bsn-2h pharma notes
TRANSCRIPT
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BSN-2H NOTES
Cardio:
Anti-hypertensive drugs
Periods of Cardiac Cycle1. Diastole
- Peroid of rest- Blood is returned to the heart2. Systole- Period of contraction- -Blood is pumped out of the heart
5 Phases1.2. Depolarization3. Repolarization4. Hyperpolarization5.
BLOOD PRESSUREElement Determining BP
HR
PR- Amount of blood that is pumped out of the
ventricle with each heart beat
Total peripheral resistance- resistance of the muscular arteries to the blood
being pumped through
REGULATORS OF BP
Baroreceptor- aorta and carotid sinus
- pressure receptor- vasomotor center in the medulla- hormones: antidiuretic (produced by the
hypothalamus and is stored and release by theposterior pituitary gland) , atrial natriureticpeptide, brain natriueretic peptide
HYPERTENSION-an increase in blood pressure such that the systolicpressure is greater than 140 mmHg and the diastolicpressure is greater than 90 mmHg
ESSENTIAL HYPERTENSION
- most common type, affecting 90% of personswith high blood- exact origin is unknown- contributing factors: family hx of hypertension,
hyperlipidemia, African American background,diabetes, obesity, aging, stress, excessivesmoking and alcohol ingestion
SECONDARY HYPERTENSION- 10 %- related to renal and endocrine disorders
CONDITIONS R/T UNTREATED HYPERTENSION-CAD and cardiac death-Stroke-Renal failure-Loss of vision
STEP CARE APPROACH IN TREATING
HYPERTENSIONStep 1: Lifestyle ModificationStep 2: Drug therapy (diuretics, ace inhibitors)Step 3: Drug therapy- switching of medsStep 4: Adding more drugs
NON-PHARMACOLOGIC CONTROL OFHYPERTENSION
Stress-reduction techniques
exercise
salt restriction
decreased alcohol ingestion
weight reduction
PHARMACOLOGIC CONTROL OF HYPERTENSION
DIURETICS-first line drugs for treating mild hypertension
MOA-promotes sodium depletion-decreases extracellular fluid volume
SAMPLE-Hydrochlorothiazide (hydroDIURIL)
CI and CAUTION-Thiazide: renal insufficiency (creatinine clearance > 30ml/min)
SYMPATHOLITICS (sympathetic Depressants)1. Beta- adrenergic blockers2. Centrally acting alpha2- agonists3. Alpha- adrenergic blockers4. Adrenergic neuron blockers (peripherally acting
sympatholytics5. Alpha1 and Beta1 adrenergic blockers
1. BETA-ADRENBERGIC BLOCKERS
-beta blockers-used as anti-hypertensive drug in combination withloop diuretic
MOABeta (B1 and B2)- adrenergic blockers reduce CO bydiminishing the sympathetic nervous system responseto decrease basal sympathetic tone
SAMPLE:*propanOLOL (inderal)
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- inhibit beta1 (heart) and beta2 (bronchia)l receptors
CI and CAUTION-2nd or 3rd degree AV block or sinus bradycardia-Propanolol: not be given to clients with COPD
SE-decreased PR
-markedly decreased BP-bronchospasm-insomnia-depression-nightmares-sexual dysfunctionNSG INT.-Monitor VS especially BP-Monitor laboratory results, especially BUN, serumcreatinine, AST and LDH-Instruct client to do not discontinue meds abruptlybecause rebound hypertension may occur-Inform client that herbs can interfere with beta blockers
2. CENTRALLY ACTING ALPHA2-AGONISTSUSEMOA-stimulate the alpha2 receptors-increase vagus activity-decrease CO-decrease serum epinephrine, norepinephrine andrennin release
*which results to: decrease the sympathetic responsefrom the brainstem to the peripheral vessels
SAMPLE:-Methyldopa (Aldomet) = one of the 1st drugs widelyused to control hypertension-Clonidine- transdermal, 7 day duration of action-Guanfacine, guanabenz
CI and CAUTION-Methydopa: impaired liver function, PAL
SE and AE-dry mouth, dizziness, slow HR (bradycardia)-Na and water retention resulting in peripheral edema
NSG INT
-Serum liver enzymes should be monitored periodically-must not be abruptly discontinued because of reboundhypertension crisis-Diuretic may be ordered with methyldopa or clonidineto decrease edema
3.ALPHA ADRENERGIC BLOCKERS-useful in treating hypertension in client with lipidabnormalities
MOA
-blocks alpha- adrenergic receptor resulting invasodilation and decreased BP-decrease very low density lipoproteins (VLDL) and lowdensity lipoproteins (LDL)-Increase High density lipoprotein levels (HDL)
SAMPLE-Selective alpha1(ZOSIN)= prazosin, terazosin,
doxazosin ------- reduce BP and used to treaty benignprostatic hypertension-Phentolamine, phenoxybenzamine and tolazolin----forhypertensive crisis and severe hypertension
SE and AE-ZOSIN: orthostatic hypotension, dizziness, faintness,light headedness, increased HR, nausea, drowsiness,nasal congestion, vasodilation, edema, wt gain-PHENTOLAMIN: hypotension, reflex tachycardia,nasalcongestion, GI disturbances
D-D
- prazosin + anti inflammatory = peripheral edema- prazosin + mitroglycerin= faintness (syncope causedby decrease BP)
NSG INT-Monitor VS especially BP-Check daily for fluid retention in the extremities-Encourage client to decrease salt intake-instruct client to report edema if present
4.ADRENERGIC NEURON BLOCKERS-potent antihypertensive drugs-last choice for treatment of chronic hypertension
MOA-block norepinephrine release from sympathetic nerveendings causes decrease in norepinephrine whichresults to decrease BP
*decrease in CO and peripheral vascular resistance
SAMPLE-Reserpine, guanethidine,and guanadrel
SE-orthostatic hypotension-Na and water retention
-may cause vivid dreams, nightmares and suicidalintention
NSG INT-advise client to rise slowly from sitting position
5.ALPHA1 AND BETA1 ADRENERGIC BLOCKERSMOA-blocks both the alpha1 and beta1 receptor- large doses could block beta2 adrenergic receptorsand may cause AV block
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*causes vasodilation, decreasing resistance to bloodflow
SAMPLE-Labetalol (Normodyne)-Carteolol (Cartrol)
CI-clients who have sever asthma
SE-orthostatic (postural) hypotension-GI disturbances-Nervousness-dry mouth-fatigue
DIRECT ACTING ARTERIOLAR VASODILATOR-very potent antihypertensive drugs
MOA-relaxes the smooth muscles of the vessels, mainly thearteries causing vasodilation-promotes an increase blood flow to the brain andkidneys
*BP decreases, Na and water are retained causingperipheral edema
SAMPLE-hydralazine-menoxidil-Nitroprusside and diazoxide (acute HPN)
SE-hydralazine: tachycardia, palpitaitons, edema, nasalcongestion, HA, dizziness, bleeding, lupus likesyndrome, tingling, numbness-Nitroprusside and diazoxide: reflex tachycardia,palpitaions, agitation, nausea,and confusion,hyperglycemia
ANGIOTENSIN CONVERTING ENZYME (ACE)INHIBITORS-promotes sodium retention and K excretion-treats HPN and HF
MOA-Inhibits the formation of angiotensin II-blocks the release of aldosterone
SAMPLE-Captopril (Capoten)-Enalapril (Vasotec)= only ACE available on oral form
CI-Pregnant women-shoukd not be taken with K sparring diuretics such as
spironolactone
SE-constant irritated cough
NSG INT-Monitor lab test (BUN, creatinine, protein) and bloodglucose levels
-Wastch for hypoglycaemic reactions in clients withdiabetes mellitus-Instruct client to administer with food-Instruct client not to abruptly discontinue meds-Teach client to record BP-Instruct client to take captopril 20 minutes to 1 hourbefore meal.-Inform patient that taste of food may be diminishedduring 1st month of drug therapy
ANGIOTENSIN II RECEPTOR BLOCKERS-similar to ACE inhibitors
MOA-prevent release of aldosterone-blocks angiotensin ii from the AT1 receptors
*causes vasodilation and decrease peripherakresistance
CI-pregnancy
SAMPLE (SARTANS)-Losartan (Cozaar)-Valsartan (Diovan)
-Irbesartan (Avapro)-Olmesartan medoxomil (Benicar)-Telmisartan (Micardis)
SE-URI-HA-Dizziness
DIRECT RENIN INHIBITOR
MOA-reduces angiotensin I and II, aldosterone levels
SAMPLE-aliskiren (Tekturna)
CALCIUM CHANNEL BLOCKERS-calcium agonists and calcium blockers-highly protein bound but have short half life
MOA-block the binding of Ca to its receptor
*results: preventing muscle contraction, smooth muscle
