Pharm II: Exam #4

Norepinephrine Class

* adrenergic drug
* alpha beta receptor agonist
* given IV

Norepinephrine Action

* constriction of blood vessels “pressor” or “vasopressor” effect increases blood pressure
* stimulates beta and alpha receptors increase contractility, HR, and vasoconstriction.
* Alpha effects (vasoconstriction) are greater than Beta (inotropic and chronotropic)

Norepinephrine Use

* used after adequate fluid volume replacement to treat persistent hypotension in severe shock
* #1 doctor recommended vasopressor (first choice) of management of sepsis and septic shock

Epinephrine Class

* adrenergic agonist
* alpha 1, beta 1, beta 2
* catecholamine

Epinephrine Use

* anaphylaxis increases cardiac output (increases rate/force)
* Used in cardiac arrest
* Used along with local anesthetic to cause vasoconstriction (keeps area numb longer)

Epinephrine Admin

* SQ or IM (Epi-Pen)
* Different strengths of Epi Ratio expressions are now prohibited on drug lables
* 1:1000 is equal to 1mg in 1mL
* 1:10,000 is equal to 0.1mg/1mL

Epinephrine Side Effects

* tachycardia
* pounding
* irregular heart beats
* anxiety

Epinephrine BBW

* extravasation of epinephrine/norepinephrine can cause tissue damage
* infuse into large vein or central line if possible
* do not use in leg veins in older adults due to occlusion
* DO NOT GIVE with MAOI’s
* lead to arrhythmias, resp. depression and acute hypertensive crisis

Dobutamine Class

* sympathomimetic
* beta-1 agonist
* some beta-2 activity
* increase force of myocardial contraction with minimal increase in HR

Dobutamine Action

* stimulates beta1 adrenergic receptors causing increased contractility and heart rate with little effect on beta 2 or alpha receptors.

Dobutamine Uses

* shock
* short-term management of patients with cardiac decompensating
* best used for cases of shock where CO needs to be increased without the need for BP support

Dobutamine Nursing Care

* monitor HR, BP, and signs of perfusion
* color, temp, cap refill

Dobutamine Side Effects

* increased heart rate and BP
* slight increased in K+
* dyspnea

Dobutamine Caution

* can cause, enhance, or worsen hypotension

Crystalloids (LR + NS 0.9%)

* standard IV fluids
* first line treatment for shock
* no agreed upon best solution in literature
* 1st line fluid treatment
* improves hypovolemia

Colloids

* albumin and blood productions
* expands blood volume
* RBCs maximize oxygenation and increases Hgb

Milrinone Class

* phosphodiesterase inhibitor

Milrinone Use

* used to manage acute heart failure (cardiogenic shock)
* used when nothing else works to keep the heart beating

Milrinone Action

* IV use produces an immediate effect
* potent inotrope
* increases force of contraction
* produces systemic and pulmonary vasodilation
* decreases preload/afterload

Milrinone Caution

* causes potentially fatal ventricular arrhythmias in 12% of patients

Digoxin Class

* positive inotrope/chronotrope
* helps with cardiogenic shock

Digoxin Admin

* can cause toxicity at high doses
* give at same time each day, do not skip a dose
* take pulse for 1 full minute
* do not administer if HR < 60
* check potassium levels
* especially if pt on a loop diuretic
* hypokalemia increases the possibility of dig toxicity

Digoxin Toxicity Side Effects

* yellow/green halos = visual changes

Albuterol Class

* beta-2 agonist

Albuterol Use

* causes bronchodilation
* used for anaphylactic shock to open airways
* given via nebulizer or inhaler

Albuterol Side Effects

* tachycardia
* jitteriness
* anxiety
* tremors

Hydrocortisone Use

* anaphylactic shock

Hydrocortisone Actions

* anti-inflammatory and immunosuppressive (suppresses the reaction)

Hydrocortisone Side Effects

* Cushing’s disease
* Cushinoid features
* moon face, buffalo hump due to fat redistribution
* Thin skin
* Hypocalcemia
* Stunts growth
* Cataracts/glaucoma
* Immunosuppression (fevers, etc)

Major Depression

* impairs ability to function in usual activities
* seasonal affective disorder (SAD)
* postnatal depression

Bipolar Disorder

* mood disorder w/ alternating episodes of depression and mania
* lithium drug of choice (chance of toxicity, must take sufficient amounts of sodium)

SSRIs

* first line treatment of depression due to favorable side effect profile
* SNRIs are similar but more anticholinergic side effects
* increased risk of suicidal ideation in children adolescents, and young adults at 18-24 age when taking antidepressants

Serotonin Syndrome S/S

* high BP
* high fever
* agitation
* seizures
* can be fatal

Methylphenidate Class

amphetamine-related drug (not amphetamine)

Methylphenidate Action

* mild cortical stimulant that acts on the CNS
* suppresses appetite
* elevates mood
* improves physical performance

