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NR 293 Exam #2 Study Guide
Resources: Pharmacology book and power point notes with notes Pseudoephedrine: contraindication Need to knowPseudoephedrine with medication teaching. Sudafed in contraindicated in patient with Dx of Hypertension. Rationale, because of the potential for vasoconstriction which could aggravate the HTN condition. Nasal Decongestant administration
- Nasal decongestants: Nose drops administration. Before administering, have the patient blow their nose before placing the drops. This allows any secretions or crust that could interfere with the distribution and absorption of the medication Diphenhydramine and side effects Its use is not advised in older adults, however, because of the “hangover” effect, increased potential for falls, and significant anticholinergic effects.
- Anticholinergic (drying) effects: most common
- Dry mouth
- Difficulty urinating
- Constipation
- Changes in vision
- Drowsiness
- Mild drowsiness to deep sleep Adrenergic drugs are usually well tolerated. Possible adverse effects of these drugs include nervousness, insomnia, palpitations, and tremor. The most common adverse effects of intranasal steroids are localized and include mucosal irritation and dryness.
Albuterol: patient teaching **** Need to know with the oral fungal: Need to teach new patient that an adverse effect of the medication is candidiasis which is a white coating in the mouth; especially with using any corticosteroid inhaler, such as Fluticasone/Salmeterol (advir)
- Teach patients to gargle and rinse the mouth with lukewarm water afterward to prevent the development of oral fungal infections.
- If a beta agonist bronchodilator and corticosteroid inhaler are both ordered, the bronchodilator should be used several minutes before the corticosteroid to provide bronchodilation before administration of the corticosteroid.
- *****Albuterol is the RESCUE Inhaler** due to the rapid onset of action (5-15 mins) - Need to KnowOften when a is prescribed Albuterol for new Dx of Asthma. RN needs to educate the patient on how to abort an Asthma attack with Albuterol Albuterol and other medications via nebulizer Need to know With using 2 medications for asthma in a nebulizer. Need to use the Albuterol 1st then use a leukotriene modifier (like cromolyn). Using the bronchodilator first to allow the airways to be open, ensuring that the max dose of the medication will get to the patient’s lungs. Status Asthmaticus: medication and nursing priority Need to know* A person who is experiencing Status Asthmaticus. With using the urgent vs non-urgent approach to patient care. The Priority action is to administer a nebulized high-dose SABA (short acting B2 agonist) to relieve bronchoconstriction and improve ventilation. This medication needs to be given via jet nebulizer
- Status asthmaticus
- Prolonged asthma attack that does not respond to typical drug therapy
- May last several minutes to hours
- Medical emergency
Asthma: theophylline and adverse effects
- Nausea, vomiting, anorexia
- Gastroesophageal reflux during sleep
- Sinus tachycardia, extrasystole, palpitations, ventricular dysrhythmias
- Transient increased urination
- Hyperglycemia
- Xanthine (zan-theen) is a bronchodilation by increasing the levels of the energy-producing substance cAMP (Cyclic adenosine monophosphate)
- Report to prescriber: Nausea, Vomiting, Restlessness, Insomnia Irritability, Tremors Asthma: montelukast granules and adverse effects
- ***Montelukast: Patient teaching regarding the medication: The medication is generally given at the night every 24 hours, with the exception if it is being used as an exercise-induced bronchospasm. It should be administered 2 hours before exercises and not again for 24 hours
- Montelukast can cause depressive & behavioral changes. SE: Headache, nausea, diarrhea Asthma attack and hypoxemia ( an abnormally low concentration of oxygen in the blood.) Need to know During an Asthma attack patient often manifests Agitation; this is expected due to the neurological changes from poor oxygen exchange.
- Commonly used during the acute phase of an asthmatic attack. They quickly reduce the airway constriction and restore airflow.
- They are agonist of the adrenergic receptors in the sympathetic nervous system.
- Imitate the effects of norepinephrine on beta receptors.
