pharm exam 2

What causes cancer?

• genetics

• viruses

• immune suppression

• carcinogens

  • environmental

  • dietary

  • lifestyle

factors affecting response to chemotherapy

• types of neoplasm

  • hematologic mealignancies vs solid neoplasms

• characterisitcs of tumor

  • location

  • size/ tumor burden

  • growth rate

  • presence of resistant cells

  • ratio of sensitivity of malignant cells and normal target cells

  • adequate blood supply with adequate drug uptake

• characterisitics of client

  • physical status

    • performance

    • age

    • co-morbidities

    • prior therapies

  • psychological status

  • social support

  • socioeconomic issues

    • nutrition

    • living conditions

    • expense of treatment

goals of cancer treatment

• cure

• control

• palliation

cancer treatment options

• hormone therapy

• surgery

• bone marrow transplant

• chemotherapy

• targeted therapy

• radiation therapy

• immunotherapy

combination chemotherapy

• different therapies affect cancer cells differently

• decreases drug resistance

• enhances tumoricidal effect

• reduces drug toxicity

Cell cycle non specific drugs

• act during any phase of the cell cycle, including the Go (resting) phase.

Cell cycle specific drugs

• exert their influence during a specific phase of the cell cycle

• are most effective against rapidly growing cancer cells

Alkylating agents

• cell cycle non specific

• treat cancer

• hematologic malignancies

  • leukemia

  • lymphoma

  • multiple myeloma

• solid tumors

  • breast

  • lung

  • ovarian

  • bladder

  • uterus

• MOA: kill fast growing cancer cells by altering DNA structure and preventing cell reproduction

Anti-metabolites

• S-phase

• cancer treatment

• most effective againts hematologic malignancies:

  • leukemia

  • lymphoma

  • myelodysplastic syndrome

• effective against solid tumors:

  • breast

  • head and neck

  • osteosarcoma

• MOA: interferes with DNA synthesis

cyclophosphamide (Cytoxan)

• MOA: prevents cell division

• cell cycle non specific

• oral or IV

• severe vesicant

• hydration is imperative to prevent hemorrhagic cystitis

  • administer in AM, void before bed

  • monitor for blood in urine

  • can give MESNA as a cytoprotectant to prevent hemorrhagic cystitis

• other adverse effects: N/V, bone marrow depression, alopecia

methotrexate

• MOA: interfere with DNA synthesis, repair, and cellular replication (S-phase)

• IV, oral, topical

• Adverse effects:

  • N/V/D

  • bone marrow depression

  • mucositis (may affect entire GI tract)

  • alopecia

cisplatin (Platinol)

• MOA: inhibits DNA, RNA, and other protein synthesis

• cell cycle non specific

• IV Q 4 weeks

• AE: N/V, bone marrow depression, peripheral neuropathy, ototoxicity, nephrotoxicity

• monitor input and output, BUN, CREA (kidney function)

Fluorouracil (5-FU)

• MOA: affect DNA and RNA synthesis

• adverse effects:

  • N/V

  • bone marrow depression

  • burning, pain, itching at site of administration

  • stomatiitis is early sign of toxicity

mucositis

• painful inflammation and ulceration of the mucous membrane lining the digestive tract

stomatitis

• when mucositis is limited to mouth only

antitumor antibiotics

• cell cycle non specific

• MOA: kills cancer cells by stopping the synthesis of RNA, DNA, or proteins

• chemotheraputic agents use to treat various cancers:

  • leukemia

  • lymphoma

  • soft tissue sarcoma

  • osteosarcoma

  • solid tumors

    • breast

    • bladder

    • ovarian

    • lung

• bleomycin

• dactinomycin

• mitomycin

• anthracylines

  • daunorubicin

  • docorubicin

  • idarubicin

  • epirubicin

bleomycin

• MOA: inhibits DNA synthesis

• AE:

  • mucositis

  • N/V

  • alopecia

  • pulmonary toxicity

hormonal inhibitor agents

• cell cycle non specific

• MOA: suppress the function of estrogens and adrogens (slows or stops growth of hormone deprendent cancers)

  • breast, endometrial, prostate

• ease symptoms of some types

  • brain

  • renal

• broadly classified as

  • sex hormones

  • antiestrogens

  • aromatase inhibitors

  • antiandrogens

  • gonadotropin: releasing hormone analogs

doxorubicin (Adriamycin)

