PHARM NR 293 Pharm notes Heart Failure Drugs: Chapter 24 25, 28, 30,31,32,33,50,51,52, 34, 35, 56, 57, & 58 pg 388

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PHARM NR 293 Pharm notes Heart Failure Drugs: Chapter 24 25, 28, 30,31,32,33,50,51,52, 34, 35, 56, 57, & 58 pg 388 Right Side: Edema Left Side: Lung - Heart failure is a decrease in cardiac output... by 30%-40% & effects major organs such as the kidneys and brain. ACE inhibitors: “pril” Removes the fluid from the lungs which is the action of diuresis. This decreased preload or the left ventricular end-volume. Prevent sodium and water resorption by inhibiting aldosterone.  end up with increased blood pressure -Lisinopril, enalapril, captopril - lisinopril  adverse effect  dry cough Angiotensin II Receptor Blockers (ARB’S): Switch ACE to ARBS d/t dry cough  “Sartan” Vasodilators. Valsartan, candesartan, losartan Beta Blockers: “lol” Reducing or blocking the SNS to reduce HR & reduce BP. Always check heart rate if it is under 60 hold medication. Aldosterone Antagonist: remove excess fluid from the heart. - Used if African American can not take arbs  Aldactone: Potassium SPARING diuretic - ***B-type Natriuretic Peptides: giving IV for severe HR. Effects include diuresis, natriuresis (urinary sodium loss), and vasodilation. Vasodilating affects arteries & veins, increases cardiac output, suppresses renin-angiotensin system - naturesis  urinary sodium loss - Natrecor: used in the ICU and often combination of drugs are taken with it. Phosphodiesterase Inhibitors: Short-term management of HF & is given to pt when pt doesn’t respond to Digoxin, diuretics,vasodilators. These drugs result in increased HR and vasodilation. Positive inotropic response (increased force & velocity of myocardial contraction) Cardiac output = stroke output Cardiac Glycosides: Digoxin falls under this category of drugs for HF. Digoxin can also treat irregular heartbeat by increasing myocardial contractility. These are supraventricular dysrhythmias. Controls ventricular response. Increased stroke volume, reduction in heart size during diastole. ALWAYS check apical pulse rate for 1 minute before administering Digoxin. DO NOT GIVE if HR <60.Toxicity can occur so ALWAYS check the blood for hypokalemia. Digoxin level MUST be monitored and should be within 0.5-2 ng/mL. ALL ANITDYSRHYTHMIA MEDICATION HAVE AN ADVERSE EFFECT OF DYSRHYTHMIA! Can also cause paroxysmal nocturnal dyspnea. The antidote for Digoxin is Digi bind. - DIGOXIN TOXICITY; pg. 382 What causes this?  Hypokalemia  Use of pacemaker  Hypercalcemia - *Dysrhythmias - *renal failure - *Bradycardia - hypomagnesium - Pulse paradoxsus – check pulses symmetrically /bilaterally - Hydralazine/isosorbide dinitrate (BiDil) was approved specifically for use in the African-American population Antidysrhythmic Drugs: Chapter 25 - Pg 390 - Calcium - Potassium - Sodium outside of cell - Chloride -- > causes polarization Used to treat and prevent disturbances in cardiac rhythm. P wave: Atrium contraction, QRS: Ventricle contraction, T wave: Relaxation. Different dysrhythmias are: * Supraventricular & ventricular: Fast * Ectopic Foci: Starting outside of SA node * Conduction Block: H block UWAVE: sinus bradycardia , low potassium, use of comidan, and hyper thyoridism , ischemic heart disease 1. Unclassified Antidysrhythmic: Used to convert paroxysmal supraventricular tachycardia to sinus rhythm. Slows conduction of AV node. - Adenocard - Phenytoin: used when digitalis toxicity causes dysrhythmias and is also used to treat seizures. Ventricular dysrhythmias only. 2. Beta Blockers: Supraventricular/ventricular dysthymias 3. Calcium Channel Blockers: used for paroxysmal supraventricular tachycardia. 