Pharmocology HESI Bible to get through PDF

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Pharmacology HESI Review Cardiac Drugs/Diuretics 

Digoxin – positive inotrope (increases force of contraction); negative chronotrope (decreases heart rate). How do you assess for this? (Always take AP for a full minute!)

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Client with long hx of daily digoxin and furosemide (Lasix) use; creates a high risk for dig toxicity (Lasix can cause hypokalemia, which can lead to dig toxicity)

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Digoxin toxicity – know normal digoxin level (0.5 – 2 ng/mL); serum potassium (K+) level (3.5 to 5.0 mEq/L); low potassium or magnesium levels may increase risk for digoxin toxicity; S/S of dig toxicity include anorexia, bradycardia, headache, dizziness, confusion, nausea, and visual disturbances (blurred vision, yellow vision, and/or halo vision); hold digoxin if AP less than 60.

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Labetalol (beta blocker) for HTN: Notify prescriber for low pulse rate and do not give med; SE is weight gain (fluid retention) – pulmonary assessment (which is…). Remember monitoring weight is one of the best indicators of fluid gain or loss – 1 kg (2.2 lb) = 1,000 mL fluid gain or loss in 24 hrs.

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Nitroglycerin transdermal patch for treating chest pain (angina) – remove at night to allow 8 hours without patch (can produce tolerance in 24 hours); may use SL nitro when wearing patch if patient having chest pain

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Why wear gloves when applying nitroglycerin paste or patch? (severe vasodilation, ↓BP, intense HA [may give acetaminophen for HA])

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Angina – for chest pain, if VS OK, leave nitro patch on and administer PRN SL nitro

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Pt. in CCU/ICU on nitro drip; becomes hypotensive, decrease rate of nitro drip

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Calcium channel blockers – dipine (like amlopidine) and verapamil (Calan) and diltiazem (Cardizem). – dipine affect vessels only (vasodilation). SE: dizziness, facial flushing, hypotension, edema. Verapamil (Calan) and diltiazem (Cardizem) also affect heart. Monitor BP, HR (↓). Constipation is SE. Avoid grapefruit juice.

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Aliskiren (Tekturna) – (direct renin inhibitor for HTN); teach don’t take if pregnant (stop drug if become pregnant); don’t take with high fat meal. May increase K+, so don’t take with other drugs that ↑ K+.

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Furosemide (Lasix) – loop diuretic; rapid acting; used for rapid diuresis in emergencies (pulmonary edema); may produce hypokalemia (assess for muscle cramps, muscle weakness). Hypotension, F/E abnormalities, dehydration. SE: dizziness, HA, tinnitus, N/V/D, ↓ K+, hyperglycemia, ototoxicity with aminoglycosides (-mycin drugs).

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May need potassium supplement. Foods containing potassium: dried fruits, fish, leafy veggies, squash, beans, meats, nuts, bananas, potatoes, dairy products.

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IV potassium (KCl) – assess overall condition of the veins. Use large vein, like antecubital (AC) vein when administering potassium. Venous access is important because IV potassium can irritate the vein. Have patient notify nurse immediately if burning at site. IV K+ extravasation can cause necrosis of tissues. Calculate and set the rate as ordered, know anticipated duration of therapy, know restrictions imposed by patient’s history. Don’t give IV push; infuse at a rate no greater than 20 mEq/hr; concentration no greater than 40 mEq/L. Always use infusion pump. Assess IV site every hour.

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Antihypertensives and low potassium (K+); hypokalemia. Antihypertensive effects are more pronounced in the elderly.

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Osmitrol (Mannitol) – osmotic diuretic; effectiveness determined by ↓ ICP. NOT used for peripheral edema; used to treat pt. with closed head injury; effective response is decreased ICP

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Spironolactone (Aldactone), amiloride (Midamor); triamterene (Dyrenium) – potassium-sparing

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diuretic (can cause ↑K+). Blocks receptors for aldosterone. Inhibits sodium and water reabsorption. Take in a.m. (diuretics in the morning if possible); avoid salt substitutes, ACE inhibitors, ARBs. Often taken with other (thiazide) diuretics to treat edema, hypertension, heart failure. Can be taken with other meds that lower K+. 

Lab value for atorvastatin (Lipitor) – HDL should increase; LDL and total cholesterol decrease. Other statin drugs include rosuvastatin (Crestor), fluvastatin, lovastatin, simvastatin, pravastatin. LFTs routinely and CK for any c/o of muscle pain. How do you evaluate effectiveness?

Adrenergics/SNS Drugs & Adrenergic Blockers 

Remember: alpha 1 stimulation – vasoconstriction; beta 1 (one heart), beta 2 (two lungs)

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Mydriatics – agents used to produce dilation of pupils for eye exams and ocular surgery

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Tamsulosin (Flomax) – alpha1 adrenergic blocker; ↓ smooth muscle contraction of prostate capsule and bladder neck. Used for treating sx of BPH. Alpha 1 blockers –zosin – antihypertensives.