• MOA: inhibits nucleic acid and protein synthesis

• cell cycle non specific

• IV (vesicant)

• AE:

  • bone marrow depression

  • alopecia

  • muscositis

  • cardiotoxicity

  • red urine, sweat, tears

• antitumor antibiotic that treats cancer

• think “ruby” red because it caues red discoloration

antiestrogens: tamoxifen (Novaldex)

• oral

• used to treat estrogen dependent breast cancers

• MOA: binds to estrogen receptors in both malignant and normal cells

• AE:

  • stroke/ thromboembolism

  • N/V

  • hot flashes

Aromatase inhibitors: anastrazole (Arimidex)

• oral

• used for breast cancer in postmenopausal women

• MOA: blocks estrogen production

• AE:

  • stroke/ thromboembolism

  • N/V

  • hot flashes

potential adverse affects of chemotherapy

• hematopoietic:

  • neutropenia

  • thrombocytopenia

  • anemia

• GI:

  • anorexia

  • taste change

  • N/V/D or constipation

  • mucositis

  • stomatitis

• integumentary:

  • dermatitis (rash)

  • hyperpigmentation

  • alopecia

  • nail changes

  • urticaria

  • pruritus (itching)

Antiandrogens: bicalutamide (Casodex)

• oral

• MOA: binds to androgen receptors in cells of the prostate gland

• AE:

  • low energy, libido

  • weight gain

  • potential for liver damage, monitor for jaundice

Plant Alkaloids

• M phase specific

• stop cell divison during mitosis

potential organ toxicities

• neurotoxicity- nitrosoureas

• ototoxicity- cisplatin

• pulmonary toxicity- bleomycin

• cardiotoxicity- doxorubicin

• nephrotoxicity- cisplatin

• hemorrhagic cystitis- cyclophosphamide

• peripheral neuropathy- vincristine

• bone marrow supression- antimetabolites

Plant Alkaloids: Taxanes and Vinca

• Taxanes: docetaxel (Taxotere), paclitaxel (Taxol)

  • adv. breast cancer and non small cell lung cancer

  • AE: bone marrow depression, N/V, peripheral neuropathy

• Vinca: vincristine (Oncovin)

  • IV (only in central line)

  • MOA: stops mitosis in M phase

  • AE: peripheral neuropathy, extravasation may lead to tissue necrosis (vesicant)

chemotherapy administration

• usually requires 2 RNs

• exposure to hazardous drugs pose a potential health risk to those who prepare, handle, administre and dispose of drugs

  • may be genotoxic, cardiotoxic, teratogenic, and may impair fertility

  • exposure may be direct or indirect contact

minimization of indirect contact

• protective clothing

• place linen with contaiminated body fluid in specially marked bag placed inside an impervious and labeled bag

• double flush toilets with lid down for 48 hours following drug administration

• keep chemo drugs out of reach of children

home care instructions for chemo patients

• provide written information on treatment, diet, hydration, self-care

  • administration schedule, medication, side effects, management of side effects

• avoid infection

  • oral hygiene

  • handwashing

  • avoid nail salons

  • consult with HCP before dentist

  • when to call HCP

Neoadjuvant theraphy

• adjuvant med used to treat cancer

• purpose- reduce primary tumor size, eliminate cancer cells that spread

• treament- chemotherapy, hormone theraphy, targeted therapy, radiation therapy

primary therapy

• adjuvant med used to treat cancer

• purpose- eliminate tumor

• treatment-surgery, radiation therapy

adjuvant therapy

• adjuvant med used to treat cancer

• purpose-eliminate remaining cancer cells

• treatment- chemotherapy, hormone therapy, targeted therapy, radiation therapy

monoclonal antibodies

• made in the lab that seek out anitgens, attatch to them, and mark them for destruction

• used for:

  • cancers

  • autoimmune disorders

  • infections, like COVID 19

• adverse effects

  • risk for infusion reaction

  • anaphylaxis

hematopoietic cytokines

• signaling proteins that help mediate immune responses, inflammation, and hematopoiesis

• 3 types used to treat cancer or chemo side effects

interferons

• communicate between cells to trigger the immune system in response to pathogens

• hematopoietic cytokine

interleukins

• activate and stimulate proliferation of immune cells

• hematopoietic cytokine

hematopoietic growth factors

• hematopoietic cytokine

• promote production, growth, and differentation of blood cells

bevacizumab (Avastin)

