Final Exam study guide PDF

Preview

Summary

Study Guide for final exam in pharmacology for nursing...

Description

Antihypertensive Treatment • Hypertension = BP > 150/90 • Essential Hypertension • Adrenergic Drugs • ACE Inhibitors • Angiotensin II Receptor Blockers • Calcium Channel Blockers • Diuretics • Vasodilators

Autonomic Nervous System is the PNS and the SNS Adrenergic Drugs- Act on the Autonomic NS • Parasympathetic Nervous System • Slow heart rate • Vasodilation • Constrict bronchi • Stimulate bowel and bladder function • Sympathetic Nervous System • Increase heart rate • Vasoconstriction • Dilate bronchi • Inhibit bowel and bladder function

Divisions of the Autonomic Nervous System Sympathetic • Increases the following: • Heart rate and force of heart contractions • Release of energy stored in the liver • The speed at which energy is used to perform body functions while a person is at rest (basal metabolic rate) • Muscle strength • Widens the airways to make breathing easier • Causes sweaty palms • Decreases functions that are less important in an emergency (such as digestion and urination) • Controls the release of semen (ejaculation) Parasympathetic • Stimulates the digestive tract to process food and eliminate wastes (in bowel movements) • Slows the heart rate • Reduces blood pressure • Controls erections

Adrenergic medications • Central-acting adrenergic• Stimulates alpha 2 receptors thus reduces sympathetic outflow resulting in a norepinephrine production= lowering the BP; also decreases Renin • clonidine (Catapress) • Methyldopa—more commonly used in pregnancy induced HTN • Alpha 1 blockers- /-zosin • Work primarily by dilating arteries and veins= decreasing vascular resistance • doxazocin (Cardura) • prazosin (Minipress) • terazosin (Hytrin) • **In addition- Alpha 1 blockers are used to treat BPH (prevents the smooth muscle contractions of the bladder and urethra) • Dual-action- Alpha1 and Beta Receptor Blockers • Used to treat HTN and mild to moderate heart failure • carvedilol (Coreg) • labetalol (Trandate) • Beta-receptor Blocker (-olol)- acts on the periphery, slows HR, decreases renin secretion, blocks beta 1 receptors • Used to treat HTN, angina, and heart failure, produces vasodilation, • propranolol (Inderal) • metoprolol (Lopressor) (Toprol) • nebivolol (Bystolic) • Indications • Used to treat HTN • Most commonly used in combination with other medications • Contraindications- allergy, patients with acute heart failure, concurrent use of MOI drugs, peptic ulcer, severe kidney and liver disease • Adverse effects- bradycardia, post-exercise hypotension, dizziness, drowsiness, depression, orthostatic hypotension, sexual dysfunction, • Abrupt discontinuation of central-acting meds results in rebound hypertension • Nursing considerations

•

Patient Teaching

Renin – Angiotensin – Aldosterone System

Beta Blockers/-olol • Block beta-1 receptors • Decrease heart rate • Decrease secretion of renin • Example Drugs • Nebivolol (Bystolic) – also causes vasodilation • Propanolol (Inderal) beta-1 & beta-2 • Metoprolol (Lopressor) • Atenolol (Tenormin) • Nadolol (Corgard) • Nursing Considerations • Patient Education

Alpha & Beta Receptor Blockers

• •

• • •

Blocks the alpha-1 receptors in the vessels Blocks the beta-1 and beta-2 receptors • Example drugs: • Carvedilol (Coreg) • Labetalol (Trandate) • Nursing Considerations • Patient Education Alpha 1 receptors usually cause vasoconstriction Beta 1 receptors usually increase HR and contractility Beta 2 receptors usually dilate bronchial passages and cause vasodilation in muscles and liver

ACE Inhibitors/-pril • ACE Inhibitors • Used to treat Heart failure and HTN • Inhibit angiotensin converting enzyme (ACE) • Prevents Angiotensin I from becoming Angiotensin II • Prevent sodium and water reabsorption by inhibiting aldosterone secretion • Example drugs: • Lisinopril (Prinivil) • Enalapril (Vasotec) • Captopril (Capoten) • Nursing Considerations • Patient Education

