Pharmacology Exam #2 Respiratory And Cardiac Ch. 29, 36-37, 41 Flashcards
1
Q
What is the main function of the respiratory system?
A
- deliver oxygen to and remove carbon dioxide from the cells of the body
2
Q
Diseases of the LOWER respiratory tract
A
- chronic obstructive disease (COPD)
-Asthma (persistent and present most of the time despite treatment)
-Emphysema
-Chronic bronchitis
** All of these are airway obstruction of bronchioles………….treat with Albuterol
3
Q
Bronchial Asthma
A
- Recurrent and reversible shortness of breath
- Occurs when the airway of the lungs become narrow as a result of:
- Bronchospasm
- Inflammation of the bronchial mucosa
- Edema of the bronchial mucosa
- Production of viscous
- The aveolar ducts and alveoli remain open, but airflow to them is obstructed.
4
Q
s/s: Wheezing and difficulty breathing
A
Bronchial Asthma
5
Q
Four categories of Asthma
A
- Intrinsic - occurring in patients with no
history of allergies - Extrinsic - occurring in patients exposed to
a known allergen - Exercise induced
- Drug induced
6
Q
Type of Asthma:
-Prolonged asthma attack that does not
respond to typical drug therapy
-May last several minutes to hours
-Medical emergency (911)
A
STATUS ASTHMATICUS
7
Q
- Continuous inflammation and low-grade infection of the bronchi
- Excessive secretions of mucus and certain pathologic changes in the bronchial structure
- Often occurs as a result of prolonged exposure to bronchial irritants
A
CHRONIC BRONCHITIS
8
Q
-Included in COPD (which is no longer used as a term)
-air spaces enlarge as a result of the destruction of alveolar walls
- Caused by the effect of proteolytic enzymes released from leukocytes in response to alveolar inflammation
- the surface area where gas exchange takes place is reduced
- Effective respiration is impaired
A
EMPHYSEMA
9
Q
These drugs relax bronchial smooth muscle, which causes dilation of the bronchi and bronchioles that are narrowed as a result of the disease process
A
BRONCHODILATORS
10
Q
Three classes of Bronchodilators
A
- Beta-adrenergic agonists
- Anticholinergics
- Xanthine derivatives
11
Q
Bronchodilators: Beta-Adrenergic Agonists
Short-acting beta agonist (SABA) inhalers
A
-Albuterol (Ventolin, ProAir)
ACUTE——-rescue inhaler
ex: pollen
12
Q
Bronchodilators: Beta-Adrenergic Agonists
Long-acting beta-agonist (LABA) inhalers
A
-Salmetrol (Servent)
CHRONICH
13
Q
Beta-Adrenergic Agonists: NEWEST LABA
LABA inhalers
A
-Indacaterol (Arcapta Neohaler)
- Vilanterol in conjuction with fluticasone (Breo Ellipta)
- Vilanterol in conjunction with the anticholinergic, umeclidinium (Anoro Ellipta)
14
Q
-Used during ACUTE phase of asthmatic attacks
-Quickly reduce airway constriction and restore normal airflow
-Agonists, or stimulators, of the adrenergic receptors in the sympathetic nervous system
**Sympothomimetics
A
BRONCHODILATORS: BETA-ANDRENERGIC AGONISTS
15
Q
BETA-ADRENERGIC AGONISTS: INTERACTIONS
A
- diminish bronchodilation when nonselective beta blockers are used with the beta agonist bronchodilators
- monoamine oxidase inhibitors (DO NOT WORK WELL WITH OTHERS)
- sympathomimetics
-monitor patients with diabetes; an increase in blood glucose levels can occur
16
Q
Beta-Adrenergic Agonists:
ALBUTEROL (Proventil)
A
- short-acting beta2-specific bronchodilating beta agonist
- most commonly used drug in this class
- must not be used too frequently
- oral and inhalation use
- inhalation dosage forms include metered dose inhalers (MDIs) as well as solutions for inhalation
17
Q
Beta-Adrenergic Agonists:
SALMETEROL (Serevent)
A
- long-lasting beta2 agonist bronchodilator
- never to be used for acute treatment
- used for the maintenance treatment of asthma and COPD and is used in conjunction with an inhaled corticosteroid
- Salmeterol should never be given more than twice daily nor should the maximum daily dose (one puff twice daily) be exceeded
18
Q
Adverse Effects of: Anticholinergics
A
- dry mouth
- nasal congestion
- heart palpitations
- gastrointestinal (GI) distress
- headache
- coughing
- anxiety
19
Q
Anticholinergics: Ipratropium (Atrovent)
A
- oldest and most commonly used anticholinergic bronchodilator
- available both as a liquid aerosol for inhalation and as a multidose inhaler
- usually dosed twice daily
- others
-Tiotropium (Spiriva)
-Aclidinium (Tudorza)
-Umeclidinium (Incruse Ellipta)
20
Q
Which medication will the nurse teach a client with asthma to use when experiencing an acute asthma attack?
