Pharm Exam 3

Blood Pressure

force exerted by the blood on arterial vessel walls

systolic:

• pressure rises d/t ventricular contraction

• force exerted when blood is ejected from L ventricle

diastolic:

• pressure falls as a result of relaxation

• force exerted when ventricles relax

normal = <120/80 mmHg

Mean Arterial Pressure (MAP)

tissue perfusion indicator

should be >/= 65mmHg

Pulse Pressure (PP)

difference between systolic + diastolic

low = low CO

high = heart working too hard

Cardiac Output (CO)

amount of blood heart pumps out in 1 min

SV x HR

Ejection Fraction (EF)

percent of total blood volume… CO in different way

should be 50-70%

low = pump failure

Peripheral Vascular Resistance (PVR)

amount of friction in vessels

Preload

amount of blood returning to heart

Afterload

pressure L ventricle needs to exert to get blood out of heart

Baroreceptors

nerve endings that allow brain to sense BP in major vessels + activate sympathetic NS to control

Hormonal Regulation of BP (Acute)

renin-angiotensin-aldosterone system

• renin secreted by kidneys

• activates angiotensin to angiotensin I

• ACE in lungs converts angiotensin I to angiotensin II

• vasoconstriction

• absorption of Na + H2O

• increased BP

vasopressin

• ADH secreted

• vasoconstriction

• increased thirst → increased BV → increased BP

epinephrine/catecholamine

• fight or flight

• vasoconstriction

• increased BP

Long-Term Regulation of BP

kidneys

• regulation of ECF

• low ECF = low BP

• high ECF = high BP

Normal Electrical Heart Activity

SA node → AV node → bundle of His → Purkinje fibers → ventricular contraction

Normal Blood Flow

superior and inferior vena cava → right atrium → left atrium → pulmonary artery → lungs → pulmonary veins → left atrium → left ventricle → aorta → body

EKG

P wave = atrial depolarization

PR interval = signal to AV node

QRS complex = ventricular depolarization

ST segment = begins ventricular repolarization… flat with baseline

T wave = ventricular repolarizations

How to Read an EKG

1. find HR → count QRS complexes in 6 sec strip x 10

2. look at whole strip… should be 1 P to each QRS, evenly spaced QRS, ST segment in line, T wave height

Normal Sinus Rhythm

rate = 60-100bpm

1 P wave : 1 QRS complex

QRS spaced evenly

ST flat with baseline

T wave normal

Dysrhythmias

any disorder of the heartbeat

Sinus Bradycardia

rate = <60bpm

normal P, QRS, ST flat, T wave

etiology: vomiting, Valsalva maneuver, pain, hypoxia, meds, hypothyroidism, suction, carotid massage, neuro disorders

Sinus Tachycardia

rate = >100bpm

normal P, QRS, ST flat, T wave

etiology: exercise, anxiety, stress, illness, pain, fever, hypovolemia, dehydration, hyperthyroidism, cocaine

Bradydysrhythmias

clinical manifestations:

• syncope

• dizziness

• confusion

• hypotension

• diaphoresis

• SOB

• CP

Tachydysrhythmias

clinical manifestations:

• palpitations/fluttering/pounding

• CP

• syncope

• pale skin

• anxiety

Ventricular Fibrilation

ventricles quivering with no blood ejected

check central pulse

EKG shaky

Pulseless Ventricular Tachycardia

no pulse

Asystole/Pulseless Electrical Activity

dead.

H and Ts

causes of cardiac arrest:

• hypovolemia

• hypoxia

• hydrogen ion (acidosis)

• hypokalemia

• hyperkalemia

• hypothermia

• tension pneumothorax

• tamponade cardiac

• toxins

• thrombosis pulmonary

• thrombosis coronary

Hypertension

etiology:

• cause unknown

risk factors:

• obesity

• sedentary lifestyle

• smoking

• alcohol

• high salt

• low potassium

• low calcium

• stress

• kidney issues

• thyroid issues

clinical manifestations:

• SEVERE HA

• BLURRY VISION

• CP

• dizziness

• nausea

• vomiting

• anxiety

• confusion

• nosebleeds

Hypertension is when BP is elevated… can be due to obesity, genetics, smoking, alcohol, salt, sedentary lifestyle, etc…. will manifest as HA, blurry vision, nausea, CP, confusion

BP Categories

normal

• systolic < 120 AND diastolic < 80

elevated

• systolic 120-129 AND diastolic < 80

HTN 1

• systolic 130-139 OR diastolic 80-89

HTN 2

• systolic >140 OR diastolic > 90

HTN Crisis

• systolic > 180 AND/OR diastolic > 120

ACE Inhibitors (-pril)

ACE = DRY COUGH + HIGH POTASSIUM

MOA:

• cause reduction in production of angiotensin II by blocking ACE in lungs and increase bradykinin levels

therapeutic uses:

• HTN

• heart failure

• MI

• neuropathy

• MI/stroke prophylaxis

meds: -PRIL

• captopril

• enalapril

• lisinopril

• ramipril

• benazepril

complications:

• DRY COUGH

• orthostatic hypotension

• dizziness/fatigue

• taste changes

• hyperkalemia → cramping, muscle issues, arrhythmia

• neutropenia

• renal failure

contraindications:

