NURSING 3210 Pharmacology Exam 1

NURSING 3210 Pharmacology Exam 1NURSING 3210 Pharmacology Exam 1 Respiratory System: Understanding the Common Cold -Most caused by viral infection (Rhinovirus or influenza virus) -Virus invades tissues (mucosa) of ...

NURSING 3210 Pharmacology Exam 1NURSING 3210 Pharmacology Exam 1 Respiratory System: Understanding the Common Cold -Most caused by viral infection (Rhinovirus or influenza virus) -Virus invades tissues (mucosa) of upper respiratory tract, causing upper respiratory infection (URI) -Excessive mucus production results from the inflammatory response to this invasion -Fluid drips down the pharynx into the esophagus and lower respiratory tract, causing cold symptoms: sore throat, coughing, upset stomach Treatment of the Common Cold: -Involves combined use of antihistamines, nasal decongestants, antitussives (cough), and expectorants -Treatment is symptomatic only, not curative -Symptomatic treatment does not eliminate the causative pathogen -Difficult to identify whether cause is viral or bacterial -Treatment is “empiric therapy” Antihistamines (Drugs end in –ine) -H1 antagonists are commonly referred to as antihistamines -chlorpheniramine, fexofenadine (Allegra), loratadine (Claritin), cetirizine (Zyrtec), diphenhydramine (Benadryl) -Antihistamines have several properties -Antihistaminic -Anticholinergic -Sedative Antihistamines: Mechanism of action -More effective in preventing the actions of histamine rather than reversing them -Should be given early in treatment, before all the histamine binds to the receptors Antihistamines: Indications -Management of: -Nasal allergies -Seasonal or perennial allergic rhinitis (hay fever) -Allergic reactions -do not wear perfume to work -Motion sickness -Parkinson’s -Sleep disorders -Vertigo -Sleep aid -Also used to relieve symptoms associated with the common cold -Sneezing, running nose, -Pallative treatment, not curative Antihistamines: Adverse Effects -Anticholinergic (drying) effects, most common -Dry mouth-Difficulty urinating -Constipation -Changes in vision -Drowsiness -Mild drowsiness to deep sleep Antihistamines: Two Types -Nonsedating/Peripherally Acting: -Developed to eliminate unwanted adverse effects, mainly sedation -Work peripherally to block the actions of histamine; thus, fewer CNS adverse effects -Longer duration of action (benedryl) -Traditional -Older -Work both peripherally and centrally -Have anticholinergic effects, making them more effective than nonsedating drugs in some cases -Examples: Diphenhydramine (Benadryl), brompheniramine (lodrane), meclizine (antivert)- for dizziness and vertigo, promethazine (phenergan) Antihistamines: Nursing implications -Gather data about the condition or allergic reaction that required treatment; also assess for drug allergies -Contraindicated in the presence of acute asthma attacks and lower respiratory diseases, such as pneumonia -Use with caution with increased intraocular pressure, cardiac or renal disease, hypertension, asthma, COPD, peptic ulcer disease, BPH (benign prostatic hyperplasia), or pregnancy -Instruct patients to report excessive sedation, confusion, or hypotension -Instruct patients to avoid driving or operating heavy machinery; advise against consuming alcohol or other CNS depressants -Instruct patients not to take these medications with other prescribed or over-the-counter medications without checking with prescriber -Best tolerated when taken with meals- reduces GI upset -If patient’s medication has drying effect, take with candy or gum -Dry mouth: perform frequent mouth care, chew gum, suck hard candy Decongestants: Types -Adrenergics: Largest Group -Anticholinergics: Less commonly used -Corticosteroids: Topical -Two dosage forms -Oral -Prolonged decongestant effects, but delayed onset -Effect less potent than topical -No rebound congestion -Exclusively adrenergics -Example: pseudoephedrine (Sudafed) -Inhaled/topically applied to the nasal membranes-Vick’s -Topical adrenergics -Prompt onset -Potent (people often take more often that prescribed) -Sustained use over several days causes rebound congestion, making the condition worse -Topical Nasal Decongestants -Adrenergics -Phenylephrine (Neo-Synephrine) -Intranasal Steroids -budesonide (Rhinocort), fluticasone (Flonase), triamcinolone (Nasacort), ciclesonide (Omnaris) -Intranasal Anticholinergic -Ipratropium (Atrovent) -Nasal Decongestants: Indications -Relief of nasal congestion associated with -Acute or chronic rhinitis -Common cold -Sinusitis -Hay fever -Other allergies -May be used to reduce swelling of the nasal passage and facilitate visualization of the nasal passage during surgery or procedures -Nasal Decongestants: Adverse Effects -Adrenergics: Nervousness, insomnia, palpitations, tremors, systemic effects caused by adrenergic stimulation -Steroids: Local mucosal dryness and irritation -Nasal Decongestants: Nursing Implications -May cause hypertension, palpitations, and CNS stimulation -Patients on medication therapy for hypertension should check with prescriber before taking over the counter decongestants -Assess for drug allergies -Monitor for intended therapeutic effects Cough Physiology -Respiratory secretions and foreign objects are naturally removed by the: -Cough reflex -Induces coughing and expectoration -Indicated by irritation of sensory receptors in the respiratory tract -Will want to suppress during thorocentesis, surgery, nosebleeds, rib fractures etc. -Productive: Coughing sputum up -Nonproductive: dry cough Antitussives: Drugs used to stop or reduce coughing -Opioid and nonopioid -Used only for nonproductive coughs -May be used in cases where coughing is harmfulAntitussives: Mechanism of Action -Opioids -Suppress the cough reflex by direct action on the cough center in the medulla -Codeine and hydrocodone -Nonopioids -Suppress the cough reflex by numbing the stretch receptors in the respiratory tract and preventing the cough reflex from being stimulated -Examples -Benzonatate (Tessalon Perles) -Dextromethorphan (Vicks Formula 44, Robitussin- DM) Antitussives: Nursing Implications -Perform respiratory and cough assessment, and assess for allergies -Auscultate -Ask about cough, is it productive, color, odor, amount, consistency -Instruct patients to avoid driving or operating heavy equipment because of possible sedation, drowsiness, or dizziness. -Report any of the following symptoms to the caregiver: -Cough that lasts more than a week -A persistent headache -Fever Expectorants -Drugs that aid in the expectoration (removal) of mucus -Reduce the viscosity of secretions -Disintegrate and thin secretions Expectorants: Drug Effects -By loosening and thinning sputum and bronchial secretions, the tendency to cough is indirectly diminished. Expectorants: Indications -Used for the relief of productive coughs associated with: -Common cold