Methylphenidate Use

* ADHD and narcolepsy

Methylphenidate Adverse Effects

* tachycardia
* HTN
* excessive CNS stimulation
* nervousness
* insomnia
* convulsion
* GI effects (N/V, diarrhea, insomnia)
* Dermatologic effects: (rash, dermatitis)
* Hematologic: leukopenia/anemia
* Anorexia/weight loss

Methylphenidate Nursing Considerations

* Monitor for CNS side/adverse effects; monitor sleep patterns.
* Obtain a baseline ECG; monitor heart rate and blood pressure.
* Instruct the child and parents that the last dose of the day should be taken at least 6 hours before bedtime (14 hours for extended-release forms) to prevent insomnia.
* Monitor height and weight (particularly in children).
* Reinforce that several weeks of therapy may be necessary before the therapeutic effect is noted
* Eat prior to taking medication to lessen effects of appetite suppression
* Instruct the child and parents that OTC medications      need to be avoided.
* Avoid caffeine and other stimulants
* Do not stop taking suddenly 

Fluoxetine Class

* SSRI
* blocks reabsorption of serotonin in the brain
* elevates mood

Fluoxetine Use

* depression and anxiety
* first line treatment

Fluoxetine Side Effects

* GI (diarrhea, weight loss)
* Sexual dysfunction (delayed ejaculation in med, impaired orgasmic ability in women)

Bupropion Class

* inhibits reuptake of dopamine, norepinephrine, and serotonin
* atypical antidepressant

Bupropion Use

* depression (often given alone, but also can be added to an SSRI)
* seasonal affective disorder
* smoking cessation

Bupropion Side Effects

* increase the seizure threshold
* don’t use in people with epilepsy or hx of seizure
* CNS stimulant
* anxiety, excitement, insomnia, restlessness

Bupropion BBW

* can cause neuropsychiatric reactions

Lithium Class

* metallic salt

Lithium Use

* control mania (effective 65-80% of patients)
* drug of choice for manic episodes r/t bipolar disorder

Lithium Action

* MOA unknown
* effects synthesis, release, and reuptake of several neurotransmitters

Lithium Admin

* doses need to be increased/decreased gradually
* requires measurement of drug levels periodically (at least every 3 months)

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Lithium Pt Teaching

* do not take with diuretics which can cause sodium loss
* can lead to lithium toxicity
* adequate salt/fluid intake
* drink plenty of fluids to prevent dehydration

Olanzepine Class

* atypical antipsychotic
* decreases dopamine activity

Olanzepine Use

* mania phase of bipolar disorder
* prescribed as a single agent for acute, mixed. or manic episodes
* often in combo with an SNRI (fluoxetine) for depression related to bipolar disorder

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Olanzepine Side Effects

* can cause DRESS
* drug reaction with eosinophilia and systemic symptoms

Seizure Med Edu

* take at same time each day
* avoid triggers
* lack of sleep
* visual triggers (strobe lights, fans, etc)
* low blood sugar
* fever
* one seizure is not considered epilepsy
* 2 or more
* Lifetime treatment is required
* Loss of independence
* driving, scuba, caring for children

Methylprednisolone Class

* corticosteroid

Methylprednisolone Use

* treatment of general inflammation (swelling)
* in patients with Spinal Cord injury
* used to prevent subsequent damage from swollen spinal cord
* used immediately after injury

Methylprednisolone Adverse Effects

* same as prednisone

Lorazepam Class

* benzodiazepine
* increases the effects of GABA (a neuro-inhibitory transmitter)

Lorazepam Uses

* seizure
* anxiety
* Diazepam (same class)
* used for seizures and status epilepticus more frequently than Ativan

Lorazepam Adverse Effects

* disorientation
* confusion
* sedation
* if given fast IVP, can cause respiratory arrest

Gapapentin Class

* GABA analog (acts like GABA)

Gapapentin Use

* adjunct treatment (use with other meds) for seizures and neuropathic pain
* also used for insomnia (off label)

Gapapentin Adverse Effects

* CNS depression
* dry skin
* itchiness
* suicidal ideation

Phenytoin Class

* hydantoin

Phenytoin Action

* stabilizes the neuronal membrane by delaying the influx of sodium into the neurons preventing excitability caused by excessive stimulation (in a seizure pathway in the brain)

Phenytoin Use

* control tonic-clonic seizures
* preventative for pts undergoing brain surgery or post brain surgery

Phenytoin Adverse Effects

* gingival hyperplasia (especially in children)
* interacts with lots of meds

Lamotrigine Class

* phenyltriazine derivative

Lamotrigine Action

* not well understood
* thought to reduce the release of glutamate

Lamotrigine Use

* used along with other meds for treatment or partial seizures
* can also be used for bipolar disorder

Lamotrigine Adverse Effects

* many drug interactions
* can cause visual changes

Sumatriptan Class

* binds to serotonin (5-HT) receptors producing vasoconstriction and relieving pain of headache

Sumatriptan Use

* acute migraine
* take at onset of a headache
* can be taken again 2 hours later

