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NR 293 Exam 3 Study Guide
Alpha 2 -adrenergic receptor stimulators (agonists)/clonidine o Stimulate alpha2-adrenergic receptors in the brain o Decrease sympathetic outflow from the CNS, decrease norepinephrine production o Stimulates alpha2-adrenergi receptors, thus reducing renin o Examples: Clonidine (Catapres), Methyldopa (aldomet): used for pregnant women w/htn Alpha 1 -blockers/”azosin,” o Block alpha 1 -adrenergic receptors o Management of severe heart failure (HF) when used with cardiac glycosides and diuretics o Some used to relieve symptoms of BPH- increase urinary flow rate o Example: “ Azosin” (dox azosin (Cardura) o Adverse Effects : Serious: hypotension (first dose) syncope Common: dizziness o Nursing implications: instruct pt. to lie down after taking first dose because they may become dizzy Beta-blockers “olol”: First-line treatment for heart failure & HTN o Reduce BP by reducing heart rate through beta 1 blockade (block receptors for norepinhrine) o Cause reduced secretion of renin o Long-term use causes reduced peripheral vascular resistance o Adverse Effects: orthostatic hypotension, bradycardia w/ reflex tachycardia , sexual dysfunction in men, possible hypoglycemia or hyperglycemia Angiotensin-converting enzyme inhibitor, “pril” Captopril o Mechanism of Action: Inhibit angiotensin-converting enzyme, which is responsible for converting angiotensin I (through the action of renin) to angiotensin II Angiotensin II is a potent vasoconstrictor and causes aldosterone secretion from the adrenal glands Result in decreased systemic vascular resistance (afterload), vasodilation, and therefore decreased blood pressure o Indications: First-line treatment for heart failure & HTN HF (either alone or in combination with diuretics or other drugs)
Slow progression of left ventricular hypertrophy after MI (cardio protective) Renal protective effects in patients with diabetes Captopril and lisinopril can be used if a patient has liver dysfunction, unlike other ACE inhibitors that are pro-drugs *Pro-drugs are inactive in their administered form and must be metabolized in the liver to an active form so as to be effective o Adverse Effects: hyperkalemia & dry, nonproductive cough o Serious drug interaction: NSAIDs Angiotensin II receptor blocker “sartan” losartan (Dovan) o Mechanism of Action: Allow angiotensin I to be converted to angiotensin II, but block the receptors that receive angiotensin II Block vasoconstriction and release of aldosterone Well tolerated, do not cause a dry cough Indications: first-line treatment for heart failure & HTN o Adverse Effects: URI, headache May cause occasional dizziness, inability to sleep, diarrhea Calcium channel blockers: Amlodipine “dipine” verapamil (calan), diltiazem (cardizem) o Mechanism of Action: cause smooth muscle relaxation by blocking the binding of calcium to its receptors, preventing muscle contraction o Adverse effect: constipation High-fiber diet with plenty of fluids will help prevent constipation o Indications: hypertension Angina- ch. 23 Ischemia: o Ischemic heart disease: Poor blood supply to the heart muscle (Atherosclerosis, Coronary artery disease) o Myocardial infarction (MI): Necrosis, or death, of cardiac tissue, disabling or fatal Therapeutic Objectives o Minimize the frequency of attacks and decrease the duration and intensity of anginal pain o Improve the patient’s functional capacity o Prevent or delay the worst possible outcome: MI Cardiac glycosides: Digoxin o Therapeutic level: between 0.5-2ng/mL