A
ALBUTEROL (Ventolom)
21
Q
Nonbronchodilating Respiratory Drugs
A
- Leukotriene receptor antagonists (montelukast, zafirlukast, and zileuton LTRA
- Corticosteroids (belcomethasone, budesonide, dexamethasone, flunisolide, fluticasone, ciclesonide, and triamcinolone)
*Bronchodilation
**Mucus production - block receptors
22
Q
Leukotriene Receptor Antagonists (LTRAs)
A
- nonbronchodilating (lung wheezing)
- newer class of asthma medications
- currently available drugs
- Montelukast (Singulair)
- Zafirlukast (Accolate)
- Zileuton (Zyflo)
23
Q
LTRAs: Mechanism of Action
A
- Leukotrienes are substances released when a trigger, such as cat hair or dust, starts a series of chemical reactions in the body
- Leukotrienes cause inflammation, bronchoconstriction, and mucus production
- result: coughing, wheezing, shortness of breath
- LRTAs prevent leikotrienes from attaching to receptors on cells in the lungs and in circulation
- inflammation in the lungs is blocked, and asthma symptoms are relieved
24
Q
LTRAs: Drug Effects
A
*By blocking leukotrienes:
- prevent smooth muscle contraction of the bronchial airways
- decrease mucus sectetion
- prevent vascular permeability
- decrease neutrophil and leukocyte infiltration to the lungs, preventing inflammation
25
LTRAs: Indications
- prophylaxis and long-term treatment and prevention of asthma in adults and children 1 years of age and older
- NOT meant for management of acute asthmatic attacks
- Montelukast is also approved for treatment of allergic rhinitis
-improve with their use is typically seen in about 1 week
26
LTRAs: Contradictions
- known drug allergy
- previous adverse drug reaction
- allergy to povidone (shell fish), lactose, titanium dioxide, or cellulose derivatives is also important to note because there are inactive ingredients in these drugs
27
Corticosteroids (Glucicorticoids)
-antiinflammatory properties
- used for chronich asthma
- DO NOT relieve symptoms of acute asthma attacks
- may be admistered IV
- oral or inhaled forms
- inhaled forms reduce systemic effects
- may take several weeks before full effects are seen
28
Corticosteroids: Mechanism of Action
- stabilize membranes of cells that release harmful bronchoconstricting substances
- the cells are called leukocytes, or WBC
- increase responsiveness of bronchial smooth muscle to beta-adrenergic stimulation
- dual effect of both reducing inflammation and enhancing the activity of beta agonists
29
Corticosteroids: Mechanism of Action
-Corticosteroids have also been shown to restore or increase the responsiveness of bronchial smooth muscle to beta-adrenergic receptor stimulation, which results in more pronounced stimulation of the beta2 receptors by beta agonist drugs such as albuterol
30
Inhaled Corticosteroids
Fluticasone (Asmanex)
31
Inhaled Corticosteroids: Indications
- Primary treatment of bronchospastic disorders to control the inflammatory responses that are believed to be the cause of these disorders
- Persistent asthma
- Often used concurrently with the beta-adrenergic agonists
- Systemic corticosteroids are generally used only to treat acute exacerbations, or severe asthma
- IV corticosteroids: acute exacerbation of asthma or other COPD
32
Inhaled Corticosteroids: Contraindications
** HIGH SUGAR CONTENT WILL CONTRIBUTE TO THRUSH
33
Inhaled Corticosteroids: Adverse Effects
- Pharyngeal inflammation
** SUGAR EQUALS POOR WOUND HEALING
34
Corticosteroids: Nursing Implications
** ALWAYS TAKE BRONCHODILATOR BEFORE THE STEROID
- Avoid exposure to conditions (allergens, smoke)
- Adequate fluid intake
- Complete medical treatment
- Encourage clients to always check with the HCP before taking any other medication, including over-the-counter (OTC) medications, and herbal supplements
35
Nursing Implications: Corticosteroids
- skin color
- baseline vital signs
- respirations (should be between 12 and 24)
- respiratory assessment, including pulse oximetry
- sputum production
- allergies
- history of respiratory problems
- other medications
- smoking history
36
Nursing Implications: Corticosteroids
- teach clients to take bronchodilators exactly as prescribed
- ensure that clients know how to use inhalers and MDIs and have client demonstrate use of the devices
- monitor adverse effects
37
Nursing Implications: Corticosteroids
*Monitor for therapeutic effects:
-decreased dyspnea
- decreased wheezing, restlessness, and anxiety
- improved respiratory patterns with return to normal rate and quality
- improved tolerance
- decreased symptoms and increased ease of breathing
38
Nursing Implications: LTRAs
- improvement should be seen in about 1
week
-access liver function
39
Nursing Implications: Inhaled Corticosteroids
- teach clients to monitor disease with a peal flow meter
-encourage use of a spacer device to ensure successful inhalations
-teach client how to keep inhalers and nebulizer equipment clean after use
40
Inhaler education
* be sure that the client is able to self-administer
- provide demonstration and return demonstration
- ensure that the client knows the correct time intervals for inhalers
- provide a spacer if the client has difficulty coordinating breathing with inhaler activation
- ensure that the client knows how to keep track of the number of doses in the inhaler device
41
A client is prescribed 2 different types of inhaled medications for COPD. After administering the first treatment, how long should the nurse wait to administer the second medication?
