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Pharm Semester 3 Exam 1
Terms in this set (95)
What is Broselow tape?
rapid pediatric height to weight assessment
-helpful for when kids are outside the main percentiles
-tells you exact dosing, sizes for tubes, suctions etc...
What meds are used to treat a HTN crisis?
What meds are used to treat hypotension/bradycardia/shock?
What is the goal for vasoactive therapy?
-optimize oxygen delivery
-minimize complications (concern for hypo-perfusion and ischemia)
When is nitroglycerin indicated?
-adjunct therapy for AMI
How can nitroglycerine be administered? How will it be administered in a HTN crisis?
-sublingual (tablet or spray)
-IV infusion (TITRATABLE)
What are the adverse effects of nitroglycerine?
Who is nitroglycerine contraindicated for? precautioned?
C: RV infarction (ride sided heart attack b/c drops preload)
P: volume depletion (treat first)
How are nitroglycerine and nitroprusside similar? different?
similar: direct acting vasodilators, metabolized to nitric acid, mediates smooth muscle relaxation
different: glycerine has more of an affect on coronary, prusside has more of an affect on the peripheral. Need to keep prusside out of the sun
What are the adverse effects of nitroprusside?
biproduct of metabolism: cyanide
CNS dysfunctions, seizures, AMS
What is important to know about nitroprusside?
breaks down in the sun! needs to be in a brown bag! if broken down turns into cyanide!
patient should not be on it for more than 3 days
What toxicity occurs from nitroprusside? What is the antidote?
Who is nitroprusside precautioned/contraindicated for?
-vasodilate in periphery causing pooling and blood not return
What is nicardipine?
calcium channel blocker
dihydropyridine (affect rate not rhythm)
What is our main concern with Nicardipine IV treatment for HTN?
localized phlebitis and infiltration!
-headache (cause ischemic stroke if too fast cause hypoperfusion)
How often do you need to rotate Nicardipine IV?
peripherally, rotate Q12
or have central access!
What does Labetalol do?
Alpha AND beta adrenergic antagonist
-help get patient to normal sinus rhythm
What is the #1 drug that causes heart block?
What are the adverse effects of Labetalol?
Who should Labetalol be precautioned with?
especially becaseu of IV!!
-not usually continuous infusion
What are the main nursing implications for vasodilators? What are our main concerns?
1. check fluid volume status
2. patient safety
3. development of chest pain (good HPI)
4. infusion site assessment
5. VS monitoring (tele, continuous, pulse ox, Q5-15 minutes) & CNS reassessments
concern for stroke, renal failure, heart failure
When are vasoconstrictors indicated?
-bring up BP
-increase vascular tone
What should be checked before a vasoconstrictor is administered?
fluid volume assessment! give fluid resuscitation first
How is administration of vasoconstrictors and dilators different?
constrictors must be through a central line
constrictors must be continuous infusion to work
What is the #1 drug fro septic shock to bring up blood pressure?
How does norepinephrine work?
Stimulates alpha receptors to cause arterial and venous vasoconstriction. Stimulates beta receptors to increase contractility.
What are adverse effects of norepinephrine?
Myocardial ischemia, HTN, dysrhythmias, and impaired organ perfusion (brain, kidneys, GI tract, fingers/toes)
Who is norepinephrine precautioned for?
-patient must be normovolemic
What shocking adverse effect may occur from using norepinephrine?
death to peripheral surfaces (fingers & toes)
How does phenylephrine work?
powerful and selective alpha-adrenergic receptor agonist that causes vasoconstriction. Has no beta effects whatsoever so it is cardiac neutral
What is unique about phenylephrine?
does not effect cranial blood vessels!
-will not cause issues in the brain
When is phenylephrine indicated?
-nasal congestion (decrease fluids to nose)
What is the adverse effects of phenylephrine? What can you do as a nurse to help with those?
-hypotension and reflex bradycardia
TITRATE DRUG SLOWLY
Which meds were mentioned that need/can be titrated?
What is vasopressin?
-direct vasoconstrictor (keeps fluid in the vessels)
Does vasopressin have positive or negative chronotropic and inotropic effects?
does not affect them at all! it is a direct vasoconstrictor
When is vasopressin indicated?
Is vasopressin a set rate or is it titratable? How long does it take to start working?