• kidney impairments

interactions:

• diuretics, other antihypertensives → increased hypotension

• meds that increase potassium

• lithium

• NSAIDs

nursing implications:

• assess BP + HR before and after

• hold for systolic BP < 100 mmHg and HR < 60 bpm

• monitor for cough + infections

• FALL RISK

• monitor potassium levels → norm 3.5-5.0 mEq/L

patient teaching:

• change positions slowly

• avoid salt substitutes

• report SOB, cough, fever

ACE inhibitors (-pril) are used for HTN, MI, heart failure… complications are DRY COUGH, hyperkalemia, dizziness, hypotension, orthostatic hypotension, neutropenia, renal failure… do not give with bad kidneys… do not mix with diuretics, meds increasing potassium… need to monitor BP and HR before admin, look for cough, monitor potassium (normal 3.5-5.0), FALL RISK

Angiotensin II Receptor Blockers (ARBs) (-sartan)

-SARTAN ON THE BEACH WITH THE SALTWATER FLOWING

MOA:

• block action of angiotensin II in body leading to vasodilation and excretion of water

therapeutic uses:

• HTN

• heart failure

• stroke prophylaxis

• MI prophylaxis

meds: -SARTAN

• losartan

• irbesartan

• candesartan

• olmesartan

• telmisartan

complications:

• orthostatic hypotension

• dizziness

• fatigue

• headache

• diarrhea

• ANGIOEDEMA → STRIDOR

• renal failure

contraindications:

• kidney issues

• angioedema with ACE inhibitors

interactions:

• other antihypertensives

nursing implications:

• assess BP + HR before and after

• hold for systolic <100 mmHg and HR < 60bpm

• monitor for angioedema

• FALL RISK

• daily weights for fluid overload

patient teaching:

• change positions slowly

• report SOB, facial swelling

ARBs (-sartans) are meds that increase excretion of salt and water leading to vasodilation… used to treat HTN, heart failure, stroke prevention, MI… complications are orthostatic hypotension, angioedema, dizziness, fatigue, renal failure… do not give with bad kidneys… do not mix with other antihypertensives… monitor BP and HR (hold for <100mmHg and <60bpm), monitor for angioedema (facial swelling, stridor, SOB), fall risk, daily fluids

Beta Blockers (-lol)

SHE’LL BE LOLING AT YOU WHEN YOU HAVE ERECTILE DYSFUNCTION

MOA:

• work on beta 1 receptors in myocardium and in electrical conduction → SLOW HR

• vasodilation and reduced renin release → LOWER BP

therapeutic uses:

• decrease HR

• decrease BP

meds: -LOL

• metoprolol

• atenolol

• propranolol

• carvedilol

• labetalol

complications:

• bradycardia

• hypotension

• erectile dysfunction

• heart block

• fatigue

• weakness

contraindications:

• heart block

• sinus bradycardia

• asthma/bronchospasm

interactions:

• Ca channel blockers

• other antihypertensives

nursing implications:

• monitor BP, HR, EKG

• apical pulse

• hold if systolic < 90 mmHg and HR < 50bpm

• do not stop abruptly

• fall risk

• ANTIDOTE = GLUCAGON

patient teaching:

• take with food

• monitor BP and HR

• do not d/c abruptly

• report SOB, slow pulse

• change positions slowly

Beta Blockers (-lol) are used to decrease BP and HR… used for HTN, angina, tachydysrhythmias, MI… complications are ERECTILE DYSFUNCTION, orthostatic hypotension, bradycardia, fatigue, dizziness, heart block… do not give with asthma/bronchospasm… do not mix with calcium channel blockers or other antihypertensives… monitor BP and HR, watch for bronchospasm, fall risk, ANTIDOTE = GLUCAGON, apical pulse for full minute… do not d/c abruptly

Myocardial Infarction (MI)

STEMI = ST elevation MI

N-STEMI = non-ST elevation MI

definition:

• ischemia of heart muscle due to abrupt d/c of oxygen

risk factors:

• HTN

• sedentary lifestyle

• smoking

• obesity

• DM

• stress

• genetics

diagnostics:

• EKG (ST segment elevation)

• creatine kinase MB

• troponin (cardiac enzyme)

clinical manifestations:

• CP

• pain down arm and into jaw

• N/V

• impending doom

• females → back pain, choking, pain b/t shoulder blades

• pallor, clammy skin

• elevated HR, SOB

Myocardial Infarction is when blood flow and oxygen is cut off to heart muscle causing tissue death… risk due to HTN, genetics, smoking, obesity, sedentary lifestyle… diagnostic is EKG, creatine kinase, troponin… will see CP, pain down arm and into jaw, impending doom, pain near shoulder blades for women, SOB

Organic Nitrates

MOA:

• dilates coronary arteries to increase blood flow

• reduces myocardial oxygen consumption

therapeutic uses:

• angina

• CHF

• MI

meds: NITRO- or -NIT

• nitroglycerin

• isosorbide dinitrate

• isosorbide mononitrate

• direct peripheral vasodilator → hydralazine

complications:

• dizziness

• hypotension

• headache

• blurred vision

• syncope

• drug-induced lupus

• tolerance

contraindications:

