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Module 5 Pharm

Terms in this set (29)

Main neurotransmitters:
-Epinephrine
-Norepinephrine

Receptor sites:
-Throughout the body

Known as Adrenergic receptor sites:
-Alpha-Adrenergic Receptor sites:
-Alpha 1- postsynaptic
-Alpha 2- presynaptic

-Beta-Adrenergic Receptor sites:
-Beta 1- primarily located in heart
-Beta 2- primarily located in smooth muscle of bronchioles, arterioles and visceral organs

-During "Fight or Flight", you need to be able to see your opponent if you are fighting or the road in front of you if you are running away from a predator-so your pupils dilate (mydriasis).
-You need a lot of oxygen to your muscles, so your bronchioles dilate.
-Your heart rate increases in order to provide oxygen rich blood to your muscles.
-The blood vessels constrict to help ensure blood flow to vital organs in your fight or flight.
-The muscles in your GI system relax, because it isn't good to poop while your fighting or running.
-Bladder relaxes so you don't pee on yourself while fighting or running.
-You need to have energy for your fight or flight; therefore your liver stimulates glucose release, raising your blood sugar

-Can you think of a disease process you would want to use an adrenergic stimulating drug to treat? Think about the lungs. Bronchodilation occurs with these drugs. Wouldn't these be useful in Asthma and COPD? What about the blood pressure? If you had low blood pressure, and these drugs cause vasoconstriction, wouldn't that help increase the blood pressure? What would be a contraindication for these drugs? IF they stimulated the heart rate to increase, a rapid heart rate, or a dysrhythmia could be a reason to withhold these medications. Because they cause pupil dilation, glaucoma could be a contraindication for these medications as well.
-Remember that albuterol, from the lower respiratory drug content, is an adrenergic agonists that stimulates beta 2, causing bronchodilation. It was useful in the treatment of asthma, COPD, pneumonia, and other respiratory diseases
-MOA: stimulates Alpha 1 which increases BP, stimulates Beta 1 which increases HR, and stimulates Beta 2 which promotes bronchodilation

-Indications: allergic reactions, anaphylaxis, asthma, bronchospasm, severe hypotension, and cardiac arrest

-Contraindications: allergy, narrow-angle glaucoma, cardiac dysrhythmias
-What if the patient has glaucoma but their airway is closing off due to anaphylaxis? Do you withhold the epinephrine because of the risk of causing vision loss and watch the patient die? No, you would give the life-saving epinephrine. These contraindications are more of a "Use cation in".

-Side effects: tremors, agitation, insomnia, decreased renal tissue perfusion, urinary retention, palpitations, tachycardia, hypertension, ventricular fibrillation
-IV infiltration causes necrosis and tissue sloughing (phentolamine mesylate antidote)
-How can you tell the difference between urinary retention and decrease renal tissue perfusion? You can palpate the bladder, above the symphysis pubis, and if you feel a hard, firm bladder, it means the problem is urinary retention. You can also a do a bladder scan and if there is urine in the bladder, it is urinary retention. If the bladder is empty, it could be decreased renal tissue perfusion. So, look at output as one indicator of renal tissue perfusion. You can also look at lab work, look at the creatinine level. If it is rising, this is also an indicator of decreased renal tissue perfusion

-Toxicity and Management of Overdose: short duration (20-30 minutes) so most often stopping drug will fix toxicity, CNS and cardiovascular risk, decrease blood pressure rapidly, support the respiratory and cardiac systems

-Interactions: beta blockers antagonize epinephrine effects, MAOI's can cause hypertensive crisis, lab shows increased blood sugar
Assessment should include the following:
-Assess baseline vital signs (especially heart rate and blood pressure)
-Auscultate lung sounds (to get a baseline, is there wheezing, meaning there is limited airflow)
-Assess renal function before administering look at urinary output, baseline creatinine if available.
-Assess drug history
-Determine health history (looking especially for cardiac history and narrow-angle glaucoma)
-Assess IV site prior to administering epinephrine, make sure it is working, that it is a large bore IV.

Diagnosis:
-Ineffective airway clearance related to anaphylaxis.
-Decrease cardiac output related to low heart rate.

PlanningOutcomes:
-Patient's respiratory rate will be between 12-20 breaths per minute, oxygen saturation will be greater than 92% on room air, lung sounds will have decrease wheezing and increased airflow upon auscultation 15 minutes after administration of epinephrine.
-Patient's systolic blood pressure will be between 95-110, heart rate will be between 60-100.