30 min- 1 hour to start
set and forget!
What are the adverse effects of vasopressin? What should be monitored?
-decreased cardiac output
-decrease urinary output
monitor Cr, BUN, K+
What is dopamine best to treat?
How does the mechanism of action change with the dose of dopamine?
low 1-5: dopaminergic --> improves renal & mesenteric perfusion (increase UOP, decrease vasculature fluid cause hypovolemia to bring off fluid, increase blood flow to GI)
intermediate 5-10: dopaminergic & beta 1 adrenergic --> positive chronotrope and vasoconstriction (increase HR, mild vasoconstric (inotrope)
high >10: alpha adrenergic --> vasoconstriction (high HR, high inotropic)
When is dopamine indicated?
impaired renal perfusion
Why is dopamine not a first line vasoconstrictor?
stacking of levels
-limited by tachycardia (110 bpm)
What are the concerns with using dopamine as a vasoconstrictor?
-limited by 110 bpm
-not as safe if poor kidney function
What are the adverse effects of dopamine?
increased oxygen demand
What are nursing implications for vasoconstrictors?
1. maintain lowest effective dose
2. adequate IV site (central line, continuous)
3. assess for complications
4. assess for signs of hypoperfusion or worsening shock
monitor Central venous pressure!!
fluid volume status
end organ damage
hand & feet damage
What is infiltration?
severe localized vasoconstriction
What nursing consideration is important to remember when taking VS for a patient on a vasoconstrictor?
no BP above insertion site!
concern for infiltration
What do you do if infiltration has occurred?
-nitroglycerin paste (locally dilate to help)
-PHENTOLAMINE!! Multiple injections, alpha adrenergic blocker, localized vasodilator of arterioles and capillaries
What are some pre-sedation considerations?
associated risk factors
anticipate potential complications
(on a CPAP, heart and lung sounds, tolerate sedation? enough oxygenation?)
When is sedation indicated
1. painful procedure (decrease stress response, reduce fear/anxiety)
2. produce amnesia
3. adjunct to neuromuscular blockade
4. enhance physiologic stability
5. adjunct to terminal care
What are the characteristics of sedation: minimal
responsiveness: normal response to verbal stimulation
spontaneous ventilation: unaffected
cardiovascular function: unaffected
What are the characteristics of sedation: moderate
responsiveness: purposeful response to verbal or tactile
airway: no intervention required
spontaneous ventilation: adequate
cardiovascular function: usually maintained
What are the characteristics of sedation: deep
responsiveness: purposeful response with repeated stimulation
airway: intervention may be required
spontaneous ventilation: may be inadequate
cardiovascular function: usually maintained
What are the characteristics of sedation: general anesthesia
responsiveness: unarousable, even with painful stimulus
airway: intervention required
spontaneous ventilation: inadequate
cardiovascular function: may be impaired
What are sedation risk factors?
►Airway obstruction history/obesity
►Chronic lung disease
►Poor control of airway secretions
►Altered neurological status
What is important to remember in a focused airway assessment?
-NEED TO SEE BACK OF THROAT!
tongue blade, gage them
-check size of neck (overweight and male)
-also concerning angle of jaw, short and narrow is hard! facial structure
-child considerations! (proportions difficult to control)
-down syndrome (short neck)
know to intervene early! give oxygen to help!! (nasal cannula)
What are the potential adverse events during sedation?
(pulling lines, saying crazy things)
To minimize aspiration risk before sedation, what is the minimum fasting period in hours?
a. clear liquids
b. breast milk
c. infant formula
d. non-human milk
e. light meal
What scale will you use before someone is in sedation? Once they are in/after?
a. Glasgow Coma Scale (above 8 is good)
b. Richmond Agitation & Sedation Scale RASS (0 is goal)
How do opioids work during sedation?
-analgesia and some sedation
-alterations of mood and perception of surroundings
-depress cough reflex
What is the onset and duration for Fentanyl?
onset: IV immediate
duration: 30-60 minutes
(super fast onset, burns off fast)
What are adverse effects of Fentanyl?
-decreased respiratory drive/apnea
-histamine release (flushed on chest and itchy early on)
-chest wall/glottal rigidity (pt cannot breath through paralyzed muscles - ambu bag/mechanical ventilation
-caution with opiate naive (may have stronger response)
What is 1mg of Fentanyl equal to in morphine?
