PHARM 1 FINAL (COMPREHENSIVE + WKS 9 & 10) Flashcards
Differentiate the actions of cardiac glycosides, antianginal drugs, and antidysrhythmic drugs
CARDIAC GLYCOSIDES
dealing with heart failure (HF)
+ Inotrope
Digoxin
Describe the signs and symptoms of digitalis toxicity
Compare the side effects and adverse reactions of nitrates, beta blockers, calcium channel blockers, quinidine, and procainamide
Apply the nursing process, including patient teaching, related to cardiac glycosides, antianginal drugs, and antidysrhythmic drugs
Drugs used to maintain or restore circulation
Anticoagulants: Prevent the formation of clots that inhibit circulation
— Anticoagulant = NO CLOTS
Antiplatelets (antithrombotics): Prevent platelet aggregation
— Antiplatelets = NO congregation
Thrombolytics: Attack and dissolve blood clots that have already formed
— Thrombolytics = CUT IT…DISSOLVE IT…the blood clots already formed
Thrombus formation
Pathophysiology
— Formation of clot in artery or vein
— Caused by decreased circulation, platelet aggregation on vessel wall, blood coagulation
Arterial vs. Venous clot formation
Arterial clot formation
— Platelets initiate process.
— Fibrin formation occurs.
— RBCs are trapped in fibrin mesh.
Venous clot formation
— Platelet aggregation with fibrin that attaches to RBCs
Action of the parenteral anticoagulant Heparin
Heparin
Step I: (binds with) Antithrombin III
Step II: (inactivates) Thrombin
Step III (inhibits conversion of) Fibrinogen ==> Decr. Fibrin
Step IV: Clot prevented
HEPARIN
Medications: low-molecular-weight heparin (LMWH): enoxaparin sodium (Lovenox), dalteparin sodium (Fragmin), and tinzaparin sodium (Innohep)
Contraindications:
— Stroke, peptic ulcer, blood anomalies
— Patients having eye, brain, or spinal surgery
Administration of heparins
— Heparin = usually given subq for prophylaxis and IV for therapeutic anticoagulation
— Lovenox = subQ only
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NOTE: As with unfractionated heparin, severe neurologic injury can occur if Lovenox is used in patients undergoing spinal puncture or spinal/epidural anesthesia.
Thrombin = creating a clot b/c last clotting factor needed to convert fibrinogen ==> fibrin ==> foundation for clotting
WARFARIN
Compare the action for anticoagulants, antiplatelets, and thrombolytics
Anticoagulants: prevent the formation of clots that inhibit circulation
Antiplatelets (antithrombotics): prevent platelet aggregation
Thrombolytics: attack and dissolve blood clots that have already formed
Differentiate the side effects and adverse reactions of anticoagulants, antiplatelets, and thrombolytic
Apply the nursing processes, including patient teaching, for anticoagulants and thrombolytics
Describe the action of the two main drug groups: antihyperlipidemics and peripheral vasodilators
Compare the side effects and adverse reactions of antihyperlipidemics
Differentiate the side effects and adverse reactions of peripheral vasodilators
Differentiate the side effects and adverse reactions of peripheral vasodilators
Apply the nursing process, including patient teaching, for antihyperlipidemics and peripheral vasodilators
Cholinergic drugs
Peripheral Nervous System
– Muscarnic agonists
Bethanechol (Urecholine)
PNS: Cholinergic drug
Muscarinic antagonists (anticholinergics)
– Atropine
–Scopolamine
Cholinesterase inhibitors
–Neostigmine (Prostigmine) AND Edrophonium (Tensiolon) = MG when peripherally acting
– Rivastigmine (Exelon) = for AD when centrally acting
Neuromuscular blockers
Succinycholine
Dantrolene = acts in CNS as muscle relaxant, but also used to tx malignant hyperthermia + neuroleptic malignant syndrome
ADRENERGIC DRUGS
Agonists
–Endogenous catecholamines: epinephrine (Adrenalin), Norepinephrine, Dopamine
–Synthetic catecholamine – Dobutamine
Beta 2 agonists = Albuterol
Alpha2 agonists = methyldopa (Aldomet), clonidine
ADRENERGIC ANTAGONISTS
Alpha 1 blockers = prazosin (Minipress), Tamsulosin (Flomax)
Beta 1 blockers = metoprolol (Lopressor) and atenolol (Tenormin) [cardioselective], propanolol (Inderal) [non-selective]
STATIN Side Effects
— Liver impairment
— Rhabdomyolysis (skeletal muscle disorder) = rare
— Cataracts
NOTE: Statins can injure muscle tissue. Mild injury occurs in 5-10% of patients, can progress to myositis ==> rhabdomyolysis ==> renal impairment.