Implementation:
-Administer 1 mg IV for cardiac arrest. Follow each dose with 20 mL of saline flush.
-Monitor IV site frequently when administering IV norepinephrine or dopamine because extravasation causes tissue necrosis.
-Administer phentolamine mesylate 5-10 mg diluted in 10-15 mL of saline in the area for IV extravasation.
-Monitor urinary output as impaired renal tissue perfusion and urinary retention may occur with epinephrine administration.

Patient teaching:
-Self-administration of EpiPen- teach to have pen readily available, give immediately upon the initial occurrence of difficulty breathing, wheezing, hoarseness, hives, itching or swelling of lips.
-Administer properly. Inspect for discoloration or particles. Inject into outer thigh.
-Side effects to report (palpitations, headache, tremors, insomnia, agitation)

Evaluation:
-Wheezing decrease, and increase airflow is present upon auscultation of lung sounds, O2 saturation is greater than 92% on room air, respirations are 14 breaths per minute, even and nonlabored.
-Systolic blood pressure is 100, Heart rate is 85 beats per minute, regular rhythm
-Examples: doxazosin, prazosin, terazosin, tamsulosin (zosin or losin is common ending)

-MOA: interrupt stimulation of SNS at the alpha 1 adrenergic receptors

-Indications: hypertension (doxazosin, prazosin, and terazosin are used to treat hypertension because they cause both arterial and venous dilation), benign prostatic hyperplasia (tamsulosin is used to treat benign prostatic hyperplasia (BPH) because it causes relaxation of the smooth muscle in the bladder neck and the prostatic portion of the urethra, this allows the patient to more completely empty their bladder)
-Remember that epinephrine extravasation was treated with phentolamine mesylate. Phentolamine is an alpha blocker and causes vasodilation. The epinephrine that leaked into the tissue is causing severe vasoconstriction, which decreases perfusion and can cause necrosis. The action of this alpha blocker (phentolamine) counteracts the effects of the epinephrine, which can prevent the need for amputation

-Contraindications: allergy, hypotension, use caution in hepatic and renal disease patients

-Side effects: first dose phenomenon (severe and sudden drop in BP), orthostatic hypotension, dizziness, headache, constipation, edema, nasal congestion

-Toxicity and management of overdose: BP should be supported through IV fluid administration, administration of vasopressors (dopamine or norepinephrine)

-Interactions: additive effects (beta-blockers, erectile dysfunction drugs, Viagra, sildenafil), antagonistic effects (epinephrine)
Assessment should include:
-Obtain a medication history. Look for medications that cause an interaction-beta-blockers and erectile dysfunction drugs will have additive effect, causing the blood pressure to become very low, and epinephrine would have an antagonistic effect, causing the blood pressure to remain elevated.
-Obtain baseline vital signs-especially looking at blood pressure and heart rate.
-Assess renal function as drug toxicity can occur in renal failures - assess urinary output and creatinine level. Th creatinine level should be less than 1.3 and urinary output should be over 30 mL per hour.
-Assess patient urinary system status (for BPH- is patient able to empty bladder completely, do they experience urgency, frequency, or nocturia, are they able to start and keep a steady stream)

Diagnosis:
-Deficient knowledge related to drug therapy

Planning:
-Patient will verbalize side effects associated with alpha-blockers.
-The patient's blood pressure will be within the range of 100/60-140/80.

Implementation:
-Monitor vital signs, if used for blood pressure, full effect may take up to 4 weeks.
-Weigh daily to observe for fluid retention.
-Monitor for ankle edema (side effect of alpha-blockers)
-First dose should be given at night

Patient teaching:
-Do not stop abruptly as this can cause rebound hypertension
-Rise slowly, in stages as orthostatic hypotension can occur
-Teach patient to weigh daily and record weight. Report weight gain of greater than 5 pounds in 2 days.
-Avoid over- the- counter cold medications as they often contain adrenergic stimulating medications and will counteract alpha-blocker effects.
-Teach to take tamsulosin in the evening. It helps with urinary frequency and urgency at night.