• anemia

• glaucoma

• head injury

• inhibitors of phosphodiesterase type 5 (ED MEDS) → HYPOTENSIVE CRISIS… -FIL MEDS

interactions:

• alcohol

• antihypertensives

• ED -FIL meds

nursing implications:

• EKG within 10 minutes

• give PO/SL/TD

• do not touch nitro paste without gloves

• max of 3 doses

• FALL RISK

patient teaching:

• if feeling CP, take 3 doses and call 911

• move positions slowly

• hydralazine- report fever, muscle + joint pain

Organic nitrates (nitroglycerin or -nitrate meds) are used for MAJOR DILATION of coronary vessels for MI and angina… complications are hypotension, syncope, dizziness, headache, weakness, drug-induced lupus, tolerance… do not give with traumatic head injury or ERECTILE DYSFUNCTION MEDS R/T HYPOTENSION… do not mix with alcohol, ED meds… use gloves to apply, EKG within 10 mins, give max 3 doses… move positions slowly and report muscle/joint pain r/t lupus

STEMI Management

pre-hospital:

• chew aspirin

• call 911

hospital = THROMBINS:

• Thienopyridines → block platelet activation

• Heparin → thin blood

• Renin-angiotensin system blockers → reduce risk of death

• Oxygen therapy → if O2 < 90%

• Morphine → decrease O2 demand and pain

• Beta-blockers → decrease HR and O2 consumption

• Invasive surgery

• Nitroglycerin → dilates coronary arteries

• Statins → work to decrease risk of atherosclerosis

THROMBINS is used to treat MI

• thienopyridines to block platelets

• heparin to thin blood

• renin-angiotensin system blockers

• oxygen if less than 90

• morphine to decrease O2 demand and pain

• beta blockers to decrease HR

• invasive surgery to remove clot

• nitroglycerin to dilate arteries

• statins to decrease atherosclerosis

Atrial Fibrillation

definition:

• irregular R to R with no P waves

risk factors:

• HTN

• HF

• obesity

• CVD

diagnostics:

• EKG

clinical manifestations:

• irregular pulse

• palpitations

• fatigue

• hypotension

• syncope

• anxiety

Atrial Fibrillation is irregular R to R with no P waves… will see irregular pulse, palpitations, hypotension, fatigue

Calcium Channel Blockers (-dipine)

MOA:

• block calcium channels to vasodilate and slow HR

therapeutic uses:

• lower BP and HR

• angina

• HTN

• cardiac dysrhythmias

meds:

• nifedipine

• amlodipine

• nicardipine

• diltiazem

• verapamil

complications:

• FLUSHING

• hypotension

• bradycardia

• anxiety

• constipation

• dysrhythmias

contraindications:

• MI

• heart block

• cardiogenic shock

interactions:

• GRAPEFRUIT JUICE

• digoxin

• beta blockers

nursing implications:

• monitor calcium → normal 9.0-10.5

• hold med if systolic < 90 mmHg and HR < 50bpm

• daily weights

• ANTIDOTE = CALCIUM, GLUCAGON, INSULIN

patient teaching:

• AVOID GRAPEFRUIT JUICE

• change positions slowly

Calcium Channel Blockers (-dipine and verapamil, diltiazem) are used to lower BP and HR and slow conduction rate… used for angina, HTN, dysrhythmias… complications are hypotension, bradycardia, FLUSHING, constipation, dizziness… caution with MI… NO GRAPEFRUIT JUICE, no digoxin, no beta blockers… monitor BP and HR, fall risk, monitor EKG, ANTIDOTE = CALCIUM/INSULIN/GLUCAGON, change positions slowly

Atherosclerosis/Hyperlipidemia

definition:

• formation of plaque within arterial wall

• elevation of serum lipid levels

risk factors:

• low HDL

• high LDL

• increased triglycerides

• genetics

• DM

• obesity

• smoking

• sedentary lifestyle

diagnostics:

• total cholesterol, HDL, LDL, triglycerides

• TOTAL CHOLESTEROL SHOULD BE <200

• bruit in larger arteries

clinical manifestations:

• HTN

• longer capillary refill

• cool periphery

• bruits in large vessels

Atherosclerosis is the buildup of plaque in vessels leading to narrowing, hyperlipidemia is high cholesterol… due to low HDL, high LDL, high triglycerides, poor diet, genetics, obesity… want TOTAL < 200, may hear bruit in arteries, prolonged cap refill, HTN

HMG-CoA Reductase Inhibitors (Statins)

MOA:

• decrease manufacture of LDL + triglycerides

• increase manufacture of HDL

therapeutic uses:

• high cholesterol

• CAD

meds: -STATIN

• atorvastatin

• simvastatin

• lovastatin

complications:

• HEPATOXICITY → JAUNDICE, ABD PAIN, ASCITES, BLEEDING

• MYOPATHY → MUSCLE ACHES, SPASMS, CRAMPS

• GI issues

contraindications:

• liver disorder

• pregnancy

interactions:

• GRAPEFRUIT JUICE

• ALCOHOL

• Ca channel blockers

• HIV protease inhibitors

nursing implications:

• admin PO with evening meal

• monitor LFTs

• monitor cholesterol levels

patient teaching:

• NO ALCOHOL OR GRAPEFRUIT JUICE

• take with evening meal

• report N/V, jaundice, muscle aches

HMG-CoA Reductase Inhibitors (-statins) are meds used to reduce cholesterol… side effects are hepatoxicity + myopathy… do not give with pregnancy or liver failure… NO ALCOHOL, NO GRAPEFRUIT JUICE… monitor LFTs, give PO HS

Heart Failure

definition:

• heart muscle cannot pump efficiently

risk factors:

• HTN

• age

• CAD

• DM

• obesity

• poor diet

• Hx MI

• genetics

diagnostics:

• B-type natriuretic peptide (BNP) <100

• x-ray

• EKG

• ABGs

clinical manifestations:

• RIGHT SIDED = REST OF BODY

  • JVD

  • peripheral edema

  • ascites

  • fatigue

  • polyurea

  • weight gain

  • hepatomegaly

• LEFT SIDED = LUNGS

  • SOB

  • dyspnea

  • orthopnea

  • fatigue

  • frothy bloody sputum

  • altered mental status

Heart Failure is when the muscle can no longer pump effectively… due to HTN, older age, hx MI, genetics, obesity, poor diet… dx with b-type natriuretic peptide, EKG, chest x-ray… RIGHT SIDE = REST OF BODY → JVD, ascites, peripheral edema, fatigue, anorexia, polyurea, weight gain… LEFT SIDE = LUNGS → SOB, orthopnea, dyspnea, bloody frothy sputum, fatigue

Loop Diuretics

MOA:

• inhibits reabsorption of sodium and chloride

therapeutic uses:

• HF

• fluid retention

meds:

• FUROSEMIDE

• ethacrynic acid

• bumetanide

• torsemide

complications:

• dehydration

• hypotension

• ototoxicity

• HYPOKALEMIA → WANT 3.5-5.0

• electrolyte imbalances

contraindications:

• anuria

• CV disease

• gout

interactions:

• digoxin

• other antihypertensives

• lithium

• NSAIDs

• licorice root

nursing implications:

• daily weights

• BP

• I&O

• MONITOR K+

• fall risk

patient teaching:

• change positions slowly

• report weight loss, weakness, tingling, hearing issues

Loop Diuretics (furosemide, ethacrynic acid, bumetanide, torsemide) are used to inhibit reabsorption of sodium and chloride and water… used for pulmonary edema, edema r/t cardiac or kidneys, HTN… complications are ototoxicity, hypokalemia, dehydration, hypotension… do not give with bad kidney… no digoxin, no antihypertensives, no NSAIDs, no lithium… need to monitor daily weights, I&O, BP, electrolyte levels, fall risk… change positions slowly

Thiazide Diuretics

MOA:

• blocks reabsorption of sodium and chloride

• blocks reabsorption of water

therapeutic uses:

• HTN

• edema

meds: -THIAZIDE

• hydrochlorothiazide

• chlorothiazide

• methyclothiazide

complications:

• dehydration

• hypokalemia

• hyperglycemia

• electrolyte imbalance

contraindications:

• renal impairment

interactions:

• other antihypertensives

• digoxin

• NSAIDs

• lithium

nursing implications:

• daily weights

• monitor K+

• FALL RISK

patient teaching:

• do not take before bed → prevent nocturia

• promote potassium → banana, oranges, dried fruit, avocado

• monitor blood sugar, BP, weight

Thiazide Diuretics (-thiazide) are used to block reabsorption of water, sodium, chloride… used for HTN, edema… complications are hypokalemia, dehydration, hypotension, hyperglycemia… do not give with bad kidney… no antihypertensives, digoxin, lithium… daily weights, I&O, BP, K+ levels, fall risk, dose before HS to prevent nocturia… potassium in diet

Potassium-Sparing Diuretics

MOA:

• block action of aldosterone → potassium retention, excretion of sodium and water

therapeutic uses:

• edema

• HTN

• HF

meds:

• spironolactone

• triamterene

• amiloride

complications:

• hyperkalemia (K+ >5.0)

• endocrine effects → deepened voice, irregular menstruation, hirsutism

• drowsiness

contraindications:

• hyperkalemia

• kidney failure

interactions:

• ACE inhibitors, ARBs, direct renin inhibitors → hyperkalemia

• potassium supplements

nursing implications:

• electrolytes, BP, weight monitoring

• ECG monitor for dysrhythmias

• monitor K+

patient teaching:

• no salt substitutes

• avoid potassium-rich foods

• triamterene → bluish urine

• report endocrine s/s

Potassium-Sparing Diuretics (spironolactone, triamterene, amiloride) block sodium and water reabsorption but maintain potassium… used for HTN, edema… complications are hyperkalemia, endocrine effects (deepened voice, irregular menstruation, hirsutism, gynecomastia), drowsiness… do not give if taking potassium supplements or bad kidneys… no ACE or ARBs r/t hyperkalemia… monitor EKG, I&O, BP, weights… no potassium supplements

Cardiac Glycoside

ONLY AFFECT HR, NOT BP

MOA:

• increased MI contraction + decreased HR

therapeutic uses:

• dysrhythmias

• HF

meds:

• DIGOXIN

complications:

• digoxin toxicity (>2ng/mL) → anorexia, fatigue, weakness, vision changes

• BRADYCARDIA

• N/V

• CNS effects

contraindications:

• AV heart block

• kidney impairment

interactions:

• ACE inhibitors

• ARBs

• St John’s Wort

nursing implications:

• monitor HR and rhythm → 1 min apical pulse

• monitor for toxicity

• ANTIDOTE = DIXOGIN IMMUNE FAB (DIGIBIND)

• fall risk

patient teaching:

• change positions slowly

• take pulse before taking, hold for <60bpm

Cardiac Glycoside (digoxin) brings down BP… used for dysrhythmias, heart failure… complications are fatigue, bradycardia, toxicity (anorexia, fatigue, vision changes), N/V… do not give with heart block… no ACE or ARBs… monitor HR, EKG, toxicity (want < 2.0), ANTIDOTE = DIGOXIN IMMUNE FAB… change positions slowly

Asthma

definition:

• chronic disorder of airways that results in INTERMITTENT and REVERSABLE airflow of bronchioles

risk factors:

• older adults

• sensitivity to beta-adrenergic receptors

• smoking

• family hx

• environmental allergies

• exposure to chemicals/dust

diagnostics:

• chest-xray

• forced vital capacity → volume of air exhaled from full inhalation to full exhalation

• forced expiratory volume → volume of air blown out as hard and fast as possible… down 15-20% with asthma, 12% increase after bronchodilation

• peak expiratory flow → fastest airflow rate reached during exhalation

clinical manifestations:

• WHEEZING

• coughing

• use of accessory muscles → nasal flaring, sternal retractions, pallor

• poor O2 levels

• chest tightness

• dyspnea

• anxiety

Asthma is the chronic, intermittent and reversible inflammation of airways… can be triggered, due to genetics, smoking… diagnostics with PFTs… will see dyspnea, wheezing, anxiety, use of accessory muscles, poor O2 levels

Chronic Obstructive Pulmonary Disease (COPD)

definition:

• emphysema- loss of lung elasticity and hyperinflation, destruction of alveoli → decreased surface for gas exchange, CO2 retention

• chronic bronchitis- inflammation of bronchi and bronchioles due to chronic irritant exposure

• IRREVERSIBLE

risk factors:

• advanced age

• smoking

• air pollution

• alpha 1-antitrypsin deficiency

diagnostics:

• chest x-ray

• alpha 1-antitrypsin levels (decreased)

• forced expiratory volume compared to forced vital capacity (typically 100%, <70% with mild COPD)

clinical manifestations:

• chronic dyspnea

• productive cough

• clubbing of fingers and toes

• barrel chest

• WHEEZES

• normal O2 = 88-92%

• irregular breathing pattern

COPD is the chronic inflammation of airway due to emphysema (loss of lung elasticity and destruction of alveoli) or chronic bronchitis… diagnosed with decreased alpha 1-antritrypsin levels or PFTs… will see clubbing, dyspnea, wheezing, barrel chest, normal O2 between 88-92%, productive cough

Inhaler Order

1. bronchodilator/beta 2 adrenergic

2. anticholinergic

3. corticosteroid

5 mins between different inhalers

Beta 2 Adrenergic Agonists/Bronchodilators

MOA:

• activate beta 2 receptors of bronchial smooth muscle → bronchodilation

therapeutic uses:

• short-acting asthma attack = BUTEROL

• long-acting asthma control = METEROL

meds:

• albuterol

• levalbuterol

• formeterol

• salmeterol

complications:

• TACHYCARDIA

• angina

• tremors

contraindications:

• tachydysrhythmias

interactions:

• beta blockers → will counteract albuterol

• NSAIDs

nursing implications:

• assess lung sounds, pulse prior and at peak

• observe for wheezing, dizziness, CP

• buterol for short term attack

• meterol for long term maintenance

patient education:

• stop taking if wheezing, cp, dizziness, palpitations

• no smoking

• PROPER INHALER USE → mouthpiece off, shake, exhale, puff of med, slow inhale, hold for 10 sec, wait 1min before next dose

Beta Adrenergic Agonists/Bronchodilators (-meterol long t

Inhaled Anticholinergics (-tropium)

MOA:

• block muscarinic receptors resulting in bronchodilation

therapeutic uses:

• relieve bronchospasm (COPD, asthma)

meds:

• ipatropium

• triotropium

complications:

• DRY MOUTH

• hoarseness

contraindications:

• peanut allergies

interactions:

• other anticholinergic meds

nursing implications:

• assess respiratory status before and after admin

• inhaler order → BRONCHODILATOR, ANTICHOLINERGIC, CORTICOSTEROIDS

• avoid with peanut allergies

patient education:

• take missed dose as soon as remembered

• treat dry mouth with gum, hard candy, water

• PROPER INHALER USE → mouthpiece off, shake, exhale, puff of med, slow inhale, hold for 10 sec, wait 1min before next dose

• DO NOT SWALLOW PILL THAT GOES INTO INHALER

Glucocorticoids

MOA:

• prevent inflammation, reduce airway mucosal edema

therapeutic uses:

