pharm 2 notes pre midterm 2

diabetes

• syndrome rather than disease

• type 1: failing to produce insulin bc dont have cells that produce it (treatment is insulin pump)

• type 2: either body becomes resistant towards insulin or not producing enough insulin

• s+s

  • elevated fasting blood glucose (higher than or equal to 7 mmol/L) (for short term, couple of days) or a hemoglobin A1c (HbA 1c) level greater than or equal to 6.5% (90-120 days)

  • polyuria (lots of urine)

  • polydipsia (excessive thirst)

  • polyphagia (extreme hunger)

  • glycosuria (sugar in urine)

  • weight loss

  • fatigue

  • blurred vision

type 1 diabetes

• lack of insulin production or defective insulin

• affected pt need exogenous insulin

• feweer than 10% of all cases are type 1

• complication: diabetec keto acidosis (main) OR hyperosmolar hyperglycemic state

pancreas

type 2 diabetes

• most common- 90% of all cases

• caused by insulin deficiency and insulin resistance

• many tissues are resistant to insulin- reduced number of insulin receptors, insulin receptors are less responsive

• comorbid conditions: obesity, coronary heart disease, dyslipidemia, hypertension, microalbuminemia (protein in urine), increased risk for thrombotic (blood clotting) events

  • these comorbidities are called metabolic syndrome or cardiometabolic syndrome

gestational diabetes

• hyperglycemia that develops during pregnancy

• insulin given to prevent birth defects

• usually subsides after delivery

• 30% of pt may develop type 2 diabetes within 10-15 yrs

long term complications of diabetes

macrovascular (atheroscletortic plague): coronary arteries, cerebral arteries, peripheral vessels

microvascular (capillary damage): retinopathy, neuropathy, nephropathy

diabetes screening

prediabetes (risk of diabetes): categories of increased risk

• HBA1c of 6.0 to 6.4%

• fasting plasma glucose levels higher than or equal to 6.1 mmol/L but less than 6.9 mmol/L

• impaired glucose tolerance test (orla glucose challenge)

screening recommended every 3 years for all patients 40 yrs of age and older

non pharmacological treatment interventions

Not for type 1

• weight loss

• improved dietary habits

• smoking cessation

• reduced alcohol consumption

• regular physical excersise

glycemic goal of treatment

• HbA1c of less than 7%

• fasting blood glucose goal for diabetic pts (4-7 mmol/L)

• 2 hr postprandial target of 5-10 mmol/L

treatment for diabetes

type 1- insulin therapy

type 2- lifestyle changes, oral drug therapy, insulin when the above no longer provide glycemic control

types of antidiabetic drugs

• insulins

• oral hypoglycemic drugs

• combination of orgal antihypoglycemic and insulin controls glucose levels

• some new injectable hypoglycemic drugs may be used in addition to insulin and antidiabetic drugs

insulins

• function as a substitute for the endogenous hormone

• effects are the same as those of normal endogenous insulin

• restores diabetic pt ability to

  • metabolise carbs, fats and proteins

  • store glucose in the liver

  • convert glycogen to fat stores

antidiabetic meds

• insulins

• oral hypoglycemic drugs

• combo of oral antihypoglycemic and insulin controls glucose levels

• some new injectable hypoglycemic drugs may be used in addition to insulin or antidiabetic drugs

anasthetics

drugs that eliminate or reduce pain by depressing nerve function in the cns and pns

anasthesia

• state of reduced neurological function

types of anasthesia

• general: complete loss of conciousness and loss of body reflexesincluding paralysis of resp muscles

• local: no paralysis of resp function, elimination of pain sensation in the tissues innervated by anasthetized nerves

general anasthesia

• drugs that induce state in which cns is altered

  • pain relief, depression of conciousness, skeletal muscle relaxation, reflex reduction

types of general anasthesia

• inhalational anasthetics: volatile liquids or gases that are vaporised in oxygen and inhaled

• parenteral anathetics: administered IV

• adjunct anasthetics: drugs that enhance clinical therapy when used simultaneously with other drugs, balanced anasthesia