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Effects of dopaminergic activation – causes dilation of the renal vasculature; this effect is exploited in the treatment of shock; by dilating renal blood vessels, we can improve renal perfusion and can thereby reduce the risk of renal failure. Dopamine itself is the only drug available that can activate dopamine receptors. It should be noted that when dopamine is given to treat shock, the drug also enhances cardiac performance (because it actives beta1 receptors in the heart.)

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Catecholamines (epinephrine, norepinephrine, dopamine, dobutamine, etc.) must be watched carefully for extravasation! The FDA has this to say about treating dopamine extravasation: To prevent sloughing and necrosis in ischemic areas, the area should be infiltrated as soon as possible with 10 to 15 mL of saline solution containing 5 to 10 mg of Regitine (brand of phentolamine), an adrenergic blocking agent. A syringe with a fine hypodermic needle should be used, and the solution liberally infiltrated throughout the ischemic area. Sympathetic blockade with phentolamine causes immediate and conspicuous local hyperemic changes if the area is infiltrated within 12 hours. Therefore, phentolamine should be given as soon as possible after the extravastation is noted.

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Epi-Pen (Epinephrine Auto Injector). Single dose of epinephrine that can be injected (IM) into the middle of the outer thigh (even through clothes). Seek emergency medical treatment immediately. SE: increase in heart rate, stronger or irregular heartbeat, sweating, nausea or vomiting, difficulty breathing, paleness, dizziness, weakness, shakiness, headache, apprehension, nervousness or anxiety. These side effects may go away if patient rests. Remember that many decongestants and bronchodilators have sympathomimetic effects (adrenergic effects). SE include ↑ HR, nervousness, insomnia, etc. Bronchodilators that stimulate β2 receptors can also stimulate β1 if dose is high enough (loses selectivity). Don’t forget cardiac assessment.

Drugs Affecting Coagulation 

Anticoagulants and geriatrics (elderly) – risky either way.

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Patient discharged on warfarin (Coumadin) – teach how to avoid bleeding: soft toothbrush, electric razor, don’t go without shoes, etc. Teaching – maintain vitamin K foods (greens- spinach, mustard greens, swiss chard, etc.) in diet (don’t increase or decrease); PT/INR monitoring; avoid activities that may cause bleeding.

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Pentoxifylline (Trental) for intermittent claudication (like cilastozal [Pletal]) – treats ischemic pain.

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Prasugrel (Effient) is an antiplatelet like clopidogrel (Plavix). Watch for S/S bleeding. Used primarily after interventional radiologic procedures (like coronary stents) and for patients who do not respond to clopidogrel.

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Clopidogrel (Plavix) – antiplatelet; notify health care provider of drug regimen prior to surgery; may need to hold any anticoagulants/antiplatelet drugs

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Enoxaparin (Lovenox) – low molecular weight heparin; 1st line therapy for treatment and prevention of DVT. SubQ in “love” handles. No routine lab to monitor, but watch CBC d/t thrombocytopenia.

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Remember that heparin sodium for injection is not same as hep-lock solution. They are NOT interchangeable. Concentration of hep-lock solution is either 10 units/mL or 100 units/mL. Heparin for injection is 10,000 units/mL or 20,000 units/mL or even 50,000 units/mL.

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Heparin is high-alert medication – requires another nurse to check dosage.

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New potent, oral anticoagulants – dabigatran (Pradaxa), apixaban (Eliquis), rivaroxaban (Xarelto); do not require monitoring of labs; ↑ risk of bleeding (teach)

Opoiods/Analgesics/NSAIDs 

MS Contin (morphine continued release) for chronic pain

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Opioids (morphine, hydrocodone, oxycodone, hydromorphone [Dilaudid] codeine) can produce CNS depression (be aware of safety for patients attempting to ambulate) and respiratory depression; administer naloxone; (Narcan) reverses respiratory depression but also reverses analgesia; may need to titrate dose and give repeated doses to prevent sudden withdrawal (repeat dose at 2-3 minute intervals) (opioid double dose – be aware of LOC and RR). Remember naloxone has shorter half-life than opioids. SE: constipation, pruritus, urinary retention, ↓ BP, ↓ HR.

