Pharmacology Exam 2 - Everything on the test was exactly in these notes PDF

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Chp 26 Hemostasis - The stopping of a flow of blood - Coagulation is hemostasis that occurs because of the physiologic clotting of blood - Thrombus: Blood clot (stationary) - Embolus: thrombus that moves through blood vessels. Coagulation System - The Liver is responsible for the clotting cascade. o The liver activates prothrombin, then it turns into a thrombin, which then turn into fibrinogen and then becomes fibrin which forms a mesh that attracts the platelets and stop the bleeding. Fibrinolytic System - Initiates the breakdown of clots and serves to balance the clotting process - Fibrinolysis o mechanism by which formed thrombi are lysed (destroyed) to prevent excessive clot formation and blood vessel blockage Hemophilia - Rare genetic disorder - Lacks certain clotting factors. - Patients with hemophilia can bleed to death if coagulation factors are not given. Coagulation Modifier Drugs - Anticoagulants o Prevents clot formation o It does not dissolve clots and it doesn’t have any action on platelets - Antiplatelet drugs o Inhibit platelet aggregation (clumping together of platelets) o Prevent platelet plug  Ex: Aspirin - Thrombolytic drugs o Lyse (break down) existing clots Anticoagulants - Also known as antithrombotic - Can be used prophylactically to prevent clots - Does not help with a blood clot that is already formed - Prevent intravascular thrombosis by decreasing blood coagulability - Used prophylactically to prevent o Clot formation (thrombus) o An embolus (dislodged clot)

Embolus - Thromboembolic events o Myocardial infarction (MI): embolus lodges in a coronary artery o Stroke: embolus obstructs a brain vessel o Pulmonary emboli: embolus in the pulmonary circulation o Deep vein thrombosis (DVT): embolus goes to a vein in the leg Anticoagulants Drugs (KNOW THIS) - Heparins-part 1 o Given prophylactically to prevent clots - Low-molecular- weight heparins (LMWH) o Enoxaparin (Lovenox)  A subcutaneous heparin given prophylactically to prevent clots.  This Is only given Sub q  No lab valued to be monitored. o Dalteparin (Fragmin) - Heparins- part 2 o Un-fractioned heparin (given IV only)  This is NOT prophylactic, this is for someone who has a thromboembolic event.  Patient usually get this on IV drip or a bolus o Must monitor PTT lab value when someone is on IV heparin. Warfarin (Coumadin) - Comes PO only - Mechanical heart valve - Most commonly prescribed oral anticoagulant - Careful monitoring of the prothrombin time/international normalized ratio (PT/INR) - A normal INR (without warfarin) is 1.0, but a therapeutic INR (with warfarin) ranges from 2 to 3.0, (3.0-3.5 mechanical valve) depending on the indication for use of the drug (e.g., atrial fibrillation, thromboprevention, prosthetic heart valve). - Many drug interactions - Dietary considerations: Green leafy vegetables (Don’t eat too much) Nursing Implications Warfarin (Coumadin) - May be started while the patient is still on heparin until PT/INR levels indicate adequate anticoagulation - Full therapeutic effect takes several days. - Monitor PT/INR regularly; keep follow-up appointments. - Antidote is vitamin K. Treatment: Toxic Effects of Warfarin (KNOW THIS)

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Discontinue the warfarin. May take 36 to 42 hours before the liver can resynthesize enough clotting factors to reverse the warfarin effects Vitamin K1 (phytonadione)-antidote to warfarin- can hasten the return to normal coagulation. High doses of vitamin K (10 mg) given IV will reverse the anticoagulation within 6 hours. Many herbal products have potential interactions; increased bleeding may occur o Capsicum pepper o Garlic o Ginger o Ginkgo o St. John’s wort o Feverfew