— The risk for this sequela is increased when statins are combined with other lipid-lowering drugs (fibrates, niacin, and to a lesser degree bile acid sequestrants).
Antihyperlipidemics: Different Types
antilipidemics:
— Bile-acid sequestrants
— Fibrates (fibric acid)
— Nicotinic acid
— Cholesterol absorption inhibitor
— Hepatic 3-hydroxy-3-methylglutaryl-coenzyme A (HMG-CoA) reductase inhibitors (statins)
Bile-acid Sequestrants
gassy poo
Drugs: Cholestyramine (Questran), colestipol (Colestid), colesevelam HCl
— Reduce LDL cholesterol (LDL-C) levels by binding with bile acids in the intestine
Side effects
— Constipation
— Flatulence
— Cramping
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NOTE:
— Bile acid sequestrants are not absorbed thus devoid of systemic effects and safer than all other lipid lowering agents. Side effects are all GI
— Most bile secreted into the intestine is reabsorbed by the body. The sequestrants promote the excretion of bile in the stool, thereby increasing the cholesterol need for the liver to synthesize more bile which reduces the circulating LDL.
Fibrates
Drugs: Gemfibrozil (Lopid)
— Gemfibrozil (Lopid) is highly protein-bound and should not be taken with anticoagulants, because they compete for protein sites. Anticoagulant dose should be reduced during antihyperlipidemic therapy, and the international normalized ratio (INR) should be closely monitored.
Uses:
— fibrates are the most effective drugs for lowering triglyceride level
— Have little to no effect on LDL cholesterol
— Increase the biliary cholesterol saturation thereby increasing the risk of gallstones.
Manifestations of gallbladder disease to watch for: upper abdominal discomfort (especially after eating), intolerance of fried foods, bloating
RN Intervention:
— Do not take with anticoagulants
—
4 Classes of Antihyperlipidemics/Antilipemics
- Statins
- Bile-acid sequestrants
- Niacin
- Fibrin-acid derivatives
Antihyperlipidemics: NIACIN
DRUGS — Nicotinic acid (Niacin, vitamin B2)
— Flushing can be intense
— Large doses are required to be effective
— As few as 20% of patients can initially tolerate niacin
— With proper counseling, careful drug titration, and concomitant use of aspirin, this number can be increased to as high as 60% to 70%.
RN Interventions:
— Warn of warm feeling and flushing within 2 hours PO and immediately parenterally
— Pellegra = dietary deficiency disease caused by Niacin (Vitamin B3); marked by: dermatitis, diarrhea, & d/o of CNS; RARE in developed countries d/t balanced diet and fortified foods
NONpharmacologic Methods for cholesterol reduction
— Reduce saturated fats in diet.
— Reduce total fat intake to 30% or less of caloric intake.
— Reduce cholesterol intake to 300 mg/day or less.
— Exercise as much as possible.
— Stop smoking.
STATINS RN Interventions
NOTE: Higher risk if you’re using Statins with other hyperlipidemics
RN Interventions:
— Monitor liver enzymes.
— Report unexplained muscle tenderness or weakness, fever, and malaise.
— Teach patient importance of compliance with health care regimen. Do not stop abruptly, which could precipitate plaque instability, leading to a thromboemboli (cardiovascular event).
— Monitor the patient’s blood lipid levels.
— Observe for signs and symptoms of GI upset.
— Inform patient that it may take several weeks before blood lipid levels decline.