Expectorants: Nursing Implications -Patients taking expectorants should receive more fluids, if permitted, to help loosen and liquefy secretions -Report a fever, cough, or symptoms lasting longer than a week -Monitor for intended therapeutic effects Herbal Products: Echinacea -Reduces symptoms of the common cold and recovery time -Aids Immune System -Adverse effects -Dermatitis Respiratory Drugs Diseases of the Lower Respiratory Tract -COPD -Asthma (persistent and present most of the time despite treatment) -Emphysema -Chronic bronchitis-Bronchial Asthma -Recurrent and reversible shortness of breaths -Occurs when the airways of the lungs become narrow -Alveolar ducts/ alveoli remain open, but airflow to them is obstructed -Symptoms: Wheezing, difficulty breathing -At what point in the breathing process are you hearing the wheezing -Inspiratory/expiratory -Four categories: -Intrinsic (occurring in patients with no history of allergies) -Extrinsic (occurring in patients exposed to a known allergen) -Exercise induced -Drug induced -Status Asthmaticus -Prolonged asthma attack that does not respond to typical drug therapy -May last several minutes to hours -Medical emergency -Start an IV, pump them with steroids, and prepare to intubate -Chronic Bronchitis -Continuous inflammation and low-grade infection of the bronchi -Excessive secretion of mucus and certain pathologic changes in the bronchial structure -Often occurs as a result of prolonged exposure to bronchial irritants -Smokers, people that live near volcanoes, people that have been to ground zero -Emphysema -Air spaces enlarge as a result of the destruction of alveolar walls -The surface area where gas exchange takes place is reduced -Effective respiration is impaired Pharmacologic Overview: -Bronchodilators -These drugs relax bronchial smooth muscle, which causes dilation of the bronchi and bronchioles that are narrowed as a result of the disease process -Three classes: -Beta-Adrenergic Agonists -Short-acting beta agonist (SABA) inhalers -Albuterol (Ventolin) -Levalbuterol (Xopenex) -Terbutaline (Brethine) -Metaproterenol (Alupent) -Long-Acting beta agonist (LABA) inhalers -Arformoterol (Brovana) -Salmeterol (Serevent) -Used during acute phase of asthmatic attacks -Quickly reduce airway constriction and restore normal airflow -Agonists, or stimulators, of the adrenergic receptors in the sympathetic nervous system-Sympathomimetics -Indications: -Relief of bronchospasm related to asthma, bronchitis, and other pulmonary disease -Used in treatment and prevention of acute attacks -Used in hypotension and shock -Used to produce uterine relaxation to prevent premature labor -Epinephrine -Adverse Effects: -Epinephrine (Alpha and Beta): Insomnia, restlessness, anorexia, vascular headache, hyperglycemia, tremor, cardiac stimulation -Metaproterenol, Alupan (Beta 1 and Beta 2): Cardiac stimulation, tremor, angina pain -Albuterol (Beta 2): Hypotension or hypertension, vascular headache, tremor -Anticholinergics -Ipratropium bromide (Atrovent) and tiotropium (Spiriva) -Atrovent is oldest and most common -Spiriva is just once a day drug -Slow and prolonged action -Used to prevent bronchoconstriction -NOT used for acute asthma exacerbations -Adverse Effects -Dry mouth or throat -Nasal congestion -Heart palpitations -Gastrointestinal distress -Headache -Coughing -Anxiety -Peanut Allergy -Chemical makeup -Xanthine Derivatives -Plant alkaloids: Caffeine, theobromine, and theophylline -Only theophylline (Theo-Dur) is used as a bronchodilator -Synthetic xanthines: aminophylline and dyphilline -Drug Effects: -Causes bronchodilation by relaxing smooth muscle in the airways -Result: Relief of bronchospasm and greater airflow into and out of the lungs -Also cause of CV stimulation: Increased force of contraction and HR -Indications: -Dilation of airways in asthmas, chronic bronchitis, and emphysema -Mild to moderate cases of acute asthma-Adjunct drug in the management of COPD -Not used as frequently because of potential for drug interactions and variables related to drug levels in blood -Adverse Effects -Nausea, vomiting, anorexia -Leukotriene Receptor Antagonists (LTRAs) -Nonbronchodilating -Newer class of asthma medications -Currently available drugs -montelukast (singulair) -Mechanism of Action -Leukotrienes are substances released when a trigger, such as cat hair or dust, starts a series of chemical reactions in the body -Leukotrienes cause inflammation, bronchoconstriction, and mucus production -Result: Coughing, wheezing -Must be 12 or older -Indications: -Monitor for liver problems -Zileuton (Zyflo): Headache, nausea, dizziness, insomnia, liver function -Zafirlukast (Accolate): Headache, nausea, diarrhea, liver function -Nursing Implications -Ensure that drug is being used for chronic management of asthma, not acute asthma -Teach patient purpose of therapy -Improvement seen in about a week -Assess liver function before beginning therapy and throughout -Teach patient to take medication every night on a continuous schedule, even if symptoms improve Corticosteroids: -Anti-inflammatory properties -Used for chronic asthma -Do not relieve symptoms of acute asthmatic attacks -Oral, inhaled or IV forms (IV for severe asthma cases) -Inhaled forms reduce systemic effects -May take several weeks before full effects are seen -Taper the patient off -Inhaled corticosteroids: -Budesonide (Pulmicort Turbuhaler) -dexamethasone sodium phosphate (Decadron Phophate Respihaler -Flunisolide (AeroBid) -Fluticasone (Flonase) -Triamcinolone acetonide (Azmacort) -Ciclesonide (Omnaris) -Inhaled Corticosteroids: Indications -Persistent asthma- Often used concurrently with beta-adrenergic agonists-Inhaled Corticosteroids: Adverse Effects -Pharyngeal irritation -Coughing -Dry mouth -Oral fungal infections -Systemic effects are rare because low doses are used for inhalation therapy -Teach patients to gargle and rinse the mouth with lukewarm water afterward to prevent the development of oral fungal infections -If a beta-agonist bronchodilator and corticosteroid inhaler are both ordered, the bronchodilator should be used several minutes before the corticosteroid to provide bronchodilation before administration of the corticosteroid -Teach patients how to monitor disease with a peak flow meter -Encourage use of a spacer device to ensure successful inhalations -Teach patient how to keep inhalers and nebulizer equipment clean after uses -Phosphodiesterase-4 Inhibitor -Roflumilast (Daliresp) -Indicated to prevent coughing and excess mucus from worsening and to decrease the frequency of life-threatening COPD exacerbations -Adverse effects include nausea, diarrhea, headache, insomnia, dizziness, weight loss, and psychiatric symptoms -Monoclonial Antibody Antiasthmatic -Omalizumab (Xolair) -Newest antiasthmatic medication -Omalizumab is given by injection -Potential