Enoxaparin (Lovenox) - Prototypical LMWH - Greater affinity for factor Xa than for factor Iia - Higher degree of bioavailability and longer elimination half-life - Lab monitoring is not necessary. - Injectable form - Used for prophylaxis and treatment - Pre-filled syringes - Do not expel air bubble Nursing Implications for LWMH - Given subcutaneously in the abdomen - Rotate injection sites. - Protamine sulfate can be given as an antidote in case of excessive anticoagulation, but rarely Heparin - Natural anticoagulant obtained from the lungs or intestinal mucosa of pigs - 10 to 40,000 units/mL - DVT prophylaxis: 5000 units subcutaneously two or three times a day; does not need to be monitored when used for prophylaxis - When heparin is used therapeutically (for treatment), continuous IV infusion. o Measurement of aPTT (usually every 4-8 hours until therapeutic effects are seen) is necessary Nursing Implications for Heparin - IV doses are usually double checked with another nurse.

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IV doses may be given by bolus or IV infusions. Anticoagulant effects are seen immediately. Laboratory values are done daily to monitor coagulation effects (aPTT). Protamine sulfate can be given as an antidote in case of excessive anticoagulation.

Treatment: Toxic Effects of Heparin (Know This) - Symptoms: hematuria, melena (blood in the stool), petechiae, ecchymoses, and gum or mucous membrane bleeding - Stop drug immediately. - Intravenous (IV) protamine sulfate-The antidote to IV Heparin: 1 mg of protamine can reverse the effects of 100 units of heparin.

Anticoagulants Indications - Used to prevent clot formation in certain settings in which clot is more likely to form o MI o Unstable angina o Atrial fibrillation  Blood get stagnant in the atria and can become clots o Indwelling devices, such as mechanical heart valves o Major orthopedic surgery

Anticoagulants Contraindications - Any acute bleeding process or high risk such an occurrence - Warfarin is contraindicated in pregnancy - LMWHs are contraindicated in patients with an indwelling epidural catheter risk of epidural hematoma.

Anticoagulants: Adverse Effects - Bleeding o Risk increases with increased dosages. o May be localized or systemic - May also cause: o Heparin-induced thrombocytopenia (HIT)-like DIC o Nausea, vomiting, abdominal cramps, thrombocytopenia, others

Anticoagulant: Heparin LMWH: Enoxaparin - No lab monitoring required - Given SQ prophylactically Unfractionated Heparin (IV) - As a bolus than infusion via pump for therapeutic use (when patient already has a clot). - Normal PTT is 30-40 seconds, when on heparin drip we want PTT to be 1.5-2 times the normal. - Nursing Implications - Monitor PTT 4-8 hours while on drip. - Antagonistic drug: Protamine Sulfate

Anticoagulant: Warfarin - PO only Indications - Prevent clots in Angina, MI, CVA (ischemic), DVT, Mechanical valves Nursing Implications - Monitor PT/INR - Normal: 0.9-1.0 secs - Therapeutic 2-3 sec for all conditions except MVR (3.0-3.5) - Antagonistic drug: Vitamin K 10mg - Monitor for bleeding - Not for use in pregnancy - Side effects: Bleeding

Antiplatelet Drugs - Works on platelets - No labs to monitor - Decrease platelets aggregation or platelet adhesion - Decrease clotting - Drugs o Aspirin o Clopidogrel (Plavix) - Aspirin o 81 mg or 325mg o Contraindicated for flulike symptoms in children and teenagers  Reye’s syndrome - Clopidogrel (Plavix) o Widely used in addition to aspirin, most common. o Oral Use o Many drug interaction  Any anticoagulation  Anything GI Thrombolytic Drugs - Drugs that break down, or lyse, preformed clots - Ase is the suffix for these drugs. - There are criteria’s before a person can take these drugs and they must be met. - Mechanism of Action o Reestablish blood flow to the heart muscle via coronary arteries, preventing tissue destruction