• long-term asthma prophylaxis

• reduce airway inflammation

meds:

• beclomethasone

• fluticasone

• budesonide

• combination inhaled meds

• prednisone/methylprednisone IV/oral

complications:

• hoarseness

• CANDIDIASIS → NEED TO RINSE MOUTH AFTER ADMIN

• bone loss, hyperglycemia, myopathy, infection, fluid/electrolyte imbalance

contraindications:

• fungal infection

• live virus vaccine

• diabetes

interactions:

• ketoconazole

• potassium-depleting diuretics

• NSAIDs

• hypoglycemic agents

nursing implications:

• monitor for adrenal insufficiency (anorexia, nausea, weakness, fatigue, hypotension)

• do not stop abruptly

• monitor blood sugar

• RINSE MOUTH

patient education:

• RINSE MOUTH AFTER

• 1 min between puffs

• avoid NSAIDs

• calcium and vitamin D supplements

• PROPER INHALER USE → mouthpiece off, shake, exhale, puff of med, slow inhale, hold for 10 sec, wait 1min before next dose

Leukotriene Modifiers

MOA:

• suppress effects of leukotrienes → reduce inflammation, bronchoconstriction

therapeutic uses:

• long-term asthma

• prevention of exercise-induced bronchospasm

meds: PILL, NOT INHALED

• montelukast

complications:

• depression/SI

• liver injury

contraindications:

• liver dysfunction

interactions:

• warfarin

• phenytoin

nursing implications:

• once daily HS or 2hr before exercise

• monitor for SI

• monitor LFTs

patient education:

• not for acute asthma

• report behavior changes, depression, SI

Pulmonary Embolism (PE)

definition:

• a substance (air, fat, amniotic fluid) forms a blockage in pulmonary vasculature

risk factors:

• long-term immobility

• oral contraceptives

• pregnancy

• tobacco

• obesity

• surgery

• long bone fractures

diagnostics:

• ABGs, d-dimer, CT, V/Q scan, chest x-ray

clinical manifestations:

• sudden onset CP

• cough with hemoptysis

• tachypnea

• pain with inspiration

• decreased O2

• anxiety

• hypotension

Acute Bronchitis

definition:

• inflammation of lining of bronchi due to viral or bacterial infection

• 60% due to viral → FLU, COVID, RHINOVIRUS, RSV

diagnostics:

• H&P

• chest x-ray

• sputum sample

• nasopharyngeal swab

clinical manifestations:

• PRODUCTIVE COUGH

• PRODUCTION OF SPUTUM

• FATIGUE

• CHEST PAIN

• SOB

• slight fever

• mild HA

Expectorants

MOA:

• promotes increased cough production by INCREASING AND THINNING MUCOUS SECRETIONS

therapeutic uses:

• WET COUGH

meds:

• guaifenesin

complications:

• GI upset

• drowsiness

• rash

contraindications:

• caution with asthma, may cause bronchospasm

interactions:

• alcohol

nursing implications:

• report cough > 1 week, persistent HA, rash

• do not take with other OTC cold meds

patient education:

• take with full glass of water to thin secretions

• do not break or chew ER tabs

Antitussives

MOA:

• suppress CNS to suppress cough

therapeutic uses:

• DRY NONPRODUCTIVE COUGH

meds:

• hydrocodone

• codeine

• dextromethorphan

• benzonatate

complications:

• N/V/C

• dizziness

• sedation

• FALL RISK

contraindications:

• respiratory depression

• head trauma

• liver dysfunction

• alcohol use disorder

• pregnancy

interactions:

• MAOIs

• alcohol

nursing implications:

• FALL RISK

• monitor RR

• only short duration

patient education:

• change positions slowly

• increase fluids + fiber

• take only short term

Mucolytics

MOA:

• THIN and ENHANCE FLOW OF SECRETIONS

therapeutic uses:

• cystic fibrosis

• acetaminophen overdose

• acute/chronic pulmonary disorders

meds:

• acetylcysteine

complications:

• ASPIRATION/BRONCHOSPASM

• N/V

• dizziness

• hypotension

• hepatoxicity

contraindications:

• renal/liver dysfunction

• asthma

• seizure disorders

interactions:

• activated charcoal

• nitroglycerin

• abx

nursing implications:

• admin by inhalation

• SMELLS LIKE ROTTEN EGGS

• emergency equipment on hand

patient education:

• rinse mouth and face after treatment

• deep cough to bring up secretions

Rhinitis

definition:

• inflammation of nasal mucosa due to an infection or allergens

risk factors:

• common cold, allergens causing edema

diagnostics:

• RHINORRHEA

• purulent nasal discharge

• itchy eyes

• red, inflamed, swollen nasal mucosa

• low grade fever

clinical manifestations:

Antihistamines

MOA:

• block histamine release in small vessels, capillaries, nerves

therapeutic uses:

• mild allergic reactions

• motion sickness

• nasal decongestion

meds:

• diphenhydramine (Benadryl)

• dimenhydrinate (Dramamine)

• meclizine (Antivert, Dramamine Less Drowsy)

• chlorpheniramine (AllerChlor)

• loratadine (Claritin)

• cetirizine (Zyrtec)