ACE Inhibitor induced angioedema • ACE inhibitor induced angioedema is due to an excess of bradykinin • May be life-threatening • Because it is not a histamine release—it not responsive to epinephrine, steroids • Treatment includes airway management and discontinuation of ACE inhibitor • Medications that might be used to treat: • Tranexamic acid • Ecallantide • Icatibant • Recent treatment is with FFP • ACE inhibitors-cause K retention, should not be administered to patients with K level greater than 5

Angiotensin II Receptor Blockers/-sartan

ARBs • Block the binding of angiotensin II to receptors • Vascular smooth muscle (blocking vasoconstriction) • Adrenal gland (blocking aldosterone secretion) • Similar to ACE inhibitors but hyperkalemia and cough is less common • Example Drugs • losartan (Cozaar) • olmesartan (Benicar) • valsartan (Diovan) • Nursing Considerations • Patient Education •

Calcium Channel Blockers • Used for HTN, antianginal, anti-dysrhythmic • Blocks calcium access to cells in vascular smooth muscle • Example drugs: • Amlodipine (Norvasc) • Nifedipine (Procardia XL) • Verapamil (Verelan) • Diltiazem (Cardizem) • Nicardipine (Cardene) • Nursing Considerations • Patient Education

Vasodilators • Vasodilators

• •

• •

Act directly on arteriolar and/or venous smooth muscle to cause relaxation Example drugs: • Hydralazine (Apresoline) • Sodium nitroprusside (Nitropress) Nursing Considerations Patient Education

Angina & Antianginal Therapy • Angina • Lack of cardiac oxygen supply to meet the demands of the heart. • 3 Types: • Chronic stable • Unstable • Vasospasmatic • Antianginal Therapy-goals • Decreases oxygen demands • Increases oxygen supply

Three main classes of drugs to treat angina 1. Nitrates and nitrites 2. Beta-blockers 3. Calcium channel blockers Three main therapeutic objectives of antianginal drug therapy: (1) minimize the frequency of attacks and decrease the duration and intensity of the angina pain; (2) improve the patient's functional capacity with as few adverse effects as possible (3) prevent or delay the worst possible outcome, myocardial infarction. Nitrates & Nitrites • Nitroglycerin • Various non-oral routes: • Sublingual tablets/spray (Nitrostat) • Transdermal paste (Nitro-Bid) • Ointment • Continuous IV drip • Mechanism of action • Nursing Considerations • Isosorbide mononitrate (Imdur)-primarily long acting - More stable • Isosorbide dinitrate (Isordil)- rapid and long acting form - Less stable

•

Dilate all blood vessels

the result of relaxation of the smooth muscle cells that are part of the wall structure of veins and arteries Nitrates are used to treat stable, unstable, and vasospastic angina. Long-acting dosage forms are used more for prevention of angina episodes. Rapid-acting dosage forms, most often sublingual nitroglycerin tablets, or an intravenous drip in the hospital setting, are used to treat acute anginal attacks. Nitrates are contraindicated with concurrent use of erectile dysfunction drugs, head injury patients, severe anemia, closed angle glaucoma, hypotension •

• •

•

Beta Blockers/-olol • Block beta-1 receptors • Decrease heart rate • Decrease secretion of renin • Example Drugs • Atenolol (Tenormin) • Metoprolol (Lopressor) • Nadolol (Corgard) • Propanolol (Inderal)

Calcium Channel Blockers • Blocks calcium access to cells in vascular smooth muscle • Example drugs: • Amlodipine (Norvasc) • Nifedipine (Procardia XL) • Verapamil (Verelan) • Diltiazem (Cardizem) • Nicardipine (Cardene)

