HESI Pharmacology

Assess AP for a full minute; if its below 60 or above 100 then hold the drug.

What do you do before administering Digoxin?

Postive & negative

Digoxin has a _______ inotrope &_________ chronotrope.

Positive inotrope

increases force of contraction

Negative chronotrope

decreases HR

Digoxin toxicity

Lasix can cause hypokalemia, which can lead to what toxicity?

dig toxicity

A client with longterm hx use of digoxin and lasix can create a high risk of what?

0.5 - 2 ng/mL

What is the normal range for digoxin?

3.5 - 5.0 mEq/L

What is the normal level for potassium?

potassium and magnesium

What 2 electrolyte deficiency would cause a increase risk for digoxin toxicity?

Anorexia, bradycardia, HA, dizziness, confusion, nausea, and visual disturbances (blurred vision, yellow vision, and/or halo vision).

What are the S/S of digoxin toxicity?

HTN

Labetalol is a beta blocker used to tx what condition?

Notify the prescriber for the low pulse (bradycardia) and do not give the med.

Patient is about to be administered Labetalol for HTN. The nurse checks the patient's pulse and it is below 60. What step does the nurse take next?

Weight gain (fluid retention); Monitor patient's weight daily. 1 kg = 2.2 lb = 1,000 mL fluid gain or loss in 24 hours.

Major SE of labetalol? How do you assess for this?

Chest Pain

Nitroglycerin transdermal patch is for tx of.....

at bedtime to allow 8 hours without patch ( can produce tolerance in 24 hours)

When do you remove the nitroglycerin patch?

patient may use SL nitro when wearing patch if patient having chest pain.

A patient who is prescribed the nitroglycerin patch for angina is still continuing to have chest pain. What is a nursing consideration for this?

B/c it can cause severe vasodilation, decrease in BP, & intense HA.

Why wear gloves when applying a nitroglycerin patch?

They can take APAP for the HA.

What can a patient take if experiencing a HA while taking nitroglycerin?

decrease rate of nitro drip

Pt. in CCU/ICU on nitro drip; becomes hypotensive, what does the nurse do?

Yes b/c nitrates cause hypotension.

is it OK to give nitroglycerin to a patient who is hypertensive?)

blood vessels; blood vessels & heart

CCB "dipines" affect the ______ only. While CCBs Verapamil & diltiazem affects the _________ & ________.

vasodilation

CCBs "dipines" causes ?

vasoconstriction

CCBs Verapamil & diltiazem causes?

dizziness, facial flushing, hypotension, edema, constipation

SE of CCBs

Monitor HR, BP. Avoid grapefruit juice.

Nursing considerations CCBs

HTN

Aliskiren (Tekturna) is a direct renin inhibitor that tx for?

1. Don't take if pregnant (Stop drug is become pregnant).

2. Don't take with high fat meal.

3. May increase potassium so don't take with other drugs that increase potassium.

Teaching for Aliskiren (Tekturna)?

pulmonary edema

Lasix is a loop diuretic that used for rapid diuresis in emergencies. It tx for....

Asses for muscle cramps, and muscle weakness.

Lasix may produce hypokalemia. How do you assess for this?

Hypokalemia, hypotension, F/E abnormalities, and dehydration, dizziness, HA, tinnitus, N/V/D, hypokalemia, ototoxicity with aminoglycosides (-mycin).

SE of lasix

1. Avoid taking lasix with aminoglycosides due to potential risk of ototoxicity.

2. Pt may need to be potassium supplements.

Lasix nursing considerations.

Dried fruits, fish, leafy veggies, squash, beans, meats, nuts, bananas, potatoes, dairy products.

Foods containing potassium....

1. assess overall condition of the veins. Use large vein, like antecubital (AC) vein when administering potassium.

2. Venous access is important because IV potassium can irritate the vein.

3. Have patient notify nurse immediately if burning at site. IV K+ extravasation can cause necrosis of tissues.

4. Calculate and set the rate as ordered, know anticipated duration of therapy.

5. Know restrictions imposed by patient's history.

6. Don't give IV push; use at a rate no greater than 10 mEq/hr for peripheral IV and 20 mEq/hr for central line. Always use infusion pump.