• MOA: prevents angiogenesis by attaching to the VEGF growth factors

• AE:

  • HTN

  • hemorrhage

  • thromboembolism

  • GI perforation

• not given within 28 days of surgery

colony stimulating factors

• MOA: stimulate or regulate bone marrow cell growth, maturation, and differentiation

• Erythropoietin- epoetin alfa (Epogen, Procrit)

• AE:

  • bone pain, HTN, N/V/D, increase risk of MI/CVA

• IV or SQ- 3/week

granulocyte colony stimulating factors (G-CSF)

• filgastrim (Neupogen)

• MOA: stimulates WBC (neutrophil) production, treat neutropenia

• SQ or IV; Neupogen daily for up to 2 weeks

• AE: drowsiness, fatigue, flu-like symptoms, nausea, bone pain

• monitor absolute neutrophil count (ANC)

  • inform provider if ANC is <10,000

trastuzumab (Herceptin)

• used to treat metastatic breast cancer

• MOA: inhibits growth factor receptors (HER2 receptors) to prevent growth of HER2 + cancer cells

• major AE is cardiotoxicity

Colony stimulating factors (interleukin 11)

• oprevlekin (Neumega)

• synthetic interleukin 11 (thrombopoietic growth factor)

• MOA: helps prevent chemo induced thrombocytopenia, by stimulating thrombocyte production

• SUB Q injection should be given 6-24 hours after chemotherapy is completed

• AE: fluid retention (peripheral edema, exertional dyspnea)

interferon alpha 2b (Intron A)

• MOA: inhibit reproduction and growth of cancer cells; increase phagocytic acitivity

• route: IV, IM, Sub Q

• AE: chest pain, alopecia, anemia, neutropenia, thrombocytopenia, flu-like symptoms

• nursing interventions: monitor blood counts, may give tylenol for flu-like symptoms

interleukin 2

• aldesleukin (Proleukin)

• activates B and T lymphocytes to enhance anticancer immune response and inhibit tumor growth

• IV

• high risk med, should be in hospital setting when recieving

• AE: risk of heart and lung problems, neutropenia, capillary leak syndrome (fluid in tissues, causes hypotension, reduced organ perfusion, edema, renal failure)

Macules

• a discolored spot on the skin that is not raised above the surface

• example: freckles

papules

• small solid rounded bumps rounding from the skin that are each usually less than 1 centimeter in diameter (less than 3/8 inch across)

vesicles

• small circumscribed elevation of the epidermis containing a serous fluid localized abnormal patch on a body part or surface and especially on the skin

plaques

• localized abnormal patch on a body part or surface and especially on the skin

causes of skin lesions

• eczema dermatitis

• contact dermatits

• drug induced dermatits

• urticaria

• psoriasis

• rosacea

• bacterial infections

• fungal infections

• viral infections - herpes simplex, herpres zoster

• acne vulgaris

• alopecia

• burns- wound care

• parasites

eczema (atopic dermatitis)

• inflammation of the skin: reddening and itching, formation of scaly or crusty patches that may leak fluid (scalp, elbows, and knees)

• may use topical coricosteroids

• tacrolimus (Protopic)

pimecrolimus (Elidil)

• 1% cream

• calcineurin inhibitor

• fewer adverse reactions than corticosteroids

• safe to use on face and neck

• safe to use on patients > 2 years of age

• for severe reactions

drug induced dermatitis

• allergic reaction

• characteristics

  • rash, urticaria, papules, vesicles

  • life threatening skin eruptions

    • stevens-johnson syndrome

  • penicillins can be a culprit

stevens johnson syndrome

• disrupts skin/mucous membrane

  1. flu like symptoms

  2. develop rash-painful

  3. blisters appear- eventually pop on own

• once blisters pop 1st layer of skin is damaged, which means infection is a BIG risk

contact dermatitis

• lesion is not likely to be systemic

• characterisitcs- rashes, redness, blisters, hives, peeling, itching, ulcers

• causes- poison ivy, poison oak

• nonpharmacologic measures

  • avoid contact

  • cleanse skin immediately

  • protective clothing

• drug therapy

  • patch testing

  • topical

  • systemic - oral meds

• antipruritic baths- helps with itching

• LEAVES OF 3, LET IT BE

psoriasis

• autoimmune disorder

• epidermis regenrates about every 20 days normally, with this disorder skin regenerates every 4 days