- Short-acting beta agonist (SABA) inhalers
- Albuterol (Ventolin, ProAir)
- Levalbuterol (Xopenex)
- Terbutaline (Brethine)
- Metaproterenol (Alupent)
- Long-acting beta agonist (LABA) inhalers
- Arformoterol (Brovana)
- Formoterol (Foradil, Perforomist)
- Salmeterol (Serevent) IV Theophylline
- Need to know: Theophylline should be administered slowly on an infusion pump. Rapid administration may cause hypotension and death. Example: The RN is preparing to administer the medication via IV
- Most commonly used xanthine derivative
- Therapeutic range for theophylline blood level is 10 to 20 mcg/mL
- Most clinicians now advise levels between 5 and 15 mcg/mL.
- Xanthine: relatively slow onset of action.
- Used for the preventions of asthmatic symptoms and COPD
- Not used for the relief of acute asthma attack
- Theophylline is metabolized to caffeine in the body.
- Aminophylline is metabolized to theophylline COPD and dietary teaching
- Vision that COPD is the Umbrella (chronic bronchitis, asthma, emphysema). All the 3 in the power point have one common feature; there is obstruction of airflow through the airways.
- Need to know Dietary tips/teaching: Limit water intake with meals. It prevents early satiety (feeling full) and increase intake of nutrients dense foods. Medication calculation X 3 ***Need to know Heparin dose. For example, if the doctor orders 3, units IV bolus X1 now. It domes in 5,000 units/ml. How a many units will the RN administer? 0.6 ml
DVT: heparin and warfarin Heparin is commonly used for DVT prophylaxis in a dose of 5000 units two or three times a day given subcutaneously; it does not need to be monitored when used for prophylaxis. When heparin is used therapeutically (for treatment), it is given by continuous IV infusion. Most hospitals have weight-based protocols for heparin administration. Other drugs that affect the coagulation cascade can have additive effects with heparin, which may lead to bleeding. Even though warfarin can cause additive effects, it is combined with IV heparin therapy. In fact, it is usually started within the first day or two of heparin infusion, and then heparin is discontinued once warfarin is at therapeutic levels as monitored by the INR. A patient is receiving an IV infusion of heparin and was started on warfarin therapy the night before. Which statement is most correct? A. The heparin provides anticoagulation until therapeutic levels of warfarin are reached. Heparin has a faster onset and therefore is used to provide anticoagulation until therapeutic levels of warfarin are reached. ▪ Warfarin (Coumadin) ▪ 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 3.5, depending on the indication for use of the drug (e.g., atrial fibrillation, thromboprevention, prosthetic heart valve). ▪ Variations in certain genes, CYP2CP and VKORC ▪ Many drugs’ interactions (Warfarin has significant interactions with many drugs, including amiodarone, fluconazole, erythromycin, metronidazole, sulfonamide antibiotics, and cimetidine).
▪ Dietary considerations Warfarin and artificial heart valve A normal INR (without warfarin) is 1, whereas a therapeutic INR (with warfarin) ranges from 2 to 3.5, depending on the indication for use of the drug (e.g., atrial fibrillation, thromboprevention, prosthetic heart valve ). Patients above 65 years of age may have a lower INR threshold for bleeding complications and may have to be monitored accordingly. Warfarin and dietary X 2 Because warfarin inhibits vitamin K–dependent clotting factors, foods that are high in vitamin K may reduce warfarin’s ability to prevent clots. Common foods rich in vitamin K include leafy green vegetables (e.g., kale, spinach, collard greens). The most important aspect of these food- drug interactions is consistency in diet. Educate patients to maintain consistency in their intake of leafy green vegetables. Many patients are under the misconception that they must avoid all leafy green vegetables. However, this is not true. Once their maintenance warfarin dose is established, patients may still eat greens, but they need to be consistent in their intake of green vegetables, because increasing or decreasing their intake can affect the INR. Herbal products that interact with warfarin and result in increased risk for bleeding include dong quai, garlic, and ginkgo. St. John’s wort decreases warfarin’s effect. **Propranolol contraindicated ***** Contraindicated in Asthma patients
- Other uses: prevention & management of MI, prevention of vascular HA, and Infantile hemangioma
- Off label: alcohol withdrawal, aggressive behavior, PTSD
- Nursing Assessment: Abrupt withdrawal of Propranolol may precipitate life threatening arrhythmias, hypertension, or MI NOTES:
- Asthma and Beta Blockers: Beta blockers may trigger exacerbation in vulnerable people. Caution is advised
Propranolol and anginal pectoris
- Inform patients that these medications are for long-term prevention of angina, not for immediate relief. Verapamil IV TIME/ACTION PROFILE (cardiovascular effects) ROUTE ONSET PEAK DURATION IV 1–5 min‡ 3–5 min 2 hr‡ ‡Antiarrhythmic effects; hemodynamic effects begin 3–5 min after injection and persist for 10–20 min. *****Nursing Interventions: with giving Verapamil IV, the patients’ blood pressure and pulse needs to be monitor before and during administration. -** Verapamil IV bolus - Adverse effect: Hypotension
- Commonly used for dysrhythmias
- Nursing Education: Need to avoid Grapefruit Juice. Can inhibit its metabolism. The excessive amount of medication can intensify the medication’s hypotensive effects, putting the patient at risk for syncope and dizziness.