for producing anaphylaxis -Monitor closely for hypersensitivity -Nursing Implications -Encourage patients to take measures that promote a generally good state of health so as to prevent, relieve, or decrease symptoms of COPD -Avoid exposure to conditions that precipitate bronchospasm (allergens, smoking, stress, air, pollutants) -Adequate fluid intake -Compliance to healthcare -Avoid excessive fatigue, heat, extremes in temperature, caffeine -Encourage patients to get prompt treatment for flu or illnesses and to get vaccinated against pneumonia or flu -Encourage patients to always check with their physician before taking any other medication, including over-the-counter medications -Perform a thorough assessment before beginning therapy including: Skin color, vital signs, respirations, respiratory assessment, sputum production, allergies, history of respiratory problems, other medicaitons -Teach patients to take bronchodilators exactly as prescribed -Ensure that patients know how to use inhalers and MDIs, and have patients demonstrate use of the devices -Monitor for adverse effects -Monitor for therapeutic effects-Decreased dyspnea -Decreased wheezing, restlessness, and anxiety -Improved respiratory patterns with return to normal rate and quality -Improved activity tolerance -Decreased symptoms and increased ease of breathing Inhalers: Patient Education -For any inhaler prescribed, ensure that the patient is able to self-administer the medication -Provide demonstration and return demonstration -Ensure that the patient knows the correct time intervals for inhalers -Provide a spacer if the patient has difficulty coordinating breathing and inhaling medication -Ensure that the patient knows how to keep track of the number of doses in the inhaler Drugs Affecting the Cardiovascular System: Antihypertensive Drugs: -Factors that determine which drug to use: -Race -Blood pressure -Other health factors -Medications used to treat hypertension -Alpha 2-adrenergic drugs -Alpha 1 blockers -Beta-blockers -Angiotensin converting enzyme (ACE) inhibitors -Angiotensin II receptor blockers (ARBs) -Calcium channel blockers (CCBs) -Diuretics -Vasodilators -Think ABC’s for most commonly used medications -A: ACE Inhibitors -B: Beta blockers -C: Calcium channel blockers -Alpha 2 Adrenergic Drugs: -MOA: -Inhibits norepinephrine release in the brain which in turn decreases blood pressure -Act centrally in the brain, not in the periphery -Examples: -Clonidine (Catapres) -Methyldopa (Aldomet) -Both safely used for hypertension in pregnancy -Alpha 1 Blockers: -MOA: -Act in the periphery by dilating arteries and veins, decreasing peripheral vascular resistance and decreasing blood pressure-Decreases systemic and pulmonary vascular resistance which increases cardiac output. -Examples: Doxazosin (Cadura), prazosin (Minipress) -Beta Blockers: MOA -MOA: -Reduce BP by reducing heart rate through blocking of the Beta 1 receptors -Long-term use causes reduced peripheral vascular resistance -Result: decreased blood pressure -Examples: End in lol -Propanolol(Inderal), Metoprolol (Lopressor), Atenolol (Tenormin) -Newest: Nebivolol (Bystolic) -Dual-Action Alpha 1 and Beta Receptor Blockers: MOA -MOA: Block alpha1- adrenergic receptors -Reduction of heart rate (Beta 1- receptor blockade) -Vasodilation (alpha1- receptor blockade) -Result in decreased blood pressure -Examples: -Carvedilol (Coreg) wean the patient onto this drug and Labetalol (Trandate) These drugs drop the heart rate, monitor the heart rate -Alpha 1&2 Receptor and Beta Blocker -Adverse Effects: -High incidence of orthostatic hypotension -Common: -Bradycardia with reflex tachycardia -Dry mouth -Drowsiness, sedation -Constipation -Headaches -Sleep disturbances -Nausea -Rash -Cardiac disturbances (palpitations) -Contraindications: -Acute heart failure -Use with MAIOS -Severe depression -Peptic ulcer disease -Severe kidney or liver disease -Asthma -Drug interactions: CNS depressants (alcohol, benzodiazepines, opioids) -Angiotensin Converting Enzyme (ACE) Inhibitors -Often used as first-line drugs for HF and hypertension -May be combined with a thiazide diuretic or calcium channel blocker -MOA:-inhibits ACE, which assists in converting Angiotensin I to Angiotensin II in the renin-angiotensin system -Decreases systemic vascular resistance (SVR) by preventing the formation of the angiotensin II -Decreases afterload on the heart, or the resistance against which the left ventricle must pump to eject its volume of blood during contraction. -Result: Decreased SVR, decreased afterload, and decreased BP -Indicated for: -Hypertension -HF (either alone, or in combination with diuretics or other drugs) -ALWAYS during discharge diuretic and ACE inhibitor -Slow progression of left ventricular hypertrophy after MI (cardioprotective) -Renal protective effects in patients with diabetics if they can tolerate it -Drugs: -Captopril (capoten) -Very short half life -Enalapril (Vasotec) -Available in oral and parenteral forms -Lisinopril (Prinivil and Zestril) and Quiapril (Accupril), others -Newer drugs, long half-lives, once-a-day dosing -Captopril and Lisinopril can be used for patients with liver failure- don’t need to be metabolized by the liver. -Adverse Effects: -Dry, nonproductive cough, which reverses when the therapy is stopped -Fatigue -Dizziness -Headache -Mood changes -Impaired taste -Possible hyperkalemia -Angioedema: Rare but potentially fatal -First-dose hypotensive effect may occur -Contraindications: -Known drug allergy or history of a reaction of angioedema -Hyperkalemia -Breastfeeding -Drug Interactions: -NSAIDS: Reduce the hypertensive effect and increase risk of acute renal failure -Other anti-hypertensives or diuretics: increased hypotensive effect -Lithium: risk of lithium toxicity -Potassium and potassium sparing diuretics -Angiotensin II Receptor Blockers: MOA and Indications-Affect mainly the vascular smooth muscle and the adrenal gland (different from ACE inhibitors) -Given when patient don’t want ACE inhibitors because of dry cough -Blocks vasoconstriction and therefore reduces BP -Indications -Hypertensive -Adjunctive drugs for the treatment of HF -May be used alone or with other drugs such as diuretics in treatment of hypertension and HF -Used primarily in patients who cannot tolerate ACE inhibitors -Examples: Iosartan (Cozaar, Hyzaar), valsartan (Diovan), eprosartan (Teveten), irbesartan (Avapro) -Adverse Effects: -URI, Headache, dizziness, inability to sleep, diarrhea, dyspnea, heartburn, nasal congestion, back pain, fatigue, hyperkalemia much less likely to occur than the ACE inhibitors -Contraindications: -Pregnancy -Breastfeeding -Elderly patients with renal dysfunction -Lifelong, take forever -Drug Indications: -Potassium supplements: causes hyperkalemia -Young men sometimes do not take BP medications because it inhibits their