4. Class I Class IIClass III: used when dysrhythmias are hard to treat & are life threatening. Ventilation and cardiac circulation during  restore electrical conductivity  ABC Nursing Implications: Assess plasma drug levels especially for Digoxin. Monitor EKG’s for prolonged QT interval with use of any antidysrhythmic drug. Teach pt’s taking Digoxin, beta blockers and other drugs to take their own radial pulse for 60 seconds & notify physician if HR is below 60 before taking medication. COumidan(Wrafin)  check INR when patient is dysrhymtic Deltazen Cardizem – atrial Fib Amiodarone –antidysrythmic Side Effects include: * SOB * Dizziness * Edema * Syncope * Chest Pain * GI Distress * Blurred Vision Diuretic Drugs Ch 28, pg 452, 154 - Drugs that accelerate the rate of urine formation - Result in the removal of sodium and water - Used in the treatment of hypertension, heart failure, and renal failure - If water not absorbed, its excreted as urine where sodium goes, water follows => edema decrease vascular resistance  decrease cardiac output Types of Diuretic Drugs: Carbonic anhydrase inhibitors (CAI) Loop diuretics (LD) Osmotic diuretics (OD) Potassium-sparing diuretics (KSD) Thiazide and thiazide-like diuretics (TD) **most common Carbonic anhydrase inhibitors (CAI): - enzyme carbonic anhydrase helps to make H+ ions available for exchange with sodium and water in the proximal tubules - CAIs block the action of carbonic anhydrase, thus preventing the exchange of H+ ions with sodium and water - Inhibition of carbonic anhydrase reduces H+ ion concentration in renal tubules - increased excretion of bicarbonate, sodium, water, and potassium - Resorption of water is decreased, urine volume is increased- Adjunct drugs in the long-term management of open-angle glaucoma - Used with miotics to lower intraocular pressure before ocular surgery in certain cases - Also useful in the treatment of Edema, High-altitude sickness Ex. acetazolamide (Diamox) => Most commonly used CAI Carbonic anhydrase inhibitors Adverse Effects: - Metabolic acidosis - Anorexia - Hematuria - Photosensitivity - Melena - Hypokalemia - Drowsiness - Paresthesias - Urticaria - Glycosuria in diabetic patients Loop Diuretics: - Renal, cardiovascular, and metabolic effects - Act directly on the ascending limb of the loop of Henle to inhibit chloride and sodium resorption - Increase renal prostaglandins, resulting in the dilation of blood vessels and reduced peripheral vascular resistance - Useful in treatment of edema - Potent diuresis and subsequent loss of fluid - Decreased fluid volume causes a reduction in: Blood pressure Pulmonary vascular resistance Systemic vascular resistance Central venous pressure Left ventricular end-diastolic pressure **Potassium and sodium depletion => potassium wasting Ex. bumetanide (Bumex) ethacrynic acid (Edecrin) furosemide (Lasix) torsemide (Demadex Loop Diuretics Indications: - Edema associated with HF, hepatic or renal disease - Control hypertension - Increase renal excretion of calcium in patients with hypercalcemia - HF resulting from diastolic dysfunction used moreBUN and creatinine Loop Diuretics Adverse Effects: Dizziness, headache, tinnitus, blurred vision, vomiting, diarrhea, Stevens-Johnson syndrome (torsemide), Agranulocytosis, neutropenia, thrombocytopenia, Hypokalemia, hyperglycemia, hyperuricemia Osmotic Diuretics: - Work mostly in the proximal tubule - Nonabsorbable, producing an osmotic effect - Pull water into the renal tubules from the surrounding tissues - Inhibit tubular resorption of water and solutes, producing rapid diuresis - Increases glomerular filtration rate & renal plasma flow => helps prevent kidney damage during acute renal failure - Reduces intracranial pressure or cerebral edema associated with head trauma - Reduces excessive intraocular pressure Ex. mannitol (Osmitrol) => Most used osmotic diuretic - Brain swelling - IV infusion only - May crystallize when exposed to low temperatures - Use of a filter is required Osmotic Diuretics Indications: - Treatment of patients in early, oliguric phase of acute renal failure (ARF) - Promote excretion of toxic substances - Reduce intracranial pressure - Treatment of cerebral edema **NOT indicated for peripheral edema** Osmotic Diuretics Adverse Effects: Convulsions, Thrombophlebitis, Pulmonary congestion, headaches, chest pains, tachycardia, blurred vision, chills, fever, thrombocytis Potassium Sparing Diuretics: - Aldosterone inhibiting diuretics - Work in collecting ducts and distal convoluted tubules - Interfere with sodium-potassium exchange - Competitively bind to aldosterone receptors - Block resorption of sodium & water usually induced by aldosterone- Prevent potassium from being pumped into the tubule, thus