Answer:
5 minutes
42
Antihistamines
- H1 (histamine 1) - more airway
- H2 (histamine 2) - more stomach
-Histamine 1 antagonists
-Allegra, Claritin, Zyrtec, diphenhydramine (Benadryl)
- Properties include: antihistamine, anticholinergic, sedative
-Histamine 2 agonists
- Pepcid
43
Decongestants
- Adrenergic, Cholinergic, and Corticosteroids
-MOA - constricts blood vessels to nasal passageway preventing fluid that can cause mucus
** cause dehydration
44
Antitussives
- drugs used to reduce cough
- opioid and / or nonopioid (Codeine)
45
Expectorant
- Drugs that promote expectoration of mucus
- Mucinex
- use in caution with asthmatics due to similar effect of Adrenergic
s/s: dehydration
46
Antitubercular Drugs
- TB is caused by Myobacterium tuberculosis
- Antitubercular drugs treat all forms of Mycobacterium (MTB)
-TB is characterized by granulomas in the lungs: more specifically with inflammatory cells (macrophages and lymphocytes) that are walled off with defines boundaries
47
- Lung (primary site)
- brain
- bone
- liver
- kidney
genitourinary tract (GI)
-Aerobic bacillus
-Passed from infected patients to others (human to human, from cows/birds)
Mycobacterium (MTB) Infections
48
MTB Infections
- droplets are expelled by coughing or sneezing, and they gain entry into the body by inhalation
-Tubercle bacilli then spread to other body organs via blood and lymphatic systems
- MTB: very slow-growing organism
- more difficult to treat than most bacterial infections
-dormancy: may test positive for exposure but are not necessarily infectious because of this dormancy process
49
How to diagnose TB
Step 1: Tuberculin skin test (Mantoux test)
Step 2: If skin test results are positive, then chest x-ray
Step 3: If chest x-ray shows signs of tuberculosis, then culture of sputum (100% accurate) or stomach secretions
50
TB Incidence Facts
1950's TB in the US
-TB in patients coinfected with HIV
* concern now: increasing number of multidrug-resistant tuberculosis (MDR-TB) cases
51
Multidrug-Resistant Tuberculosis (TB)
- TB infects 1/3 of the words population
- MDR-TB that is resistant to both isoniazid (INH) and rifampin
- extensively drug resistant tuberculosis (XDR-TB): relatively rare type of MDR-TB
52
Antitubercular Drugs
First-Line Drugs:
- Isoniazid (INH): primary drug used
-Ethambutol
-Rifampin
53
Antitubercular Drugs
Levofloxicin
54
Tuberculosis-Related Injections
-Purified protein derivative (PPD) (Mantoux)
-a diagnostic injection given intradermally in doses of 5 tuberculin units (0.1mL) to detect exposure on the TB organism
-positive results is indicated by induration (not erythema) at the site of injection
Bacille Calmette-Guerin (BCG)
-a vaccine injection derived from an inactivated strain of Myobacterium bovis
55
Antitubercular Drug Therapy: Considerations
-major effects of drug therapy: reduction of cough and therefore, reduction of the infectiousness of the patient
-successful treatment: several antibiotic drugs for at least 6 months and sometimes for as long as 12 months
56
When is the best time to collect a sputum culture of a TB patient who has been taking antitubercular drugs?
Answer:
In the morning
57
Antitubercular Drug Therapy: Consideration
- adjust drug regimen after the results of susceptibility testing are known
- monitor patient compliance closely during therapy
- Problems with success therapy occur because of patient nonadherence....which causes increase incidence of drug resistant organisms
58
Mechanism of Action (TB) Drug Therapy)
Three Groups:
-Protein wall synthesis inhibitors
- cell wall synthesis inhibitors
- other mechanisms of action
59
Antitubercular Therapy
Effectiveness Depends on:
-type of infection (adjust based on specificity)
-adequate dosing
- sufficient duration of treatment
- adherence to drug regimen
Problems:
-drug resistant organisms
- drug toxicity
- patient nonadherence
MDR-TB: changes may need to be made half way through
60
TB Drugs
Ethambutol (Myambutol)
- first bacteriostatic drug used in treatment of TB
- diffuse into the mycobacteria and suppress RNA synthesis, inhibiting protein synthesis
Contradictions: optic neuritis, pediatric patients (younger than 13)
61
TB Drug
Isoniazid (INH)
TB drug of choice
Contradictions: with liver disease
62
TB DRUGS
Rifabutin, Rifampin, Rifapentine
- Rifamycin antibiotics
- also used to treat infections caused by non-TB mycobacterial species
- adverse effect: turn urine, feces, saliva, skin, sputum, sweat, and tears a red-orange-brown color
- oral use only
63
Adverse Effects of TB Drug
INH: peripheral neuropathy, hepatotoxicity
Ethambutol: retrobulbar neuritis, blindness
Rifampin: hepatitis; discoloration of urine, stools, and other body fluids
64
TB DRUGS: Nursing Implications
-perform liver function studies in patients who are to receive INH or rifampin (especially in older patients and those who use alcohol daily)
- patient education is crucial
-take medication exactly as ordered at the same time every day