Take medications as scheduled and not to skip doses or double up for missed doses Contact their physician for instructions if a dose is missed Notify health care provider of any worsening of dysrhythmia or toxic effects Nitrates and nitrites: Nitroglycerin o Prototypical nitrate o Large first-pass effect with oral forms o Used for symptomatic treatment of ischemic heart conditions (angina) o IV form used for BP control in perioperative hypertension, treatment of HF, ischemic pain, pulmonary edema associated with acute MI, and hypertensive emergencies o Adverse effects: headaches Reflex tachycardia Postural hypotension Tolerance may develop o Tolerance Occurs in patients taking nitrates around the clock or with long- acting forms Prevent tolerance by removing patch at bedtime for 8 hours, then apply a new patch in the morning o Nitroglycerin Nursing implications: If the chest pain is not relieved after one tablet, call 911 immediately. Never to chew or swallow the sublingual form Non-polyvinylchloride (non-PVC) plastic intravenous bags and tubing must be used when giving IV nitroglycerin Burning sensation felt with sublingual forms indicates that the drug is still potent Proper application of nitrate ointments and transdermal forms, including site rotation and removal of old medication before new dose is applied. Instruct patients to take PRN nitrates at the first hint of anginal pain Antidysrhythmia patient implications: Do not chew or crush ER meds If GI distress occurs take the drug with food Limit or avoid the use of caffeine Chapter 28 Loop diuretics: furosemide (Lasix) o Mechanism of Action:
Rapid onset of action and cause rapid diuresis Act directly on the ascending limb of the loop of Henle to inhibit chloride and sodium resorption Increase renal prostaglandins-dilation of blood vessels o Examples: Bumetanide (Bumex), furosemide (Lasix) o Indications: Edema associated with HF or hepatic or renal disease, HTN Hypercalcemia: increase renal excretion of calcium o Adverse effects: FDA warning: Fluid and electrolyte depletion Serious: severe hypokalemia, bone marrow suppression Common: dizziness, hypotension, hyperglycemia. Osmotic diuretics: mannitol (Osmitrol) o Mechanism of Action/Drug Effects Intravenous infusion only, filter is required Works in the proximal tubule, no absorbable, producing an osmotic effect Pull water into the renal tubules from the surrounding tissues o Indications: reduces intracranial pressure, treatment of cerebral edema o Acute renal failure: early, oliguric phase o Adverse Effects: convulsions, thrombophlebitis, pulmonary congestion Potassium-sparing diuretics: Spironolactone (Aldactone) o Also known as aldosterone-inhibiting diuretics o Mechanism of Action: Competitively bind to aldosterone receptors Block resorption of sodium and water Interfere with sodium-potassium exchange o Indications: hypertension, hyperadlosteronism o Adverse effects: hyperkalemia, GI cramping Thiazides and thiazide-like diuretics: “ Thiazide” hydrochlorothiazide (HydroDIURIL) o Mechanism of Action: Inhibit tubular resorption of sodium, chloride, and potassium Dilate the arterioles by direct relaxation Not be used if creatinine clearance is less than 30 to 50 mL/min (normal is 125 mL/min) o Indications: hypertension (first line for HTN) & edematous states o Interaction: digitalis (digoxin) o Adverse effects: hypokalemia, electrolyte imbalance, & bone marrow
o Mechanism of action: increase activity of lipase, which breaks down lipids Effective in lowering triglyceride, total serum cholesterol, and LDL levels, increases HDL levels o Adverse Effects: hepatotoxicity, cutaneous flushing, pruritus, GI distress, hyperuricemia o Nursing implications: Small dose of aspirin or may be taken 30 minutes before niacin to minimize cutaneous flushing Fibric acid derivatives and cholesterol absorption inhibitor (fibrates) o Mechanism of Action: believed to work by activating lipase, which breaks down cholesterol o Examples: gemfibrozil (Lopid), fenofibrate (Tricor) o Adverse Effects: diarrhea, myopathy, rhabdomyolysis, increased risk of gallstones, liver enzyme levels increase, abdominal discomfort, prolonged prothrombin time o Interactions: Oral anticoagulants and Statins (Risk for myopathy is increased) Laboratory test reactions: (lactate dehydrogenase level, Decreased H/H, wbc, Increased aPTT, and bilirubin level) Nursing Implication for all of Chapter 27: o Monitor for liver dysfunction o Report abnormal/unusual bleeding or yellow