preventing its secretion - Block aldosterone receptors and inhibit their action - Promote excretion of sodium & water pg 457  Remodeling --. Area of damage  thrombis  collateral circulation Plaque in artery  thrombis causes MI Ex. spironolactone (Aldactone) Potassium Sparing Diuretics Indications: spironolactone and triamterene - Hyperaldosteronism - Hypertension - Reversing potassium loss caused by potassium-losing drugs - Certain cases of HF amiloride - Treatment of HF Potassium Sparing Diuretics Adverse Effects: Dizziness, headache, cramps, nausea, vomiting, diarrhea, urinary frequency, weakness, hyperkalemia spironolactone (Aldactone) adverse effects: - Gynecomastia - Amenorrhea - Irregular menses - Postmenopausal bleeding Thiazide and Thiazide-like Diuretics: - Inhibit tubular resorption of sodium, chloride, and potassium ions - Action primarily in the distal convoluted tubule - Result: water, sodium, and chloride are excreted - Potassium is also excreted to a lesser extent - Dilate arterioles by direct relaxation - Lowered peripheral vascular resistance - Depletion of sodium & water (and potassium) *** Thiazides should not be used if creatinine clearance is less than 30 to 50 mL/min (normal is 125 mL/min) Thiazide and Thiazide-like Diuretics Indications: - Hypertension ***most prescribed group of drugs for this***- Edematous states - Idiopathic hypercalciuria - Diabetes insipidus - Heart failure due to diastolic dysfunction - Adjunct drugs in treatment of edema related to HF, hepatic cirrhosis, or corticosteroid or estrogen therapy Thiazide diuretics - hydrochlorothiazide (Esidrix, HydroDIURIL) - chlorothiazide (Diuril) Thiazide-like diuretics - metolazone (Mykrox, Zaroxolyn) - chlorthalidone (Hydone, Thalitone) - indapamide (Lozol) Thiazide and Thiazide-like Diuretics Adverse Effects: Dizziness, headaches, blurred vision, vomiting, nausea, diarrhea, anorexia, impotence, jaundice, leukopenia, urticarial (hives), photosensitivity, hypokalemia, hyperglycemia, hyperuricemia (gout), hypochloremic alkalosis Hypokalemia -- > electrolyte replacement Nursing Implications: - Assessment – baseline breath sounds, skin turgor, mucus membrane, and capillary refill , weight intake and output, postural orthastic hypotension, drop of blood pressure of 30 or more notify HCP, liver function testing Perform patient history, physical examination - Assess baseline fluid volume status, intake/output, serum electrolyte values, weight, vital signs (especially postural BPs) - Instruct patients to take the medication in the morning if possible to avoid interference with sleep patterns - Monitor serum potassium levels during therapy - Teach patients to maintain proper nutritional and fluid volume status, eat more potassium-rich foods when taking any but the potassium-sparing drugs - Foods high in potassium: bananas, oranges, dates, apricots, raisins, broccoli, green beans, potatoes, meats, fish, legumes - Patients taking diuretics along with a digitalis preparation should be taught to monitor for digitalis toxicity - Patients with diabetes mellitus who are taking thiazide and/or loop diuretics should be told to monitor blood glucose and watch for elevated levels- Teach patients to change positions slowly and to rise slowly after sitting or lying to prevent dizziness and fainting related to orthostatic hypotension - Encourage patients to keep a log of their daily weight Pituitary Drugs Ch 30 - Either augments or antagonizes the natural effects of the pituitary hormones Anterior pituitary drugs: 4-1 pg something - cosyntropin - bromocriptine - pergonal - somatropin - somatrem - octreotide - thyrotropin Posterior pituitary drugs: 484  30.1 - vasopressin - desmopressin Indications: cosyntropin (Cortrosyn) - Stimulates release of cortisol from adrenal cortex - Antiinflammatory effect - Used in diagnosis of adrenocortical insufficiency - Addison’s disease Somatropin and somatrem Recombinantly made human growth hormone (GH) Stimulate skeletal growth in patients with deficient GH, such as hypopituitary dwarfism Also used for wasting associated with human immunodeficiency virus infection (HIV) octreotide (Sandostatin) / LAR - Can be given IV, IM, or subcut - Carcinoid tumors secrete VIP (vasoactive