Evaluation:
-Blood pressure is between desired range.
-Patient reports taking medication as prescribed.
-Evaluate for any potential side effects.
-Able to start and keep a stream of urine.
Assessment should include:
-Obtain medication history: look for medications that cause interactions with beta-blockers (digoxin, diuretics, antacids, atropine)
-Assess vital signs- especially noting blood pressure and heart rate (hold if blood pressure less than 100 systolic or heart rate less than 60).
-Assess severe pulmonary disease (especially with non-selective beta-blockers).
-Assess for history of diabetes mellitus

Diagnosis:
-Decreased cardiac output

Planning:
-The patient's blood pressure will be within the range of 100/60-140/80.
-The patient's heart rate will be within the range of 60-100, with a regular rhythm.

Implementation:
-Monitor blood pressure and if the systolic reading is below 100 mm/Hg, the dose of the beta-blocker should be held.
-Count apical pulse for full minute to determine heart rate is greater than 60 beats per minute. If less than 60 beats per minutes, the beta-blocker should be held. Remember any time you withhold a medication; the healthcare provider should be notified.
-If patient is diabetic, monitor patient closely for signs of hypoglycemia as beta-blockers mask the symptoms of hypoglycemia.

Patient teaching:
-Do not stop abruptly as this can cause rebound hypertension or increase the potential for myocardial infarction (MI, AKA heart attack).
-Teach patient how to check blood pressure and radial pulse
-Instruct to rise slowly in stages to help prevent injury related to orthostatic hypotension
-Teach patients with diabetes to monitor blood sugar more closely
-Take with small sip of water on morning of surgery unless instructed otherwise by surgeon. This can decrease cardiac stress during surgery and help prevent a MI during surgery or post-operatively.

Evaluation:
-Blood pressure is between desired range.
-Patient reports taking medication as prescribed.
-Evaluate for any potential adverse effects.
Assessment should include:
-Blood pressure and pulse
-Assess for past history of allergy to ACE inhibitors or ARBS-look especially for past angioedema
-Assess potassium level since ACE and ARB can raise potassium level-Do you still remember the normal potassium level?
-Assess pregnancy as ACE inhibitors and ARBS are contraindicated in pregnancy

Diagnosis:
-Risk for injury related to the possibility of falling related to orthostatic hypotension

Planning:
-Blood pressure will be within the range of 100/60-140/80.

Implementation:
-Hold ACE inhibitor or ARB if blood pressure is less than 100 systolic or follow the parameter the healthcare provider has written on the order.
-Monitor potassium level during therapy
-Monitor for signs and symptoms of angioedema-facial swelling, swollen lips, even the patient complaining that their tongue feels thick.
-Monitor for dry, hacking cough (side effect of the ACE inhibitor). If this occurs, the patient can be switched to an ARB (the health care provider is responsible for prescribing the ARB, not the nurse). ARB's have less incidence of cough but are much more expensive.

Patient teaching:
-Avoid salt substitutes because they made with potassium chloride instead of sodium chloride
-Rise slowly in stages to prevent orthostatic hypotension
-Teach the patient that if they feel like their tongue is thick, or their lips are swollen, this is an adverse effect of the medication and should be reported to the physician immediately
-Do not stop the medication abruptly as rebound hypertension can occur
-Teach the patient how to take blood pressure at home and to record readings for the healthcare provider to review at follow-up appointments.

Evaluation:
-Reassess the blood pressure to ensure the medication was effective in lowering the blood pressure.
Assessment:
-Assess potassium level (If potassium wasting diuretic-such as loop or thiazide, look for low potassium; if potassium-sparing diuretic, look for high potassium)
-Assess for drug interactions (look at each type of diuretic and know the selected drugs that interact)
-Assess past medical history (look for contraindications as specified for each drug)
-Assess weight for baseline
-Assess vital signs-look especially at blood pressure since diuretics decrease circulating volume, which can lower blood pressure

Diagnosis:
-Decreased cardiac output related to decreased volume due to diuresis of fluid.

Planning:
-Patient will have balance intake and output ratios.

Implementation:
-Monitor blood pressure throughout therapy
-Monitor for fluid retention-edema and weight gain (weigh patient daily) Weight is the most sensitive indicator of fluid balance.
-Monitor intake and output, looking at balance.
-Monitor potassium levels and for signs of electrolyte imbalances
-If giving furosemide intravenously, give at a rate no faster than 20 mg/min. If given too rapidly, furosemide can cause transient hearing loss.
-Monitor for gout-like symptoms with loop and thiazide diuretics.
-Check blood sugar more frequently in diabetic patient's prescribed loop or thiazide diuretics.