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relaxation, decrease peripheral smooth muscle tone
SAMPLE-dihydropyridine (amlodipine) common=largest group of calcium channel blockers= used to control HPN= Nimodipine- prevent ischemic brain injury due
to vasospasm
-diphenylalkalamine (verampil)=used to treat chronic hypertension, angina pectoris
and cardiac dysrhytmias-benzodiazepines (diltiazem)
SE/AE-flush-headache-dizziness-ankle edema-bradycardia-AV block
CI-heart block
NSG INT-do not prescribe with beta blockers
Cardiotonic agents
Cardiac Glycosides-heart failure-positive inotropic action-negative chronotropic action-increase stroke volume
Ex.Digoxin(lanoxin, lanixocaps)-doesnt need liver to metabolize-more dosageDigitoxin(crystodigin)-needs liver-less dosageI:CHF, Atrial flutter, atrial fibrillation, paroxysmal atrialtachycardia.CI: -ventricular tachycardia/fibrillation
-heart block-acute MI(heart attack/myocardial infarction)-renal insufficiency-electrolyte abnormalities
ex. Hypokalemia(increase effect of digoxin toxicity)Drug interactions-diuretics(potassium losing)-glucocorticoids-antacids-herbal interaction-thyroid hormones-verapamil, amiodarone, quinidine, quinine,erythromycin, tetracycline or cyclosporine.NORMAL THERAPEUTIC LEVEL OF DIGOXIN-0.5-2ng/ml
S.E.:HA,weakness, drowsiness, vision changes, GIupset, digitalis toxicity.Digitalis toxicitys/sx: anorexia, diarrhea, bradycardia, PVC, N/V, cardiacdysrhythmias, blurred vision, visual illusions, HA,malaise, confusions, delirium.Digoxin-antidote for digitalis toxicity
-digoxin immune tab(orine, digiland)Assessment:-drug and herbal history-VS, PR-ECG-renal function-serum electrolytes-s/sx of digitalis toxicityIntervention:-monitor PR,dont administer if PR below 60-eat foods high in potassium-drug compliance-avoid OTC drugs
-weigh daily
Cardiac dysrhythmia (arrhythymia)-any deviation from the normal rate or pattern of
the hearbeat-bradycardia; tachycardiaECG- identifies the type of dysrhythmia
P wave indicates atrial activationQRS complex ventricular depolarizationT wave ventricular depolarization
PR interval AV conduction timeQT interval ventricular action potentialAtrial Dysrhythmias prevent proper filling of theventricles and decrease cardiac output by 1/3Ventricular dysrhythmias life threatening becauseineffective filling of the ventricles results in decreased /absence of cardiac output
Cardiac Action PotentialsPhase 0 rapid depolarization caused by an influx ofsodium ionsPhase 1 initial repolarization; termination of sodiumionsPhase 2 is the plateau; characterized by the influx of
ionsPhase 3 rapid repolarizationPhase 4 resting membrane potential betweenhearbeats
Type of Antidysrhythmic drugsClass I (sodium channel blockers)
Slow conduction and prolong repolarization
Quinidine, Procainamide, Disopyramide
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Class II (beta blockers)
Reduce calcium entry
Decrease conduction velocity, automaticity andrecovery time
Propanolol (inderal)
Acebutolol (sectral)
Esmolol (brevibloc)
Sotalol (betapace)Class III (drugs that prolong repolarization)
Prolong repolarization during ventriculardysrhythmias
Prolong action potential duration
Bretylium (bretylol)
Amiodarone (cordarone)
Class IV (calcium channel blockers)
Block calcium influx
Slow conduction velocity
Decrease myocardial contractility
Increase refraction in the AV node
Verapamil (Calan, Isoptin) Diltiazem (cardizem)
Nursing process
Obtain health and drug histories
Obtain baseline VS and ECG for futurecomparisons
Diagnosis
Decreased cardiac output related to cardiacdysrhythmia
Anxiety related to irregular heartbeat
Risk for activity intolerance related to lack of
oxygen because of irregular heart rate
Nursing intervention
Monitor VS signs. Hypotension canoccur
Administer drug by IV push or bolusover a period of 2-3 mins, or asprescribed
Monitor ECG for abnormal patterns andreport findings
Client teaching
Instruct client to take prescribed drug asordered
Provide specific instructions for eachdrug
Side effects:
Instruct client to report side effects andadverse reactions to the health careprovider. These can include dizziness,faintness, N/V.
Advise client to avoid alcohol, caffeine,and tobacco.
Evaluation:
Evaluate the effectiveness of the prescribedantydysrhythmic by comparing heart rates withbaseline hear rate and assessing clientsresponse to drugs
Antianginal agents:
ANTI ANGINAL DRUGS - used to treat angina pectoris
ANGINA PECTORIS - condition of acute cardiac paincaused by inadequate blood flow to the myocardiumdue to either plaque occlusions within or spasms of thecoronary arteries, with decreased blood flow, there is adecrease in O2 to the myocardium which results in painANGINAL PAIN - tightness, pressure in the center of
the chest and pain radiating down theleft arm-usually lasts for only a fewminutes
REFERRED PAIN: felt in the neck and left arm- severeangina pectorisANGINAL ATTACKS may lead to MYOCARDIALINFARCTION or HEART ATTACK.STRESS TESTS, ECHOCARDIOGRAM, CARDIACPROFILE LABORATORY TESTS AND CARDIACCATHETERIZATION determine the degree ofblockage in the coronary arteries
TYPES OF ANGINA PECTORIS1.CLASSIC (STABLE) - occurs with stress or exertion2.UNSTABLE (PREINFARCTION)- occurs frequently over the course of a day with
progressive severity-often indicates an impending MI-emergency that needs immediate medical intervention
3.VARIANT (PRINZMETAL, VASOSPASTIC) - occursduring rest-caused by vessel spasm (vasospasm)
FIRST TWO TYPES: caused by a narrowing or partialocclusion of the coronary arteries
NONPHARMACOLOGIC WAYS OF DECREASINGANGINAL ATTACKS:
- Avoid heavy meals, smoking, extremes inweather changes, strenuous exercise andemotional upset
- Promote nutrition, moderate exercise, adequate
rest and relaxation techniquesANTIANGINAL DRUGS- increase blood flow either byincreasing oxygen supply or by decreasing oxygendemand by the myocardiumTYPES OF ANTIANGINAL DRUGS
NITRATES- fast effect-MAJOR SYSTEMIC EFFECT: reduction ofvenous tone which decreases the workload ofthe heart and promotes vasodilation-effective in treating variant angina pectoris-first agents used to relieve angina
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-affect coronary arteries and blood vessels inthe venous circulation-cause generalized vascular and coronaryvasodilation thus increasing blood flow throughthe coronary arteries to the myocardial cells-reduces myocardial ischemia but can causehypotensionMOA: cause vasodilation due to relaxation of
smooth musclesPotent dilating effect on coronary
arteriesINDICATION: used for prophylaxis andtreatment of anginaCONTRAINDICATION: severe anemia,head trauma or cerebral hemmorhageEXAMPLES:1. NITROGLYCERIN (NITROBID, NITROSTAT)-AVERAGE DOSE PRESCRIBED FORSUBLINGUAL NITROGLYCERIN TABLET: 0.4mg or gr 1/150 repeated every 5 minutes for atotal of 3 doses
-SL TABLETS: decompose when exposed toheat and light should be kept in their originalAIRTIGHT GLASS CONTAINERS- not swallowed because it undergoes first-pass metabolism by the liver which decreasesits effectiveness2. ISOSORBIDE DINITRATE ( ISORDIL,SORBITRATE)3. ISOSORBIDE MONONITRATE ( MONOKET,IMDUR)SIDE EFFECTS: Headache most common
but may becomeless frequent with
continued useHypotension, dizziness, weakness andfaintness
When nitroglycerin is discontinued, the doseshould be tapered over several weeks toprevent the rebound effect of severe paincaused by myocardial ischemia.Reflex Tachycardia- occur if nitrate is given toorapidly; heart rate increases greatly because ofovercompensation of the cardiovascularsystem.DRUG INTERACTIONS: increase effect withalcohol, beta-blockers, calcium channelblockers, antihypertensiveness; decrease
effects of heparinNURSING INTERVENTION: NITROGLYCERIN1. Monitor VS2. Instruct to rise slowly to standing position3. Sip water before sublingual nitrates4. Apply ointments- use gloves5. Do not apply nitrates with defibrillation-cardioverter6. Instruct patient to take PRN nitrates at thefirst hint of angina pain.