Drugs that Decrease Preload • Diuretics • ACE Inhibitors • Aldosterone antagonists • Beta Blockers • Metoprolol • Carvedilol (alpha and beta blocker) • B-Type Natriuretic Peptide • Nesiritide (Natrecor) B-Type Natriuretic Peptide (BNP) • Nesiritide (Natrecor) • Synthetic version of the BNP that is normally secreted by the ventricles in response to changes in BP • MOA- causes vasodilation of arteries and veins, causes diuresis, and sodium loss, decreases Reninangiotensin system • Use in the ICU for severe HF • Adverse effects- hypotension, dysrhythmias, abdominal pain, headache, insomnia, renal dysfunction

Drugs that Decrease Afterload

• • • • • • •

Centrally acting alpha-agonists Alpha-receptor Blockers ACE Inhibitors ARBs Calcium channel blockers Vasodilators B-Type Natriuretic Peptide

Pharm Review • Drugs that increase the force of myocardial contraction are called positive inotropic drugs • Drugs that increase the rate at which the heart beats are called positive chronotropic drugs • Drugs that accelerate conduction are referred to as positive dromotropic drugs • Dilantin use to be the drug of choice for HF, but have been replaced by the use of ACE inhibitors, ARBs, and certain beta-blockers Inotropic Drugs: Phosphodiesterase Inhibitors • Phosphodiesterase Inhibitors • milrinone (Primacor) • Mechanism of Action - exerts both a positive inotropic effect and a vasodilatory effect • Cardiac glycosides • Digoxin (Lanoxin) - Antidote: Digoxin Immune Fab (Digifab)

Diuretics

•

Loop/-ide

Block sodium reabsorption in the loop of Henle Example drug: • Furosemide (Lasix) • Bumetanide (Bumex) • Nursing Considerations Thiazide • Block potassium, sodium and chloride reabsorption in the distal convoluted tubule • Example drugs: • Hydrochlorothiazide (HCTZ) • Nursing Considerations Potassium sparing Binds to aldosterone receptors to prevent the reabsorption of sodium Example drug: Aldosterone (Spironolactone) Nursing Considerations • •

•

• • • • •

Osmotic Diuretics • Mannitol (Osmitrol) • A common osmotic diuretic- given IV • Works along the entire nephron, but the primary action is the proximal tubule and descending limb of the loop of Henle causing rapid diuresis and increased urine output • Produces only a slight loss of electrolytes- especially Na • May also be used to reduce intracranial pressure and cerebral edema due to head injury Contraindications: anuria, severe renal disease, pulmonary edema, active intracranial bleeding Adverse effects- thrombophlebitis, convulsions, pulmonary congestion

• 1. 2. 3. 4.

Normal cardiac conduction: SA node – 60-100bpm AV node – 40-60bpm Left & right bundle branches – 40-60bpm Purkinje fibers – 20-40bpm

Treatment of Bradycardia • Atropine • Anticholinergic • Blocks inhibitory vagal effects on pacemaker cells • Epinephrine • alpha- and beta-adrenergic agonists • Used to treat asystole, life threatening allergic reactions

• works by relaxing the muscles in the airways and tightening the blood vessels Tachycardia- treatment is to find the cause Amiodarone • known to block both the alpha- and beta-adrenergic receptors of the sympathetic nervous system • Treats Atrial flutter and fibrillation, Ventricular tachycardia and fibrillation (fast rhythms) • 75% of patients experience adverse effects • corneal microdeposits, which may cause visual halos, photophobia, and dry eyes • Photosensitivity • Pulmonary toxicity leading to pulmonary fibrosis 10% can be fatal • Can cause lethal dysrhythmias Lidocaine (Xylocaine) • Lidocaine (Xylocaine) is effective for the treatment of ventricular dysrhythmias, but it can only be administered intravenously because it has an extensive first-pass effect • exerts its effects on the conduction system of the heart by making it difficult for the ventricles to develop a dysrhythmia • adverse effects include CNS toxic effects such as twitching, convulsions, and confusion; respiratory depression or arrest and CV effects of hypotension, bradycardia, and dysrhythmias. Adenosine • Adenosine (Adenocard) is an unclassified anti-dysrhythmic drug • Used to treat SVT (HR of 180-200 bpm) • extremely short half-life of less than 10 seconds. For this reason, it is administered only intravenously and only as a fast intravenous push. • It commonly causes asystole for a period of seconds.