• characteristics

  • chronic skin disorder that affects 1-2% of U.S. population

  • more common in whites than african americans

  • Erythematous papules and plaques covered with silvery scales (scalp, elbows, knees)

  • have periods of exacerbations/ remissions

  • severe or mild

severe psoriasis

• biologic agents

  • etanercept (Enbrel)

    • subq injection site reactions and reactivation of TB

  • adalimumab (Humira)

    • moderate to severe

    • TNF-alpha inhibitor (tumor necrosis factor)

    • subq every other week

    • CI: active infection , cancer

    • adverse reaction: reactivation of latent TB, increased risk for infection

etanercept (Enbrel)

• tumor necrosis factor (TNF) inhibitor, prevents binding of TNF to receptors and prevents the cell-mediated inflammatory response

• increase rate of opportunistic infections or malignancy observed

• given as weekly subq injections

• common adverse reactions: injection site reactions, URI (upper respiratory infections), headache, nausea, rhinitis (stuffy nose)

  • TB test, CBC, C- reactive protein, and ESR

rosacea

• chronic disease characterized by: persistent skin erythema, telangiectosias (dilated small blood vessels on the skin or mucous membrane), acne-like lesions of the face. Hyperplasia of the nose may develop (small bumps on nose). periods of exacerbation and remission

• epidemiology: middle aged men

• treatment:

  • no cure

  • metronidazole (metrogel) - topically BID

  • accutane may be beneficial in severe cases - women need birth control

  • category x drug

  • must use sunscreen

impetigo

• bacterial infection

• etiology:

  • staph aureus

• population affected

  • children 2-5 years old

• treatment

  • topical (mild- mod) - Bactoban

  • systemic (severe) - oral antibiotic therpy

• contagious

verruca vulgaris (warts)

• characteristics

  • hard, horny nodule, may appear anywhere on body

• drugs for treatment

  • salicyclic acid (promotes desquamation)

acne vulgharis

• try non-pharmacologic approach first

• drugs:

  • topical: tretinoin (Retin-A)

  • systemic: isotretinion (Accutane), tetracycline

  • mild to moderate

    • side effects: burning, pruritus, erythema

    • cleanse face first, apply in thin layer, use sunscreen

  • topical: clindamycin and erythromycin creams

    • side effects: rash, pruritis, dryness, contact dermatitis

  • systemic: isotretinoin (Accutane), tetracycline

    • side effects of Accutane:

      • skin irritation, thrombocytopenia, nosebleeds, teratogenic effects

    • side effects of tetracycline:

      • photosensitivity, severe sunburn, teratogenic effects

acne vulgaris (systemic meds)

• isotretinoin (Accutane)

• severe, persistent, nodular cystic acne

  • pregancy category x

  • oral

  • avoid sunlight, contact lenses (ocular dryness), and use with tetracyline and vitamin A (increase adverse effects)

  • pregnancy prevention mandatory

  • 2 pregnancy test prior to start then monthly

  • monitor CBC, glucose, and lipids

• tetracycline (Doryx)

• moderate acne

  • Tx 3-6 months for max effect

  • Category D

  • oral

  • sunscreen

  • dont take with milk or antacids- binds and becomes insoluble

  • pregancy prevention

alopecia

• etiology

  • family history

  • aging

  • drug induced

  • febrile illnesses

  • pregnancy

  • myxedema (swollen, puffy skin, often in hypothyroidism)

• treatment

  • minoxidil (Rogaine) 2%

  • finasteride (Propecia) 1 mg tablets

sunscreen

• SPF

• FDA recommends SPF 30 or higher , blocks 93.7%

• national cancer institute states that women who use tanning beds more than once a month are 55% more likely to develop melanoma

Burns

• topical drugs

  • mafenide (Sulfamylon)

    • side effects: burning sensations, blistering, superinfection, metabolic acidosis

  • silver sulfadiazine ( silvadene cream)

    • side effects: skin discoloration, local reactions, burning sensation, rashes, possbile lecuopenia

• nursing interventions:

  • administer pain meds

  • monitor I&O

  • use caution with patients in acute renal failure

  • infection prevention and fluid resuscitation

Scabies

• eruption of skin caused by female mites

• lesions commonly occur between fingers, on extremeties, in axillary and gluteal folds, around trunk and in pubic area

• major symptoms: intense itching and vigorous scratching may lead to secondary infections