- If pain persists, repeat in 5 mins
- DO NOT GIVE MORE THAN 3 TABLETS- if chest pain persists longer than 15 mins,
immediate medical help is necessary7. Never chew or swallow8. burning sensation-normal9. Lying down or sit to prevent dizziness10 .Blood level monitor11. Take before meals
12. Limit caffeine intake13. To avoid hypotension, weakness andfaintness, instruct client not to ingest alcoholwhile taking nitroglycerin14. Tolerance can occur.15. Instruct client about the Transderm-Nitropatch. Apply once a day, usually in the morning.Rotation of skin sites is necessary. The patch isusually applied to the chest wall, but thighs andarms may also be used. Avoid hairy areas.15. Headaches commonly occur when firsttaking nitroglycerin products and last about 30mins. Acetaminophen is suggested for relief.
16. If hypotension results from SL nitroglycerin,place in supine position with legs elevated.
BETA-BLOCKERS-decrease the workload of the heart anddecrease oxygen demands-effective with stable angina-decrease the effects of the sympatheticnervous system by blocking the action of thecatecholamines epinephrine andnorepinephrine thereby decreasing the heartrate and blood pressure-used as antianginal, antidysrhythmic and
antihypertensive-effective as antianginal because by decreasingthe heart rate and myocardial contractility, theyreduce the need for oxygen consumption andconsequently reduce anginal pain-most useful for classic angina-should not be abruptly discontinued; doseshould be tapered over a specified no. of daysto avoid reflex tachycardia and recurrenceangina pain-clients with decreased heart rate and bloodpressure usually cannot take beta blockers-clients with second or third degree AV blockshould not take beta-blockersEXAMPLES OF NONSELECTIVE BETA-BLOCKERS:
Propanolol ( Inderal)
Nadolol ( Corgard)
Pindolol ( Visken)- Decrease heart rate and can cause
bronchoconstriction
- Cardioselective beta-blockers act morestrongly on the beta1 receptor thusdecreasing the heart rate but avoiding
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bronchoconstriction because of theirrelative lack of activity at the beta2receptor
EXAMPLES OF SELECTIVE BETA-BLOCKERS:
Atenolol ( Tenormin)
Metoprolol ( Lopressor, Toprol-XL)- grp of choice for controlling angina
pectoris
SIDE EFFECTS AND ADVERSE REACTIONS:decrease in heart rate and blood pressure both selective and non selective drugsbronchospasm, behavioural or psychoticresponse and impotence potential adversereactions for non-selective beta-blockersNURSING INTERVENTION:Vital signs need to be closely monitored in theearly stages of beta blocker therapyWhen discontinuing, dosage should be taperedfor 1-2 wks to prevent rebound effect like reflex
tachycardia or life-threatening cardiacdysrhythmiasMonitor PRInform patient it is a long term med
CALCIUM CHANNEL BLOCKERS- decrease the workload of the heart anddecrease oxygen demands- effective in treating variant angina pectoris-treatment of stable and variant angina pectoris,certain dysrhythmias and hypertension-relax coronary artery spasm and relaxperipheral arterioles decreasing cardiac oxygen
demand-decrease cardiac contractility, decreaseafterload, decrease peripheral resistance andreduce the workload of the heart thusdecreasing the need for oxygen-achieve their effect in controlling variant anginaby relaxing coronary arteries and in controllingclassic angina by decreasing oxygen demandCALCIUM- activates myocardial contraction,increasing the workload of the heart and theneed for more oxygenEXAMPLES:Verapamil (Calan)- first calcium blocker
- Bradycardia is a commonproblemNifedipine ( Procardia) most potent of the calciumblockers, promotes vasodilation of the coronary andperipheral vessels-hypotension can result
Diltiazem (Cardizem)SIDE EFFECTS AND ADVERSE REACTIONS- Headache- Hypotension ( more common with Nifedipine
and less common with Diltiazem)
- Dizziness- Flushing of the skin- Reflex Tachycardia can occur as a result of
hypotension- Can cause changes in the liver and kidney
function serum liver enzymes should bechecked periodically
Anti-platelet
Used to prevent thrombosis in the arteries bysuppressing platelet aggregation
Mainly for prophylactic use in:o Prevention of myocardial infarction or stroke
for client w/ familial hxo Prevention of repeat MI or stroke
o Prevention of a stroke for clients having transient
ischemic attacks (TIAs)xamples:
ASPIRINo Long-term & low dose aspirin therapy
Effective & inexpensive tx forsuppressing platelet aggregation
o MOA: inhibits cyclooxygenase (enzyme
needed by platelet to synthesizethromboxane A2 (TxA2)
o Indications:
Prevention of thrombosis before or afterCVA or MI
Familial hx of MI or stroke
o Dose: 81, 162, or 325 md/day
Should be discontinued at least 7 daysbefore surgery
CLOPIDOGREL (Plavix)o MOA:
inhibits platelet aggregation
prevents ADP from binding w/ the ADPplatelet recptor
o May be prescribed singly or w/ aspirin
(more effective)
o CI: peptic ulcer, active bleeding, intracranial
hemorrhage
o SE: upper RTI, flulike symptoms, dizziness,
HA, fatigue, chest pain, diarrhea, maycause HTN & bronchitis
Drug interaction: NSAIDs may bleeding
o Lab: prolongs bleeding time
o Herb: ginger, garlic, gingko, feverfew may
bleeding
GP IIb/IIIa inhibitors
o MOA: blocks the binding of fibrinogen to the
glycoprotein IIb/IIIa receptor on the plateletsurface
o Used primarily for acute coronary
syndromes (unstable angina or non-Q-wave
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MI)o Prevents reocclusion of coronary arteries
flowing percutaneous transuminal coronaryangioplasty (PTCA) given before & afterPTCA
o Example: abciximab (ReoPro) drug of
choice for angioplasty
CILOSTAZOL (Pletal)o Also a vasodilator that may be used for
intermittent claudicationNursing Considerations:
Monitor BP
Provide safety precautions
Monitor INR regularly
Advise client not to smoke. Nicotine causesvasoconstriction, which alters the effectivenessof antiplatelet agents
Monitoring for abnormal bleeding
Anticoagulant
Pathophysiology Thrombus is the formation of a clot in an arterial
or venous vessel.
Arterial clots are usually made up of WBC andRBC initiating the process, followed by fibrinformation and trapping of RBC in fibrin mesh.
Embolus blood clot moving through thebloodstream.
Thromboxane A2 product of prostaglandin anda potent stimulus for platelet aggregation.
Glycoprotein IIb/IIIa or GP IIb/IIIa plateletreceptor protein that binds fibrinogen.
Anticoagulants- inhibits clot formation.- act prophylactically to prevent new clots
from forming.- Used in clients with arterial and venous
vessel disorder.
PARENTERAL (IV/SubQ)
HeparinMOA:
- prevent new fibrin/clot formation byenhancing inhibitory actions of antithrombinIII on several factors essential to normalblood clotting, thereby blocking the
conversion of pro thrombin to thrombin andfibrinogen to fibrin.
Indications:- prevents and treats venous vesseldisorders such as DVT, pulmonaryembolism and emboli in arterial fibrillation,diagnoses and treats disseminated
intravascular coagulation; preferredanticoagulant during pregnancy.
Contraindications:Bleeding tendenciesThrombocytopeniaPost operative clients
Side Effect:bleeding
Tests:PTT and aPTT
Drug-Drug interactions:- any drugs that will cause bleeding-
Antidote:Protamine Sulfate (1mg of protamine for every
1mg of LMWH)
*Low-molecular-weight heparins (no need for PTT/aPTTmonitoring)
- + : 2-4 times longer than heparin- administered subQ once or twice perday.
- usually injected at abdomen.- preferable when client is at homebecause a family member can be taught howto administer.
Examples:Dalteparin sodium (Fragmin)Enoxaparin sodium (Lovenox)Tinzaparin sodium (Innohep)
ORAL
WarfarinMAO:
- antagonist of vit. K, which is necessaryfor the synthesis of clotting factors VII, IX, Xand pro thrombin; as a result, it disrupts thecoagulation cascade.