Patient teaching:
-Teach to rise slowly in stages related to orthostatic hypotension (especially the elderly)
-Teach to either increase potassium intake (potassium wasting diuretics) or decrease potassium intake (potassium-sparing diuretics)
-Teach to weigh daily (in the same clothes, at the same time, on the same scale) and record their weight and report weight gain of greater than 5 pounds in 2 days.
-Teach diabetic patients that thiazide diuretics and loop diuretics cause hyperglycemia and may decrease the effectiveness of their antidiabetic medication

Evaluation:
-The patient has increased output.
-Daily weight shows decrease in patient weight
-The oldest cardiac drug, has many adverse effects and a greater risk of toxicity

-MOA: positive inotropic (increases myocardial contractility), negative chronotropic (decreases heart rate), negative dromotropic (decreases conduction), increase stroke volume (increases cardiac output), reduces heart size during diastole, decreases venous BP and vein engorgement, increases coronary circulation, promotes tissue perfusion and diuresis as a result of improved blood circulation

-Indication: treatment of CFH, atrial fibrillation and atrial flutter
-These effects all strengthen cardiac, peripheral, and kidney function by enhancing cardiac output, decreasing preload, improving blood flow to the periphery and kidneys, decreasing edema, and promoting fluid excretion, which results in fluid retention decreasing in the lungs.

-Contraindications: allergy, second and third degree heart block, ventricular fibrillation

-Side effects: bradycardia, hypotension

-Toxicity and management of overdose: therapeutic range is .5-2 ng/mL, toxicity is over 2 ng/mL, signs and symptoms of toxicity (anorexia, nausea, vomiting, diarrhea, bradycardia, cardiac dysrhythmias, colored vision changes, confusion, delirium
-Antidote: digoxin immune Fab (DigiBind)

-Interactions: potassium wasting diuretics, herbal supplements
-Herbal supplements such as St. John's Wart may reduce digoxin levels. Food interactions include high fiber meals.
-Digoxin should be administered 1 hour before or 2 hours after a high fiber meal to help prevent decreased absorption
Assessment should include:
-Past medical history, looking for kidney disease. Impaired renal function can decrease renal excretion of digoxin and lead to toxicity.
-Current medications-looking for drug interactions. Remember that heart failure is commonly treated with diuretics-especially loop diuretics. Your patient may be on furosemide, this does not mean that they cannot take digoxin, it means that you must monitor the potassium level more closely, and, most often, the patient will also be on a potassium supplement.
-Assess vital signs, especially pulse and blood pressure. Count the apical pulse for 60 seconds and if less than 60, do not administer the dose of digoxin. If the Apical pulse is greater than 120, this can also be a sign of toxicity and the dose should be held and the healthcare provider notified.
-Assess for sign of digoxin toxicity prior to administering the dose. Be sure that you know all the signs of digoxin toxicity
-Assess digoxin level-make sure you memorize the therapeutic range
-Assess potassium level: if it is low, it can lead to digoxin toxicity.

Diagnosis:
-Decreased cardiac outputIneffective cardiac and cerebral perfusion

Planning:
-Heart rate will be within the range of 60-100 BPM.

Implementation:
-Monitor apical pulse rate before administering digoxin (hold if less than 60).
-Monitor digoxin level
-Weigh the patient daily
-Monitor K level because hypokalemia potentiates the effects of digoxin and can lead to digoxin toxicity
-Be sure to check dose that is ordered for safety (think about those leading zeros and trailing zeros)
-Monitor signs of digoxin toxicity-there are a lot and you need to know them

Patient teaching:
-Teach how to take pulse and report to HCP if pulse rate <60 BPM.
-Teach the importance of medication compliance and lifestyle modifications
-Teach the patient to weigh themselves daily and record. Report a weight gain of 5 pounds in 2 days. If caught early, this fluid retention can be treated before the patient is in crisis in the emergency department. Remember that weight is the most sensitive indicator of fluid balance.
-Teach signs and symptoms of digoxin toxicity and to report to health care provider.
-Teach patient to increase potassium in diet (fresh fruit, dried fruit, fruit juices and vegetables)
-Teach to avoid high fiber meals when taking a dose of digoxin. Digoxin is often dosed in the morning and I know that I love to eat oatmeal for breakfast. If I were on digoxin, I would have to modify my routine to make sure I ate my oatmeal either 2 hours before or 1 hour after the dose.

Evaluation:
-Evaluate drug effectiveness (Decreased HR)
-Digoxin level within therapeutic range.
-Diuresis is increased, and fluid retention is decreased. We can do this by looking out urinary output and the daily weight.