discoloration of skin, report muscle pain immediately, & eat extra servings of raw veggies and fruit Chapter 31 Levothyroxine o Mechanism of Action: replace what the thyroid gland cannot produce to achieve normal thyroid levels (euthyroid) o Indications: to treat all three forms of hypothyroidism. Levothyroxine is the preferred drug because its hormonal content is standardized. o Adverse effects: tachycardia, palpitations, angina o Nursing implications: don’t switch pharmaceutical brands Tapazole, PTU o Treatment: Antithyroid drugs- thioamide derivatives Methimazole (Tapazole) Propylthiouracil (PTU) Decrease formation of thyroid hormone o Adverse effects: decreased WBC count, liver and bone marrow toxicity Nursing implication: Better tolerated when given with food
Give at the same time each day to maintain consistent blood levels Never stop these medications abruptly Avoid eating foods high in iodine (seafood, soy sauce, tofu, and iodized salt) Assess Drug allergies, contraindications, potential drug interactions Baseline vital signs, weight Cautious use advised for those with cardiac disease, hypertension, and pregnant women During pregnancy, Fetal growth may be retarded if maternal hypothyroidism is untreated during pregnancy o Need to adjust the dosage every 4 weeks to keep TSH at the lower end of the normal range Chapter 32 Insulin: onset/peak Humulin R/glargine o Short-acting Regular insulin (Humulin R) Onset 30 to 60 minutes; Duration: 6-10 hr Only regular insulin can be given IV o Long-acting Onset 1-2 hr, Duration: 24 hr Clear, colorless solution Usually dosed once daily, referred to as basal insulin Examples: Glargine (Lantus), detemir (Levemir) Sulfonylureas: Glipizide (glucotrol) o Mechanism of action Stimulate pancreas to secretion insulin (Beta cell function?) result in lower blood glucose levels o Examples: Second generation: glipizide (Glucotrol) , glyburide (DiaBeta, Micronase) glimepiride (Amaryl), o Adverse effect: The most common: Hypoglycemia, weight gain Others: hematologic effects, nausea, epigastric fullness, heartburn, many others o Contraindication: Hypoglycemia, limited caloric intake, allergic to sulfa Glinides “Glinide”: Repaglinide (Prandin)
o Mechanism of action Decrease food absorption Reduce fasting and postprandial glucose concentrations o Adverse effects: FDA: postmarketing cases of acute pancreatitis Hypoglycemia can occur and is more common if used in conjunction with a sulfonylurea o Chapter 33 Glucocorticoids/ Mineralocorticoid o Adrenal steroid Glucocorticoids (Antinflammatory or immune suppressant) Fluticasone propionate, dexamethasone, hydrocortisone (several formulations), cortisone, methylprednisolone (Solu- Medrol), prednisone (Deltasone, Sterapred, Liquid Pred), Triamcinolone o Mineralocorticoid (replacement therapy) Fludrocortisone (Florinef) o Mechanism of Action: Most corticosteroids exert their effects by modifying enzyme activity Glucocorticoids differ in their potency, duration of action, and the extent to which they cause salt and fluid retention Glucocorticoids inhibit or help control inflammatory and immune responses o Indications: wide variety of indications Adrenocortical deficiency, cerebral edema, collagen diseases, dermatologic diseases, GI diseases, exacerbations of asthma & COPD, organ transplant, management of leukemia and lymphomas, spinal cord injury o Contraindications: Drug allergies Serious infections, including septicemia, systemic fungal infections, and varicella However, in the presence of tuberculosis meningitis, glucocorticoids may be used to prevent inflammatory CNS damage Cautious use in patients with Gastritis, reflux disease, peptic ulcer disease Diabetes Cardiac/renal/liver dysfunction o Adverse effect: hypokalemia (glucocorticoid) Cardiovascular: heart failure, cardiac edema, electrolyte imbalances CNS: convulsion, headache, vertigo, steroid psychosis