65
TB DRUGS: Nursing Implications
- Patient education is critical
- remind patients that they are CONTAGIOUS during the initial period of their illness
-Patients should not consume alcohol
-Rifampin causes oral contraceptives to become ineffective
-tell patients Rifampin will turn bodily fluids reddish-orange
-Oral preps may be given with meals to reduce GI upset (even though recommendations are to take them 1-2 hours before meals)
66
TB DRUGS: Nursing Implications
- monitor for adverse effects
-fatigue, nausea, vomiting, numbness, and tingling of extremities, fever, loss of appetite, depression, and jaundice
-monitor for therapeutic effects
-x-ray = effective (check for granuloma decrease)
67
Fluid Balance
Total body water
-composed of:
-intracellular fluid (ICF)
-extracellular fluid (ECF)
-interstitial fluid (ISF)
-intravascular fluid (IVF)
-60% of adult human body is water
-plasma proteins exert constant osmotic pressure (anything not water or electrolytes)
68
Crystalloids
solution containing fluids and electrolytes that are normally found in the body
maintain the osmotic gradient between extravascular and intravascular compartments
NO PROTEINS
69
Colloids
Protein substance
70
Electrolytes
Principal ECF electrolytes
-cations (Na+)
Principal of ICF electrolyte
-Potassium (K+)
**Control the RAAS, SNS, Antidiuretic hormone system
71
Potassium
most abundant positively charged electrolyte inside cells
72
Sodium
most abundant positively charged electrolyte outside cells
Maintained through dietary intake of sodium chloride
73
Fluid Balance: Nursing Implications
assess baseline fluid volume and electrolyte status
assess baseline vital signs
74
Other Electrolytes
Magnesium
Chloride
Phosphorus
Calcium
Glucose - charged element which can impact Anion Gap
75
What is hypertension?
"High blood pressure"
60 0r older: systolic pressure of greater than 150mmHg or Diastolic (bottom number) greater than 90 mmHg
Younger than 60 and those who have chronic kidney disease or diabetes: SBP greater than 140mmHg and DBP greater than 90mmHg
76
What is a risk factor for coronary artery disease (CAD), cardiovascular disease (CVD)
Hypertension
**can cause Atherosclerosis
77
Drug therapy for hypertension must be individualized.
What are the 7 main categories of drugs to treat hypertension?
1. Diuretics (kidneys)
2. Adrenergic drugs (week 2)
3. Vasodilators (veins)
4. Angiotensin-converting enzyme (ACE)
inhibitors (RAAS)
5. Angiotensin II receptor blockers (ARBs)
(RAAS)
6. Calcium channel blockers (CCB)
*contractility
7. Direct renin inhibitors (RAAS)
78
5 subcategories of Adrenergic Drugs
1. Adrenergic neuron blockers (central and
peripheral
2. Alpha2 receptor agonists (central)
3. Alpha1 receptor blockers (peripheral)
4. Beta receptor blockers (peripheral)
5. Combo of Alpha1 and beta receptor
blockers (peripheral)
79
Centrally Acting Adrenergic Drugs
Clonide and Methyldopa(safe for
pregnancy/hypertension/anxiety)
- stimulate alpha2-adrenergic receptors in
the brain
- decrease sympathetic outflow from the
central nervous system (cause
cholinergic response)
- decrease norepinephrine production
- stimulate alpha2-adrenergic receptors,
thus reducing renin activity in the
kidneys
(RESULT IN DECREASE BLOOD PRESSURE)
80
Peripherally Acting Alpha1 Blockers
- Doxazosin
- Prazosin
- Terazosin
(block Alpha1 adrenergic receptors)
*decrease in Bp
* dilate arteries and veins
*Increase urinary flow rate
Use: Benign prostatic hyperplasia (BPH)
81
Alpha2-Adrenergic Receptor Stimulators
(Agonists)
- not typically described as first line drug
- high incidence of unwanted adverse
effects: fatigue, dizzy, orthostatic
hypotension
- Do not give to: p/t with head injury
- last line of defense
- DO NOT give if p/t has taken Benadryl
82
Clonidine (Catapres)
- used primarily for its ability to decrease
blood pressure
- used to manage Opioid withdraw
- Oral and topical patch
- Do not stop abruptly
*May lead to rebound hypertension
83
Angiotensin-Converting Enzyme
(ACE) Inhibitors
- Large group of safe and effective drugs
- currently 10 ACE inhibitors
-Often used as 1st line for heart failure and
hypertension
- may be combined with a thiazide diuretic
or CCB
-Block effect of Angiotensin
84
Angiotensin-Converting Enzyme
(ACE) Inhibitors
**End in PRIL**
- Captopril (Capoten) *PO (by mouth)
- Enalapril (Lotensin) *PO & IV
-Lisinopril (Prinivil) *PO & IV
85
ACE Inhibitors: Mechanism of Action
-Inhibit ACE
-ACE converts angiotensin I (formed
through the action of renin to
angiotensin II)
- ALL: potent vasoconstrictor that induce
aldosterone secretion by the adrenal
gland
- Aldosterone: stimulates sodium and water
reabsorption, which can raise Bp
ACE inhibitors, thus low BP
86
Primary Effects of the ACE Inhibitors
-Effects cardiovascular and renal systems
-Bp: reduce Bp by decreasing systemic
vascular resistance (SVR) *decreasing
force; lower Bp
-Prevent sodium and water resorption
- Diuresis: decrease blood volume and
return to the heart