- Indications o Acute MI o Arterial thrombolysis o DVT o Occlusion of shunts or catheters o Pulmonary embolus o Acute ischemic stroke - Adverse effects o Bleeding Chapter 27 Liproproteins - Low-density lipoprotein (LDL) o Bad cholesterol o Get LDL lower  We want people LDL to be below 70 for patients with heart disease and diabetes etc. - High-density lipoprotein (HDL) o Responsible for “recycling” of cholesterol o Also known as “good cholesterol” o Get HDL higher Vitamin B3 and Statin drugs are needed to treat Statins (Know THIS) - First-line drug therapy for hypercholesterolemia - Treatment of types IIa and IIb hyperlipidemias o Reduces LDL levels by up to 50% o Increases HDL levels by 2% to 15% o Reduces triglycerides by 10% to 30% - Recommended to take at night time Adverse effects on Statin (KNOW THIS) - Monitor liver with liver function test because drug is metabolized in the liver. - Biggest side effect is mayalsia and muscle pain - Myopathy (muscle pain), possibly leading to the serious condition rhabdomyolysis (muscle break down) - Rhabdomyolysis o Breakdown of muscle protein o Myoglobinuria: urinary elimination of the muscle protein myoglobin o Can lead to acute renal failure and even death

o When recognized reasonably early, rhabdomyolysis is usually reversible with discontinuation of the statin drug. o Instruct patients to immediately report any signs of toxicity, including muscle soreness or changes in urine color.

Niacin (Nicotinic Acid) - Vitamin B3 - Lipid-lowering properties require much higher doses than when used as a vitamin. - Used with the statin drugs - Mechanism of Action o Thought to increase activity of lipase, which breaks down lipids o Reduces the metabolism or catabolism of cholesterol and triglycerides - Indications o Effective in lowering triglyceride, total serum cholesterol, and LDL levels o Increases HDL levels - Adverse effects o Flushing (caused by histamine release)  Small dose aspirin or NSAIDS 30 minutes before Niacin may help cutaneous flushing o Pruritus’ (itchy) Herbal Product: Garlic, flax and Omega 3 Statin Drugs Indications: Lower LDL, Increase HDL, 1st line for LDL lowering. Nursing Implications: Check Livre function test. Medicine is metabolized in the liver Side effects: Myalgia, which can lead to rhabdomyolysis

Niacin B3 (b12) Indications: Primarily to increase HDL, lower trig, commonly used with statin. Nursing Implications: Take with snack QHS or baby ASA to reduce flushing and itching. Titrate dose Side Effects: Flushing, palpitation

Anaphylaxis: Severe Allergic Reactions - Release of excessive amounts of histamine can lead to: o Constriction of smooth muscle, especially in the stomach and lungs o Increase in body secretions o Vasodilatation and increased capillary permeability, movement of fluid out of the blood vessels and into the tissues, and drop in blood pressure and edema Histamine - Major inflammatory mediator in allergic disorders

o Allergic rhinitis (hay fever and mold, dust allergies) o Angioedema o Urticaria (itching) Antihistamine - H1 antagonists (also called H1 blockers) o Examples: chlorpheniramine, fexofenadine (Allegra), loratadine (Claritin), cetirizine (Zyrtec), diphenhydramine (Benadryl) - Antihistamines have several properties o Antihistaminic o Anticholinergic o Sedative

Antihistamine effects - Cardiovascular (small blood vessels) o Histamine effects  Dilation and increased permeability (allowing substances to leak into tissues) o Antihistamine effects  Reduce dilation of blood vessels  Reduce increased permeability of blood vessels - Smooth muscle (on exocrine glands) o Histamine effects  Stimulate salivary, gastric, lacrimal, and bronchial secretions o Antihistamine effects  Reduce salivary, gastric, lacrimal, and bronchial secretions Antihistamine: Indications - Management of: o Nasal allergies o Seasonal or perennial allergic rhinitis (hay fever) o Allergic reactions o Motion sickness o Parkinson’s disease o Sleep disorders o Sneezing, runny nose Antihistamines: Contraindications - Known drug allergy - Narrow-angle glaucoma - Cardiac disease, hypertension - Kidney disease - Bronchial asthma, chronic obstructive pulmonary disease (COPD)