• fexofenadine (Allegra)

complications:

• sedation, drowsiness

• anticholinergic

• GI discomfort

• respiratory depression

contraindications:

• children/pregnancy/older adults

• asthma

interactions:

• CNS depressants

• alcohol

nursing implications:

• FALL RISK

• increase fluids + bowel regimen

• monitor for urinary retention

• do not give with CNS depressants

patient education:

• take before bed

• do not operate heavy machinery

Gout

definition:

• inflammatory arthritis with URIC ACID CRYSTALS IN JOINTS/TISSUES

risk factors:

• obesity

• genetics

• postmenopause

• CVD

• starvation diet

• diuretic use

diagnostics:

• erythrocyte sedimentation rate

• serum uric acid level

• BUN/Cr

clinical manifestations:

• severe joint pain → common big toe

• redness/swelling/warmth

• tophi

Antigout Agents

MOA:

• inhibit production of uric acid

therapeutic uses:

• prophylaxis of gouty arthritis, gouty arthritis, treatment of hyperuricemia

meds:

• allopurinol = long-term

• febuxostat = long-term

• probenecid = long-term

• colchicine = acute

complications:

• agranulocytosis with colchicine

• renal calculi

• hepatitis

contraindications:

• probenecid → do not give within 2-3 weeks of acute attach

• allopurinol → hypersensitivity idiopathic

• kidney injury

interactions:

• aspirin

• warfarin

• anti-infectives

nursing implications:

• monitor uric acid, CBC, UA, LFTs, BUN/Cr

• monitor I&O

• report rash

patient education:

• low purine diet (avoid meat, liver, alcohol)

• high fluid intake

• report rash/myalgia/weakness

Cerebral Vascular Accident (Stroke)

definition:

• disruption in cerebral blood flow

• ischemic = tissue death… 87% of all strokes, blockage, can be reversible with TPA

• hemorrhagic = bleeding… poor prognosis

risk factors:

• oral contraceptives

• genetics

• atherosclerosis

• hyperlipidemia

• alcohol

• smoking

diagnostics:

• CT scan

• CBC

• coags

• carotid dopplers

• MRI

clinical manifestations:

• BE FAST → balance, eyes, facial drooping, arm weakness, slurred speech, timely reaction

• UNILATERAL NUMBNESS/WEAKNESS

• aphasia, agraphia

• mood change

• ataxia

• unilateral neglect syndrome

Parkinson’s Disease

definition:

• progressive movement disorder

• overstimulation of basal ganglia with acetylcholine → substantia nigra degeneration → DECREASED DOPAMINE

risk factors:

• older age

• male sex

• environmental toxins

• antipsychotic med use

diagnostics:

• rule out other diseases

clinical manifestations:

• tremors

• pin rolling

• shuffling gait

• bradykinesia

• flat affect

• muscle rigidity

• postural instability

• mood swings

• drooling

Antiparkinsons Agents (-dopa)

MOA:

• relief of dyskinesias due to balance of dopamine and acetylcholine

therapeutic uses:

• parkinson’s disease

meds:

• levocopa

• carbidopa

complications:

• dyskinesias (ataxia, eye twitch, tongue protrusion)

• N/V

• orthostatic hypotension

• reddish/brown urine

• activation of malignant melanoma

contraindications:

• allergy

• melanoma

interactions:

• HIGH PROTEIN MEALS

• MAOIs

• vitamin B6

nursing implications:

• monitor for toxicity → muscle twitching, grimacing, tongue protrusion

• slow onset 2-6 weeks

patient education:

• no abrupt d/c

• may cause color change to bodily fluids

• report involuntary movements

• may cause drowsiness

Seizures

definition:

• abrupt, abnormal, uncontrolled electrical activity within brain

risk factors:

• genetics

• acute febrile state

• head trauma

• hypoglycemia

• stroke

• brain tumor

• drugs

diagnostics:

• alcohol/drug levels

• EEG

• CT/MRI

• CSF analysis

clinical manifestations:

• preictal (b4) → aura (halo, taste change) + prodrome (mood change)

• ictal (seizure) → actual seizure

• postictal (after) → fatigue, confusion, distress, sleepy

Tonic-Clonic

few seconds of tonic (stiff + LOC) followed by 1-2 mins of clonic (jerking)

can see irregular RR, cyanosis, bite tongue, incontinence

Tonic

LOC and muscle stiffness for <30 sec

apnea, vomiting, salivation, arrythmias

Clonic

several minutes of jerking

muscles contract + relax

Myoclonic

brief jerking + stiffening for a few seconds

Atonic/Akinetic

lose muscle tone for a few sec

FALL RISK

Complete Partial

automatisms (unaware behaviors)

lip smacking, picking clothes

amnesia after

Simple Partial

LOC maintained, can have deja vu, autonomic abnormalities (flushing, change in HR), unilateral extremity movements, offensive smell

Anticonvulsants/Antiepileptics

MOA:

• control seizure by slowing movement of sodium and calcium into neuron and enhancing GABA

therapeutic uses:

• seizures

meds:

• phenytoin (Dilantin)

• phenobarbital (Solfoton)

• carbamazepine (Tegetrol)

• levetiracetam (Keppra)