MOA of general anasthetics

• varies by drug

• overall effects: orderly and systematic reduction of sensory and motor cns function, progressive depression of cerebral and spinal cord functions

• overton-meyer theory:

  • for all anasthetics, potency varies directly with lipid solubility

  • fat soluble drugs are stronger anasthetics than water soluble drugs

  • nerve cell membreanes have high lipid content, as does blood brain barrier

  • lipid soluble anasthetic drugs can therefor cross the blood brain barrier to concentrate in the membranes

indications of general anasthesia

• surgical procedures

  • unconciousness

  • skeletal muscular relaxation

  • visceral smooth muscle relaxation

• rapid onset, quickly metabolised

• also used in electroconvulsive therapy treatments for severe depression

AE of gen anasthesia

• vary according to dosage and drug

• sites affected: heart, peripheral circulation, liver, kidneys, resp tract

• myocardial depression commonly seen

• malignant hyperthermia

  • during or after volatile inhaled general anasthesia or use of neuromuscular blocking drug (NMBD) succinycholine

  • sudden elevation of body temp (over 40 deg C), tachypnea, tachycardia, muscle rigidity, life threatening emergency, treated with cardiorespiratory supportive care and dantrolene sodium (skeletal muscle relaxant)

• toxicity and overdose: life threatening in large doses, cardiac and resp arrest care causes of death, admin only in controlled environment

• interactions: antihypertensives: cause increased hypotensive effect, B blockers: increased myocardial depression

nitrous oxide

• laughing gas

• inhaled currently as gen anasthetic

• weakest of gen anasthetic drugs

• primarily for dental prodedures of as supplement to more potent anasthesia

propofol

• parenteral gen anasthetic

• used for induction and maintenance of gen anasthesia

• sedation for mechanical ventilation in ccu settings

• low doses: sedative- hypnotic for moderate sedation

• use with caution in pts that are hemodynamically unstable

procedural sedation

• aka consious or moderate sedation

• doesn’t cause complete loss of conciousness and doesn’t normally cause resp arrest

• combo of an IV benzodiasepine (ex midazolam) or propofol and an opiate analgesic (fentanyl or morphine)

• propofol common

• anxiety and sensitivity to pain are reduced and the patient cannot recall the proceudre

• preserves pts ability to maintain own airway and respond to verbal commands

• used for diagnositc procedures and minor surgical procedures that do not require deep anasthesia

• rapid recovery time and greater safety profile than gen anasthesia

local anasthetics

• aka regional anasthetics

• render a specific part of body insensitive to pain

• interfere with nerve impulse transmission to specific areas of body

• dont cause loss of conciousness

types of local anasthetics

topical: applied directly to skin or mucous membranes, creams solutions, ointments, gels, opthalmic drops, powders, suppositories

parenteral: injected IV or into cns by various spinal injection techniques

spinal or intraspinal: intrathecal (spinal canal or subarachnoid space) or epidural (epidural spaces)

infiltration, nerve block topical

benzocaine lidocaine

drug effects of local anasthetics: paralysis

1. autonomic activity is lost

2. pain and other sensory function is lost

3. motor activity is lost

as local drug wears off, recovery orders in reverse order

indications of local anasthetics

• surgical, dental and diagnositc procedures

• treatment of certain types of persistent pain

• spinal anasthesia during surgical procedures and childbirth for pain

• local anasthetics are given by infitration anasthesia

infiltration anasthesia

• minor surgical and dental procedures

• injection of inasthetic solution intraderma, subcutaneously, submucosally or intramuscularly across the path of nerves supplying target area

• may be given in circular pattern around operative area

infiltration anasthesia and epinephrine indications

• used for infiltration or nerve block are combined with vasoconstrictors to

  • prevent systemic absorption of anasthetic

  • help confine local anasthetics to injected area

  • reduce local blood loss during the procedure

nerve block anasthesia indications

• diagnostic procedures such as laryngoscopy, bronchoscopy, esophagoscopy

• injected directly into or around the nerve trunks or nerve ganglia that supply area to be number

adverse effects of spinal anasthetics

• spinal headache

• 70% of pts experience inadvertent dural punctire during epidural anasthesia or undergo intrathecal anasthesia