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Sole drug therapy during acute asthmatic attacks Albuterol or epinephrine Benign prostatic hyperplasia (BPH)

Antihistamines: Adverse Effects - Anticholinergic (drying) effects: most common o Dry mouth o Difficulty urinating o Constipation o Changes in vision - Drowsiness o Mild drowsiness to deep sleep Non-sedating: (KNOW THIS) - loratadine, cetirizine, and fexofenadine Nursing Implications (KNOW THIS) - Contraindicated in the presence of acute asthma attacks and lower respiratory diseases, such as pneumonia o We want to expectorate the mucus, not dry it up. - Best tolerated when taken with meals; reduces GI upset

Decongestants: Types - Adrenergics o Largest group o Sympathomimetics - Anticholinergics o Less commonly used o Parasympatholytics - Corticosteroids o Topical, intranasal steroids Topical Nasal Decongestants - Steroids decrease inflammation in the nasal passage way. - We don’t have to worry about systemic affects when it is administered through nasal passageway. - Steroids end in (ide or one)

Mechanism of Action - Constrict small blood vessels that supply upper respiratory tract structures - As a result, these tissues shrink, and nasal secretions in the swollen mucous membranes are better able to drain. Contraindications (KNOW THIS) - Drug allergy - Narrow-angle glaucoma - Uncontrolled cardiovascular disease, hypertension - Diabetes and hyperthyroidism - History of cerebrovascular accident or transient ischemic attacks - Long-standing asthma - BPH - Diabetes Nursing Implications (KNOW THIS) - Patients should avoid caffeine and caffeine-containing products. - Patients should report a fever, cough, or other symptoms lasting longer than 1 week. Two types of Cough - Productive cough: congested; removes excessive secretions - Nonproductive cough: dry cough Coughing - Most of the time, coughing is beneficial. o Removes excessive secretions o Removes potentially harmful foreign substances - In some situations, coughing can be harmful, such as after hernia repair surgery. Antitussives (KNOW THIS) - Drugs used to stop or reduce coughing - Opioid and nonopioid - Used only for nonproductive coughs! - May be used in cases when coughing is harmful Antitussives: Mechanism of Action - Nonopioids o Dextromethorphan: works in the same way o Not an opioid o No analgesic properties o No CNS depression o Benzonatate

o Suppress the cough reflex by numbing the stretch receptors in the respiratory tract and prevent reflex stimulation of the medullary cough center Antitussives: Contraindications - Drug allergy - Opioid dependency - Respiratory depression

Expectorants (KNOW THIS ) - Drugs that aid in the expectoration (removal) of mucus - Reduce the viscosity of secretions - Disintegrate and thin secretions - Example: guaifenesin o Expectorants such as guaifenesin aid in the expectoration (i.e., coughing up and spitting out) of excessive mucus that has accumulated in the respiratory tract by breaking down and thinning out the secretions.

Expectorants: Nursing Implications (KNOW THIS) - Expectorants should be used with caution in older adults and patients with asthma or respiratory insufficiency. - Patients taking expectorants should receive more fluids, if permitted, to help loosen and liquefy secretions. Chapter 37 Diseases of the Lower Respiratory Tract - Chronic obstructive pulmonary disease (COPD) o Asthma (persistent and present most of the time despite treatment) o Emphysema o Chronic bronchitis Bronchial Asthma - Recurrent and reversible shortness of breath - Occurs when the airways of the lungs become narrow as a result of: o Bronchospasms o Inflammation of the bronchial mucosa o Edema of the bronchial mucosa o Production of viscous mucus o Wheezing Asthma

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Four categories o Intrinsic (occurring in patients with no history of allergies) o Extrinsic (occurring in patients exposed to a known allergen) o Exercise induced  Occurs when exercising, patient may use inhaler prior to working out. o Drug induced