- CCBs; Constipation is a common problem; instruct patients to take in adequate fluids and eat high-fiber foods. Verapamil (Calan, others) has actions similar to those of diltiazem in that it also inhibits calcium ion influx across the slow calcium channels in cardiac conduction tissue. This results in dramatic effects on the AV node. Verapamil is used to prevent and convert recurrent PSVT and to control ventricular response in AFL or AF. It can also temporarily control a rapid ventricular response to these frequent atrial stimulations, usually decreasing the heart rate by at least 20%. Verapamil is used not only for the management of various dysrhythmias but also to treat angina, hypertension, and hypertrophic cardiomyopathy. The contraindications that apply to diltiazem apply to verapamil as well. It is also available in both oral and parenteral forms.
Lisinopril and therapeutic effect
- ACE or a pril: there therapeutic effect of the medication is what? Decrease blood pressure
- Dry cough is very common = annoying
- Patient may need intermittent labs
- Onset is 1 hour and duration is 24 hours
- Pregnancy: Black box warning and should be avoided R/T their fetal toxicity and harmful effects in the neonate - Category C: in the 1 st trimester - Category D: 2 nd and 3 rd trimester
- Often are the 1 st line drugs efficiency and safe to use
- Can be used in Heart Failure as well
- ACE inhibitors can cause renal impairment, which can be identified with serum creatinine. - ACE inhibitors can also cause hyperkalemia , so potassium levels need to be monitored. Ferrous Sulfate X 3 Ferrous Sulfate Tablets are best given on an empty stomach with orange juice to increase the bioavailability and the absorption of the iron. Drinking the OJ will also help the GI side effects. Ferrous salts are contraindicated in patients with ulcerative colitis, peptic ulcer disease, liver disease, and other gastrointestinal (GI) disorders. Keep away from children because oral forms may look like candy. Iron dextran is contraindicated in all anemias except for iron- deficiency anemia. Instruct the patient to take liquid iron preparations through a straw to avoid staining tooth enamel. Oral forms of iron should be taken between meals for maximum absorption but may be taken with meals if GI distress occurs. Oral forms should be given with juice but not with milk or antacids.
Blood transfusion: if the hemoglobin is critical low, the patient may need a blood transfusion. Hospital have protocols with blood transfusion and the RN will need to take the patients vital signs every hour during the blood transfusion. Hgb less than 6 take note above… Angina pectoris and transdermal nitroglycerin X 2
- Nitroglycerin: several different forms:
- Transdermal: that should be applied in the morning; to a hairless spot, keep in place for 12 to 14 hours, and then remove in the evening.
- A transdermal patch must never be applied to irritated or open skin, and if the patch becomes loose, the patient needs to remove it and gently wash off the residue with lukewarm soap and water, pat the area dry, and place another patch in another area. Encourage rotation of sites to prevent irritation (with ointments, too). The prescriber may order the removal of the patch for an 8-hour period on specific days to help decrease or prevent drug tolerance, which may develop over time. Emphasize all directions/information with both written and verbal instructions.
- Nitroglycerin
- Large first-pass effect with oral forms
- Used for symptomatic treatment of ischemic heart conditions (angina)
- IV form used for BP control in perioperative hypertension, treatment of heart failure (HF), ischemic pain, pulmonary edema associated with acute MI, and hypertensive emergencies SL nitroglycerin: patient teaching X 2
- ***With sublingual nitroglycerin, the medication should be taken at the first sign of chest pain and not be delayed until the pain is severe.