— Instruct patient to have annual eye examinations and report changes in visual acuity.
Peripheral Vasodilators
Peripheral arterial (vascular) disease (PAD, PVD)
— arteriosclerosis
— hyperlipidemia
Symptoms: PAD = cool, pale; dry, shiny ulcers | PVD = swollen legs, blood can’t get back to heart; beefy ulcers
Both PAD, and PVD can develop ulcers
Treatment: peripheral vasodilators to improve blood flow
What is intermittent claudication?
— Pain in calf upon walking (short vs. long-distances; around the kitchen or around the park)
— It comes and goes
— Will tell me how bad/aggressive it is depending on the distance it begins to hurt
NOTE:
Ginkgo biloba + an antiplatelet drug = has been used to treat intermittent claudication, because of its vasodilating and antioxidant effects
— Gingko biloba = NOT been approved by the FDA.
Peripheral Vasodilators Drugs
Classifications:
— Alpha-adrenergic antagonists
— Direct-acting peripheral vasodilators
— Hemorrheologic : agent that lowers the affect of blood viscosity (blood is not that thick)
Others Include:
— Antiplatelets
— Selected antihypertensives
Peripheral Vasodilators that promote vasodilation
DRUGS
papaverine (Para-Time): Direct-acting peripheral vasodilator (Promote vasodilation = work right on the BVs to help dilate them)
prazosin (Minipress): Alpha blocker to cause vasodilation will be ALPHA-1 BLOCKER
nifedipine (Procardia): Calcium channel blocker — significant vasodilation
Side effects:
— Lightheadedness
— Dizziness
— Orthostatic hypotension
— Tachycardia
— Palpitation
— Flush
— GI distress
— vasodilation can cause dangerous hypotension and reflex tachycardia (b/c heart will try to compensate)
ANTIINFLAMMATORY DRUGS
Understand inflammation pathophysiology
1st generation NSAIDS – aspirin, ibuprofen (Motrin), ketorolac (Toradol), indomethacin (Indocin)
2nd generation NSAIDS – celecoxib (Celebrex)
Dopaminergic/dopamine agonist agents
levodopa/cabidopa
VS amantadine (Symmetrel)
NMDA receptor antagonist
Memantine (Namenda) – for AD
AED’s
Traditional: phenytoin, valproic acid, Phenobarbital
Newer: gabapentin (Neurontin), pregabalin (Lyrica) – has uses other than AED
ANALGESICS
Opioids: morphine, hydromorphone (Dilaudid), meperidine (Demerol)
competitive antagonist: naloxone (Narcan)
selective mu receptor blocker: alvimopan (Entereg)
how to use PCA
Nonopioid: acetaminophen (Tylenol, Ofirmev)
ANTIPSYCHOTICS
FGA/conventional: haloperidol (Haldol)
SGA/atypical: clozapine (Clozaril), risperidone (Risperdal), ziprasidone (Geodon), aripiprazole (Abilify)
ANTIDEPRESSANTS
TCAs: amitriptyline (Elavil)
SSRIs: fluoxetine (Prozac), sertraline (Zoloft), paroxetine (Paxil)
SNRI: venlafaxine (Effexor)
Atypical: trazodone (Desyrel)
MAOIs: phenelzine (Nardil)
MOOD STABILIZERS
Lithium VS. valproic acid – for BPD
SEDATIVES/HYPNOTICS
zolpidem (Ambien)
ramelteon (Rozerem)