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Duragesic (transdermal fentanyl) – fentanyl patch. Opioid analgesic. Relief of moderate to severe chronic pain, like cancer pain. Not for postop or short-term pain relief. Patch usually lasts 72 hours. Remove old patch before applying new one. SE: CNS depression, confusion, sedation, weakness, dizziness, restlessness; apnea, respiratory depression; anorexia, constipation, dry mouth, nausea, vomiting. Considered one of safest opioid analgesics for patients with renal impairment. Avoid MAOIs. Avoid grapefruit and grapefruit juice. Avoid other CNS depressants. Monitor RR!!! Notify MD if RR below 12. Reverse effects with naloxone. Reverses respiratory depression but also reverses analgesia; may need to titrate dose and give repeated doses to prevent sudden withdrawal

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Epidural pump priority – monitor vital signs every 15 minutes; do not administer other sedatives; be sure feeling/function has returned to lower extremities before returning pt. to floor. Label epidural tubing as epidural only!

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Tolerance and dependence – what are they? Assess for tolerance (patient not getting pain relief with same dosage pt. has been receiving).

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Acetaminophen (Tylenol) – Nonopioid analgesic. Not an NSAID (no anti-inflammatory properties). Maximum daily dose 3,000 mg; 2,000 mg for elderly and those with liver disease. LT use can produce nephrotoxicity. Overdose/frequent use can produce hepatotoxicity. Sx of hepatotoxicity include jaundice, abdominal pain, clay-colored stools, dark urine.

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Lorcet (hydrocodone and acetaminophen) Percocet (oxycodone & acetaminophen); Fioricet (butalbital & acet.); Lorcet (hydrocodone & acet.); Ultracet (tramadol & acet.) – double dose (respiratory sedation and too much Tylenol) – pay attention to drugs that may contain acetaminophen! Check LFTs.

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Aspirin (ASA) – caution with PUD, children under 18 with recent viral illness (Reye’s syndrome), interacts with other antiplatelets, anticoagulants, NSAIDs, etc. (bleeding)

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Pregabalin (Lyrica) – nonopioid analgesic for peripheral neuropathy, postherpetic (shingles) neuralgia, fibromyalgia. SE: suicidal thoughts, dizziness, drowsiness, edema, dry mouth, abdominal pain, constipation.

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Ketorolac (Toradol) NSAID (causes gastric irritation) should be given with meals or snack; also has pain relief comparable to morphine but is NOT an opioid; postop pain (not used for chronic pain); do not give for more than 5 days. SE same as other NSAIDs.

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NSAID therapeutic uses – anti-inflammatory, analgesic (mild to moderate pain), antipyretic, dysmenorrhea, treatment of RA, OA, GA; Aspirin also antiplatelet effects (prior stroke, MI); contraindicated in renal impairment.

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Ibuprofen (Advil) and other NSAIDs commonly taken with antacids to decrease GI distress.

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Diclofenac (Zipsor) – NSAID; also can increase LFTs (hepatotoxicity). Like other NSAIDs, may increase risk of stroke and MI. SE as other NSAIDs, including GI bleeding.

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Medications for treatment of gout – NSAIDs first-line therapy; second-line agents include allopurinol, colchicine, probenecid. Decrease uric acid. Colchicine – GI/GU bleeding (monitor CBC); probenecid – don’t use with renal impairment; allopurinol – agranulocytosis, Stevens-Johnson syndrome (notify MD if rash develops).

Respiratory Drugs 

Albuterol (Proventil, Ventolin), levalbuterol (Xopenex), pirbuterol (Maxair), short-acting Beta2 agonists (SABA) – should be used during acute asthmatic episodes, not long term use; fluticasone is glucocorticoid for prevention of acute asthma (not for acute episode); fluticasone is given BID

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Albuterol (Proventil) – SA beta agonist. (See sympathomimetic/adrenergic effects). Assessment is for improved breathing; open airway. Also may stimulate the heart – increased HR, nervousness, etc.

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Topical/inhaled adrenergics (decongestants) use no longer than 3-5 days; can produce rebound congestion.

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Fluticasone and salmeterol (Advair) inhaler – use only BID (not more often; can ↑BP)

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Tiotropium (Spiriva) – bronchodilator used in LT maintenance of COPD; given by inhaler; rinse mouth after inhaler use

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Pirbuterol (Maxair) inhaler – beta2 agonist (bronchodilator) used for treatment of asthma in pts. 12 and older. Similar in effects to levalbuterol. Use cautiously in pts. with cardiovascular disorders, including ischemic heart disease, hypertension, or cardiac arrhythmias, in patients with hyperthyroidism or diabetes mellitus, and in patients who are unusually responsive to sympathomimetic amines or who have convulsive disorders. Avoid use with beta blockers.

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Bronchodilators should produce ease of breathing and decreased wheezing.

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Teaching for use of inhaler with 2 puffs of same med; two different meds

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Montelukast (Singulair) – indicated for treatment of asthma; can be given to patients 2 yrs and older; administer orally at bedtime. SE: HA and dizziness. Leukotriene modifiers/inhibitors also include zileuton (Zyflo), zafirlukast (Accolate). Check LFTs for these two.