Indications:- prevent venous thrombosis and
thromboembolism associated with atrial
Venous Problems Arterial ProblemsDeep VeinThrombosis (DVT)
Coronary Thrombosis(myocardial infarction)
PulmonaryEmbolism
Presence of artificialheart valvesCerebrovascular Accident(CVA)
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fibrillation and prosthetic heart valves; risk ofrecurrent transient ischemic attack, CVA andMI.
Contraindications:bleedingvit. K deficiencypregnancy category x
breastfeeding crosses into breast milkSide Effect:red-orange discoloration of urineweakening of bones(long-term use)
Tests:PT and INR
Antidote:Vitamin K
NSG RESPONSIBILITY
check VS - PR, BP (bleeding)
control and prevent bleeding
if bleeding occurs, apply pressure for at least 5-10 minutes
heparin: PTT and aPTTwarfarin: PT and INR
heparin: IV/subQwarfarin: oral
instruct client to decrease intake of green, leafyvegetables when taking warfarin.
Check for bleeding, tarry stools
Soft toothbrush to prevent gums from bleeding
Caution with use of electric razor
Do not smoke increases drug metabolism
Use acetaminophen for pain instead of aspirin(bleeding)
Avoid coffee, tea, cola (caffeine), excessivealcohol.
ThrombolyticsUsed since the early 1980s to promote thefibrinolytic mechanism (converting plasminogento plasma, which destroys the fibrin in the bloodclot).Should be administered within 3 hours of athrombolic stroke.
Five commonly used thrombolytics are:
1. Streptokinase (Streptase, Kibikinase)Use: act systematically to promote the conversionof plasminogen to plasma.
: dissolve blood clots caused by coronaryartery thrombi
Pregnancy Category C
2. Urokinase
Use: enzymes that act systematically to
promote the conversion of plasminogen toplasma.
3. Alteplase a.k.a Tissue Plasminogen Activator (TPA)
MOA: promotes conversion of plasminogen toplasmin and initiates fibrinolysis
Use: to dissolve clot following an acute MI,pulmonary embolism, acute ischemic stroke.
Contraindication: internal bleeding, bleedingdisorders, recent CVA, surgery or trauma,bacterial endocarditis, severe liver dysfunction,severe uncontrolled hypertension
Side Effects: bleeding
Adverse Reaction: Life-threatening:intracerebral hemorrhage, stroke, atrial orventricular dysrhythmias.
Drug-Drug Interaction: increase bleeding whentaken with oral anticoagulants, NSAIDs,cefotetan, plicamycin
4. Reteplase (Retavase)
Use: to treat coronary thrombosis bycausing lysis of thrombi; inhibits fibrinaspect of the thrombus
Pregnancy Category C
More effective than TPA with less risk ofhemorrhage
5. Tenecteplase (TNKase)
Use: to reduce mortality associated withAMI
A clot buster that can be administeredin 5 seconds in one dose
Pregnancy Category C
Dose is based on body weight
Nursing Responsibilities:- Monitor VS- Observe for s/sx of active bleeding from
the mouth to the rectum.AMINOCAPROIC ACID can be given as an
intervention to stop bleeding.- Check for active bleeding for 24hrs after
thrombolytic therapy has beendiscontinued.
- Observe for signs of allergic reaction tostreptokinase : itching, hives, flush,
fever, dyspnea, bronchospasm,hypotension, and/or cardiovascularcollapse.
- Avoid administering aspirin andNSAIDs. Acetaminophen can besubstituted.
- Monitor ECG- Instruct the client to report any side
effects, such as lightheadedness,dizziness, palpitations, nausea,pruritus or urticaria.
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-(Contraindications and cautions) prescribed cautiously for clients withlow BP and HR
(2) Metoclopramide HCl (Reglan)
-usually prescribed to treat gastroesophagealreflux disease (GERD)- () gastric emptying time
DIRECT-ACTING CHOLINERGIC: EYE-Pilocarpine
constricts pupils of the eyes thusopening the canal of Schlemm to promotedrainage of aqueous humor (fluid) .
Used to treat glaucoma by relievingfluid (intraocular) pressure in the eye.
-NURSING INTERVENTIONS: (Direct Acting)
-Monitor VS HR and BP () when large doses ofcholinergics are given.-Record I&O () urinary output should be reported
because it may be r/t urinary obstruction.-Give 1 hr. before or 2 hrs. after meals.
-Auscultate for bowel sounds report () orhyperactive bowel sounds.-Auscultate breath sounds for rales or rhonchicholinergic drugs can () bronchial secretions.-Have IV atropine sulfate (0.6 mg) available as anantidote for cholinergic overdose.
**Early signs of overdose include salivation,sweating, abdominal cramps, and flushing.
-Report severe dizziness or a () in HR below 60 bpm.-Instruct client arise slowly from lying position slowly toavoid dizziness or orthostatic hypotension.-Encourage client to maintain effective oral hygiene ifexcess salivation occurs.
INDIRECT-ACTING CHOLINERGICS-do not act on receptors-inhibit cholinesterase by forming a chemical complex,thus permitting acetylcholine to persist and attach to thereceptor.
**Cholinesterase- break down into choline andacetic acid.- may destroy acetylcholine before it reaches
the receptor or after it has attached to the site.-drugs that inhibit cholinesterase are calledcholinesterase inhibitors, acetylcholinesterase (AChE)inhibitors, or anticholinesterases.
**By inhibiting cholinesterase, moreacetylcholine is available to stimulate receptorand remain in contact with it longer.
-Primary use of cholinesterase inhibitors is to treatmyasthenia gravis (a neuromuscular disorder)because cholinesterase inhibitors are useful to muscletone.
- NURSING INTERVENTIONS: (Indirect- Acting)-Beware of the possibility of cholinergic crisis(overdose); symptoms include muscular weaknessand () salivation.-Instruct client to take the drug on time to avoidrespiratory muscle weakness.-Instruct client to assess changes in musclestrength cholinesterase inhibitors () muscle
strength.
-cholinesterase inhibitors can be separated intoreversible inhibitors and irreversible inhibitors.
REVERSIBLE CHOLINESTERASE INHIBITORS-Use to: (1) produce pupillary constriction in thetreatment of glaucoma.
(2) () muscle strength in myasthenia gravis.-Drugs used to () muscular strength in myastheniagravis include:
(1) Neostigmine (Prostigmin) short- acting(2) Pyridostigmine bromide (Mestinon)
moderate-acting(3) Ambenonium chloride (Mytelase) long-
acting(4) Edrophonium chloride (Tensilon) short-acting for diagnostic purposes
-(Caution) clients with bradycardia, asthma, pepticulcers, or hyperthyroidism.-(Contraindications) clients with intestinal or urinaryobstruction.
IRREVERSIBLE CHOLINESTERASE INHIBITORS-potent agentsbecause of their long-lasting effect.-these drugs are used to produce pupillary constriction
and to manufacture organophosphate insecticides.-the bond between the irreversible cholinesteraseinhibitor and cholinesterase is considered permanent;however, this bond can be broken with the use of thedrug Pralidoxime (Protopam) an antidote to reversethe irreversible organophosphate.
Cholinergic Blocking Agents
-are drugs that inhibit the actions ofacetylcholine by occupying the acetylcholine
receptors.
-also known as parasympatholytics, adrenergicblocking agents, cholinergic or muscarinicantagonists, and antiparasympatethics.
-Major body tissues and organs affected by theanticholinergic group of drugs are the heart,respiratory tract, GI tract, urinary bladder, eyes,and exocrine glands.
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NURSING REPONSIBILITIES- Check for history to hypersensitivity to
Atropine; anticholinergics.- Ensure adequate hydration; provide
environmental control to preventhyperpyrexia (temperature).
- Have patient void before takingmedication if urinary retention is a
problem.- Advise patient to finish course of
medicine.- Take the medicine as prescribed, 30
min. before meals; avoid excessivedosage.
- Avoid hot environments; for the patientwill be heat intolerant, the dangerousreaction may occur.
- Teaching the patient that there arevarious side effects and to takeprecautions before any actions.
- Advise the patient not to involve self
into extreme activities e.g. driving.- Tell patient to report rash, eye pain,
difficulty breathing, irregular heartbeats,loss of coordination, abdominaldistention, difficulty swallowing,sensitivity to light and, constipation.
GLYCOPYRROLATE(Robinul)
DRUG CLASS:Anticholinergic,antimuscarinic, parasympatholytic,antispasmodic
MODE OD ACTION-competitively blocks the effects of acetylcholine atreceptors that mediate the effects of parasympatheticpostganglionic impulses; depresses salivary andbronchial secretion; dilates the bronchi, inhibits vagalinfluences to the heart, relaxes the GI and GU tracts,inhibits gastric secretions.