intestinal polypeptide) - VIP causes profuse, watery diarrhea - Octreotide reduces this severe diarrhea, flushing, and potentially life-threatening hypotension that may occur with a carcinoid crisis - Used for treatment of esophageal varices Vasopressin and desmopressin - Used in treatment of diabetes insipidus- Because of their vasoconstrictor properties, they are useful in the treatment of various types of bleeding, in particular gastrointestinal hemorrhage - Desmopressin is useful in treatment of hemophilia A & type I von Willebrand’s disease because of its effects on various blood-clotting factors Nursing Implications: - Emotional stress – starvation - Disturbed body images - ACTH - ADH - TSH Provide specific instructions for nasal spray forms of vasopressin - Rotate injection sites - Do not discontinue drugs abruptly - Do not take over-the-counter products without checking with health care provider - Parents of children who are receiving growth hormones should keep a journal reflecting the child’s growth Prescriber may order EKG Glucose level, repsiraroy status, liver and kidney function octreotide (Sandostatin) - May impair gallbladder function—instruct patient to report abdominal pain - Use with caution in patients with renal impairment - Monitor glucose levels in patients with diabetes, and even in those who do not have diabetes Thyroid /Antithyroid Drugs Ch 31 - Thyroid preparations are given to replace what thyroid gland cannot produce to achieve normal thyroid levels (euthyroid) - Thyroid drugs work the same way as endogenous thyroid hormones Iodine – from food / salt T3 – thyroxine  3 molecules  potent  4 times what 4 is  stored in thyroid gland New born gets PKU Thyroid regulates basal rate , normal growth and development, heat regulation, neuromuscular Deficiency in Thyroid Hormones: Primary: abnormality in thyroid gland itselfSecondary: results when pituitary gland is dysfunctional and does not secrete TSH Tertiary: results when hypothalamus gland does not secrete thyrotropin-releasing hormone, which stimulates release of TSH Oral coagulants  increased Hypothyroidism: pg 492 Common symptoms: hypercholesteremia lipids return - Thickened skin - Hair loss - Constipation - Lethargy - Anorexia T4 thyroxine, calcitonin levothyroxine (Synthroid, Levoxyl) => Synthetic thyroid hormone T4 liothyronine (Cytomel) => Synthetic thyroid hormone T3 liotrix (Thyrolar) => Synthetic thyroid hormone T3 and T4 combined thyroid, desiccated (Armour Thyroid, Westhroid) => Desiccated (dried) animal thyroid gland Indications: - To treat all three forms of hypothyroidism - Levothyroxine is the preferred drug because its hormonal content is standardized; therefore, its effect is predictable - ―Euthyroid‖ => normal thyroid function - used for thyroid replacement in patients whose thyroid glands have been surgically removed or destroyed by radioactive iodine in the treatment of thyroid cancer or hyperthyroidism Adverse Effects: - Cardiac dysrhythmia is the most significant adverse effect - Tachycardia, palpitations, angina, hypertension, insomnia, tremors, headache, anxiety, nausea, diarrhea, menstrual irregularities, weight loss, sweating, heat intolerance, fever Hyperthyroidism: 494 Affects multiple body systems, resulting in an overall increase in metabolism - Diarrhea - Flushing - Increased appetite - Muscle weakness - Sleep disorders - Altered menstrual flow - Fatigue - Palpitations - Nervousness - Heat intolerance - Irritability - Bone and liver toxicityCaused by several diseases: - Graves’ disease - Multinodular disease - Plummer’s disease (rare) - Thyroid storm (induced by stress or infection) Treatment: - Radioactive iodine (I131) works by destroying the thyroid gland - Surgery to remove all or part of the thyroid gland - Lifelong thyroid hormone replacement will be needed - Antithyroid drugs: thioamide derivatives, methimazole (Tapazole), propylthiouracil - Used to treat hyperthyroidism & to prevent surge in thyroid hormones that occurs after surgical treatment or during radioactive iodine treatment for hyperthyroidism - May cause liver, bone marrow toxicity Nursing Implications: - During pregnancy, treatment for hypothyroidism should continue - Fetal growth may be retarded