• usually self limiting

• treatment: bed rest, analgesics, caffiene, blood patch

neuromuscular blocking drugs

• prevent nerve transmission in skeletal and smooth muscle, results in muscle paralysis

• also paralyse skeletal muscles required for breathing: intercostal muscles and diaphragm

• used with anasthetics during surgery

• artificial mechanical ventilation is required

  • bc these drugs paralyse resp and skeletal muscles, pt cant breathe on their own, do not cause sedation or pain relief, pt may be paralysed yet conciousness

depolarising druugs

• succinycholine and pancuronium bromide

  • rapid onset, short duration

  • toxicity: cardiac arrythmias, prolonged apnea, malignant hyperthermia (treatment with muscle relaxant: dantrolene)

non depolarising drygs

• short acting

• intermediate acting

• long acting

neuromuscuar blocking drugs

• nmbd induced paralysis during surgical procedure

• muscle weakness, total flaccid limbs (first fingers then eyes, then limbs and trunk, finally intercostal muscles and diaphragm)- recovery is opposite order

• nmbds do not cause sedation of pain relief

indications of neuromuscular blocking drugs

• facilitating controlled ventillation during short procedures

• endotracheal intubation (short acting)

• reduce muscle contraction in an area that needs surgery

• diagnostic drug for myasthenia gravis

safety for neuromuscular blocking drugs

• resp muscle paralysis occurs with these drugs

• emergency ventilation equipment must be avalable immediately

nursing implications of nmbd

• always assess past hisotry of surgeries and response to anasthesia

• assess med history, allergies and meds

• assess use of alcohol, illicit drugs and opioids

• assessment during pre op, intraop and post op,

• vital signs, baseline lab work, electrocardiogram, oxygen saturation, abcs, all body systems

• each perioperative phase has its own complex and specific nursing actions

• pre op teaching abt surgical procedure of anasthesia

• malignant hyperthermia s+s (be aware of it)

• monirot for cardiovascular depression, resp depression and complications of anasthesia both intra and post op

• safety measures during recovery esp if motor or sensory loss occurs bc of anasthesia

• reorient pt to surrounding

• teach pt abt post op turning, coughing and deep breathing

treatment for diabetes

type 1: insulin

type 2: lifestyle changes, oral drug therapy, insulin when above doesn’t provide glycemic control

types of antidiabetic drugs

• insulines

• oral hypoglycemic drugs

• combo

• some new injectable hypoglycemic drugs can be used as adjuvant

insulins

• substitute for endogenous hormone

• same effects as endogenous hormone

  • metabolised carbs, fats and proteins

  • store glucose in liver

  • convert glycogen to fat stores

human insulin

• derived using recombinant deoxyribonucleic acid (DNA) technologies

• recombinant insulin produced by bacteria and yeast

• goal: tight glucose control- reduces incidence of long term complications

fast acting

• onset in 4 mins, taken as soon as food is taken, peak is btwn .5 to 1.5 hours, duration is 3-5 hrs

• ex: insulin lispro aabc - within seconds

• rapid acting treatment for type 1 and type 2

• ex: insulin lispro (Humalog) (similar action to human insulin), insulin aspart (Novorapid), Insulin glulisine (apidra)

• can be given subq or via continous infusion pumps

can insulin be given iv

ONLY human insulin (Humalin) or regular insulin, only used in crisis states such as DKA

short acting insulin

• reg insulin (Humalin R, Novolin ge Toronto)

• IV, IV bolus or infusion, IM, Subcut)

• subcut: onset is 30 mins, peak around 2-3 hrs and duration is 6.5 hours

intermediate acting insulins

• trying to stay away from these, if pt is on this drug, give snack before bed so they can sleep longer

• ex insuline isophane suspension (NPH)

  • cloudy

  • combined w reg insulin often

  • onset 1-3 hrs, peak of 5-8 hrs and duration can be up to 18 hrs

long acting insulin

• usually once every 12 to 24 hrs, dont usually cause spikes and dips

• ex insulin glargine (lantus)