benzodiazepines: alprazolam (Xanax), lorazepam (Ativan)
flumazenil (Romazicon) – reversal agent
ANXIOLYTICS
benzodiazepines: alprazolam (Xanax), lorazepam (Ativan)
flumazenil (Romazicon) – reversal agent
buspirone hydrochloride (Buspar)
Drugs that affect BP + Heart
– Diuretics
– RAAS
– CCBs
– Direct-Acting Arterial Vasodilators
– Central-Acting Alpha 2 Agonists
– Alpha 1/Beta 1 Blockers
–Antidysrhythmic
– Cardiac Glycosides
– Antianginals
– Antihyperlipidemics
– Anticoagulants, Antithrombics, Thrombolytics
Loop diuretics
Furosemide (Lasix)
Thiazide diuretics
HCTZ (Hydrodiuril)
Potassium-sparing diuretics
Spironolactone (Aldactone)
ACE-Inhibitors
Lisinopril (Prinivil)
ARBs
Valsartan (Diovan)
Calcium-channel blockers
Nifedipine (Procardia)
___________________
Diltiazem (Cardizem)
Direct-Acting arterial vasodilators
Hydralazine (Apresoline)
__________
Minoxidil (Loniten; Rogaine when used topically for hair growth)
_________
Nitroprusside (Nitropress)
Central Acting Alpha2 Agonists
Clonidine
___________
Methyldopa (Aldomet)
Alpha 1 + Beta 2 Blockers
Same as adrenergic antagonists
Antidysrhythmic
procainamide (Procan) – Class IA
lidocaine – Class IB
acebutolol (Sectral) – Class II
amiodarone (Cordarone) – Class III
diltiazem (Cardizem) – Class IV
Cardiac Glycoside
Digoxin
Antianginals
– KNOW types of chest pain
– Nitrates = Nitroglycerin + Isosorbide dinitrate (Isordil)
Antihyperlipidemics
Understand metabolic syndrome and associated lipid, waist, blood pressure, and blood sugar levels
_______________
– cholestyramine (Questran) – bile acid sequesterant
_____________
– genfibrozil (Lopid) – fibrate
– nicotinic acid (Niacin) – own class
– ezetimibe (Zetia) – cholesterol absorption inhibitor
– rosuastatin (Crestor) – statin
Anticoagulants, Antithrombics, and Thrombolytics
Heparin
Anticoagulants, Antithrombics, and Thrombolytics
antagonist: protamine
enoxaparin sodium (Lovenox)
warfarin (Coumadin)
antagonist: Vitamin K
cilostazol (Pletal)
clopidogrel bisulfate (Plavix)
alteplase tPA (Activase)
CILOSTAZON (PLETAL)
Type: Direct-acting vasodilator and antiplatelet drug
MOA
— Causes peripheral vasodilation
— Inhibits platelet aggregation
USES — Tx intermittent claudication | help prevent aggregation of platelets that can cause an occlusion
SIDE EFFECTS — N/V, dizziness, syncope, blood in eye, headache, abdominal pain, abnormal stools, peripheral edema
RN INTERVENTIONS — Inform patient that a desired therapeutic response may take 1.5 to 3 months.
HEMORRHEOLOGIC AGENT
DRUG: Pentoxifylline (Trental)
USES
— Good for someone who does not have good circulation of their blood
— Improves microcirculation and tissue perfusion
— Decreases blood viscosity
— Improves flexibility of erythrocytes
— Inhibits aggregation of platelets and red blood cells | makes your blood slicker…SLICK [PENTO]XIF[YLLINE]!
