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)

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

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