• valproic acid (Depakote)

• lamotrigine (Lamictal)

• topiramate (Topamax)

• oxcarbazepine (Trileptal)

• pregabalin (Lyrica)

• gabapentin (Neurontin)

complications:

• CNS effects (sedation, drowiness, depression)

• toxicity from phenytoin → bone marrow suppression, ataxia, respiratory depression

• Steven Johnson Syndrome

• gingival hyperplasia

• hepatoxicity

• risk for suicide

contraindications:

• pregnancy

interactions:

• oral contraceptives

• warfarin

• CNS depressants

• alcohol

nursing implications:

• FALL RISK

• monitor therapeutic levels

• do not combine with CNS depressants

patient education:

• LIFELONG MED

• periodic blood work

• avoid alert activities

• NO ALCOHOL

• brush + floss well with phenytoin

Benzodiazepines (PAM AND LAM)

MOA:

• enhance GABA in CNS

therapeutic uses:

• GAD

• seizures

• alcohol withdrawal

meds:

• lorazepam

• diazepam

• alprazolam

• clonazepam

complications:

• CNS depression

• anterograde amnesia

• paradoxical response (older adults excitation)

• dependence

• withdrawal

contraindications:

• sleep apnea, respiratory depression

• substance use disorder

interactions:

• grapefruit juice

• high fat meals

• alcohol

• CNS depressants

nursing implications:

• baseline VS

• antidote = FLUMAZENIL

• monitor for hypotension + respiratory depression

• FALL RISK

patient education:

• short-term use

• no alter activities

• no alcohol

• no grapefruit juice + fatty foods

Non-Benzodiazepines

MOA:

• binds to GABA to produce CNS depression

therapeutic uses:

• short-term insomnia

meds:

• zolpidem

• zaleplon

• eszopiclone

complications:

• drowsiness

• dizziness

• HA

• complex sleep behaviors

contraindications:

• hx sleep behaviors

• sleep apnea

• older adults

interactions:

• CNS depressants

• alcohol

nursing implications:

• assess mental status + sleep

• do not give for >7-10days

• administer before 2am, want 7-8hr sleep

patient education:

• DO NOT READMIN OVERNIGHT

• short-term/PRN

• no driving

Muscle Relaxants/Antispasmodics

MOA:

• enhances GABA + decreases spasticity of muscles

therapeutic uses:

• relief of muscle spasm r/t injury, CP, spinal cord injury, MS

meds:

• diazepam

• baclofen

• cyclobenzaprine

• methocarbamol

complications:

• CNS depression

• seizure activity

• constipation

• urinary retention

contraindications:

• substance misuse disorder

• liver/renal impairment

interactions:

• CNS depressants

• alcohol

nursing implications:

• baseline VS + neuro

• start low and slow

• do not d/c abruptly

• monitor LOC

patient education:

• increase fiber and fluids

• taper off

• no driving

• no alcohol

Alzheimer’s Dementia

definition:

• nonreversible dementia with multiple cognitive deficits that impair motor and memory

risk factors:

• advanced age

• chemical imbalances

• family hx

• previous head injury

• race

diagnostics:

• rule out other causes

clinical manifestations:

• memory lapses

• forgetting own history

• difficulty with math

• personality changes

• getting lost

• decreased ADLs

• stupor or coma

Antidementia Agents

MOA:

• transmission of nerve impulses related to increased acetylcholine

therapeutic uses:

• parkison’s

• alzheimer’s

meds:

• donepezil

• memantine

complications:

• HA

• EXCESSIVE MUSCARINIC STIMULATION (diarrhea, secretions, salivation, diaphoresis)

• cholinergic crisis

contraindications:

• succinylcholine

• GI obstruction

• seizure disorders

interactions:

• atropine

• succinylcholine

• alcohol

nursing implications:

• monitor for toxicity

• FALL RISK

• neuro status assessment

• bradycardia monitoring

patient education:

• no alert activities

Migraine Headaches

definition:

• headaches causing severe throbbing or pulsing

risk factors:

• triggers = alcohol, allergies, odors, lights, fatigue, depression, anxiety, hormone changes, tyramine foods

diagnostics:

• neuroimaging

clinical manifestations:

• with aura

  • prodromal = before… irritable, depression, stomach upset

  • aura = numbness/tingling of face or hands, acute confusion, visual changes

  • severe throbbing headache for 4-72hr, N/V/drowsiness

• without aura

  • pain with physical activity

  • unilateral pulsing pain

  • photophobia, phonophobia

  • 4-72hr

Migraine Medications

MOA:

• cause vasoconstriction of blood vessels

therapeutic uses:

• migraines

meds:

• ergotamine

• triptans

• dihydroergotamine

• aspirin

complications:

• bone marrow suppression

• MI

• CP

• dizziness/vertigo

• ergotism → muscle pain, paresthesia

contraindications:

• HX CAD/MI/HEART DISEASE

• oral contraceptives

• bleeding disorders

interactions:

• NSAIDs

• alcohol

• tobacco

nursing implications:

• FALL RISK

• monitor for toxicity

• teach about triggers

patient education:

• use PRN

• avoid triggers

• avoid tyramine foods

• report muscle pain + tingling