• spread through contact with upholstery and shared linens

lice

• larger than mites

• spread by infected clothing or close personal contact

• require human blood for survival and die within 12 hours without host

• may infest head, body, and pubic area

• major symptom: intense itching due to release of saliva

permethrin (Acticin, Nix)

• preffered tx for scabies and lice

• 1% for lice, 5% for scabies

• leave on scalp and hair for 10 minutes

• itching may last up to 2-3 weeks

• adverse reactions: causes few systemic effects

  • local effects: pruritus, rash, transient tingling, burning, stinging, erythema, and edema

• administration alerts

  • do not use on premature infants and children < 2

  • do not use on skin that has abrasion, rash, or inflammation

• nursing interventions:

  • assess area daily for 1-2 weeks for reinfestation

  • louse eggs-nits

vitamin deficiency

lack that can cause cellular or organ dysfunction and slow healing/recovery from illness

RDA

recommended daily allowance

why do clients need vitamin supplements ?

1. inaquequate absoprtion

2. inability to use vitamins

3. increased vitamin losses

4. increased vitamin requirements

fat soluble

• vitamins A, D, E, K

• metabolized slowly

• can be stored in fatty tissue, liver, and muscle

• slowly excreted in urine

• Vitamins A and D are toxic in large amounts

water soluble

• vitamins B1, B2, B3, B6 (known as B complex vitamins ) and Vitamin C

• are not stored in the body and are usually not toxic

• requires steady, consistent suplemetation via diet

• readily excreted in urine

vitamin A

• function: essential for bone growth, maintenance of epithelial tissue, skin, hair, and eyes

• source:

  • whole milk

  • butter

  • eggs

  • leafy green and yellow vegetables and fruits

• deficiency conditions

  • dry skin

  • night blindness

vitamin D (Calciferol)

• function: regulating Ca+ ( calcium) & phosphorous metabolism (needed for Ca+ absoprtion from intestine)

• sources:

  • fortified milk

  • egg yolk

  • tuna

  • salmon

• deficiency conditions

  • rickets (soft, weakened bones)

  • blood calcium deficit

Vitamin E

• function: promotes formation & functioning of RBCs , muscle and other tissues

• sources:

  • whole grain cereals

  • wheat germ

  • vegetable oils

  • lettuce

  • sunflower seeds

  • milk

  • eggs

  • meat

• deficiency conditions

  • breakdown of RBC

Vitamin K

• function: needed for synthesis of prothrombin & the clotting factors (7,9,10)

• sources:

  • leafy green vegetables

  • liver

  • cheese

  • egg yolk

  • vegatable oil

  • tomatoes

• deficiency conditions

  • increased blood clotting time with resulting bleeding and hemorrhage

  • reversal agent to warfarin (Coumadin)

vitamin B1 (Thiamine)

• function: promotes use of sugars needed for good function of nervous sytem and heart

• sources:

  • enriched breads and cereals

  • yeast

  • liver

  • pork

  • fish

  • milk

• deficiency conditions

  • often given to ETOH abusers (alcohol abusers)

vitamin B2

• function: promotes body use of carbs, proteins & fats by releasing energy to cells, required for tissue integrity

• sources:

  • milk

  • enriched breads and cereals

  • liver

  • lean meat

  • eggs

  • leafy green vergetables

• deficiency conditions:

  • blurred vision

  • photophobia (sensitivty to light)

  • cheilosis

  • rash on nose

  • numbness of extremities

Biotin

• part of the vitamin B2 complex

• necessary for fat and carb metabolism

• sources:

  • meat

  • egg yolk

  • nuts, cereal

  • most vegetables

• deficiency conditions:

  • anorexia

  • nausea

  • depression

  • muscle pain

  • dermatitis

Vitamin B3 (Niacin)

• function: necessary for energy producing reactions & assists in nervous system

• sources:

  • eggs

  • meat

  • liver

  • beans

  • peas

  • enriched bread

  • cereals

• deficiency conditions:

  • retarded growth

  • headache

  • memory loss

  • anorexia

  • insomnia

Vitamin B6 (Pyridoxine)

• function: essential building block of nucleic acids, RBC formation & synthesis of hemoglobin

• sources:

  • lean meat

  • leafy green vegetables

  • whole grain cereals

  • yeast

  • bananas

• deficiency conditions:

  • neuritis: caused by INH therapy (TB drug)

  • seizures

Vitamin B12 (Cyanocobalamin)