ability to perform in the bedroom. -Calcium Channel Blockers: MOA and Types of Drugs: -Cause smooth muscle relaxation by blocking the binding of calcium to its receptors, preventing muscle contraction -Results in: -Decreased peripheral smooth muscle tone -Decreased systemic vascular resistance -Decreased blood pressure -Examples: (Very Nice Drugs) -Diltiazem (Cardizem, Dilacor) -Verapamil (Calan, Isoptin) -Amlodipine (Norvasc) -Most commonly used for hypertension -Bepridil (Vasocor) -Nicardipine (Cardene) -Nifedipine (Procardia) -Indications: -Angina -Hypertension -Commonly given with a thiazide diuretic -This combination works well for the African American population -Dysrhythmias-Migraine headaches -Adverse Effects: -Cardiovascular: Hypotension, palpitations, tachycardia -Gastrointestinal: Constipation, nausea -Vasodilators: MOA: -Directly relax arteriolar and/or venous smooth muscle -Results in: -Decreased systemic vascular response -Decreased afterload -Peripheral vasodilation and decreased BP -Common vasodilators: -Diazoxide (Hyperstat) -Hydralazine HCl (Apresoline) -Minoxidil (Loniten) -Sodium nitroprusside (Nipride, Nitropress) -Adverse Effects: -Hydralazine (Apresoline) -Dizziness, headache, anxiety, tachycardia, nausea and vomiting, diarrhea, anemia, dyspnea, edema, nasal congestion, others -Sodium Nitroprusside (Nitropress) -Bradycardia, hypotension, possible cyanide toxicity (rare) -Diazoxide (Hyperstat) -Dizziness, headache, anxiety, orthostatic hypotension, dysrhythmias, sodium and water retention, nausea, vomiting, hyperglycemia in diabetic patients, others. -Contraindications: -Hypotension -Cerebral edema -Head injury -Acute MI -Coronary artery disease -Drug Interactions -Very few -Hydralazine can produce additive hypotensive effects when given with other antihypertensives -Miscellaneous Antihypertensive Drugs -Eplerenone (Inspra) -Used in routine treatment of HTN and post-MI heart failure -Bosentan (Tracleer) -Treprostinil (Remodulin) -Both used in the treatment of pulmonary artery HTN in patients with moderate to severe heart failure -Nursing Implications: Patient Education -Educate patients about the importance of not missing a dose and taking the medications exactly as prescribed-Instruct patients to check with their physician for instructions on what to do if a dose is missed; patients should never double up on doses if a dose is missed -Monitor BP during therapy; instruct patients to keep a journal of regular BP checks -Instruct patients that the drugs should not be stopped abruptly because this may cause a rebound hypertensive crisis, and perhaps lead to stroke -Oral forms should be given with meals so that absorption is more gradual and effective -Encourage patients to watch their diet, stress level, weight, and alcohol intake -Instruct patients to avoid smoking and eating food high in sodium -Encourage supervised exercise -Instruct patients to report unusual SOB; difficulty breathing; swelling of feet, ankles, eyes. Weight gain or loss, chest pain, palpitations, or excessive fatigue -Monitor for therapeutic effect Antianginal Drugs: Ischemia vs. Infarction -Ischemia: Poor blood supply to an organ -Ischemic heart disease: Poor blood supply to the heart muscle -Atherosclerosis -Coronary artery disease -Myocardia Infarction (MI): -Necrosis, or death, of cardiac tissue -Disabling or fatal Types of Angina: -Classic/Chronic stable angina: -Normally triggered by exertion, stress, caffeine, or alcohol -Atherosclerosis is the primary cause -The pain is intense but subsides with rest (within 15 min) or appropriate drug therapy -Unstable angina: -Usually the early stages of CAD that eventually leads to an MI -Pain and frequency of attacks increases in severity -Pain can occur while the patient is at rest -Vasospastic (Prinzmental) Angina: -Triggered by spasms in the layer of smooth muscle that surrounds atherosclerotic coronary arteries Drugs for Angina: -Nitrates/Nitrites -Common available forms: -Sublingual -Intravenous solutions -Transdermal patches -Ointments -Translingual sprays -Oral doses -Rapid acting forms:-Used to treat acute angina attacks -Sublingual tables; sprays; intravenous infusion -Sublingual is most common for rapid acting Monitor the patient’s blood pressure and oxygen -Will drop patients’ blood pressure -Can give one nitroglycerin or spray every 5 minutes -If patient is still having chest pain, try bolus of fluids -Can only give up to three tablets -CHECK BLOOD PRESSURE IN BETWEEN -Long-acting forms -Used to prevent angina episodes -Nitro-bid patch, nitro ointments, sustained release tabs/caplets -Cause vasodilation because of relaxation of smooth muscles -Nitroglycerin -Prototypical nitrate -Used for symptomatic treatment of angina -Headaches occur -Tolerance can occur in patients taking nitrates around the clock or with long-acting forms -Preventing by allowing a regular nitrate-free period to allow enzyme pathways to replenish -Transdermal forms: remove patch at bedtime for 8 hours, then apply a new patch in the morning -Isosorbide Dinitrate (Isordil) -Organic nitrate -Same effects of other nitrates -Amyl Nitrite -Rapid acting -Same effects as other nitrates -Inhaled form -Adverse Effects: -Most common: Headache -Reflex tachycardia -Postural hypotension -Topical nitrates: Can cause contact dermatitis -Cannot take if you are taking erectile dysfunction medication -Nursing Implications: Nitroglycerin -Instruct patients never to chew or swallow the sublingual form -Instruct patients that a burning sensation felt with sublingual forms indicates that the drug is still potent -To preserve potency, medications should be stored in an airtight, dark glass bottle with a metal cap and no cotton filler. IN A DARK ROOM -Intruct patients in the proper application of nitrate topical ointments and transdermal forms, including site rotation and removal of old medication -ALWAYS WEAR GLOVES-To reduce tolerance, the patient may be instructed to remove topical forms at bedtime and reapply new doses in the morning, allowing for a nitrate-free period -Instruct patients to take prn nitrates at the first hint of angina pain -If experiencing chest pain, the patient taking sublingual nitroflycerin should lie down to prevent or decrease dizziness and fainting that may occur because of hypotension -If angina pain occurs: -Stop activity or lie down -Call 911 and take nitroglycerin tablet -Beta blockers: -Decrease HR, resulting in decreased myocardial oxygen demand and increased oxygen delivery to the heart -Decrease myocardial infarction -Most common: -Carvedilol (coreg) -Metoprolol (Lopressor, Toprol-XL) -Atenolol -Indications for Beta Blockers: -Angina -HTN -Cardiac dysrhythmias -Adverse Effects: -Cardiovascular: Bradycardia, hypotension, second- or third-degree heart block, heart failure -Metabolic: Altered glucose and lipid metabolism -Can mask