-decrease preload (amount of blood that
goes back to the heart) or the left
ventricle end-diastolic volume
-Decrease work required by the heart
87
Cardioprotective Effects of the ACE
Inhibitors
-ACE inhibitors decrease SVR(measure of afterload) and preload
-Used to prevent complications after MI
-Ventricular remodeling: left ventricular hypertrophy, which is sometimes seen after MI
-ACE inhibitors have been show to decrease mortality in p/t with HF
-Drugs of choice for hypertensive p/t with HF
88
Renal Protective Effects of the
ACE Inhibitors
-ACE inhibitors: reduce glomerular filtration
pressure (GFR measure of blood flow
to kidneys, so useable blood)
-Cardiovascular drug of choice for p/t with
diabetes
-ACE inhibitors reduce proteinuria (this is
how it is renal protective)
-Standard therapy for diabetic patients to
prevent the progression of diabetic
nephropathy
89
Renal Protective Ace Inhibitors
Only renal protective for diabetics
If diabetic has poor kidney function--- than it is not protective
90
ACE Inhibitors: Indications
- Hypertension
- HF (either alone or in combo with diuretics
or other drugs)
- Slow progression of left ventricle
hypertrophy after myocardial
infarction (MI) (cardioprotective
- Renal protective in p/t with DIABETES
91
ACE Inhibitors: Adverse Effects
-Fatigue
-Dizziness
-Hyperkalemia (know levels; high K can
cause harm)
-Cough
-Angiodema: rare but potentially fatal
*not indicated for African Americans (give
them ARB instead
92
ACE Inhibitor: Adverse Effects
Note: First dose; hypotensive effect may
occur
A - angiodema
C - cough HELP REMEMBER!
E - everything else
93
Angiotensin II Receptor Blockers (ARB)
- Also referred to as angiotensin II
- Well tolerated
- Do not cause dry cough that is common
with ACE Inhibitors
94
Angoitensin II Receptor Blockers
- Losartan (Cozaar)
- Valsartan (Diovan
**Block Angiotensin II from being effective
95
Angiotensin II Receptor Blockers:
Mechanism of Action
- ARBs block vasoconstriction and the
secretion of aldosterone (prevent Bp
from rising)
Prevent vasoconstriction of ORGANS; not the same as arteries in ACE
96
Angiotensin II Receptor Blockers:
Adverse Effects
-Fatigue
-Chest Pain
-Hypoglycemia
-Anemia
Hyperkalemia and cough are less likely to
occur with the ACE Inhibitors
97
Losartan (Cozaar)
**Not safe for breastfeeding women and
should not be used in pregnancy
- beneficial in p/t with HF and hypertension
-used with caution in p/t with renal or
hepatic dysfunction and in p/t with
renal artery stenosis
98
Calcium Channel Blockers:
Mechanism of Action
-primary use: HTN and angina
-cause smooth muscle relaxation by
blocking the binding of calcium to its
receptor, preventing muscle contraction
-result in:
-decreased peripheral smooth muscle
tone
-decreased SVP
-decreased Bp
- Nifedipine = safe for pregnancy
99
Calcium Channel Blockers: Indications
-angina
-hypertension: amlodipine (Norvasc)
-dysrhythmias
-migraine headaches
-Raynaud's disease
-prevent the cerebral artery spasms after
subarachnoid hemorrhage nimodipine
100
Diuretics
-American Heart Assoc. says ACE is 1st line of heart treatment
-JNC 8 says 1st line antihypertensives (but that is old guideline)
-decreased plasma and extracellular fluid
volumes
- Results
-decreased preload
-decreased CO
-decreased total peripheral resistance
-Overall effect
-decreased workload of the heart and
decreased Bp
- Thiazide diuretics are the most commonly
used diuretics for hypertension
101
Diuretics
*Act on Kidneys to raise production of
urnine
-Thiazide & Thiazide-like diuretics -
-Potassium sparing diuretics
-Loop diuretics
TEST: IV push of loop to fast can cause tinnitus (ringing in the ear)
102
Diuretics
Lasix = Loop
HCTZ = Thiazide
Aldactone = Potassium sparing
Thiazide = Thiazide
103
Vasodilators (dilate veins)
Hydralazine (Apresonline)
Minoxidil (Rogaine)
-for hair growth
104
Vasodilators: Mechanism of Action
- directly relax arteriolar or venous smooth
muscle (or both)
-Results in:
-decreased SVR
-decreased afterload
-peripheral vasodilation
105
Vasodilators: Adverse Effects
-Hydralazine: dizziness, headache, anxiety,
edema, diarrhea, hepatitis, systemic
lupus
106
Vasodilators: Hydralazine (Apresoline)
-Orally: route of essential hypertension
-Injectable: hypertensive emergencies
-BiDil: specifically indicated as an adjunct for treatment of HF in African-American patients
107
Vasodilators: Nursing Implications
-Before beginning therapy, obtain a
thorough health history
-Assess for contraindications to specific
antihypertensive drugs
-Assess for conditions that require caution
use of the drugs
108
Vasodilators: Nursing Implications
-educate about missing a dose and taking EXACTLY line its ordered
-monitor Bp
-instruct patients to keep a journal
-do not stop abruptly
-oral forms should be given with meals
-administer IV forms with extreme caution
and use an IV pump
109
Vasodilators: Nursing Implications
- remind p/t that medication is only part of
the therapy.