Treatment for Atrial Dysrhythmias Dysrhythmia

Pharmacological Treatment

Atrial Fibrillation

Amiodarone Digoxin

Atrial Flutter

Amiodarone Digoxin

Supraventricular tachycardia

Adenosine Beta blockers

Bradycardia

Atropine Epinephrine

Tachycardia

Treat the underlying cause

Treatment for Ventricular Dysrhythmias Dysrhythmia

Pharmacological Treatment

Premature Ventricular Contractions

Lidocaine Beta blockers

Ventricular Tachycardia

Lidocaine Amiodarone Epinephrine

Ventricular Fibrillation

Amiodarone Epinephrine

Adrenergic Drugs • Adrenergics are drugs with effects that are similar to or mimic the effects of the SNS neurotransmitters norepinephrine, epinephrine, and dopamine • Bronchodilators- stimulate the beta2-adrenergic receptors and cause bronchodilation • Nasal decongestants-stimulating alpha1-adrenergic receptors, constrict arterioles and reduce blood flow to mucus membranes • Ophthalmic applications-stimulate alpha-adrenergic receptors located on small arterioles in the eye and temporarily relieve conjunctival congestion • CV medications-- have a variety of effects on the various alpha- and beta-adrenergic receptors, and the effects can be related to the specific dose of the adrenergic drug • Unwanted CNS effects of the alpha-adrenergic drugs include headache, restlessness, excitement, insomnia, and euphoria • Possible cardiovascular adverse effects of the alpha-adrenergic drugs include chest pain, vasoconstriction, hypertension, reflexive bradycardia, and palpitations or dysrhythmias. Effects on other body systems include anorexia (loss of appetite), dry mouth, nausea, vomiting, and, rarely, taste changes. • dobutamine (Dobutrex) • dopamine (Intropin) • Epinephrine • phenylephrine (Neo-Synephrine)

Adrenergic Blocking Drugs • Alpha blockers such as doxazosin, prazosin, and terazosin cause both arterial and venous dilation, which reduces peripheral vascular resistance and blood pressure (covered in HTN lecture) • tamsulosin (Flomax)- used to treat BPH • Adverse effects- First dose phenomenon and orthostatic hypotension • Betablockers- used for angina, HTN, heart failure, MI, dysrhythmias, (Covered in cardiac lecture)

Diabetes Management • Type I- Insulin dependent • Insulin deficiency • Normal insulin receptors

• Type II- NON- Insulin dependent • Insulin receptor resistance • Eventually insulin deficiency Normal Blood sugar= 70-110

GOAL = Hemoglobin A1C less than/ equal to 6.5%

Major Long-term consequences of Type 1 and 2 Macrovascular (atherosclerosis plaque) • Coronary arteries, Cerebral arteries, Peripheral vessels Microvascular (Capillary damage) • Retinopathy, Neuropathy, Nephropathy

Rapid Acting Insulin • Examples: • Insulin lispro (Humalog) • Insulin aspart (NovoLog) • Insulin glulisine (Apidra)

Important Notes to Know -

-

Dosed in units NOT milliliters, must use an insulin syringe with unit dosing. U-100 insulin has 100 units in 1mL, U-500 is five times as concentrated insulin and is extremely dangerous! - May use insulin pens. Subcutaneous injections typically in the back of the arm, may also use the abdomen 2 inches away from the umbilicus. Safety issues – 2 RN check Multidose vial – expires 28 days after opening, always look for expiration date – if you open the insulin, you date it. Interprofessional care - Diabetic educator - Dietician - Social services or home health

Patient Education regarding Insulin - Provide instructions and demonstrations regarding the proper storage of insulin (room temperature unless traveling), equipment needed for administration, how to draw up and administer the insulin. - Rotate sites

-

Sick care instructions How and when to assess blood glucose levels (pre-prandial). A1C monitoring importance. Lifestyle modifications: diet, exercise, smoking cessation Hypoglycemia management – keep some form of glucose on them at all times! Planning for vacations. Strict foot care – assess toes/feet for sores, cuts etc. Notify prescriber for any abnormalities.