INDICATIONS
As a preoperative medication to decreasesalivary secretions.
As an antispasmodic drug to treat peptic ulcers,
because it relaxes the smooth muscles of theGI tract and decrease peristalsis.
As an agent to increase heart rate whenbradycardia is present.
CONTRAINDICATIONS-contraindicated with glaucoma, adhesions between irisand lens, stenosing peptic ulcer, toxic megacolon,cardiac arrhythmias, MI, COPD, impaired liver or kidneyfunctions. Use cautiously with elderly with Downsyndrome, brain damage, spasticity, HPN,
hyperthyroidism, pregnancy.
PHARMACOKINETICS
ROUTE
ONSET PEAK DURATION
ORAL 60min 60min 8-12 hr
IM, SC 15-30min
30-45min
2-7 hr
IV 1 min End of infusion
METABOLISM: Hepatic: T : 2.5 hrDISTRIBUTION: crosses placenta; enters breast milkEXCRETION: Urine
ADVERSE EFFECCTS
Headache, flushing, nervousness,drowsiness, mental confusion, fever.
Tachycardia
Dry mouth, altered taste perceptions,nausea, vomiting, dyphagia,heartburn, constipation, bloated feeling,paralytic ileus.
Urinary hesitancy and retention;impotence.
Irritation at the site of IM injection.
Blurred vision, mydriasis, cycloplegia,photophobia, increased IOP.
DRUG-DRUG INTERACTION-decreased antipsychotic effectiveness of
haloperidol with anticholinergic drugs, increasedanticholinergic side effects with amantadines, TCAs,decreased antipsychotic effects and increasedanticholinergic effects with phenothiazines.
NURSING RESPONSIBILITIES
Assess for glaucoma, adhesions between irisand lens, stenosing peptic ulcer.
- Ensure adequate hydration; provideenvironmental control to preventhyperpyrexia (temperature).
- Have patient void before takingmedication if urinary retention is a
problem.- Advise patient to finish course ofmedicine.
Take the medicine as prescribed.
Teach patient to have proper diet.
Tell patient to report rash, eye pain, difficultybreathing, irregular heartbeats, loss ofcoordination, abdominal distention, difficultyswallowing, sensitivity to light and, constipation.
Anxiolytic and Hypnotic agents
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An anxiolytic or anti-anxiety agent is a drug prescribedfor the treatment of symptoms of anxiety.
Anxiety disorders as recognized clinically include:
Generalized anxiety disorder(excessive anxietylacking any clear reason)
Panic disorder(sudden attack of overwhelmingfear occur in association with marked somaticsymptoms, such as sweating, tachycardia,chest pains, trembling and choking.)
Phobias (strong fears of specific objects orsituations e.g. snakes, open spaces, flying,social interactions)
Classification of Anxiolytic and Hypnotic Drugs
Benzodiazepines
Buspirone
Barbiturates
B-blockers
Sedative antihistamines Antidepressant
Antiepileptic drugs
Zolpidem. (for insomnia)
BenzodiazepinesAct by binding to GABA receptor, thus enhancing theinhibitory effect of GABA.ANXIOLYTIC effects are mediated by GABA receptorcontaining the A2 subunit, while sedation occursthrough those with the a1 subunit.
Effects of Benzodiazepines
Benzodiazepines cause:- Reduction of anxiety and aggression.- Sedation, leading to improvement of insomnia.- Benzodiazepines decrease the time taken to
get to sleep, and increase the total duration ofsleep, and increase the total duration of sleep.
- Muscle relaxation and loss of motorcoordination (clonazepam)
Side effects of benzodiazepines-drowsiness and confusion-amnesia
-Impaired coordination, which considerably affectsmanual skill such as driving performance.
BUSPIRONE
Buspirone is a partial agonist at 5-HT1areceptors is used to treat various anxietydisorders. It alsobinds to dopamine receptors(e.g. ipsapirone)Side Effect of Buspirone- Nausea
- Dizziness- Headache and restlessness
BARBITURATES
Barbiturates are Non-selective CNS depressants(act partly by enhancing action of GABA) thatproduce effect ranging from sedation and reductionof anxiety and death from respiratory andcardiovascular failure-therefore dangerous inoverdose.
Barbiturates Drug
- Phenobarbital, to treat epilepsy
- Thiopental, used as an intravenousanaesthetic agent.
Antidepressants as Selective serotonin reuptake
inhibitors such as fluoxetine and sertraline are usedto treat certain anxiety disorders.
Drug interaction with anxiolytic or hypnotic Drugs
- Cimetidine metabolism of benzodiazepinesinhibited by cimetidine
- Rifampicin metabolism of benzodiazepinespossibly accelerated by rifampicin.
- Theophylline effects of benzodiazepinespossibly reduced by theophylline.
- Digoxin/ alprazolam increases plasmaconcentration of digoxin (inc. Risk of toxicity)
- Valproate/ clobazam possibly inc. Plamaconcentration of valproate.
- Omeprazole/ metabolism of diazepampossibly inhibited by omeprazole.
Anti-depressant
Tricyclic antidepressants (TCAs) orTricycles
Action: block reuptake of serotonin andnorepinephrine by synaptic neuronsCI: - with MAOIs or within 14days of use, duringacute MI recovery.
- effects with carbamazepine,Phenobarbital, rifampin,cholestyraminemcolestipol, tobacco
- effects with cimetidine, quinidine,indinavir, retonavir, CNS depressants,SSRIs, haloperidol
- effect of amphetamines,anticholinergics, epinephrine,hypoglycemics, phenylephrine
Labs: glucose, false carbamasepinen levelsS/E: agranulocytosis, orthostatic hypotension
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Nx Intervention: monitor CBC, advice client tostand-up slowly
Fluxetine or Floxetine (Prozac)Action: Selective Serotonin Reuptake Inhibitors(SSRIs)CI: - MAOI or thioridazine (wait for 5 weeks afterdiscontinuation before MAOI)
- effect with CNS depressants, MAOIs,st. Johns wort
- effects of alparazolam,carbamazepine, clozapine, cardiacglycosides, diazepam,dextromethorpan, loop diuretics,haloperidol, phenytoin, ritonavir, warfin,sympathomimetic drugs.
- effects of buspironeLabs: BUN, Cr, urine albumineS/E: dry mouth, blurred vision, insomnia, HA,nervousness, anorexia, nausea, diarrhea, suicidalideation. Some may experience sexual dysfunction.
SE may decrease or cease over 2-4 wksNx Intervention: monitor kidney output, fluid and
fiber intake
monoamine oxidase inhibitors(MAOIs)
Action: CNS synaptic serotonin or norepinephrineCI: acute recovery from MI, CHF, angina, arrythmiasS/E: risk of hypertensive crisis they are particularlyeffective in treating atypical depression and havealso shown efficacy in smoking cessation.Nx Intervention: avoid dairy products or food(cheese, chocolates, cake) , avoid foods with tyramine content.
atypical antidepressants / second-generation antidepressants
CI: Should not be taken with MAOIs, should not beused within 14 days after discontinuing MAOIs.S/E: drowsiness, dizziness, EPS, posturalhypotension, increased apetite, urinary retention,light-headedness, orthostatic hypotension, drymouth,Nx intervention: take it with food to decrease GIdistress
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NURSING PROCESS:
Assessment: Record clients baseline VS and weight for
future comparison
Check clients liver and renal function byassessing urine output (>600ml/d), blood ureanitrogen (BUN), and serum creatinine and liverenzyme levels
Obtain health hx of episodes of depression,assess mental status and assess for suicidaltendencies.
Secure a drug hx of the current drugs, alcohol
and herbs client is taking. CNS depressants cancause an additive effect. Antidepressants thatcause anticholingeric-like symptoms arecontraindicated if client has glaucoma
Assess for tardive dyskinesia and neurolepticmalignant syndrome (NMS), includinghyperpyrexia, muscle rigidity, tachycardia andcardiac dysrhythmias.
Nursing diagnosis:
Risk for self-directed violence and injury relatedto feelings of despair.
Anxiety related to situational crisis
Social isolation related to feelings of sadness
Ineffective coping related to negative thoughtpatterns
Hopelessness related to feelings of despair
Deficient knowledge related to inexperiencewith escitalopram (Lexapro)
Ineffective health maintenance related to lack ofinterest
PlanningNx Interventions:
Observe for s/sx of depression: moodchanges, insomnia, apathy or lack ofinterest in activities
Check clients VS. Orthostatichypotension is common. Check foranticholinergic-like symptoms; drymouth, heart rate, urinary retention,constipation. Check weight 2-3xweek
Monitor client for suicidal tendencieswhen marked depression is present.