the tachycardia related to hypoglycemia -Use with caution in diabetic patients -CNS: Dizziness, fatigue, mental depression, lethargy, drowsiness, unusual dreams -Other: Impotence, wheezing, dyspnea -Contraindications: -Serious conduction disturbances -Bronchial asthma -Patients with diabetes (causes hypo or hyperglycemia) -Drug Interactions: -Diuretics and other antihypertensives: -Increased hypotensive effects -Calcium channel blockers: cause added electrical effects which can result in hypotension, bradycardia, heart block -Calcium-Channel Blockers: -Mechanism of action: -Cause coronary artery vasodilation -Cause peripheral arterial vasodilation, thus decreasing systemic vascular resistance -Reduce the workload of the heart-Indications: -First-line drugs for treatment of angina, hypertension, and supraventricular tachycardia -Adverse Effects: -May cause hypotension, palpitations, tachycardia, or bradycardia, constipation, nausea, dyspnea -Do not take with grapefruit juice -Nursing Implications: -Alcohol consumption and spending time in hot baths or whirlpools -Calcium channel and beta-blockers: -Constipation is a common problem; instruct patients to take in adequate fluids and eat fiber-filled foods -Beta Blockers: -Patients taking beta-blockers should monitor pulse rate daily and report any rate lower than 60 beats per minute -Instruct patients to report dizziness or fainting. -Drug Therapy Goals: -Increase blood flow to ischemic heart muscle -Decrease myocardial oxygen demand -Minimize the frequency of attacks and decrease the duration and intensity of anginal pain -Improve the patient’s functional capacity with as few adverse effects Heart Failure Drugs: Heart Failure: What is it? -Not a specific disease, but a syndrome caused by many cardiac disorders -The heart is unable to pump blood in sufficient amounts from the ventricles to meet the body’s metabolic needs. -Less than 35% Heart Failure: Causes: -Cardiac defect -Myocardial infarction -Valve deficiency -Defect outside of the heart -Coronary artery disease -Pulmonary hypertension -Diabetes Drug Therapy: What is the Goal? -Increase the force of myocardial contraction -Alters the heart rate -Accelerate cardiac conduction Drug Therapy for Heart Failure: -ACE Inhibitors -The drug of choice for HF - Prevent sodium and water reabsorption by inhibiting aldosterone secretion by inhibiting ACE (all part of the renin-angiotensin system) -Angiotensin II receptor blockers-Beta Blockers -Aldosterone Antagonists (BiDil, Dobutamine) -for African Americans -B-type natriuretic peptides (natrecor) -ICU drugs, do not need to know -Phosphodiesterase inhibitors (milrinone) -ICU drugs, do not need to know -Cardiac glycosides -No longer used as first-line treatment -Digoxin is the prototype -Used for 2nd line treatment for heart failure -Also used to control ventricular response to common dysrhythmias like atrial fibrillation and flutter -Example: Digoxin (lanoxin) -Patients do not tolerate very well -Mechanism of Action: Increase myocardial contractility -Adverse Effects: -Digoxin (Lanoxin): Very narrow therapeutic window -Drug levels must be monitored, low potassium levels increase its toxicity, electrolyte levels must be monitored -Cardiovascular effects: Dysrhythmias including bradycardia or tachycardia -CNS effects: headaches, fatigue, malaise, confusion, convulsions -Eye effects: Colored vision (seeing green, yellow, purple), halo vision, flickering lights -GI Effects: Anorexia, nausea, vomiting, diarrhea -Contraindications: Heart block, certain arrhythmias -Drug interactions: -Beta blockers: Reduce the therapeutic effect -Calcium channel blockers: Enhance the bradycardiac effect by blocking the beta receptors of the heart -Loop diuretics: Produce hypokalemia -Toxicity -Uses of Digoxin Immune Fab (Digifab) therapy: -Antidote for digoxin toxicity -Hyperkalemia in a digitalis-toxic patient -Life-threatening cardiac dysrhythmias -Life-threatening digoxin overdose -Infuse Digifab for 30 min over IV -Must hospitalize the patient to monitor their electrolyte levels Nursing Implications: -Assess clinical parameters, including -BP, apical pulse for 1 full minute, heart sounds, breath sounds, weight, I&O measures, EKG, serum labs: Potassium, sodium, magnesium, calcium -Before giving any dose, count apical pulse for 1 full minute-For apical pulse less than 60 or greater than 100 beats/minute -Hold dose -Notify physician -Hold dose and notify physician if patient experiences signs/symptoms of toxicity -Avoid giving digoxin with high-fiber foods (fiber binds with digitalis) -Patients should immediately report a weight gain of 2 or more pounds in 1 day or 5 or more points in 1 week. Anti-Dysrhythmia Drugs: Dysrhythmias: -Dysrhythmia: Electrical disturbances in the normal cardiac electrical cycle -Dysrhythmias can occur as a result from an MI, Cardiac surgery or coronary artery disease -There are many types of cardiac dysrhythmias with various drugs appropriate for each. Dysrhythmias and Drug Therapy: -Drug Therapy: Drugs are categorized based on how they affect the cardiac cells Anti-Dysrhythmics: Indications: -Quinidine, procainamide, disopyramide -Depresses myocardial excitability -Used for atrial fibrillation, premature atrial contractions, premature ventricular contractions, and ventricular tachycardia -Phenytoin and Lidocaine -Decreases myocardial excitability in the ventricles -Used for ventricular dysrhythmias ONLY Lidocaine: Monitor for seizures if on a Lidocaine drip -Lidocaine keeps muscle of heart from being excitable -Flecainide, propafenone -Used for severe ventricular dysrhythmias -May be used in atrial fibrillation -Amiodarone, sotalol, ibutilide (Covert) -Test III used for dysrhythmias that are difficult to treat -Life-threatening ventricular tachycardia or fibrillation, atrial fibrillation or flutter that is resistant to other drugs -Verapamil, diltiazem (Cardizem) -Calcium channel blockers -Reduce AV node conduction -Used for paroxysmal supraventricular tachycardia; rate control for atrial fibrillation and flutter -Diltiazem (Cardizem) is given continuous IV following a loading dose given by IV bolus for rapid rate atrial flutter/ fibrillation and paroxysmal SVT -Change colors when you increase the dosage pay attention to if patient says it looks different -Adenosine: -An unclassified anti-dysrhythmic -Slows electrical conduction through the AV node -Indicated for the conversion of paroxysmal SVT to sinus rhythm-Has extremely slow half life of less than 10 seconds so only administered IV and only as fast IVP -Commonly causes asystole for a few seconds following administration -Given by IV to stop the heart, have oxygen, have them on a monitor, have a crash cart at the door, put patient on IV fluids. Need two nurses and a physician at bedside Antidysrhythmics: Adverse Effects: -ALL antidysrhythmics -Contraindications