— Poor perfusion/occlusions are decreased
XA INHIBITOR: ORAL ANTICOAGULANTS
Rivaroxaban (Xarelto)
Apixaban (Eliquis)
— Administered: QD or BID; either 5mg (normal dose) or 2.5mg (for renal disease)
RN Interventions:
— Do not require routine coagulation monitoring
— Report bleeding, bloody nose, gums, in urine, stool, let dentist know because you’re at risk for bleeding, soft toothbrush, electric razor to prevent nicks, do not greatly change your intake of Vitamin K,
ANTIDOTE = FFP and not a quick antidote; must be in hospital
ANTIPLATELETS USES
— Prevents thrombosis in the arteries by suppressing platelet aggregation (inhibiting), which occurs after platelets are activated
— The most effective preventing arterial thrombosis (often prescribed with PAD d/t atherosclerotic plaques
— Heparin (Lovenox) and warfarin (Coumadin) prevent thrombosis
Prophylactic uses
— Prevent thrombosis in the arteries
— Prevention of myocardial infarction or stroke for patients with familial history
— Prevention of a repeat myocardial infarction or stroke
— Prevention of a stroke for patients having transient ischemic attacks
Antiplatelets: ASPIRIN
— Effective and inexpensive treatment for suppressing platelet aggregation
— Long-term, low-dose therapy
— Inhibits cyclooxygenase, an enzyme needed by platelets to synthesize thromboxane A2 (TxA2)
Other Antiplatelet Drugs
Dipyridamole (Persantine)
Ticlopidine (Ticlid)
Clopidogrel (Plavix)
Anagrelide HCl (Agrylin)
Abciximab (ReoPro)*
Eptifibatide (Integrilin)*
Tirofiban (Aggrastat)*
Ticagrelor (Brilinta)
- = parenteral meds used in hospital settings
— “super aspirins” = most effective antiplatelet drugs on the market
— short term in acute coronary syndromes; e.g. unstable angina, non-Q wave MI and after PCI to prevent reocclusion
Clopidogrel (Plavix)
MOA — inhibits platelet aggregation + prevents ADP from binding w/ the ADP platelet receptor
USE: Thromboembolism prophylaxis in AMI
S/EFF: abdominal pain, dizziness, confusion, epistaxis, H/A
Adverse: HoTN, HTN, bronchospasm, bleeding, peptic ulcer, agranulocytosis, aplastic anemia, thrombocytopenia, pancytopenia
Contraindications — intracranial hemorrhage, GI bleeding, hepatic/renal disease, surgery
RN INTERVENTIONS:
— Drug may increase bleeding when taken with NSAIDs, anticoagulant, SSRIs, barbiturates
— Interferes w/ metabolism of phenytoin, warfarin, fluvastatin, tamoxifen, CCBs, morphine and amiodarone
— Do not take w/ grapefruit juice; decreases effects of drug
— Herbs NOT to take w/ b/c will increase bleeding: ginger, garlic, ginkgo, feverfew, green tea
— d/c for 7 days PRIOR to surgery
Which antiplatelet drugs are used for acute coronary syndromes in the hospital?
Abciximab (ReoPro) |Eptifibatide (Integrilin) | Tirofiban (Aggrastat)
— Known as “super aspirins” and most effective anti platelet drugs on the market
— Used short-term for ACS (unstable angina, non-Q wave MI), after PCI to prevent occlusion
— Reocclusion is common because PCI damages the arterial wall, and thereby encourages platelet aggregation.
— All are parenteral medications used in hospital settings.
THROMBOLYTICS
Purpose: dissolve clot
Function: promotes conversion of plasminogen to plasmin
_Examples_
Streptokinase (Streptase)
Urokinase (Abbokinase)
Alteplase tPA (Activase) — very expensive
Reteplase rPA (Retavase) — very expensive
Tenecteplase TNK-tPA (TNKase)
Thrombolytics Uses
— Myocardial infarction: thrombus, or blood clot, disintegrates when a thrombolytic drug is administered within 4 hours.
— Thrombolic stroke: drugs should be administered within 3 hours.
— Pulmonary embolism
— DVT
— Noncoronary arterial occlusion from an acute thromboembolism
Thrombolytics RN INTERVENTIONS
— Monitor vital signs.
— Observe for signs and symptoms of active bleeding.
— Observe for signs of allergic reaction to thrombolytics.
— Avoid administering aspirin or NSAIDs for pain or discomfort when receiving a thrombolytic.
— Avoid venipuncture/arterial sticks.
** Amicar (aminocaproic acid) is used to stop bleeding that results from antithrombolytics**
Anticoagulant Antagonists/ANTIDOTE
ANTIDOTE/ANTAGONIST FOR WARFARIN (COUMADIN) = VITAMIN K (PHYTONADIONE)
— Bleeding occurs in about 10% of patients taking oral anticoagulants
— Used for warfarin overdose or uncontrollable bleeding
— 24 to 48 hours to be effective
— Usually 1 to 10 mg of vitamin K1 is given at once
— Failure to control bleeding: Fresh whole blood, fresh-frozen plasma or platelets
ANTIDOTES