• building block of nucleic acids, protein synthesis, RBC formation, fat & carb metabolism & functioning of nervous system

• energy vitamin

• sources:

  • liver

  • kidney

  • fish

  • milk

• deficiency condition:

  • GI disorders

  • poor growth

  • anemia- pernicious anemia

vitamin C (Ascorbic acid)

• common during flu season

• function: folic acid metabolism, tissue repair, essential for erythropoiesis & enchances absorption of iron

• sources:

  • citrus fruits

  • tomatoes

  • leafy green vegetables

  • potatoes

  • strawberries

• deficiency conditions:

  • poor wound healing

  • bleeding gums

  • scury (bruising, bleeding gums, rash)

  • increased incidence of infection

folic acid

• folate (active form of folic acid) is circulated to all tissues.

• stored in the liver and tissues, it is essential for DNA synthesis

• without this, cellular divison is disrupted

• deficiency during the 1st trimester of pregnancy can cause neural tube defects such as spina bifida or anacephaly (underdevloped brain and incomplete skull) of the fetus

folic acid supplement

• 400 mcg each day for women

  1. who have had previous NTD

  2. taking certain medications

  3. certain high risk pregnancies - take more

• 400 mcg = 4 mg

folic acid sources

• leafy green veggies

• yellow fruit and veggies

• yeast

• organ meats

• black eyes peas

• lentils, peas

• dried beans

• oranges

folic acid deficiency signs and symptoms

• anorexia

• nausea

• diarrhea

• fatigue

• alopecia

• blood disorder

• stomatitis (swelling/ sores inside mouth)

iron

• also known as ferrous sulfate, ferrous gluconate, or furmarate

• 60% of bodys iron is found in hemoglobin

• foods rich are liver, lean meats, egg yolksm dried beans, green vegetables, fruit

• side effects: nausea, vomiting, diarrhea, constipation, dark colored stools

• elixir may stain teeth; oral hygiene

• poisoning may cause cardiovascular collapse- usually in children

• take on empty stomach with orange juice - vitamin C breaks down and helps absorb

iron routes

• oral (ferrous sulfate most common)

• IM ( Z-track: ferric gluconate")

• IV ( iron destran- test dose: wait one hour)

iron poisoning

• most common cause of pediatric death in U.S.

• Tx: symptomatic & supportive:

  • suctioning

  • control of shock state

  • IV’s for dehydration

  • oxygen

  • whole gut lavage

  • stomach pump

copper

• used for formation of RBCs and connective tissue

zinc

• important to enzymatic reactions, important for growth and tissue repair, major role in wound healing, taste and smell

• large doses may lead to copper deficiency , weakened immune response and decreased HDL

chromium

• helpful in control of type 2 diabetes by increasing insulin’s effect on the cells

selenium

• cofactor for antioxidant enzyme that protects protein and nucleic acids from oxidative damage. partners with Vitamin E

• anticarcinogenic effect (doses < 200 mcg)

H2O facts

• adult human body= 60% water

• human embryo= 97% water

• newborn infant= 70-80% water

• fever increases water need by 15%

• approximate daily water need for an adult is 15 ml/pound

LBS to KG

1. weight in pounds: kg weight X 2.2

2. weight in kilograms: weight in pounds divided by 2.2

3. Example:

   • 150 IBS/ 2.2= 68.18 kg

   • 75 kg X 2.2= 165 Ibs

Hypovolemia

• loss of both Na+ and water- decrease in volume of extracellular fluid (causes diarrhea and vomitting)

• signs and symptoms: marked thirst, dry mucous membranes, poor skin turgor, decreased urine output, tachycardia and slight decrease in systolic B/P

hypervolemia

• causes: CHF, hypoalbuminemia, increased Na+ intake & primary Na+ renal retention

• signs and symptoms: constant irritated cough, dyspnea, neck vein engorgement, hand vein engorgement & moist crackles in lungs

electrolytes in circulation

• either a + cation or - anion charge and transmit nerve impulses to muscles and aide in the contraction of both smooth and skeletal muscles

• intracellular: potassium, magnesium, calcium

• extracellular (blood vessels and tissue spaces): sodium, chloride, and calcium

• cations: potassium (K+), sodium (Na+), calcium (Ca+), magnesium (Mg+)

• anions: chlroide (Cl-), bicarbonate (HCO3-), phosphate (PO4-), sulfate (SO4-)