Nursing Implications: -Obtain a thorough drug and medical history -During therapy, monitor cardiac rhythm, heart rate, BP, general well-being, skin color, temperature, heart and lung sounds -Assess plasma drug levels as indicated -Monitor for toxic effects Patient Education: -Instruct patients to take medications as scheduled and not to skip or double up on doses Cardiovascular Drugs: Hemostasis and the Coagulation System: -Hemostasis: The process that halts bleeding after injury to a blood vessel -Coagulation System: -“Cascade” -Each activated factor serves as a catalyst that amplifies the next reaction -Result is fibrin, a clot-forming substance Coagulation Modifier Drugs: -Anticoagulants: Known as antithrombotic drugs, no direct effect on a blood clot that is already formed, Used to prevent clot formation (thrombus) and an embolus (dislodged clot) -Inhibit the action or formation of clotting factors -Prevent clot formation -MOA: -Vary, depending on drug -Work on different points of the clotting cascade -Do not lyse existing clot -Agatraban: For HIT patients or post cardiac procedures -Allergie to Heparin -Dabigatran (Pradaxa): First oral thrombin inhibitor -Arixtra (Fondaparinux): Prophylaxis and/or treatment of acute DVT/PE -Heparin and low-molecular weight heparins (LMWH) includes enoxaparin (Lovenox) and Fragmin -Turns off coagulation pathway and prevents clot formation -Warfarin (Coumadin) -Inhibits Vitamin K synthesis by bacteria in the GI tract, which in turn inhibits clotting factors. Results in prevention of clot forming -Indications-Used to prevent clot formation in certain settings where clot formation is likely -Myocardial infarction -Unstable angina -Atrial fibrillation -Indwelling devices, such as mechanical heart valves -Major orthopedic surgery -Prolonged periods of immobilization (on a plane for several hours) -Drugs: -Heparin: Used for BOTH prevention and treatment of excemic stroke, MI, DVT, and PE -Can be given IV or subcutaneously -Monitored by activated partial thromboplastin times (aPTTs) -There is a heparin protocol for bolus and drip -Toxicity: Reversed by protamine sulfate -Nursing Implications: -IV doses are usually verified with another RN -Ensure that SC doses are given SC, not IM -SC doses should be given in areas of deep subcutaneous fat, and sites rotated -Do not give SC doses within 2 inches of: -The umbilicus, abdominal incisions, or open wounds, scars, drainage tubes, stomas -Do not aspirate SC injections or massage injection site -May cause hematoma formation -IV doses may be given by bolus or IV infusion -Anticoagulant effects seen immediately -Laboratory values done daily to monitor coagulation effects (aPTT) -Warfarin Sodium (Coumadin) -Used for thrombo prevention and treatment of MI, DVT, atrial fibrillation, and PE -Given almost exclusively orally (also available in IV form) -Monitored by prothombin time (PT) and INR (PT-INR) -Toxicity Revered by Vitamin K -Nursing Implications: -May be started while the patient is still on heparin until PT-INR levels indicate adequate anticoagulation -Full therapeutic effect takes several days -Monitor PT-INR regularly- keep follow up appointments -Many herbal products have potential interactions with increased bleeding (garlic, ginger, ginko, ginseng) -Low-molecular-weight heparins (LMWH) -Same uses as Heparin -Enoxaparin (Lovenox)-More predictable anticoagulant response -Do not require laboratory monitoring -Given subcutaneously -Contraindications: -Acute bleeding or risk for bleeding -May be localized bleeding or internal -Coumadin: contraindicated in pregnancy -LMWH: Contraindicated in patients with epidural catheters (may cause epidural hematomas) May be given two hours after catheter removed -Drug Interactions: -Coumadin CAN be given at the same time as Heparin until PT and INR levels are therapeutic -NSAIDS increased risk of bleeding episodes in patients taking Heparin and Coumadin -Patient Education: -Importance of regular lab testing -Signs of abnormal bleeding -Wearing a medical alert bracelet -Consulting a physician before taking other meds or over-the-counter products, including herbals -Antiplatelet drugs: Inhibit platelet aggregation and prevents platelet plugs -MOA: Prevent platelet adhesion -Examples: -Aspirin: Inhibits the formation of an enzyme that prevents the blood vessels from constricting and forming a clot -Clopidogrel (Plavix): MOA is different from aspirin, inhibits the membrane around the platelet which allows a signal to form a clot -Indications and Adverse Effects: -Given because of antithrombic effects -Reduce risk of fatal and nonfatal strokes -Acute unstable angina and MI -Adverse effects -All pose a risk for induced bleeding -Contraindications: -Thombocytopenia -Active bleeding -Leukemia -Traumatic injury -GI ulcer -Recent stroke -Drug Interactions: -Use of clopidogrel, apirin with other NSAIDS= additive platelet activity and increased bleeding potential Aspirin allergy: Should not take NSAIDS related to cross sensitivity -Thrombolytic drugs: Lyse (break down) existing clots (Can only use 6 hours after a stroke)-Examples: tPAs (End in –ase) -Anistreplase (Eminase) -Alteplase (Activase) -Reteplase (Retavase) -Tenecteplase (TNKase) -MOA: -Activate the system to break down the clot on the blood vessel quickly -Reestablish blood flow to the heart muscle via coronary arteries, preventing tissue destruction -Indications: -Acute MI -Arterial thrombosis -DVT -Occlusion of shunts or catheters -Pulmonary embolus -Acute ischemic stroke -Adverse Effects -Bleeding: Internal, intracranial, superficial -Other effects: Nausea, vomiting, hypotension, anaphylactic reactions, cardiac dysrhythmias; can be dangerous -Contraindications: Drugs that alter clotting -Drug Interactions: Anticoagulants and antiplatelets: can cause an increased bleeding tendency -Nursing Implications: -140/90 or less for BP -Cannot give if they have fallen recently -Follow strict manufacturer’s guidelines for preparation and administration -Monitor IV sites for bleeding, redness, pain -Monitor for bleeding from gums, mucous membranes, nose, injection sites -Observe for signs of internal bleeding (Decreased BP, restlessness, increased pulse) -For any potential interactions- there are many -For a history of abnormal bleeding conditions -Antifibrinolytic drugs: Promote blood coagulation -Prevents the lysis of fibrin (good for patients with hemophelia) -Results in promoting clot formation -Used for prevention and treatment of excessive bleeding resulting from hyperfibrinolysis or surgical complications -Drugs and MOA: -Aminocaproic Acid (Amicar): -Inhibits the breakdown of fibrin, which prevents the destruction of the formed clot -Desmopressin (DDAVP) -Increases platelet aggregation and clot formation-Indications: -Prevention and treatment of excessive bleeding -Hyperfibrinolysis -Surgical