7. Assess IV site every hour.

8. Treatment of hypokalemia adults IV: 10-20 mEq/dose (maximum 40 mEq/dose) to infuse over 2-3 hr (maximum infusion rate: 40mEq/hr)

IV potassium KCL nursing considerations

Elderly

Antihypertensive effects are more pronounced in the

ACE inhibitors (-pril), aldosterone antagonists (-one), direct renin inhibitor Aliskiren (Tekturna)

Which antihypertensives will raise potassium?

Osmitrol (Mannitol)

This Osmotic diuretic effectiveness is determined by ↓ ICP. NOT used for peripheral edema; used to treat pt. with closed head injury; effective response is decreased ICP.

Potassium Sparing Diuretics

Spironolactone (Aldactone), amiloride (Midamor); triamterene (Dyrenium) are all in what class of drugs?

potassium-sparing diuretic

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

atorvastatin (lipitor), rosuvastatin (Crestor), fluvastatin, lovastatin, simvastatin, pravastatin.

Statin drugs include....

HDL should increase; LDL and total cholesterol decrease.

How do you evaluate effectiveness of statin drugs?

Check LFTs due to risk of hepatotoxicity risk & CK for any c/o of muscle pain.

What labs should be routinely checked during Statin therapy?

1.) Take lovastatin with evening meals. 2.) All other statins can be taken without regards to meals. 3.) Dosing in the evenings is preferred for all satins. 4.) Take with at least 6 oz. of water. 5.) Take with food to decrease GI distress. 6.) Avoid alcohol 7.) Avoid foods that are high in fats 8.) Increase fiber in diet due to constipation SE.

Statin Teaching diet.

Vasoconstriction

Alpha 1 stimulation causes

heart ("1 heart")

Beta 1 causes stimulation of the

lungs ("2 lungs")

Beta 2 causes stimulation of the

Mydriatics

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

Tamsulosin (Flomax)

alpha1 adrenergic blocker; ↓ smooth muscle contraction of prostate capsule and bladder neck. Used for treating sx of BPH.

Antihypertensives

Alpha 1 blockers -zosin have what kind of indication?

1) dopaminergic activation; 2) Shock; 3) renal

The effects of ___(1)___ activation causes dilation of the renal vasculature; this effect is exploited in the treatment of ___(2)___; by dilating ___(3)___ blood vessels, we can improve renal perfusion and can thereby reduce the risk of renal failure.

Dopamine

Which drug is the only drug available that can activate dopamine receptors?

Cardiac performance (because it actives beta1 receptors in the heart.)

When dopamine is given to treat shock, the drug also enhances? why?

epinephrine, norepinephrine, dopamine, dobutamine, etc.)

What are some names Catecholamines drugs?

Extravasation

Catecholamines must be watched carefully for what?

1) sloughing 2) necrosis 3) infiltrated 4) saline 5) hypodermic 6) hyperemic 7) 12 hours

The FDA has this to say about treating dopamine extravasation: To prevent ___(1)___ and ___(2)___ in ischemic areas, the area should be ___(3)___ as soon as possible with 10 to 15 mL of ___(4)___ solution containing 5 to 10 mg of Regitine (brand of phentolamine), an adrenergic blocking agent. A syringe with a fine ___(5)___ needle should be used, and the solution liberally infiltrated throughout the ischemic area. Sympathetic blockade with phentolamine causes immediate and conspicuous local ___(6)___ changes if the area is infiltrated within ___(7)___ hours. Therefore, phentolamine should be given as soon as possible after the extravastation is noted.

Epi-Pen

This Epinephrine Auto Injector is a single dose of epinephrine that can be injected (IM) into the middle of the outer thigh (even through clothes). Seek emergency medical treatment immediately.

increase in heart rate, stronger or irregular heartbeat, sweating, nausea or vomiting, difficulty breathing, paleness, dizziness, weakness, shakiness, headache, apprehension, nervousness or anxiety.

SE of Epi-Pen (Epinephrine Auto Injector): These side effects may go away if patient rests.

Sympathomimetic

Remember that many decongestants and bronchodilators have _________ effects (adrenergic effects). SE include ↑ HR, nervousness, insomnia, etc.