-Encourage p/t to watch their diet, stress
level, weight, and alcohol intake.
-Avoid smoking and eating foods high in
soduium
-Encourage supervised exercise for elderly
patients
110
Vasodilators: Nursing Implications
-teach patients to change positions slowly to avoid syncope from postural hypotension
-instruct patients to report unusual shortness of breath; difficulty breathing; swelling of the feet; ankles; face; or around the eyes; weight gain or loss; chest pain; palpitations; an excessive fatigue
111
Vasodilators: Nursing Implications
-male patients who take these drugs may
not be aware that impotence is
expected effect, and this may influence
compliance with drug therapy
112
Vasodilators: Nursing Implications
-Hot tubs, showers, or baths; hot weather; prolonged sitting or standing; physical exercise; and alcohol ingestion may aggravate low Bp, leading to fainting and injury; p/t should sit or lie down until symptoms subside
- p/t should never take OTC or any other meds without talking to HCP first
113
ACE Inhibitors: Lab Values
--if creatinine is high = no ACE Inhibitors
**ACE inhibitors can cause hyperkalemia, so potassium levels need to be monitored
- Potassium level = 3.5-5.0
114
General term for any process that stops bleeding
HEMOSTASIS
115
Hemostasis that occurs because of the physiologic clotting factor
COAGULATION
116
technical term for a blood clot
THROMBUS
117
thrombus that moves through the blood vessels
EMBOLUS
118
Rare genetic disorder where natural coagulation and hemostasis factors are limited or absent
HEMOPHILIA
119
Two types of hemophilia that inhibit platelet aggregation
- Factor VII deficiency
-Factor VIII/ or factor IX deficiency
120
What are some of the most dangerous drugs used today.
Numerous factors can affect their action such as drug interactions and electrolyte interactions (potassium)
Drugs that effect coagulation
121
Coagulation Modifier Drugs
Anticoagulants
-inhibit the action formation of clotting
factors
-Prevent clot formation (includes fibrin)
promotes clotting factor
122
Coagulation Modifier Drugs
-Hemorheologic drugs
-alter platelet function without
preventing the platelets from working
-Thrombolytic drugs
-Lyse (break down) existing clots
-Antifibrinolytic or hemostatic
-promote blood coagulation
123
Anticoagulants
-known as antithrombotic drugs
-have no direct effect on blood clot that is already formed
-Used prophylactically to prevent
-clot formation
-an embolus (dislodged clot)
124
Embolus
Thromboembolitic events
-MI: embolus lodges in a coronary artery
-Stroke: embolus obstructs a brain vessel
-Pulmonary embolism: embolus in the
pulmonary circulation
-Deep vein thrombosis (DVT): embolus goes
to a vein in the leg
125
Anticoagulants
Heparins - part 1
-action: inhibit clotting factor IIa (thrombin) and Xa
TEST: KNOW THIS
126
Anticoagulants
Heparins - part 1
-unfractioned heparin: "heparin"
- low-molecular-weight heparins
(LMWHs)
-Enoxaparin
-Dalteparin (Fragmin)
127
Heparin - part 2
-Unfractioned heparin (heparin)
-Relatively large molecule that is derived
from animal sources (PORK)
-Frequent lab monitoring for bleeding times
such as aPTT
-Heparin for catheter flush (10 to 100 units/mL): no monitoring is needed
128
Heparin - part 3
-LMWHs
-Enoxaparin (Lovenox) and dalteparin
(Fragmin)
-Synthetic smaller molecular structure
-More predictable anticoagulant response
-Frequent lab monitoring of bleeding times
using tests such as aPTT not needed
TEST: what labs go with which drug & lab values..... look it up
129
aPPT
activated partial thromboplastin time
130
Anticoagulants
Coumarins
-action: inhibit vitamin K
Warfarin (Coumadin)
-inhibits vitamin K
Body needs vitamin K to produce prothrombin
TEST QUESTON!!!!!!!
131
Anticoagulants: Factor Xa Drugs
End in........ ABAN
132
Anticoagulants
Direct thrombin inhibitors
-Action: inhibit thrombin (factor IIa)
-human antithrombin III (Thrombate)
-Lepirudin (Refludan)
-Argatroban (Agratroban)
-Bivalirudin (Angiomax)
133
Anticoagulants: Indicators
Used to prevent clot formation in certain settings in which clot formation is likely
-MI
-unstable angina
-atrial fibrillation
-indwelling devices, such as mechanical
heart valves
-major orthopedic surgery
134
Anitcoagulants: Contraindications
Do NOT GIVE Heparin for GI bleeding!
(TEST QUEST!!!!!!!!)