Endocrine: growth suppression, cushing’s syndrome, menstrual irregularities o Nursing Implications: Perform a physical assessment to determine Baseline weight, height, intake and output status, vital signs (especially BP), hydration status, immune status Baseline laboratory studies Edema and electrolyte imbalances Be aware that these drugs may alter serum glucose and electrolyte Oral form should be given with food/milk to decrease GI upset Clear nasal passages before giving a nasal corticosteroid Can be given orally, IM, IV, or rectal routes Instruct patient to rinse mouth to prevent possible oral fungal infections Sudden stop can cause adrenal crisis caused by a sudden drop in serum levels of cortisone Chapter 50 Acid-controlling drugs: Antacids (along vs. combination) indication, contraindication, Aluminum salts/Magnesium salts/Calcium Salts/Sodium Bicarbonate o Mechanism of Action: neutralize acid secretions, & neutralize pH Do not prevent the overproduction of acid o Promote gastric mucosal defensive mechanisms Stimulate secretion of: Mucus, Bicarbonate, and prostaglandins. o Reduction of pain associated with acid-related disorders Raising gastric pH 1 point (1.3 to 2.3) neutralizes 90% of the gastric acid Reducing acidity reduces pain as a result of: o Aluminum Salts Stays in the GI tract, only Give patient who have kidney dysfunction so does not effect kidney o Magnesium Salts Major and Common side effect diarrhea Dangerous when used with renal failure—the failing kidney cannot excrete extra magnesium, resulting in accumulation Hydroxide salt: magnesium hydroxide (Milk of Magnesia) o Calcium Salts May cause constipation, do not give pt. who has kidney stones Also not recommended for patients with renal disease—may accumulate to toxic levels
Mechanism of Action: the parietal cells release positive hydrogen ions (protons) during HCl production Major effect is osteoporosis for long term use Indications: GERD, Erosive esophagitis, Stress ulcer prophylaxis, Treatment of Helicobacter pylori–induced ulcers, given with an antibiotic, NSAID–induced ulcers, etc. Adverse Effects: PPIs are generally well tolerated Possible predisposition to GI tract infections (C. diff) Osteoporosis in long-term users (FDA regulated, use for one month) Nursing Implication: Assess for allergies and history of liver disease Not all are available for parenteral administration May increase serum levels of diazepam and phenytoin; may increase chance for bleeding with warfarin The granules of pantoprazole capsules may be given via nasogastric (NG) tubes, but the NG tube must be at least 16 gauge or the tube may become clogged Capsule contents may be opened and mixed with apple juice, but do not chew or crush delayed-release granules o Miscellaneous acid-controlling drugs: Sucralfate (Carafate) Cover on the GI system Attracted to and binds to the base of ulcers and erosions, forming a protective barrier over these areas Protects these areas from pepsin, which normally breaks down proteins (making ulcers worse) o Little absorption from the gut o May cause constipation Misoprostol Prostaglandins have cytoprotective activity o Protect gastric mucosa by enhancing local production of mucus or bicarbonate o Promote local cell regeneration, maintain mucosal blood flow Used for prevention of NSAID-induced gastric ulcers Simethicone Used to reduce intestinal gas (flatulence) Breaking gas bubbles into smaller ones Result is decreased gas pain and increased expulsion o Nursing Implication Assess
For allergies and preexisting conditions that may restrict the use of antacids, such as: Fluid imbalances, renal disease, or GI obstruction Heart failure (HF) Patients with heart failure or hypertension should not use antacids with high sodium content Pregnancy Instruct patient (antacids) Be sure that chewable tablets are chewed thoroughly, and liquid forms are shaken well before giving Administer with at least 8 ounces of water to enhance absorption (except for “rapid-dissolve” forms) Long-term self-medication with antacids may mask symptoms of serious underlying diseases, such as malignancy or bleeding ulcers If symptoms remain ongoing, patient should seek medical evaluation Chapter 51