Sumatriptan Adverse Effects

* chest pain (transient)
* changes in BP
* Myalgia
* fatigue
* tryptan rush

Sumatriptan Nursing Considerations

* Patients should be forewarned of “chest” side effects 
* Do not give to patients at risk for CAD, history of MI, uncontrolled HTN, TIA, stroke
* Teratogenic: avoid during pregnancy
* Patient teaching for intranasal & SubQ administration
* Take at onset of symptoms

Vasopressin Class

* vasopressor
* antidiuretic hormone
* increases BP in those with vasodilatory shock

Vasopressin Action

* The vasoconstrictive effects of vasopressin are mediated by vascular V1 receptors


* Vascular V1 receptors are directly coupled to phopholipase C, resulting in release of calcium, leading to vasoconstriction
* In addition, vasopressin stimulates antidiuresis via stimulation of V2 receptors which are coupled to adenyl cyclase.
* Contracts vascular and other smooth muscles to raise BP

Vasopressin Adverse Reactions

* decreased CO
* bradycardia
* tachyarrhythmias
* ischemia
* acute renal insufficiency
* a-fib, or heart failure
* hyponatremia

Glucagon Class

* hypoglycemic antidote
* glycogenolytic hormone

Glucagon Use

* increase blood glucose
* used for severe hypoglycemic reactions
* made by alpha cells in pancreas

Glucagon Actions

* given IM, sometimes pt can give themselves unless super hypoglycemic
* stimulates glycogenolysis (breakdown of glycogen stored in liver) to increase blood glucose

Glucagon Adverse Effects

* nausea
* vomiting
* low BP

Haloperidol Class

* typical antipsychotic

Haloperidol Action

* D2 (dopamine) receptor antagonist
* Haloperidol competitively blocks post-synaptic dopamine (D2) receptors in the brain, eliminating dopamine neurotransmission and leading to the relief of delusions and hallucinations that are commonly associated with psychosis

Haloperidol Use

* schizophrenia
* delirium
* hallucinations
* bipolar disorder

Haloperidol Side Effects

* dry mouth.
* increased saliva.
* blurred vision.
* loss of appetite.
* constipation.
* diarrhea.
* heartburn.
* nausea

(MANY)

Typical Antipsychotics

* MOA: not fully understood; may block cerebral dopamine receptor

Typical Antipsychotics Caution

* Neuroleptic Malignant Syndrome
* Cardiac dysrhythmias
* Use with caution in liver impairment
* Extrapyramidal symptoms

Typical Antipsychotics Nursing Teaching

* Take the medication as prescribed
* Maintain hydration
* Wear protective clothing outdoors & use sunscreen
* Do not drive a car or operate heavy machinery as medication may cause dizziness and decreased alertness
* Notify the prescriber if tardive dyskinesia, dystonia, or akathisia occurs
* Do not discontinue abruptly
* Monitor for symptoms of Neuroleptic Malignant Syndrome

Typical Antipsychotics Caution

* Side Effects:
* CNS effects- drowsiness, impaired mobility and mental processes, lowers seizure threshold
* Anticholinergic symptoms (hypotension, urinary retention)
* extrapyramidal symptoms: tardive dyskinesia, akthisia, dystonia, drug-induced parkinsonism
* Photosensitivity
* Some may cause agranulocytosis

Risperidone Class

* atypical antipsychotics

Risperidone Action

* decrease dopaminergic and serotonergic pathway activity in the brain, therefore decreasing symptoms of schizophrenia and mood disorders


* Risperidone has a high binding affinity for **serotonergic 5-HT2A receptors** when compared to dopaminergic D2 receptors in the brain.

Risperidone Use

* schizophrenia
* bipolar disorder

Risperidone Side Effects

* feeling sleepy in the day or difficulty falling asleep at night.
* problems with your movement – difficulty moving, stiff muscles with movements which are difficult to control, a slow shuffling walk, shakes and drooling – this is known as dyskinesia.
* headaches.
* N/V
* GI issues
* putting on weight or changes in appetite.

Atypical Antipsychotics

* MOA: not fully understood; likely blocks cerebral dopamine receptors, along with serotonin & glutamate receptors; has anticholinergic, antihistamine, & alpha-adrenergic blocking activity

Atypical Antipsychotics Side Effects

* heart disease
* lipid problems
* HTN
* type 2 diabetes
* dementia
* cancer

Atypical Antipsychotics Nursing Implications

* Baseline WBC along with continued monitoring


* Monitor for DM
* Monitor cardiovascular status 
* Do not operate car or machinery due to dizziness and decreased mental alertness
* Do not discontinue abruptly
* Advise the patient to monitor for hypotension, tachycardia, weight gain, symptoms of hyperglycemia or infection

Amitriptyline Class

* tricyclic antidepressants

Amitriptyline Action

* Serotonin + norepinephrine re-uptake inhibitor
* Inhibition of serotonin and norepinephrine transporters by through interference with neuronal reuptake of serotonin and norepinephrine
* Prolong activity of serotonergic and adrenergic neurons as they stay in the synapse for longer

Amitriptyline Use

* depression
* anxiety