium
Function of calcium: stabilize cell membranes specifically nerve cells.
Hypercalcemia-->under stimulation of neurons
Hypocalcemia--> overstimulation of neurons
Normal calcium levels: 9-10
Hypocalcemia: calcium levels below 9
#1 cause of hypocalcemia is hypoparathyroidism.
Thiazide diuretics enhance calcemic effect.
194
Signs and Symptoms of hypocalcemia:
Due to neuronal hyperactivity
* Paresthesia (tingling or prickling, “pins-and-needles” sensation; usually temporary, often occurs in the arms, hands, legs, or feet.)
* Spasms
* Inc DTRs (deep tendon reflex)
* Tetany (involuntary muscle cramp or spasm)
* Seizures
* Chvostek’s/Trousseau’s signs
195
Treatment of hypocalcemia:
* Calcium supplementation
* Vit D supplementation: Calcitriol
196
Calcitriol: Vit D analog
Action:
Activated Vit D receptors, stimulates intestinal calcium absorption.
197
Calcitriol: Vit D analog
Use:
Treatment of hypercalcemia associated with hypothyroidism
198
Calcitriol: Vit D analog
Administration:
o IV
o Oral
199
Calcitriol: Vit D analog
SEs/ADRs:
o Hypercalcemia
o Headache
o Rash
o Thirst
200
Calcitriol: Vit D analog
Contraindications:
o Hypercalcemia
o Vit D toxicity
201
Adrenal Gland
Two adrenal glands, one on each side; sit on kidneys, roughly at level of pancreas.
Function: make hormones (chemical messengers that tells the body what to do)
Various levels of glands:
1. Adrenal cortex
* Aldosterone- mineralocorticoid, influences sodium and water retention, potassium excretion.
* Cortisol- glucocorticoid, regulates metabolic activity, immune function, and behavior.
* DHEA- sex hormone precursor.
2. Adrenal medulla: makes catecholamines (epinephrine, norepinephrine, and dopamine)
202
Addison’s Disease
Adrenal insufficiency due to loss of adrenal function dec cortisol, dec aldosterone
203
Addison’s Disease
Signs & Symptoms:
* Salt craving
* Orthostatic hypotension
* Weakness
* Weight loss
* Inc in skin pigmentation
* Nausea and vomiting
* Amenorrhea (no menstrual cycle)
* Inc potassium
* Dec sodium
204
Treatment for Addison's Disease:
* Fludrocortisone
* Prednisone
205
Prednisone: systemic corticosteroid
Action:
Dec inflammation, suppress the immune system, glucocorticoid replacement in adrenal insufficiency.
206
Prednisone: systemic corticosteroid
Uses:
o Anti-inflammatory and immune suppressant in a variety of conditions:
- Allergic
- Hematologic
- Dermatologic
- GI
- Nervous system
- Endocrine
- Organ rejection
207
Prednisone: systemic corticosteroid
SEs/ADRs:
o Hypertension
o Fluid retention
o Weight gain
o Electrolyte disturbances – inc sodium, dec potassium
o Psychiatric disturbances
o Gastritis
o Peptic ulcer disease
o Abdominal distension
o Hyperglycemia
o Inc risk of infections
o Osteoporosis
208
Prednisone: systemic corticosteroid
Administration, Caution:
1. Administration:
o After meals or with food or milk to dec GI upset
2. Caution:
o Discontinuation of therapy- withdraw therapy with gradual tapering of dose.
209
Prednisone: systemic corticosteroid
Interactions:
o Antacids
o Dec effects of vaccines
o May dec serum concentration of INH
o Diuretics (enhance hypokalemic effects)
210
Fludrocortisone: very potent mineralocorticoid.
Action:
Promotes reabsorption of sodium, water and potassium loss.
211
Fludrocortisone: very potent mineralocorticoid.
Uses:
o Adrenal insufficiency
o Orthostatic hypotension
212
Fludrocortisone: very potent mineralocorticoid.
Administration:
With or without food
213
Fludrocortisone: very potent mineralocorticoid.
SEs/ADRs:
o Hypertension
o Heart failure
o Hypokalemia
o Abdominal distension
o Pancreatitis
o Headache
o Mental status changes
o Psychiatric disturbances
214
Fludrocortisone: very potent mineralocorticoid.
Caution, Interactions:
1. Caution:
o Monitor serum potassium.
2. Interactions:
o Dec effect of vaccines
o INH (Isoniazide)
215
Nursing action for Prednisone and Fludrocortisone:
* Baseline vital signs
* Monitor weight.
* Monitor electrolytes: sodium and potassium.
* Inc potassium in diet
* Fall precautions (Prednisone): inc risk of fractures.
* Do not stop abruptly (Prednisone)
* Take with food (Prednisone)