Drug allergy
Warfarin is strongly contraindicated in pregnancy
Heparin is safe for pregnancy
135
Anticoagulants: Adverse Effects
-Bleeding
-May also cause:
-Heparin induced thromocytopenia
-Nausea, vomiting, abdominal cramps, thrombocytopenia, others
136
Treatment: Toxic Effects of Heparin
-Symptoms: hematuria, melena (blood in stool), petechiae, ecchymosis, and gum mucous membrane bleeding
-stop drug immediately
-IV protamine sulfate: 1mg of protamine can reverse the effects of 100 units of heparin
TEST>>>>> KNOW THUS!
137
Treatment: Toxic Effects of Warfarin
-discontinue
-may take 36-42 hours before the liver can resynthesize enough clotting factors to reverse the warfarin effects
-vitamin K1 (phytonadione) can hasten the return to normal coagulation
-high dose vitamin K (10mg) given IV will reverse the anticoagulation within 6 hours
Reversal vitamin K (caution: warfarin resistance will occur for up to 7 days)
TEST KNOW THIS!!!!!!
138
Drug Interactions: Anticoagulants
-enzyme inhibition of metabolism
-displacement of the drug from inactive
protein binding sites
-decrease in vitamin K absorption or
synthesis by the bacterial flora of the
large intestines
-alteration in the platelet count or activity
139
Argatroban
-synthetic direct thrombin inhibitor
-used for active HIT and percutaneous coronary intervention procedures in p/t at risk for HIT
-ONLY give IV
140
Dabigatran (Pradaxa)
-first oral direct thrombin that is approved for prevention of strokes and thrombosis in p/t with nonvalvular atrial fibrillation
-specifically and reversibly binds to both free and clot-bound thrombin
-dose dependent on renal function
-adverse effects: bleeding, GI bleeding
-no coagulation monitoring is required
141
Enoxaparin (Lovenox)
Prototypical LMWH
-greater affinity for factor Xa than for factor
lia
-Higher degree of bioavailability and longer
elimination half-life
-lab monitoring is not necessary die PT/INR,
but is required for kidney function
-injectable form
-used for prophylaxis and treatment
-pre-filled syringes
-do not expel air bubble
142
Heparin
Natural anticoagulant obtained from the lungs or intestinal mucosa of pigs
-10-40,000 units/mL
-DVT prophylaxis: 5000 units subcu 2-3 times a day; does not need to be monitored when used for prophylaxis
-when heparin is used therapeutically (for treatment) continuous IV infusion.
**measurement of aPTT (usually every 6 hours until therapeutic effects are seen) is necessary
143
Rivaroxaban (Xarelto)
-first oral factor Xa inhibitor
-used for prevention of strokes in patients with a-fib; post op thromboprophylaxis with ortho surgeries; treatment of DVT and PE
Adverse reactions: peripheral edema, dizziness, headache, bruising, diarrhea, hematuria, and bleeding
144
Warfarin (Coumadin)
-most commonly prescribed oral
anticoagulant
-careful monitoring of the prothrombin
time/international normalized ratio (PT?
INR)
-a normal INR (with warfarin) ranges from 2
to 3.5 depending on indication of the
drug
-many drug interactions
-dietary considerations
145
Reversal for Warfarin
Vitamin K
146
Antiplatelet Drugs
work to prevent platelet adhesion at the site of blood vessel injury
-Prevent platelet adhesion
-Aspirin
-Clopidogrel (Plavix)
147
Antiplatelet Drugs: Indications and Adverse Effect
-antithrombotic effects (clotting)
-Adverse effects
-vary according to drug, bur BLEEDING is common (if someone is bleeding)
148
Clopidogrel (Plavix)
-most widely used ADP inhibitor (adenosine diphosphate)
-oral use
-Prasugrel (Effient),
Many drug interactions
149
Thrombolytic Drugs
-drugs that break down, or lyse, preformed
clots
-older drugs
-Streptokinase and urokinase
-current drugs
- Alteplase (activase, cathflo activase)
TPA>>>>active stroke
150
Thrombolytic Drugs
Break Down Clot in blood vessel quickly
TEST!!!! KNOW
151
Thrombolytic Drug: Indications
-acute MI
-arterial thombolysis
-DVT
-occlusion of shunts or catheters
-pulmonary embolus
-acute ischemic stroke
152
Thrombolytic Drugs: Adverse Effects
Bleeding
TEST!!!!!
153
Alteplase (Activase)
t-PA made through recombinant DNA techniques (t-PA 2yr gap if given prior)
-fibrin specific so does not produce a systemic lytic state
-present in the body in natural state
-very short half life (5 minutes)
Indications:
-stroke, MI
-smaller doses to flush clogged IV or arterial lines
154
Antifibrinolytic Drugs
*if someone is bleeding out
-prevent lysis of fibrin
-result in promoting clot formation
-Aminocaproic acid (Amicar)
-Tranexamic acid (Cyklokapron)
Desmopressin
155
Antifibrinolytic Drugs: Adverse Effects
Rare reports of thromotic (blood clot) events
156
Antifibrinolytic Drug: Nursing Implications
Assess:
-patient history, medication history, allergies
-contraindications
-baseline vital signs, lab values
-potential drug interactions
-history of abnormal bleeding conditions
157
Heparin: Nursing Implications
-IV doses are usually double checked with
another nurse
-do not give subcutaneous dose within 2
inches of:
-the umbilicus, abdominal incisions,
open wounds, scars, drainage
tubes, or stomas
-DO NOT aspirate subcutaneous injections
or massage the injection site (may cause
hematoma formation)
158
Heparin: Nursing Implications
-IV doses may be given by bolus or IV infusions.