Observe client for seizures when clientis taking an anticonvulsant;antidepressants lower seizurethreshold. The anticonvulsant dosemight need to be increased.
Monitor drug-drug and food-druginteractions. Provide client with a list offood to avoid when taking MAOIs.These include cheese, red wine, beer,liver, bananas, yogurt, and sausage.
Check client for extremely BP whentaking MAOIs. Sympathomimetic-likedrugs and foods containing tyramine
may cause a hypertensive crisis if takenwith MAOIsSide Effects:
Advise client that antidepressants maybe taken at bedtime to decreasedangers from the sedative effect. Haveclient check with health care provider.Transient side effects include nausea,drowsiness, HA, and nervousness.
Antiepileptic
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Drugs used for epileptic seizures
It suppresses the abdominal electricimpulses from the seizures
It is also classified as CNSdepressants.
ANTICONVULSANTS ACTS IN THREE WAYS
By suppressing sodium influx through the drugbinding to the sodium channel
By suppressing the calcium influx, preventingthe electric current generated by the calciumoins
By increasing the action of gamma-aminobutyicacid, which inhibits neurotransmitter throughoutthe brain.
INTERNATIONAL CLASSIFICATIONS OF SEIZURES
Grand mal (tonic-clonic)- most common form of seizure.- In the TONIC PHASE; the skeletal musclecontract/ tighten in a spasm,usully last 3-5seconds.- In the CLONIC PHASE; there is dysrhytmicmuscular contraction, or jerkiness of legs andarms lasting for 2-4 minutes.
Petit mal ( absence)- breif loss of consciousness lasting less than10 seconds; fewer than 3 spike waves on theelectroencephalogram (EEG) printout- It usually occurs in children.
Psychomotor- Complex symptoms; automatisms(repetitivebehavior such as chewing or swallowing
motions), behavioral changes, and motorseizures.
A. HYDANTOINS-It acts by inhibiting sodium influx, stabilizingcell membrane, redcing repetitive neuronalfiring, and limiting seizures.-Should no tbe used during pregnancy, becauseit can have a TERATOGENIC effect on thefetus.-THERAPEUTIC RANGE: 10-20mcg/ml.*CONTRAINDIATION:- hypersensitivity, heart block, psychiatric
disorders, during pregnancy.*SIDE EFFECTS:- headache, confusion, dizziness, decreasedcoordination, slurred speech, rash, anorexia,nausea and vomiting, hypotension(IV), pink-red/brown discoloration of urine.*NURSING RESPONSIBILITIES:- Give alower dose for newborns, persons withliver disease, and older adults: DECREASE INMETABOLISM RESULTING IN MOREAVAILABLE DRUGS.
- Watch out for drug toxicity.- Monitor the therapeutic serum drug range: TOENSURE DRUG EFFECTIVENESS.
B. BARBITUATES
Prescribed to treat partial seizure,grand mal seizures and episodes ofstatus epileptic siezures, meningitis ,
toxic reactions and eclampsia. May also be used to manage delirium
treatment.
Drugs that act as CNS depressants andby the virtue of this they produced awide spectrum of effect from mildsedation to total anesthesia.
*SIDE EFFECTS:- Agitated mood; clumsiness; confusion;dizziness; excessive daytime drowsiness;headache; injection site reactions;lightheadedness; low blood pressure; nausea;
slow heartbeat; slowed breathing; vomiting.
*NURSING INTERVETION:- use only for few days at the most- advice patient not to drive.- do not discontinue abruptly.
C. SUCCUNIMIDES
Used to treat absence or petit malsiezures
It acts by decreasing the calcium influxthrough the T-type calcium cahnnels.
THERAPEUTIC RANGE: 40-100mcg/ml.
Drug of choice:ETHOSUXIMIDE(ZARONTIN)
*ADVERSE EFFECTS:- blood dyscrasias, renal and liver impairment,and systemic lupus erythematosus.
*SIDE EFFECTS:- drowsiness, dizziness, confusion, blurredvision.
*NURSING RESPONSIBILITIES:- may cause gastric irritation; must be taken
with food.-advice patient to increase fluid intake.-Monitor CBC and differential before andfrequently during therapy.-Take drug as prescribed, and do notdiscontinue drug abruptly.-advice patient no to drink alcohol.
D.OXAZOLIDONES/ OXAZOLIDINEDIONE
Prescribed to treat petite mal seizures.
DRUGS: Trimethadione andParamethadione.
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A. Trimethadione*SIDE EFFECTS:- Mild dizziness, poor coordination, ordrowsiness;blurred or double vision, or irregularback-and-forth movements of theeyes;decreased appetite, nausea, or vomiting;or increased sensitivity of the skin to sunlight.
*NURSING RESPONSIBILITIES:-Drugs should be gradually withdrawn.- Take trimethadione exactly as directed by yourdoctor.- Advice the patinet to take each dose oftrimethadione with a full glass of water.Trimethadione can be taken on an emptystomach or with food to decrease stomachupset.- Advice the patient to chew the chewabletablets before swallowing them.
B. Paramethadione*SIDE EFFECTS:-mild dizziness, poor coordination, ordrowsiness;blurred or double vision, or irregularback-and-forth movements of theeyes;decreased appetite, nausea, or vomiting;or increased sensitivity of your skin to sunlight.
*NURSING RESPONSIBILITIES:-Do not discontinue drug abruptly.- Carry or wear a medical identification tag to letothers know that you are taking this medicine inthe case of an emergency.
-Take paramethadione exactly as directed byyour doctor.-Take each dose of paramethadione with a fullglass of water. Paramethadione can be takenwith food if it upsets your stomach.
E.BENZODIAZEPINES
CLONAZEPAM
Effective in controlling petit mal(absence) seizures
Tolerance may occur 6 months afterdrug therapy starts
Consequently dosage has to be
adjusted. THERAPEUTIS RANGE: 20-80 ng/ml.
*SIDE EFFECTS:- drowsiness, dizziness, GI upset, fatigue,nervousness, depression, emotional changes,bedwetting, urinary incontinence.
* NURSING RESPONSIBILITIES:-Monitor addiction-prone patients carefullybecause of thier predipositon to habituation to
habituation and drug dependence.- Monitor for liver function and blood counts.-Advice patient to take drug on time.- Avoid alcohol.- Avoid pregnancy. Using barrier contraceptivesis adviced while taking this drug.-Always take drug with food.- Avoid driving and other dangerous activities.
CLORAZEPATE DIPOTASSIUM
Frequently administered in adjunctivetherapy for trearting partial seizures.
*SIDE EFFECTS:- drowsiness, dizziness, GI upset, fatigue,nervousness, depression, emotional changes,bedwetting, urinary incontinence.
*NURSING RESPONSIBILITIES:- Advice patient to take drug on time.- Avoid alcohol
- Avoid pregnancy. Using barrier contraceptivesis adviced while taking this drug.-Always take drug with food.- Avoid driving and other dangerous activities.
DIAZEPAM
Primarily prescribed for treating acutestatus epilepticus
Must be administed IV to achive thedesired response.
Drug has a short-term effect; otherdrugs such as phentoin andphenobarbital need to be given during
or immediately after administration ofdiazepam.
*SIDE EFFECTS:- drowsiness, dizziness, GI upset, fatigue,nervousness, difficulty concentrating.
*NURSING RESPONSIBILITIES:- advice patient to take this drug on time. Do notattempt to discontinue drug without consultingthe health care provider.- Caregiver should learn to assess seizures,administer rectal form, and monitor patient.
- Use of barrier contraceptives is adviced whileon this drug.
F.IMINOSTILBENES
Prescribed to treat grand mal seizures,complex partial seizures and statusepilepticus.
Effective in treating refractory seizuresdisorders that have not responded toother anticonvulsant therapies.
Most common drug: CARBAMAZEPINE
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Used for psychiatric disorders,trigeminal neuralgia, and alcoholwithdrawal.
THERAPEUTIC RANGE: 5-12 mcg/ml.*SIDE EFFECTS:- Drowsiness, dizziness, blurred vision, GIupset.
*NURSING RESPONSIBILITIES:- Take drug as prescribed. Swallow the tabletsin whole; do not crush, cut or chew the tablet.- Do not discontinue drug abruptly.- Avoid alcohol, sleep-inducing, or over-the-counter drugs ; these could dangerous effects.- Arrange for frequent check-ups, includingblood tests, to monitor response to drug.- Use of contraceptives at all times, is advised.-advise patient not to drive or do dangerousactivities.- Take drug with meals.