  • clear, colourless

  • constant level

  • basal insulin

  • onset is 90 mins, peak is none and duration is around 24 hrs

• ex insulin detemir

  • duration of action is dose dependant

  • lower dose requires twice daily dosing

  • higher doses may be given once daily

check out insulin guide

fixed combination insulin

• contain cloudy insulin and clear (Clear before cloudy, short acting then intermediate)

• mixed acting contains one intermediate along with either rapid or short acting

humalin (30/70)

Novolin (30/70, 40/60, 50/50)

Novomix (30)

Humalog (Mix50 or Mix25)

correction scale insulin dosing

• subcut rapid acting (lispro or aspart)- short acting regular insulins, adjusted according to blood glucose test results

• typically used in hospitalised diabetic pt or those on total parenteral or enteral nutrition/tube feedings

• subcut insulin ordered in amt that increases as blood glucose increases

• disadvantage: delays insulin admin until hyperglycemia occurs results in large swings in glucose control

• recent research doesnt support sliding scale but it is commonly used

  • look at MOST current order of correction scale

basal bolus insulin dose

• preferred treatment for hospitalised pts with diabetes

• mimics a healthy pancreas by delivering basal insulin constantly and then as needed bolus

• basal insulin is long acting (insulin glargine) and bolus insulin (lispro or aspart)

types of insulin summary

correcting scale example

injectable antidiabetic drugs MOA

• amylin agonist

  • mimics natural hormone amylin

  • slows gastric emptying

  • suppresses glucagon secretion, reducing hepatic glucose output

  • used when other drugs haven’t acheived adequate glucose control

  • subcut injection

• incretin mimetics ***only work if pt has beta cells that can actuallly make insulin

  • mimic incretin hormone released by GI tract in response to food

  • stimulates insuline secretion

  • decreases postprandial glucagon production

  • slow gastric emptying leads to increased satiety (fullness)

injectable antidiabetic drugs AE

amylin agonist: nausea, vomiting, anorexia, headache

incretin mimetics: nausea, vomiting, diarrhea, rare cases of hemorrhagic or necrotising pancreatitis, weight loss

oral antidiabetic drugs

• used for type 2

• effective treatment involves: lifestyle changes, careful monitoring of blood glucose levels, therapty with one or more drugs, treatment of associated comorbid conditions such as high cholesterol and high bp

• most common most prescribed: metformin

  • it is oral biguanide drug

• if modifications dont acheive recomended A1c goals after 3-6 months

  • additional treatment: dipeptidyl peptidase 4 (DPP-4) inhibitors and glucagon like peptide 1 (GLP 1) receptor agonists (liraglutide, exenatide, abligludide) or insulin

gestational diabetes treatment

• only insulin

biguanide: metformin (oral antidiabetic)

AE: abdominal bloating, nausea, cramping, fullness, diarrhea, metalic taste, hypoglycemia, reduction in B12 levels long term, complication is lactic acidosis (rare)

Interactions: metformin with iodine containing ragiological constrast medium (contrast dye test) can cause acute kidney failure and lactic acidosis

contrast dye test

• 48 hrs before or just 24 hrs if in hospital, test do not take metformin, can cause renal issues

lactic acidosis

• build up of lactic acidoses

sulphonylureas (oral antidiabetic)

• second gen: glimepiride (amaryl), gliclazide (diamicron), hlyburide (diabeta)

• for type 2 diabetes

• contraindications: severe liver or kidney disease

• ae: hypoglycemia, weight gain, skin rash, nausea, epigastic fullness, heartburn

• increased hypoglycemic effect with alcohol

glinides

• type 2 diabetes

• ex: repaglinide

• similar to sulphonylureas

3 Gs

sulphonylureas: glimepiride (amaryl), gliclazide (diamicron), glyburide (diabeta)

glinides: repaglinide

thiazolidinediones (glitazones): pioglitazone (actos), rosiglitazone (avandia)

***must have diabetes type 2 with working beta cells

mind hepatic and kidney function

thiazolidinedoines (glitazones)