complications -Excessive oozing from surgical sites such as test tubes -Reducing total blood loss and duration of bleeding in the postoperative period -Treatment of hemophilia (Desmopression) -Adverse Effects: -Uncommon and usually mild -Rarely can cause acute MI and acute cerebrovascular effects -Contraindications: Known allergy, current DIC state -Drug interactions: Oral contraceptives or estrogens: Increased coagulation -Nursing Implications: Coagulation Modifier Drugs: -Monitor for therapeutic effects -Monitor for signs of excessive bleeding -Bleeding of gums while brushing teeth, unexplained nosebleeds, heavier menstrual bleeding, bloody or tarry stools, bloody urine or sputum, abdominal pain, vomiting blood -Monitor for adverse effects Antilipemic Drugs: Lipoproteins: -Very low density lipoprotein (VLDL) -Produced by liver -Assists in the production of LDL -Low density lipoprotein (LDL) -The “bad cholesterol -High density lipoprotein (HDL) -Responsible for “recycling” of cholesterol -Also known as “good cholesterol” Coronary Artery Disease -Positive Risk Factors: -Age: -Male: 45 years or older -Female: 55 years or older -Family history of premature CHD -Current cigarette smoker -Hypertension -BP 140/90 or higher, or on antihypertensive medication -Low HDL levels: Less than 40mg/dL -Diabetes Mellitus Coronary Artery Disease and Drug Therapy -Decrease risk for developing CAD -High HDL (“good” cholesterol): 60mg/dL or higher -Antilipemic drugs -Drugs used to lower lipid levels-Used as an adjunct to diet therapy -Drug choice based on the specific lipid profile of the patient -All responsible non-drug means of controlling blood cholesterol levels (diet, exercise), should be tried for at least 6 months and found to fail before drug therapy is considered Antilipemics: -HMG-CoA reductase inhibitors (HMGs or statins) -The “statins” Lower total cholesterol and LDL -Most potent LDL reducers: -Pravastatin (Pravachol) -Simvastatin (Zocor) -Atrovastatin (Lipitor) -Fluvastatin (Lescol) -MOA: -Inhibit HMB-CoA reductase, which is used by the liver to produce cholesterol -Lower the rate of cholesterol production -Lowers the LDL by 30-40% -Indications: -First line treatment for hypercholesterolemia -Significantly reduces LDL and triglyceride levels -Adverse Effects: -Mild GI disturbances -Rash -Headache -Myalgia (muscle pain), possibly leading to the serious condition rhabdomyolysis -Elevations in liver enzymes or liver disease -Contraindications: -Pregnancy -Liver disease or known elevated liver enzymes (Do a liver panel before, during, and after treatment) -Drug Interactions: -Oral anticoagulants- use cautiously -Grapefruit juice increases chances of developing rhabdomyolysis -Other drug interactions: See page 449 -Bile acid Sequestrants: Will take about 6 weeks to see results -Examples: Second line treatment after the statins -Cholestyramine (Questran) -Colestipol Hydrochloride (Colestid) -Colesevelam (tablet form only) -MOA: -Prevent resorption of bile acids from small intestine -Bile acids are necessary for absorption of cholesterol -Indications: -Advanced hyperlipoproteinemia: Cannot digest fats -Second line treatment after more potent statins-Suitable when stains are not tolerated well -Relief of pruritus associated with partial biliary obstruction (cholestyramine) -May be used along with statins -Adverse Effects: -Constipation accompanied by heartburn, nausea, belching, bloating -These adverse effects tend to disappear over time -Contraindications -Biliary or bowel obstruction -Phenylketonuria (PKU -Drug interactions: -All drugs can be taken at least 1 hour before or 4-6 hours after the administration of bile acid sequestrants -Decrease the absorption of Vitamins A,D,E, and K -Niacin (Nicotinic Acid) -Vitamin B3 -Lipid-lowering properties require much higher doses than when used as a vitamin -Effective, inexpensive, often used in combination with other lipid-lowering drugs -Indications: -Effective in lowering triglyceride, total serum cholesterol, and LDL levels -Increases HDL -Adverse Effects: -Flushing (caused by Histamine release)- can take Aspirin an hour or so before to help with this -Pruritus -GI distress -Contraindications: -Liver disease -Hypertension -Peptic ulcer disease -Drug Interactions: -HMG-CoA inhibs- likelihood of myopathy development is greater although it is not uncommon to see these 2 drugs given together -Fibric acid derivatives (Fibrates) -Examples: -Gemfibrozil (Lopid) -Fenofibrate (Tricor) -MOA: -Believed to work by activating lipase, which breaks down cholesterol -Drug Effects: -Decrease the triglyceride levels -Increase HDL by as much as 25% -Adverse Effects: -Abdominal discomfort, diarrhea, nausea-Blurred vision, headache -Increased risk of gallstones -Prolonged prothrombin time -Liver studies may show increased function -Contraindications -Severe kidney or liver disease -Cirrhosis -Gallbladder disease -Known allergy -Drug Interactions: -Gemfibrozil (Lopid) can enhance the action of oral anticoagulants -NOT RECOMMENDED TO BE COMBINED WITH A STATIN -Increase risk of rhabdomyolysis -Cholesterol Absorption Inhibitor -Ezetimibe (Zetia) -Inhibits absorption of cholesterol in small intestine -Results in reduced total cholesterol, LDL, and triglyceride levels -Also increases HDL levels -Often combined with a statin drug -Clinical usefulness has been questioned; new trials underway -Currently recommended only when patients have not responded to other therapy -Nursing Implications: -Before beginning therapy, obtain thorough health and medication history -Assess dietary patterns, exercise level, weight, height, VS, tobacco and alcohol use, family history -Assess for contraindications, conditions that require cautious use, and drug interactions -Obtain baseline liver function studies -Patients on long-term therapy may need supplemental fat-soluble vitamins (A, D, K) when taking bile acid sequestrants -Take bile acid sequrestrants with meals to decrease GI upset -Counsel patient concerning diet and nutrition on an ongoing basis -Monitor for therapeutic effects: reduced levels of triglycerides and cholesterol -Other medications should be taken 1 hours before or 4 to 6 hours after bile acid sequestrant to avoid interference with absorption -Inform patients that these drugs may take several weeks to show effectiveness -Instruct patients to report persistent GI upset, constipation, abnormal or unusual bleeding, and yellow discoloration of the skin -Monitor for adverse effects, including increased liver enzyme studies. Diuretic Drugs: Diuretic Drugs: -Drugs that accelerate the rate of urine formation -Results in the removal of sodium and waterTypes: -Carbon anhydrase inhibitors -Acetazolamide (Diamox) -May be used for edema secondary to heart failure for HTN -Mostly used as adjunct drug for open-angle glaucoma -High altitude sickness -Seizures -Loop diuretics (end in –ide) -Bumetanide (Bumex), Furosemide (Lasix), Torsemide (Demedex) -Potassium is lost in the fluid, so greater increase of hypokalemia -Work very well and very fast -Also treat liver disease -Osmotic diuretics -Mannitol (Osmitrol) -To reduce intracranial pressure for treatment of cerebral edema -NOT Indicated for peripheral edema -Potassium-sparing diuretics -Amiloride (Midamor), Spironolactone (Aldactone), Triamterene (Dyrenium) -Potassium is not as heavily excreted in the urine -Poses risk for hyperkalemia -Thiazide diuretics -Hydrochlorothiazide (HydroDIURIL) most common, Metolazone (Zaroxolyn) -Most frequently used for the initial treatment of hypertension Nursing Implications -Assess baseline fluid volume status, intake and output, serum electrolyte values, weight, and vital signs- especially postural BPs -The patient’s intake, output, and weight are the BEST indicators of fluid volume status -Monitor for therapeutic effects -Reduction of edema and fluid volume overload -Decreased blood pressure -Monitor serum potassium levels during therapy -Teach patients to eat more potassium-rick foods when taking any but the potassiumsparing drugs -Signs and symptoms of hypokalemia include muscle weakness, constipation, irregular pulse rate, and overall feeling of lethargy -Monitor for hyperkalemia with potassium-sparing diuretics Patient Education: -Teach patients to change positions slowly and to rise slowly after sitting or lying to prevent dizziness and fainting related to orthostatic hypotension -Instruct patients to take the medication in the morning if possible to avoid interference with sleep patterns -Encourage patients to keep a log of their daily weight -Educate patients to notify their physican IMMEDIATELY if: -The patient experiences rapid heart rate or syncope (could indicate hypotension or weight loss) -Rapid weight gain such as 5 or more pounds in one weekPatient Implications: -Patients taking diuretics along with a digitalis preparation should be taught to monitor for digitalis toxicity -Hypokalemia increases risk for digoxin toxicity -Diabetic patients who are taking thiazide and/or loop diuretics should be told to monitor blood glucose and watch for elevated levels Fluids and Electrolytes: When fluid (crystalloids, blood, colloids) becomes imbalanced: -Result: Edema, Dehydration Crystalloids: -Fluids that supply water and sedum -Are plasma-volume expanders -Better for treating dehydration rather than just expanding plasma volume alone -Most commonly used as maintenance fluids -Indications: -Compensate for fluid losses and manage specific fluid and electrolyte disturbances -Replace fluids -Promote urinary flow Crystalloids: Examples and Adverse Effects -Examples: -Lactated Ringers (LR), Normal Saline (0.9% Sodium Chloride), Half Normal Saline (0.45% Normal Saline), D5W (5% Dextrose in water) -Adverse Effects: -May cause edema, especially peripheral or pulmonary -Effects may be short-lived Colloids: MOA: -Move fluid from outside the blood vessels to inside the blood vessles -Are also called “plasma expanders” because they increase blood volume -Examples: -Albumin 5% and 25% (from human donors) -Dextran 40, 70, 0r 75 (a glucose solution) -Hetastarch (synthetic, derived from cornstarch) -Indications: -Treat a wide variety of conditions -Superior to crystalloids in plasma volume expansion, but more expansive -Nursing Implications: -Administer colloids slowly -Monitor for fluid overload and possible heart failure -Monitor for therapeutic response -Normal lab values -RBCs, WBC, H&H, electrolyte levels -Improved fluid volume status Blood Products: Only class of fluids that are able to carry oxygen -Increase tissue oxygenation-Increase plasma volume -Most expensive and least available fluid because they require human donors -Indications: -Cryoprecipitate and plasma protein factors (PPF) -Management of acute bleeding (greater than 50% slow blood loss or 20% acutely) -Fresh frozen plasma (FFP) -Increase clotting factor levels in patients with demonstrated deficiency -PRBCs and whole blood -To increase oxygen-carrying capacity in patients with severe anemia, substantial hemoglobin deficits -PRBCs: For blood loss up to 25% of total blood volume -Whole blood: For blood loss over 25% of total blood volume -Given to patients who have lost a massive amount of blood after emergency surgery -Adverse Effects: -Incompatibility with recipient’s immune system -Transfusion reaction -TURN OFF TRANSFUSION IMMEDIATELY IF ANY SIGN OF REACTION -ALWAYS HAVE NORMAL SALINE HANGING BEHIND IT -Anaphylaxis -Transmission of pathogens to recipient (hepatitis, HIV) Potassium: -Most abundant electrolyte inside of the cell -Critical for normal body function -May be obtained from a variety of foods -Excreted by the kidneys Hypokalemia: -Signs and Symptoms: -Early: Anorexia, hypotension, lethargy, mental confusion, muscle weakness, nausea -Late: Cardiac dysrhythmias, neuropathy, paralytic ileus, secondary alkalosis -Treatment: -Potassium supplementation orally or IV -Pain at the injection site is common -Potassium supplements are contraindicated in severe renal disease, acute dehydration, and others -Always diluted and always on a pump in mEq Hyperkalemia: -Signs and Symptoms: -Muscle weakness, paresthesia, paralysis, cardiac rhythm irregularities (leading to possible ventricular fibrillation and cardiac arrest) -Treatment: -IV sodium bicarbonate, calcium salts, dextrose with insulin-Sodium Polystyrene Sulfonate (Kayexalate) or hemodialysis to remove excess potassium -Hemodialysis for ESRD patients Nursing Implications: -Parenteral infusions of potassium must be monitored closely -Rate should not exceed 20-40 mEq for peripheral infusion and 60 mEq for central line (No more than 20 mEq/hr) -Never give as an IV bolus or undiluted -Really irritating to the skin -Oral forms of potassium -Must be diluted in water or fruit juice to minimize GI distress or irritation -Monitor for complaints of nausea, vomiting, GI pain, or GI bleeding Sodium: -Signs of hypernatremia (excessive sodium) -Water retention (edema), hypertension -Red flushed skin; dry sticky mucous membranes; increased thirst; elevated temperature; decreased urine output -Signs of hyponatremia (decreased sodium levels) -Lethargy, stomach cramps, hypotension, vomiting, diarrhea, seizures -Hypotension, seizures -Treatment for Hyponatremia: Newest Class -Conivaptan (Vaprisol) -Tolvaptan (Samsca) Nursing Implications: -Monitor serum electrolyte levels during therapy -Monitor infusion rate, infusion site -Observe for infiltration, other complications of IV therapy -Assess baseline fluid volume and electrolyte status -Assess baseline vital signs -Assess skin, mucous membranes, daily weights, I&O -Before giving potassium, assess EKG -Assess for contraindications to therapy -Assess transfusion history -Establish venous access as needed