-anticoagulants effects are seen immediately
-lab valued are done daily to monitor coagulation effects aPTT
-protamine sulfate can be given as an antidote in case of excessive anticoagulation
159
LMWHs: Nursing Implications
Low Molecular Weight Heparin
-given subcutaneously in the abdomen
-rotate injection sires
**Protamine sulfate can be given as as antidote
160
Warfarin (Coumadin): Nursing Implications
-effects take several days
-monitor PT/INR
-Antidote is vitamin K*******
161
Warfarin: Nursing Implications
Avoid all herbal products!
TEST QUES
162
Anticoagulant: Patient Education
-measures to prevent bruising, bleeding, and tissue injury
-wearing a medical alert bracelet
-avoiding foods high in vitamin K (tomatoes, dark leafy green vegetables)
163
Drug Therapy for HF
-Positive Inotropic Drugs: INCREASE force of myocardial contraction
-Positive Chronotropic Drugs: INCREASE heart rate
Positive Dromotropic Drugs: ACCELERATE cardiac conduction
-ACE's, ARB's, BB, Diuretics
164
Positive Inotropic Drugs
Dobutamine - greater force, more blood that comes out of the heart
165
Cardiac Glycosides
Positive inotropic effect - increased force and velocity of myocardial contraction (without an increase in oxygen(heart pain) consumption
166
Cardiac Glycosides
Negative chronotropic effect - reduced heart rate
167
Cardiac Glycosides
Negative dromotropic effect - decreased automaticity at SA node, decreased AV nodal conduction, and other effects
168
Cardiac Glycosides
-increased stroke volume
-reduction in heart size during diastole
-decrease in venous BP and vein engorgement
-increase in coronary circulation
-decrease in exertional and paroxysmal noturnal (diff breathing at night)
-improved system control, quality of life, and exercise tolerance
-no apparent reduction in mortality
169
Cardiac Glycosides
Dogoxin (Lanoxin)
-drug levels must be monitored
-0.5 to 2 ng/mL
-low potassium levels increase its toxicity
KNOW THIS!!!
170
Digoxin Toxicity
Digoxin immune Fab (Digibind) therapy
-life-threatening cardiac dysrhthias
-life-threatening digoxin overdose
Digiband - REVERSAL
171
Drugs for Angina
Nitrates or nitrites (expand cardiac arteries)
Beta Blockers
Calcium channel blockers (CCBs)
172
Nitrates and Nitrates
Available forms
-*sublingual (only 3 doses allowed before needing new order; 5 min between doses)
-chewable tabs
-oral capsules/tabs
-*IV solutions
-*Transdermal patches
-oitnments
-*Translingual sprays
Morphine reduces demand on the heart
173
Nitrates and Nitrites: Mechanism of Action
Cause vasodilation because of relaxation of smooth muscles
Result: oxygen to ischemic myocardial tissue
174
Nitrates and Nitrites: Indications
-treat stable, unstable, and vasospastic angina
-rapid-acting forms
-treat acute anginal attacks
-sublingual tabs; IV infusion
-long-acting form
-prevent anginal episodes
175
Nitrates: Contraindications
-known drug allergy
-severe anemia
-closed-angle glaucoma
-hypotension
-severe head injury
-use of the erectile dysfunction drugs silenafil (viagra), tadaladil (Cialis), and vardenadil (Levitra
176
Nitrates: Adverse Effects
-Headaches
-Reflex tachycardia
-postural hypotension
-skin irritation with topical application
-tolerance may develop
177
Antidysrhythmic Drugs
Dysrhythmia
any deviation from the normal rhythm of the heart
Arrhythmia
"no rhythm" which implies asystole
178
Vaughan Williams Classification:
Mechanism of Action & Indications
Class III - amiodarone, sotalol
179
Amiodarone (Cordarone, Pacerone)
Class III
-blocks both alpha and beta adrenergic receptors of the sympathetic nervous system
uses: effective antidysrhythmic
indications: management of dysrhythmias
adverse effects: visual halos, photosensitivity
180
Verapamil (Calan)
Class IV
results in dramatic effects on the AV node
181
Antilipemics: HMG-CoA Reductase Inhibitors (Statins)
Statins
Patients with LDL cholesterol levels greater than or equal to 190 mg/dl
HDL higher than 150
LDL levels between 70 and 189mg/dl
182
Antilipemics: HMG-CoA Reductase Inhibitors (Statins)
Statins
Patients with LDLcholesterol levels
183
Statins
Simvastatin (Zocor)
Avorvastatin (Lipitor)
184
Rhabdomyloysis
-breakdown of muscle protein
-myoglobinuria: urinary elimination of the muscle protein myoglobin
-can lead to acute renal failure and even death
if muscle pain exists-----no Statins-----could cause myoglobinuria