1mg = 100mg
2.5-5mg of morphine = 25-50 mcg
What are special considerations with opioids?
̶Decreased metabolism and clearance (hold onto it more and then released all at once)
̶Increased sensitivity (liver and kidney considerations)
►Pediatric clients (under 6 months)
̶Immature BBB and clearance
̶Increased sensitivity (affect RR)
Where is fentanyl metabolized? excreted?
M = liver
E = kidneys
What is the reversal agent for opioids?
-shorter half life
What meds are used specifically for sedation and do not provide any analgesic effects?
Benzodiazepine (Midazolam - Versed)
Ketamine (jk provides a little)
Dexmedatomidine (some analgesics)
How does midazolam work?
►Provides sedation, amnesia, anxiolysis, and anticonvulsant properties
►Occupies GABA receptors in the brain
►High lipid solubility
What is the onset and half life of Midazolam?
onset: IV 1-5 mins
half life: 2-6 hours (works for longer procedures than fentanyl)
What is the reversal agent for Midazolam (Benzos)? How does it work? What is a concern?
►Return of respiratory depression
►Cessation of amnesia
-could cause seizure!!
-other option is to intubate
How do barbiturates vary?
►Ultrashort-acting (quick 40 mins) seizure/sleep
-depends on length of surgery
What are the properties of barbiturates?
-what does it do?
-who is it cautioned in?
-what needs to be monitored?
►Mild sedation to total anesthesia
►Anxiolytics, hypnotics, and anticonvulsants properties
►Caution in patients with
̶Congestive heart failure
̶Tissue necrosis with extravasation
monitor Central Venous Pressure (could get hypovolemic)
What does Ketamine do?
►Derivative of phencyclidine (PCP)
►Dissociation between the cortical & limbic systems
►Inhibits catecholamine uptake
What is special about Ketamine in relation to the heart and lungs?
►Does not cause cardiovascular compromise
►not likely to affect RR
How does Ketamine inhibit catecholamine uptake?
What are the adverse effects of Ketamine?
̶Consider re-medicating with benzodiazepines
With severe delirium after Ketamine, to what alternative medication may you switch them?
What drug may need to be administered with Ketamine to help with adverse effects?
atropine? but can increase HR
What is etomidate used for?
hypnotic (used to help intubate or short sedation)
often utilized: Joint reduction, Intubation, Cardioversion
-no analagesic effects
-minimal cardiovascular effects
How many doses of Etomidate are needed?
ONE TIME DOSE
What are adverse effects of Etomidate?
►Mortality with continuous infusion
How does Propofol work?
►Promotes release of GABA
►No analgesic properties
►Lipophilic/ lipid suspension
What is the reversal agent for Propofol?
there is none! but has a short half life
What nursing considerations are important for a patient on Propofol?
-need fluids!!! / blood pressure up!
-be prepared for hypotension!
-NEED TO BE INTUBATED!
-take VS Q5 mins
What are the adverse effects of Propofol?
►Loss of protective reflexes (aspiration)
►Rapid progression between light sedation and general anesthesia (titrate up and down quickly)
What is Dexmedetomidine used for? How does it work?
►Produces analgesia and sedation
►No impact on respiratory drive
̶Sedation of intubated and non-intubated patients
-used to help with alcohol withdrawal
What are the adverse effects of Dexmedetomidine?
Hypotension and bradycardia (dose dependent secondary to decrease in catecholamines).
-does not slow RR (no need to intubate)
What interaction does Dexmedetomidine have with Benzos and narcotics?
potentiation! increase the effects
When sedation orders have been placed, what else is needed?
-check 2 pt identifiers
-oxygen up & prepared (nasal cannula)
►Baseline vital signs
̶Reassessment at least every 15 minutes
How often do you assess respiration during sedation?
at least every 15 minutes
What are nursing interventions for when a patient is sedated?
►Tactile & verbal stimulation
►Protect "body parts"
(turn patient, speak to them)
How do you put in an airway?
head lift and chin tilt
pointed up and then flipped once past the gag
If a person has an intact gag reflex what type of airway do they need?
only oral if gag reflex is not intact!
What nursing interventions are important to monitor when a patient is sedated?
-increase oxygen delivery
-assess for changes in vital signs/EKG
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