G.VALPROATE Is prescribed for petite mal, grand mal,
and mixed type of seizures.
HEPATOTOXICITY is one of thepossible adverse reactions.
THERAPEUTIC RANGE: 40-100mcg/ml.
Drug: DIVALPROEXSODIUM(Depakote)
- for treatment of manic episodes associatedwith bipolar disorder.
* SIDE EFFECTS:
- mild stomach cramps, change in menstrualcycle, diarrhea, loss of hair, indigestion,decreased appetite, nausea and vomiting,trembling in the hands and arms, and weightloss or weight gain.
Less common side effects include severestomach cramps or continued nausea andvomiting, changes in mood, behavior, orthinking, double vision or seeing spots, severefatigue ,easy bruising or unusual bleeding,yellow cast to the skin or the whites of the eyes(jaundice), odd eye movements, and increased
seizures.
*NURSING RESPONSIBILITIES:- Take this medication exactly as it wasprescribed for you. Do not take the medicationin larger amounts, or take it for longer thanrecommended by your doctor. Follow theinstructions on your prescription label.- Advice patient to increase fluid intake.- Do not discontinue abruptly.
Antiparkinsonism
Panrkinsonism -is a chronic neurologic disorder thataffects the extrapyramidal motor tract (which controlsposture, balance, and locomotion).Symptoms: (1)involuntary tremors of the limbs,(2)rigidity of muscles, and (3) slowness of movement
Levodopa + Carbidopa :MOA: CNS dopamine levelsCI: suspicious skin lesion (may activate melanoma),helanoma, MAOI useSE: Psych disturbances, orthostatic, BP, dyskinesiasDrug-Drug Interaction: Risk of hypotension withantihypersives, risk of HTN with MAOIs, effect withantacids, effect with anticholinergics andanticonvulsantsDrug-Lab: Alk phos, aspartate aminotransferase,bilirubin, BUN, uric acid, HMGNursing Intervention: Darkened urine, Sweat mayresult, N crush/chew S tabs, take with food,
muscle/eyelid twitching may suggest toxicity
Benztropine:MOA: blocks striatal cholinergic receptorsSE: Anticholinergic (tachycardia, ileus, nausea andvomiting, etc) anlydrosis, heat strokeDrug-Drug Interaction: sedation and depressanteffects with CNS depressants, anticholinergic effectwith antihistamine, phenothiazine, quinidine, effect ofdigoxin, effect of levodopa, effect with antacids andantidiarrheal drugsNursing Interaction: susceptibility to heat stroke,take with meals to avoid GI upset
Muscle Relaxant
relieve muscular spasms and painassociated with traumatic injuries andspasticity from chronic debilitatingdisorders.
Depress neuron activity in the spinalcord or brain act directly on the skeletalmuscles.
A. Spasticity results from increased muscle tone fromhyper-excitable neurons or lack of inhibition in the spinalcord or skeletal muscles. Ex: baclofenLioresal,Dantroline(Dantrium) , Tizanidine (Zanaflex).B. Muscle spasm to decrease pain and increaserange of motion. Ex: Carisoprodol(Soma),Chlorzoxazone(Paraflex), cyclobenzaprine(Flexeril),metaxalone(Skelaxin), methocarbamol(Robaxin) andOrphenedrine citrate(Norflex)
MOA: blocks interneural activity.
CI: severe liver or renal disease.
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SE : N/V, dizziness, weakness, insomnia, drowsiness,HA, light-headedness, GI sensitivity, diarrhea andabhdominal distress.
AE: Asamthic attack, tachycardia, hypotension anddiplopia.
Drug-drug interaction: increase CNS depression w/
alcohol, narcotics, sedative-hypnotics, antihistamines,tricyclic anti-depressants. May increase risk ofventricular fibrillation w/ calcium channel blockers.
Nsg Intervention:
monitor VS, serum liver enzymes levels
observe for CNS side Effects
it should not abruptly stop. Taperedover 1week.
Advise Px not to drive or use dangerousmachinery.
Inmform px that muscle relaxant usuallytaken not longer than 3weeks.
Tae meds with meals.
Avoid with alcohol and CNSdepressants
Warn px that this medication arecontraindicated with pregnant andnursing mothers.
General and local Anesthetics
GENERAL ANESTHETICS-depress the CNS-alleviate pain-cause a loss of consciousness
NITROUS OXIDE-laughing gas; first anesthetic-effective and is frequently used in dental surgeries
Balanced Anesthesia-a combination of drugs; frequently used in generalanesthesia
It includes:
Hypnotic (at night)
Premed w/ a narcotic analgesic/benzodiazepine plus an anticholinergic (given
about 1hr before surgery to secretions)
Short-acting barbiturate
Inhaled gas (often nitrous oxide & O2)
Muscle relaxant as needed
MOA:-minimizes CV problems- amt of general anesthetic needed-reduces possible postanesthetic N/V-minimizes the disturbance of organ function
- pain
Stages of General Anesthesia
ANALGESIA (Induction Stage)- begins w/ consciousness & ends w/ loss of
consciousness
- SPEECH is difficult; sensations of SMELL &PAIN are lost
- DREAMS, AUDITORY & VISUALHALLUCINATIONS may occur
Excitement or Delirium- produces loss of consciousness caused byDEPRESSION of the cerebral cortex- confusion, excitement or delirium occur-SHORT induction time
Surgical- surgery is performed usu at phase 2 & upper
phase 3*as anesthesia deepens, respirations becomeSHALLOW and RR is
Medullary Paralysis- TOXIC- respirations are lost, circulatory collapse occur- ventilator assistance is necessary
ASSESSMENT: (before surgery)
The response may differ accdg to variables r/t the healthstatus of the individual.
Age (young and elderly) Current health disorder
Pregnancy
Hx of heavy smoking
Obesity
Freq use of alcohol and drugs
Inhalation Anesthetics-used to deliver general anesthesia dur the 3rd stage ofanesthesia- provide smooth induction-usu combined w/ a barbiturate (ex. Thiopental), astrong analgesic (ex. Morphine) & a muscle relaxant
(ex. Pancuronium) for SURGICAL PROCED.
NITROUS OXIDE & CYCLOPROPANE- absorbedquickly, have rapid action, eliminated rapidly- CYCLOPROPANE is no longer used bec of its highlyflammable state as ether
Halothane, isoflurane, enflurane- 1hr for recovery ofconsciousness Desulfrane, sevoflurane- minutes for recovery
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AE: respiratory depression, hypotension, dysrhythmias,hepatic dysfunction*clients @ risk- malignant hyperthermia
Intravenous Anesthetics-used for general anesthesia/ for the induction stage-short term surgery THIOPENTAL SODIUM- ultrashort acting barbiturate
used for short term surgery; still used for rapid inductionstage and dental procedures
IV anesthetics have rapid onsets & short durations ofaction. Droperidol, etomidate, ketamine hydrochloride
MIDAZOLAM and PROPOFOL-for induction & maintenance of anesthesia-conscious sedation for minor surgery/ procedures likemech ventilation/ intubation*Clients are sedated and relaxed but is RESPONSIVETO COMMANDS
AE (IV anesthetics): respi & cardio depression; risk forbacterial infection (propofol)
Topical Anesthetics
-limited to mucous mem, broken/ unbroken skinsurfaces and burns-solution, liquid spray, ointment, cream, gel, powder- sensitive nerve endings of the affected area
LOCAL ANESTHETICS- block pain @ the site where the drug is administered
-allow consciousness to be maintained- useful in dental procedures, suturing skin lacerations,short term/minor surgery @ a localized area, blockingnerve impulses (nerve block) below the insertion of aspinal anesthetic, dx procedures (lumbar puncture andthoracentesis)-ESTERS & AMIDES; amides have a very low incidenceof allergic rxn
Short Acting:Chloroprocaine (ester)- for infiltration, caudal and epidural anesthesiaProcaine HCl (ester)- for nerve block, infiltration, epidural and spinalanesthesia**CAUTION to clients allergic to ester-type anesthetics.