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Status asthmaticus (KNOW THIS) o Prolonged asthma attack that does not respond to typical drug therapy o May last several minutes to hours o Medical emergency

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Chronic Bronchitis o Continuous inflammation and low-grade infection of the bronchi o Excessive secretion of mucus and certain pathologic changes in the bronchial structure o Often occurs as a result of prolonged exposure to bronchial irritants

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Emphysema o No longer used as a term but is included into COPD o Air spaces enlarge as a result of the destruction of alveolar walls. o Caused by the effect of proteolytic enzymes released from leukocytes in response to alveolar inflammation o The surface area where gas exchange takes place is reduced. o Effective respiration is impaired. o Alveoli is dead (bleb), they have decreased or no breath sounds

Pharmacologic Overview - Bronchodilators o These drugs relax bronchial smooth muscle, which causes dilation of the bronchi and bronchioles that are narrowed as a result of the disease process. o Three classes: beta-adrenergic agonists, anticholinergics, and xanthine derivatives - Short-acting beta agonist (SABA) inhalers o Albuterol (Ventolin, ProAir)- quick acting and used for acute asthma o Levalbuterol (Xopenex) o Pirbuterol (Maxair) o Terbutaline (Brethine) o Metaproterenol (Alupent) - Long-acting beta agonist (LABA) inhalers o Arformoterol (Brovana) o Formoterol (Foradil, Perforomist) o Salmeterol (Serevent)- maintaince only -1 puff

Bronchodilators: Beta-Adrenergic Agonists - 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 o Sympathomimetics o Warn patient that they may feel palpitations but it will go away. - Three Types o Nonselective adrenergics  Stimulate alpha, beta1 (cardiac), and beta2 (respiratory) receptors  Example: epinephrine (EpiPen)- status asthmaticus o Nonselective beta-adrenergics  Stimulate both beta1 and beta2 receptors  Beta1 receptor is in the heart  Example: metaproterenol o Selective beta2 drugs  Stimulate only beta2 receptors (in the lungs)  Example: albuterol o Mechanisms of Action  Dilates bronchioles and increase airflow o Indications  Relief of bronchospasm related to asthma, bronchitis, and other pulmonary diseases  Used in treatment and prevention of acute attacks  Used in hypotension and shock o Contraindications  Known drug allergy  Cardiac dysrhythmias  uncontrolled hypertension  High risk of stroke (because of the vasoconstrictive drug action) Beta-Adrenergic Agonists: Albuterol (Proventil) (KNOW THIS) - Short-acting beta2-specific bronchodilating beta agonist - Most commonly used drug in this class - Must not be used too frequently - Oral and inhalational use - Inhalational dosage forms include metered-dose inhalers (MDIs) as well as solutions for inhalation. Beta-Adrenergic Agonists: Salmeterol (Serevent) (KNOW THIS) - Long-acting beta2 agonist bronchodilator - Never to be used for acute treatment

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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.

Anticholinergics: Mechanism of Action (KNOW THIS) - Acetylcholine (ACh) causes bronchial constriction and narrowing of the airways. - Anticholinergics bind to the ACh receptors, preventing ACh from binding. - Result: bronchoconstriction is prevented, airways dilate - Ipratropium (Atrovent) is most commonly used - Indirectly cause airway relaxation and dilation - Help reduce secretions in COPD patients - Indications o prevention of the bronchospasm associated with chronic bronchitis or emphysema; not for the management of acute symptoms Xanthine Derivatives (KNOW THIS) - Commonly given as a PO drug - Narrow therapeutic index so labs must be drawn - Therapeutic range for theophylline blood level is 10 to 20 mcg/mL - Aminophylline o Given IV form and is used for Status asthmaticus that don’t respond to albuterol - Must be on telemetry because has a lot of tachycardia - Avoid Caffeine Nonbronchodilating Respiratory Drugs (KNOW TH...