• insulin sensitising drugs

• for type 2

• ex: pioglitazone (actos), rosiglitazone (avandia)

a-glucosidase inhibitor

• acarbose (glucobay)

• indication: type 2

• moa: prevents digestion of carbohydrates and prevents full absorption

• contraindications

• ae: flatulence, diarrhea, abdominal pain

dipeptidyl peptidase 4 (DPP-4 inhibitors)

• delay breakdown of incretin hormone, increases insulin synthesis and decrease glucagon secretion

• ex: sitagliptin (januvia)

• dpp 4 is an enxyme that breaks down incretin hormones

• combo therapy made with metformin improves blood glucose levels

glucagon like peptide (GLP 1) receptor agonist

• subcut injection

• increase insulin levels

• lowers glucagon levels

• slow digestion

• AE: nause, vomiting, diarrhea

• ex: exenatide and dulaglutide

• contraindicated: family history of medullary thyroid cancer bc impacts hormones and metabolism

sodium glucose cotransporter 2 (SGLT2) inhibitors

• eliminates glucose in urine

• low risk of hypoglycemia

• ae: UTIs, hypotension, caution with renal dysfunction, breathing difficulty, nausea, vomiting, abdominal pain, confusion and fatigue,

• *even in absense of high blood glucose, should be evaluated if ketoacidosis

• ex: canagliflozin (invokana), dapagliflozin (forxiga)

• decrease in blood glucose caused by increase in renal excretion

• moa: work independantly of insulin to prevent glucose reabsorption from the glomerular filtrate, results in a reduced renal threshold for glucose and glycosuria
  
  

sick day management

• if pt is ill and unable to maintain fluid intake (ex diarrhea or vomiting) or if decline in renal function

• SADMANS (hold bc of reduced kidney function)

• add image

• s: sulfaylureas

• a: ace inhibitors

• d: diuretics

• m: metformin

• a: angiotensin receptor blockers

• n: nsaids

• s: sglt2 inhibitors

hypoglycemia

• abnormally low blood glucose (under 4 mmol/L)

• mild cases can be treated with diet (more protein, less carbs- to prevent rebound post prandial hypoglycemia)

  • for quick increase- give fruit juices, not reg table sugar bc disaccharides

  • carb is for blood glucose and protein for longer term

• symptoms: anxiety, tremors, hunder, palpitations, sweating, difficulty concentrating, confusion, weakness, drowsy, headache, vision changes, difficulty speaking, dizzy,

  • later signs: hypothermia, seizures, coma, death

glucose elevating drugs

• complex carbs (15 g)

• oral forms of concentrated glucose (gel, liquid or tablet)

• 50% dextrose in water (D50W)

• glucagon

nursing implications for diabetics

• before giving drugs that alter blood glucose

  • thorough history

  • vital signs

  • blood glucose levels (HbA1c level)

  • potential complications and drug interactions

  • assess for ability to consume foods

  • nausea or vomiting

  • hypoglycemia issue if med given and pt doesnt eat)

  • if pt is npo for procedure- call provider to clarify orders

• overall concerns for diabetic increase when

  • pt under stress

  • pregnant or lactating

  • infection

  • illness or trauma

nursing education for diabetics

• disease process

• diet and excersise recommendations

• self admin of insulin or oral drugs

  • timing of doses, monitoring of blood glucose levels and injection site rotations

• potenital complications

nursing implications for insulin

• ensure correct drug, route, type of insulin, dosage, check insulin order and prepared dose are second checked by another RN (per agency policy)

• check blood glucose first, to mix suspensions - roll dont shake, ensure correct storage of insulin

• only use insulin syringes (calibrated in units)

• ensure correct timing of insulin dose with meals

• when drawing up 2 types of insulin in one syringe- withdraw regular or rapid acting (clear) first

nursing implications for oral antidiabetic drugs

• always check blood glucose first

• usually given 30 mins before meals

hypoglcemia nursing implications

monitoring therapeutic response for diabtics

• decrease in blood glucose levels (level prescribed)