Moderate Acting:Lidocaine (amide)-for nerve block, infiltration, epidural and spinalanesthesia- used to treat cardiac dysrhythmiasMepivacaine (amide)- for nerve block, infiltration, caudal and epidural
anaesthesias- may be used in dentistryPrilocaine HCl (amide)- for peri nerve block, infiltration, caudal and epiduralanesthetics- may be used in dentistry
Long Acting
Bupivacaine (amide)- for peri nerve block, infiltration, caudal and epiduralanesthesiaDibucaine (amide)- for topical use to affected area (creams, ointments)Etidocaine (amide)- for peri nerve block, infiltration, caudal and epiduralanesthesiaTetracaine (ester)- for spinal anesthesia, topical use to affected areassuch as the eye (to anesthesize cornea), to nose andthroat (for bronchoscopy), to skin (for relief of pain andpruritus)
Spinal Anesthesia- a local anesthetic injected in the SUBARACHNOIDSPACE @ the 3rd or 4th LUMBAR SPACE- may result to HEADACHE possibly bec of a in CSFpressure caused by a leak of fluid @ the needleinsertion point** Encourage client to remain FLAT in bed ff surgery &to take fluids. ( likelihood of leaking spinal fluid)
SPINAL BLOCK- penetration of the anesthetic into thesubarachnoid mem, the 2nd layer of the local anesthetic
EPIDURAL BLOCK- placement of the local anestheticin the outer covering of the spinal cord/ dura matter
CAUDAL BLOCK- placed near the sacrum
SADDLE BLOCK- given @ the lower end of the spinalcolumn to block the perineal area-usu used for women in labor dur child birth
Nursing ProcessASSESSMENT-VS-drug hx (particularly those that affect cardiopulmonarysystems)
DIAGNOSIS-Pain r/t injury- Ineffective breathing pattern r/t CNS depression
PLANNING- participate in pre-op preparation & understand post-opcare- VS will remain stable ff surgery
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INTERVENTION-Prepare client for surgery by explaining preparationsand completing the pre-op orders inclu premeds(enhance safety and effectiveness of anesthesia andsurgery)-Monitor post-op state of sensorium. Report if stillunresponsive/ confused for a time-Check pre-op and post-op urine output
-Monitor VS (hypotension and respi distress may occur)-Administer analgesic/ a narcotic analgesic w/ cautionuntil client fully recovers from anesthetic-Doses may need to be adjusted to prevent adversereactions
EVALUATION-clients response to anesthetics
Neuromuscular
Neuromuscular Disorders Myasthenia gravis
1. lack of nerve impulses and muscleresponses at the myoneural(nerves inmuscle endings) junction
2. causes fatigue and muscular weakness ofthe respiratory system, facial muscles andextremities
3. includes ptosis (drooping eyelid) anddifficulty in chewing and swallowing due tocranial nerve involvement
4. caused by inadequate or low secretion ofacetylcholine because of an increase in
enzyme acetylcholinesterase which breaksdown acetylcholine at the myoneuraljunction
Pathophysiology:
amts. Of Ach
Antibody response against alpha subunit ofAcetylcholine receptor sites (AChR) in the
skeletal muscle
Antibodies attack AChR sites
Antibodies accumulate at neuromusculartransmission
Inhibition of normal neuromuscular transmission
Ineffective muscle contraction
Acetylcholinesterase inhibitors/cholinesterase inhibitors
MOA:Prevents destruction of acetylcholine thus,
permits transmission of neuromuscularimpulses
neostigmine (Prostigmin)5. fast-acting but has a short duration with a
half-life of 0.5-1hr. Given q2-q4
pyridostigmine bromide (Mestinon)6. has intermediate action; given q3-q6
ambenonium chloride (Mylelase)7. given when client does not repond to
neostigmine and ambenonium chlorideendrophonium (Tensilon)
8. short-acting drug used to distinguishbetween Myasthenia crisis and cholinergiccrisis(both have similar symptoms)
9. after administration, if symptoms arealleviated because of increase in Ach, thecause is myasthenia crisis and if symptomsbecome severe, the cause is cholinergic
crisis.
Symptoms ofUnderdosing
Symptoms ofOverdosing
Muscle weakness Muscle weaknessDyspnea Dyspnea
Dysphagia Dysphagia
Increased salivation
bradycardia
Abdominal cramping
Increased tearing&sweating
Myasthenia crisis Cholinergic crisis
Side effects:
GI disturbances
N/VDiarrheaAbdominal cramps
Increase salivation
Tearing
Miosis (constricted pupil)
Nursing Interventions:
Assess for respirations (depth and rate) andmuscle strength
Check for liver and kidney function
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Make sure that Acetylcholinesterase inhibitors/cholinesterase inhibitors are administered ontime bec. Late administration results to muscleweakness
Avoid taking muscle relaxants
Administer drug with food to avoid GIdisturbances
Check for availability and prepare atropinesulfate(antidote) in case of overdosing
Multiple sclerosis-autoimmune disorder that attacks the myelinsheath of the nerve fibers of the brain andspinal cord which causes plaques (lesions)- symptoms include diplopia, weakness inextremities and spasticity- Lab tests mau suggest MS
Increase immunoglobulin G in cerebrospinalfluid
Increase IgG/albumin ratio
Multiple lesions observed through MRI
3 Phases1. Acute Attack- characterized by fatigue,motor weakness, optic neuritis
2. remission exacerbation- recurrence ofclinical symptoms, spasticity
3. chronic progressive- progressive MSsymptoms (wheelchair bound)
* goals for treatment strategies are todecrease inflammation process of nerve
fibers and improve conduction ofdemyelinating axons
Skeletal Muscle Relaxants1. relieve symptoms of spasticity w/c results
from increased muscle tone fromhyperexcitable neurons caused by increasedstimulation from cerebral neurons or lack ofinhibition in the spinal cord
Centrally acting Muscle relaxants2. suppress hyperactive reflex and muscle
spasms that do not respond to anti-inflammatory agents or physical therapy
3. for spasticity: baclofen (Lioresal),dantrolene (Dantrium), tizanidine (Zanaflex)and Diazepam a benzodiazepine
4. agents for muscle spasms are used todecrease pain and increase range ofmotion, ex. Carisoprodol (Soma),chlorpleresin carbamate (Maolate),chlorzoxazon (Paraflex) etc
Side effects:1. dizziness2. drowsiness
3. light headedness4. Headache5. N/V6. Diarrhea7. GI upset
Nursing Interventions:
Avoid drugs such as histamine (H2)
blocker, indomethacin, beta-blockers Avoid CNS depressants(barbiturates,
narcotics, alcohol) while taking musclerelaxants
Discourage driving and operatingmachines
(for carisoprodol)
Monitor serum liver andenzyme levels. Report elevated levelsof ALT,ALP,GGT
Tapered over 1wk. toavoid rebound spasms
Usually taken for nolonger than 3wks.
Take with food todecrease GI upset
Anti-Migraine drugs
Anti Migraine drugs
Migraine HA-unilateral throbbing head painaccompanied by N/V and photophobia-Sx frequently persist foo4-24 hrs and forseveral days in some cases-2/3 are experienced by women in their20s and 30s s-Sx usually decrease or are absentduring preg. And menopause-disrupts daily activities-Two types of Migraine: Classic migrainesand Common MigrainesClassic migraines-associated with an AURA that occursminutes to 1 hour before onset
Common migraines-NOT associated with an aura
Cluster HA-severe unilateral non throbbing painusually located around the eye-occur in a series of cluster attacks---oneor more attacks every day for severalweeks-NOT associated with an aura, do not
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cause N/V-men are more commonly affectedPreventive treatment of migraineHA
1. Beta adrenergic blockers:
Propanolol (Inderal), atenolol
(Tenormin)
2. Anti convulsants: valproic acid
(depakote), gabapentin (neurontin)
3. Tri cyclic antidepressants:
amitriptyline (elavil), imipramine
(tofranil)
Tx or cessation of a migraine attackdepends on the intensity of pain
drugs used to treat migraines include:Analgesics, opoid analgesics, ergotalkaloids, selective serotonin (5-HT)receptor agonists, also known astriptans
for mild migraine attacks: aspirin (maybe used w/ caffeine), NSAIDS s/aibuprofen or naproxen (Aleve)
Opoid analgesics: Meperidine(Demerol) and butorphanol nasal spray(Stadol NS)
Ergotamine tartrate- nonspecific serotonin agonist and
vasoconstrictor
- used to treat moderate to severe
migraine attacks
- should be taken early during the
attack
- N/V might occur (antiemeticsdecrease these sx)
- available in sublingual tablets or
with caffeine in oral tablets and
suppositories
- Dihydroergotamine (an ergot
alkaloid) can be SQ, IM, IV or nasal
spray
Triptans (5-HT receptor agonist)-Sumatriptan(Imitrex): short duration of
action, 1st
triptan drug, considered moreeffevtive than ergotamine in treatingacute migraine attacks
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