β1

Bronchodilators that stimulate β2 receptors can also stimulate _______ if dose is high enough (loses selectivity).

1) Teach how to avoid bleeding: soft toothbrush, electric razor, don't go without shoes, etc.; 2) Teaching maintain vitamin K foods (greens- spinach, mustard greens, swiss chard, etc.) in diet (don't increase or decrease); 3) PT/INR monitored routinely 4) avoid activities that may cause bleeding.

Patient is discharged on warfarin (Coumadin), what are some teaching instructions for the patient?

1) claudication 2) ischemic

Pentoxifylline (Trental) for intermittent ____(1)____ (like cilastozal [Pletal]) - treats ____(2)____ pain.

Prasugrel (Effient)

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

Clopidogrel (Plavix)

An antiplatelet that reduces MI, stroke, or vascular death w/ PAD; notify health care provider of drug regimen prior to surgery; may need to hold any anticoagulants/antiplatelet drugs

Enoxaparin (Lovenox)

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

NOT

Heparin sodium for injection is not same as hep-lock solution. They are _____ interchangeable.

1) 10 2) 100

Concentration of hep-lock solution is either __(1)__ units/mL or __(2)__ units/mL.

1) 10,000 2) 20,000 3) 50,000

Concentration for heparin injection is ___(1)___ units/mL or ___(2)___ units/mL or even ___(3)___ units/mL.

Heparin

is high-alert medication - requires another nurse to check dosage. Bleeding is potential SE. Protamine sulfate is antidote/reversal agent.

Bivalirudin (Angiomax)

Anticoagulant therapy indicated for patients with unstable angina undergoing percutaneous transluminal coronary angioplasty (PTCA). IV administration only. Is intended to be used in patients on aspirin therapy (receiving concomitant aspirin). Use in patients who do or do NOT have HIT: IV bolus of 0.75 mg/kg followed immediately by an infusion of 1.75 mg/kg/hr for the duration of the PTCA procedure. If pt does NOT have HIT, 5 minutes after bolus dose, an activated clotting time (ACT) should be performed; give an additional bolus of 0.3 mg/kg if needed.

Chronic

MS Contin (morphine continued release) tx for ______ pain.

Opioids (morphine, hydrocodone, oxycodone, hydromorphone [Dilaudid] codeine)

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

Fentanyl Patch

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

Methadone (Dolophine)

treatment of breakthrough pain. Half-life is longer than duration of action. With repeated doses drug accumulates in the tissues, which is then slowly released. Allows for 24-hour dosing.

Meperidine (Demerol)

is an opioid analgesic that may be used for treating the acute pain of pancreatitis.

1) vital signs 2) sedatives 3) extremities 4) "Epidural Only"

Epidural pump priority- monitor ___(1)___ every 15 minutes; do not administer other ____(2)____; be sure feeling/function has returned to lower ____(3)____ before returning pt. to floor. Label epidural tubing as "____(4)_____"!

Acetaminophen (Tylenol)

Nonopioid analgesic. Not an NSAID (no anti-inflammatory properties). Maximum daily dose 4,000 mg; 3,000 mg for elderly and those with liver disease. LT use can produce nephrotoxicity. Overdose/frequent use can produce hepatotoxicity. Sx of hepatotoxicity include jaundice, abdominal pain, clay-colored stools, dark urine. Antidote: acetylcysteine (Mucomyst).

Aspirin (ASA)

Caution with PUD, children under 18 with recent viral illness (Reye's syndrome), interacts with other antiplatelets, anticoagulants, NSAIDs, etc. (bleeding)

Pregabalin (Lyrica)

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

Ketorolac (Toradol)

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

anti-inflammatory, analgesic (mild to moderate pain), antipyretic, dysmenorrhea, treatment of RA, OA, GA; Aspirin also antiplatelet effects (prior stroke, MI);

NSAID therapeutic uses

renal

NSAIDs are contraindicated with patients who have _________ impairment.

antacids

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

1) LFTs 2) stroke 3) MI 4) GI 5) Anemia

Diclofenac (Zipsor) NSAID; also can increase __(1)__ (hepatotoxicity). Like other NSAIDs, may increase risk of __(2)__ and __(3)__. SE as other NSAIDs, including __(4)__ bleeding. Check for __(5)___.

