BSN-2H Pharma Notes

8/6/2019 BSN-2H Pharma Notes

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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


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


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

ito lang nakuha ko sa book e :|

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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BSN-2H Pharma Notes

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