1. Antidiarrheals Adsorbents: bismuth subsalicylate (aspirin in it) o Adsorbents Mechanism of Action Coat the walls of the gastrointestinal (GI) tract Bind to the causative bacteria or toxin, which is then eliminated through the stool Examples: bismuth subsalicylate (Pepto -Bismol), activated charcoal, aluminum hydroxide, others o Can absorb all the stool and the water to make it more concentrated. Pepto bismol is OTC. Not for pediatric patients Adverse effects: Serious: Increased bleeding time Commons: Constipation, dark stools Others: Confusion, Tinnitus, Metallic taste, blue tongue Drug interactions: warfarin Anticholinergics: Belladonna alkaloid combinations Mechanism of Action Decrease intestinal muscle tone and peristalsis of GI tract Decrease motility Result: slows the movement of fecal matter through the GI tract Belladonna alkaloids
Adverse effects: abdominal bloating, electrolyte imbalances, rectal irritation o Saline laxatives: magnesium salts (milk of magnesium) Increase osmotic pressure, causing more water to enter the intestines, Results in bowel distention, increased peristalsis, and evacuation Acute constipation Adverse effects: Magnesium toxicity (with renal insufficiency) Not for pt. with kidney disease Cramping, diarrhea o Stimulant laxatives: bisacodyl (Dulcolax) Increases peristalsis via intestinal nerve stimulation Acute constipation, diagnostic and surgical preps Senna (Senekot), bisacodyl (Dulcolax) Adverse effects: Nutrient malabsorption, electrolyte imbalances, rectal irritation *Give bisacodyl with water because of interactions with milk, antacids, and juices o Nursing Implications Obtain a thorough history of presenting symptoms, elimination patterns, and allergies Assess fluid and electrolytes before initiating therapy Instruct patients: A healthy, high-fiber diet and increased fluid intake should be encouraged Long-term use of laxatives often results in decreased bowel tone and may lead to dependency Chapter 52 Anticholinergics : Scopolamine (Transderm-Scōp) o Mechanism of action: bind to and block acetylcholine (ACh) receptors in the inner ear labyrinth o Nursing implications: change patch every 3 days Antihistamines : Meclizine (Antivert), Benadryl o Mechanism of action: Inhibit ACh by binding to H 1 receptors, prevent cholinergic stimulation in vestibular and reticular areas, o Indications: used for motion sickness, allergy symptoms, sedation o Nursing implications: avoid driving because of possible dizziness Antidopaminergics : prochlorperazine (Compazine) o Mechanism of action: block dopamine receptors in the CTZ o Indications: used for psychotic disorders, intractable hiccups o Examples: promethazine (Phenergan)
Give IV push, be careful can make blood vessel constrict and block the circulation. Dilute 20cc of saline for 15 min. Do not want to end up with necrosis. Start very slow!! Stop if burning or hurting!! Droperidol: use is controversial because of associated cardiac dysrhythmia Prokinetic: metoclopramide (Reglan) o Mechanism of action: block dopamine receptors in the CTZ, CTZ to be desensitized to impulses it receives from the GI tract o Also stimulate peristalsis in GI tract, enhancing emptying of stomach contents o Indications: used for gastroesophageal reflux disease (GERD), delayed gastric emptying Long-term use may cause irreversible tardive dyskinesia o Contraindications: hypersensitivity to procaine Serotonin blockers: “setron” ondansetron (Zofran)/ Granisetron (Hytril) o Block serotonin receptors in the GI tract, CTZ, and VC o Used for nausea and vomiting in patients receiving chemotherapy and for postoperative nausea and vomiting o Adverse effects: diarrhea Nursing Implication: o Many of these drugs cause severe drowsiness; warn patients about driving or performing any hazardous tasks o Taking antiemetics with alcohol may cause severe CNS depression o Teach patients to change positions slowly to avoid hypotensive effects o For chemotherapy, antiemetics are often given 30 to 60 minutes before chemotherapy begins