GI Bleeding

Coffee-grounds emesis (vomitus) may indicate?

NSAIDs

What class of drugs are the first-line therapy for gout?

allopurinol, colchicine, probenecid.

What class of drugs are the second-line agents for gout?

Allopurinol

Second line agent for tx of gout; prevents uric acid production; SE: agranulocytosis, Stevens-Johnson syndrome (notify MD if rash develops).

Colchicine

Second line agent for tx of gout; Reduces inflammation response; SE: GI/GU bleeding (monitor CBC).

Probenecid

Second line agent for tx of gout; increases excretion of uric acid; don't use with renal impairment.

Albuterol (Proventil, Ventolin), levalbuterol (Xopenex), pirbuterol (Maxair) short-acting Beta2 agonists (SABA)

Should be used during acute asthmatic episodes, not long term use (See sympathomimetic/adrenergic effects). Assessment is for improved breathing; open airway. Also may stimulate the heart - increased HR, nervousness, etc. Use cautiously in pts. with cardiovascular disorders, including ischemic heart disease, hypertension, or cardiac arrhythmias, in patients with hyperthyroidism or diabetes mellitus, and in patients who are unusually responsive to sympathomimetic amines or who have convulsive disorders. Avoid use with beta blockers.

Topical/inhaled adrenergics (decongestants)

use no longer than 3-5 days; can produce rebound congestion.

Fluticasone and salmeterol (Advair) inhaler

use only BID (not more often; can ↑BP); fluticasone is glucocorticoid for prevention of acute asthma (not for acute episode).

Tiotropium (Spiriva)

bronchodilator used in LT maintenance of COPD; given by inhaler; rinse mouth after inhaler use

Ease of breathing and decreased wheezing.

Bronchodilators should produce ease of ________ and decreased ________.

1) 1 to 2 minutes; 2) bronchodilator; 3) 2 to 5 minutes;

When using an inhaler, make sure to wait ___(1)___ in between puffs of same drug. If using 2 different drugs make sure use ___(2)___ first then glucocorticoids or anti-inflammatory → wait ___(3)___ between inhalation of the medication.

Montelukast (Singulair)

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

Antihistamines (eg. diphenhydramine [Benadryl])

This class of drugs decrease nasopharyngeal secretions by blocking H1 receptors; use cautiously with elderly; major SE is sedation. Use cautiously with COPD, asthma, pneumonia.

Theophylline (methylxanthine bronchodilator)

TheoDur, Theo-24, Uniphyl; indicated for treatment of COPD. IV form (aminophylline) for status asthmaticus. Severe wheezing from bronchial constriction. Avoid caffeinated beverages, as caffeine is a methylxanthine. Monitor plasma drug level. Toxicity can produce life-threatening dysrhythmias.

Glucocorticoids → Prednisone (Deltasone), prednisolone (Orapred, Pediapred), methylprednisolone (Solu-Medrol), triamcinolone (Kenalog).

This drug class of anti-inflammatories: highest priority assessment is risk of infection (R/T immunosuppression). SE: Cushing syndrome (moon face, hump back, hirsutism, weight gain, etc.). Increased risk of infection (immunosuppression); thin, fragile skin; hyperglycemia; osteoporosis; steroid psychosis (euphoria); stunts bone growth in children.

Adrenal Insufficiency

SE of LT glucocorticoid use can cause SE such as Cushing syndrome (moon face, hump back, hirsutism, weight gain, etc.). Increased risk of infection (immunosuppression); thin, fragile skin; hyperglycemia; osteoporosis; steroid psychosis (euphoria); stunts bone growth in children. But it can also cause _________ [which can be life-threatening]; be sure to taper steroids rather than discontinuing abruptly (adrenal crisis); need stress dosing of steroids when hospitalized (be able to identify glucocorticoids by their names, like prednisone -sone, -cort, -methasone, -nisolone).

Replacement therapy (levothyroxine)

Hypothyroidism treatment is?