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Antihistamines (eg. diphenhydramine [Benadryl]) decrease nasopharyngeal secretions by blocking H1 receptors; use cautiously with elderly; major SE is sedation. Use cautiously with COPD, asthma, pneumonia.

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Theophylline (methylxanthine bronchodilator) – TheoDur, Theo-24, Uniphyl; indicated for treatment of COPD. IV form (aminophylline) for status asthmaticus. Severe wheezing from bronchial constriction. Avoid caffeinated beverages, as caffeine is a methylxanthine.

Adrenal Agents/Endocrine Drugs 

Prednisone (Deltasone), prednisolone (Orapred, Pediapred), methylprednisolone (Solu-Medrol),

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triamcinolone (Kenalog) – glucocorticoid; highest priority assessment is risk of infection (R/T immunosuppression. Glucocorticoids (steroids). SE: Cushing syndrome (moon face, hump back, hirsutism, weight gain, etc.). Increased risk of infection (immunosuppression); thin, fragile skin; hyperglycemia; osteoporosis; steroid psychosis (euphoria); stunts bone growth in children. 

LT use of steroids with asthma and COPD – SE of LT glucocorticoid use – see above. In addition, adrenal insufficiency [which can be life-threatening]; be sure to taper steroids rather than discontinuing abruptly (adrenal crisis); need stress dosing of steroids when hospitalized (be able to identify glucocorticoids by their names, like prednisone –sone, -cort, -methasone, -nisolone).

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Hypothyroidism treatment is replacement therapy (levothyroxine) – S/S of OD would be symptoms of hyperthyroidism (increased metabolism) – tachycardia, weight loss, diarrhea, increased body temp and intolerance to heat, perspiration, insomnia, etc. May even produce angina.

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Radioactive iodine is given for thyroid gland ablation. Large capsules are odorless and tasteless. Can dry up salivary glands. Excreted in urine, so force fluids. Pt. will be radioactive until removed from body. Isolation. Double flush toilets, etc. Administered by the nuclear medicine physician.

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Methimazole (Tapazole) or propylthiouracil (PTU) – for treatment of hyperthyroidism (Graves disease). Take at same time every day with meal or snack. Avoid foods high in iodine (iodized salt; seafood). May take 2 weeks to be effective. SE: hypothyroidism symptoms (sluggish, tired, weight gain, cold intolerance, constipation). Take one hour apart from Lugol’s solution (potassium iodide) for treatment of severe hyperthyroidism (thyroid storm/thyroid crisis).

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Antidiuretic hormone (ADH) – prevents excess fluid loss. Pts. with diabetes insipidus have insufficient ADH and produce large amounts of very dilute urine. Pt. on ADH should have decreased urine output. Watch for fluid overload. Renal assessment. Drug may be Desmopressin or Vasopressin. (DDAVP) – intranasal antidiuretic hormone (ADH) for treatment of diabetes insipidus caused by deficiency of vasopressin (ADH); also controls bleeding in certain types of hemophilia and von Willebrand’s disease; prevention of nocturnal enuresis (bedwetting). Check serum osmolality (Fundamentals).

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Only rapid (lispro [Humalog], aspart [Novolog], glulisine) and short-acting (regular) insulin can be given IV; for emergencies. Rapid acting insulin: onset 5-10 minutes, peak 1 hour, duration 2-4 hours. Take immediately before eating. Hypoglycemia can occur quickly if not consuming adequate calories immediately after injection.

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Regular insulin peaks in 2-3 hours (mid-morning when given before breakfast). Give 30-60 minutes before meal. Pt. receiving Regular insulin at 7:30 a.m., be sure pt. eats breakfast

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Insulin can ONLY be administered using an insulin (orange tip) syringe; always measured in units.

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Lantus insulin has no peak – flat effect (lasts 24 hours)

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Diabetic pt. on oral antidiabetic NPO prior to surgery; a.m. BS 250; call MD for sliding scale insulin order. What about patient NPO who has hypoglycemia? May need IV glucose/dextrose.

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Second generation sulfonylureas (glipizide [Glucotrol], glimepiride [Amaryl]) SE include hypoglycemia, weight gain, skin rash, N/V/D.

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Exenatide (Byetta) and liraglutide (Victoza) – incretin mimetic agent (antidiabetic) given subcutaneously (NOT insulin). Only for type 2 DM. Cannot be used with insulin. Mimics the action of incretin which promotes endogenous insulin secretion and promotes other mechanisms of glucose lowering. Used for improved control of blood glucose. Take subQ injection within 60 minutes before morning and evening meals. Teach to watch for signs of hypoglycemia: confusion, abdominal pain, sweating, hunger, weakness, dizziness, headache, drowsiness, tremor, tachycardia, anxiety, irritability (especially when combined with oral sulfonylur...