• measure HbA1c to monitor long term

• watch for hypo and hyper glycemia

biosimular insulin

• treats diabetes, similar to product but more affordable

• ex: basaglar (similar to lantus or glargine), admelog (simular to humalog or lispro), trurapi (similar to novorapid or aspart)

CNS depressants- sedatives

• drugs that have an inhibitory effect on CNS

• reduce nervousnness, excitability, irritability

CNS depressants- hypnotics

• cause sleep

• more potent effect on cns than sedatives

• sedative can become hypnotic in large dose

cns depressants

sedative - hypnotics are dose dependant

• low doses: calm cns without sleep

• high doses: calms and causes sleep

• 3 main groups: barbituates, benzodiazepines, miscallaneous drugs

sleep

• normal sleep is cyclic and repetitive

• sleeping persons response to stimuli is reduced

• sleep architecture: REM (deep sleep around 4-5 cycles good) and non REM sleep

• rem interference:

• rem rebound:

CNS depressant: benzodiadepines examples

CNS depressant: benzodiadepines

• formerly the most prescribed sedative-hypnotic drug

• nonbenzos currently more frequently prescribed (bc of cns ae)

• favourable ae profiles, efficacy, safety

• either sedative-hypnotic or anxiolytic (med that relieves anxiety, given in low doses)

• good short term sleep aid (good for grief)

• long acting: for sleep

• intermediate acting: procedures like invasive (gastroscopy)

• short acting: for MRIs

CNS depressant: benzodiadepines MOA and effects and indications

• MOA: depress cns activity, affect hypothalamic, thaliamic and limbic systems, work on benzodiasepine receptors (gamma aminobutyric acid (GABA)), dont suppress rem, do not increase metabolism of other drugs

• calms cns, controls agitation and anxiety, reduce sensory stimulation, skeletal muscle relaxation

• indications: sedation, sleep induction, skeletal muscle relaxation, agitation or anxiety relief, anxiety related depression, for acute seizure disorders, alcohol withdrawal, short term therapy for insomnia

benzodiasepines ae

• mild and infrequent

• headache, drowsy, paradoxical excitement or nervousness, dizzy, cognitive impairment, vertifo, lethargy, fall risk for older adults, hangover effect or daytime sleepiness

which drug effects sleep

• benzo dont interfere with sleep

benzodiasepines toxicity and overdose

• somnolence, confusion, coma, diminished relfexes, rarely results in hypotension and resp depression unless taken with other cns depressents, treatment is symptomatic and supportive

• *flumazenil as an antidote for benzo toxicity

benzodiadepines interactions

• azole antifungals, verapamil, diltiazem, protease inhibitors, macrolide, antibiotics, grapefruit juice

• cns depressants: alcohol, opioids, muscle relaxants

• kava and valerian (drugs for anxiety)

• food drug interactions with grapefruit and grapefruit juice (impacts enzyme actions of P450- impacts metabolism of meds)

diazepam

• first clinicaly available

• varied uses: anxiety, adjunct in proceudral sedation, acute seizures, skeletal muscle relaxant (injury or surgery)

• long acting

• IV or PO

midazolam (versed)

• common preop and for procedural sedation

• amnesia and anxiolysis as well as sedation

• IV in adults, liquid oral for children

temazepam (restoril)

• intermediate acting benzo

• metabolites in diazepam

• normally induces sleep within 20-40 mins

• long onset of action, should be taken an hour before sleep

• effective hypnotic but replaced by newer drugs

non benzo: ramelteon

• similar to melatonin, agonist at melatonin

non benzo: zopiclone (imovane, rhovane)

• short acting benzo LIKE drug

• very short half life

• its blue

• short term treatment (7-10 days)

non benzo : zolpidem

herbal products kava

herbal products: valerian

barbituates

• 1903 introduced, standard for insomnia and sedation

• habit forming and low therapeutic index

• not used as much tofat bc of safety of efficacy of benzo

barbituates MOA

• works in brainstem (reticular formation)

• potentiating action of GABA, nerve impulses traveling in cerebral cortex are inhibited