Short Acting/Intermediate Acting Insulin • Examples: • Short: Regular, Humulin, Novolin insulin • Intermediate: NPH insulin, Lente

Long Acting Insulin • Examples: • Insulin glargine (Lantus) • Insulin detemir (Levemir) • Never given IV • Often given in combination with a short acting-but don’t mix in the same syringe Antidiabetic Medications • Class: Biguanide: • metformin (Glucophage)-PO Do not use IV contrast dye with metformin. DC day of and 48 hrs after! • Contraindications:

Renal disease because it is primarily excreted through the kidneys (serum Cr > 1.5 in males and 1.4 in females) • Alcoholism • Metabolic acidosis • Hepatic disease • Heart failure and other conditions that predispose patients to tissue hypoxia and lactic acidosis Side effects: • Moderate weight loss • Abdominal bloating, nausea, diarrhea > usually self limiting and can be helped with starting with low dosages and titrating up slowly • Less common: metallic taste, hypoglycemia, B12 reduction after long term use • Most severe: Lactic acidosis (symptoms: hyperventilation, cold and clammy skin, muscle pain, abdominal pain, dizziness, irregular heart beat) •

Class: Sulfonyureas/gl-ide • Examples: • glipizide (Glucotrol) • glyburide (Diabeta) • glimepriride (Amaryl) Must have a working pancreas: Stimulates insulin, Decrease glucagon (stops formation of glucose in the liver) Contraindications: allergy/cross allergy to sulfonamides, hypoglycemia - * It is NOT contraindicated in patients with renal failure Adverse effects: - Hypoglycemia, Weight gain because of the stimulation of insulin secretion, Other less common: skin rash, nausea, epigastric fullness, heartburn Patient Education: Take 30 minutes before meals so that insulin levels will be maximized during increased postprandial blood glucose levels Thiazolidinediones/-glitazones • Examples: • Rosiglitazone (Avandia) • pioglitazone (Actos) Contraindications: Stage III or IV heart failure, liver/kidney failure Adverse effects: BLACK BOX WARNING: They can exacerbate or cause heart failure. • Increase peripheral edema and weight gain secondary to water retention. • Reduced bone mineral and increased risk for fractures • Hypoglycemia • Perform fluid status checks with daily weights and I/Os Meglitinides/-glinides • Example: • Repaglinide (Prandin) Alpha-glucosidase Inhibitors • Examples • acarbose (Precose) • miglitol (Glyset) • Contraindications: • GI affects so do not use : IBD, malabsorption syndromes, intestinal obstruction

•

• DKA • Cirrhosis Adverse effects: • High incidence of flatulence, diarrhea, abdominal pain • They do not cause hypoglycemia or weight gain.

Dipeptidyl Peptidase IV Inhibitors (DPP-IV)/ -gliptins • Example: • Sitagliptin (Januvia) Endocrine: Pituitary Drugs

Pituitary Drugs: • Variety of drugs which are used as replacement drug therapy or make up for hormonal deficiencies or diagnostic aids to determine a person’s hormonal function • Anterior pituitary gland • Adrenocorticotropic hormone (ACTH) • Follicle-stimulating hormone (FSH) • Growth hormone (GH)—somatropin (Nutropin) • Luteinizing hormone (LH) • Prolactin • Thyroid stimulating hormone (TSH) • Posterior pituitary gland • Antidiuretic hormone • Oxytocin Octreotide (Sandostatin) Uses: • Acromegaly • Carcinoid tumor symptoms • Carcinoid crisis (severe diarrhea, flushing and life-threatening hypotension) • Esophageal varices • Given IV, IM, SQ

May cause GB issues and use with caution in patients with renal disease May cause hypoglycemia or hyperglycemia Toxic effects - can cause prolonged QT intervals Pituitary Drugs (CONT.) • Drugs to control polydipsia, polyuria and dehydration • Example drugs: • Vasopressin (Pitressin) •...