- The patient should sit or lie down and take one sublingual tablet. According to current guidelines, if the chest pain or discomfort is
not relieved in 5 minutes after one dose, the patient (or family member) should call 911 immediately.
- The patient can take one more tablet while awaiting emergency care and a third tablet 5 minutes later but no more than three tablets in total. These guidelines reflect the fact that angina pain that does not respond to nitroglycerin may indicate an MI. **- ***One common side effect with patients taking SL** Nitroglycerin is HA; will be transient. The RN can suggest to the **_patient taking a mild analgesic for the HA
- *Administration guidelines for sublingual nitroglycerin_ indicate that it is appropriate to administer another tablet 5 min after the first one if the client is still reporting pain
- If anginal pain occurs:
- Stop activity and sit or lie down and take a sublingual tablet.
- If there is no relief in 5 minutes, call 911 or emergency services immediately and take a second sublingual tablet.
- If there is no relief in 5 minutes, take a third sublingual tablet.
- Do not try to drive to the hospital.
- If experiencing chest pain, the patient taking sublingual nitroglycerin should lie down to prevent or decrease dizziness and fainting that may occur because of hypotension.
- Instruct patients never to chew or swallow the sublingual form.
- Instruct patients that a burning sensation felt with sublingual forms indicates that the drug is still potent. Glass ampule Breaking an ampule. Carefully break the neck of the ampule in a direction away from you and away from others near you (p. 112). Breaking an ampule:
- Wash and sanitize your hands.
- Score the ampule if it does not have a score marking.
- Clean the ampule with an alcohol swab.
- Make sure all the liquid is in the bottle of the ampule.
Need to know Heparin dose. For example, if the doctor orders 3, units IV bolus X1 now. It domes in 5,000 units/ml. How a many units will the RN administer? 0.6 ml OTHER NOTES:
- Central acting adrenergic drugs
- Clonidine has other “off label” with Insomnia and in the withdrawal infants
- Doxazosin: trade names Cardura
- Prazosin: trade name Minipress
- Beers criteria (be careful with older people)
- Terazosin: trade name Hytrin
- Place holder
- Beta1: receptor sites in the myocardial
- Beta2: receptor sites in pulmonary, vascular, and uterine
- Metoprolol: trade name Lopressor or Toprol
- Hypertension
- Angina pectoris
- Off label: Migraine, tremors, aggressive behavior or anxiety
- Adverse reactions: Bradycardia, HF, and Pulmonary edema - A patient that is having side effects with the Metoprolol can benefit with adding a diuretic, such as Hydrochlorothiazide (HCTZ) and decrease some of the side effects.
- Atenolol:
- Hypertension, angina pectoris, and prevention of MI
- Adverse reaction: Bradycardia, HF, and Pulmonary edema
- Withhold the medications for HCTZ
- Labetalol: If HR under 50 need to hold medication and notify provider
- Carvedilol: Trade name Coreg
- If HR under 50 need to hold medication and notify provider Clonidine (Catapres): comes in a patch form; remember to remove the old patch before applying the new one *Tamsulosin is not used to control BP but is indicated solely for symptomatic control of BPH. Another off label is for Kidney stones
- Enalapril Prodrug: a drug that is inactive in its administered form and must be metabolized to its active form in the body, generally by the liver, to be effective
- ARBs II Contraindicated:
- Pregnancy and lactation
- Caution in the older adults
- Caution in patients with renal dysfunction
- Need an Apical pulse rate
- Vasodilators: Hydralazine (Apresoline)
- BiDil: Isosorbide dinitrate 20 mg and hydralazine 37.5 mg
- PO form
- FDA approved in 2005 Shown to improve patients’ survival and prolonged LOS for heart failure in the African American populace
- Isosorbide Dinitrate (Isordil)- Prophylactic management of angina pectoris
- Off label for chronic heart failure
- Sildenafil is used in the Neonatal populace Name that Artery: The heart’s much-needed oxygen supply is delivered to the heart muscle by the means of arteries (Answer: Coronary)