if maternal hypothyroidism is untreated during pregnancy - Teach patient to take thyroid drugs once daily in morning to decrease likelihood of insomnia if taken later in day - Teach patient to take medications at same time every day & not to switch brands without primary care provider approval - Teach patients to report any unusual symptoms, chest pain, or heart palpitations - Teach patients not to take OTC medications without primary care provider approval - Teach patients that therapeutic effects may take several weeks to occur - Teach patients the importance of alerting health care providers of thyroid medication use May enhance activity of anticoagulants Diabetic patients may need increased dosages of hypoglycemic meds May decrease serum digoxin levels - Antithyroid medications: Better tolerated when given with food Give at same time each day to maintain consistent blood levels Never stop these medications abruptly Avoid eating foods high in iodine (seafood, soy sauce, tofu, and iodized salt) Antidiabetic Drugs Ch 32Corticosteroid and –works synergistically Tests Ultrasound of liver or pancreas Urinalysis Hypoglycemia <70-100>hyperglycemia A1C level – 5.7 to 6.4% Type 1: - Lack of insulin production or production of defective insulin - Affected patients need exogenous insulin - Fewer than 10% of all diabetes cases are type 1 Inuslin stabilizes metabolic – glucose into cells Can be combined with type 2 - Complications: Diabetic ketoacidosis (DKA)younger than 50, o pH is low - Hyperosmolar nonketotic syndrome Type 2: - Most common type: 90% of all cases - Caused by insulin deficiency and insulin resistance - Many tissues are resistant to insulin: Reduced number of insulin receptors, Insulin receptors less responsive -Several comorbid conditions: Obesity, Coronary heart disease, Dyslipidemia, Hypertension, Microalbuminemia (protein in the urine), Increased risk for thrombotic (blood clotting) events - These comorbidities are collectively referred to as metabolic syndrome or insulinresistance syndrome or syndrome X Long term consequences of Type I and II diabetes 503 HHNS – higher than 40 – sodium is normal or high -insulin not needed - Metabolic syndrome - nonpharmalogical – diet and exercise Gestational: - Hyperglycemia that develops during pregnancy - Insulin must be given to prevent birth defects - Usually subsides after delivery - 30% of patients may develop Type 2 DM within 10-15 yearsLong Term Complications of Diabetes: Macrovascular (atherosclerotic plaque): Coronary arteries, Cerebral arteries, Peripheral vessels Microvascular (capillary damage): Retinopathy, Neuropathy, Nephropathy Treatment: Type 1: Insulin therapy Type 2: Lifestyle changes, Oral drug therapy, Insulin Antidiabetic Drugs: - Insulins - Oral hypoglycemic drugs - Both aim to produce normal blood glucose states - Some new injectable hypoglycemic drugs may be used in addition to insulin or antidiabetic drugs Insulins: - Function as a substitute for the endogenous hormone - Effects are the same as normal endogenous insulin - Restores the diabetic patient’s ability to: Metabolize carbohydrates, fats, proteins Store glucose in the liver Convert glycogen to fat stores Human insulin: Derived using recombinant DNA technologies, Recombinant insulin produced by bacteria and yeast Goal: tight glucose control, reduce the incidence of long-term complications Rapid-acting: - Most rapid onset of action (5 to 15 minutes) Short-acting: - Regular insulin (Humulin R) - Acts in 15 minutes - Onset 30 to 60 minutes - The only insulin product that can be given by IV bolus, IV infusion, or even IM Intermediate-acting: - Insulin isophane suspension (also called NPH)- Cloudy appearance - Slower in onset and more prolonged in duration than endogenous insulin Long-acting: - glargine (Lantus), detemir (Levemir) - based on body weight - Referred to as basal insulin Regular than long acting meds pulled Sliding-Scale Insulin Dosing: - Subcutaneous short-acting or regular insulin doses adjusted according to blood glucose test results - Used in hospitalized diabetic patients or those on total parenteral nutrition (TPN) or enteral tube feedings - Subcutaneous insulin is ordered in an amount that increases as the blood glucose increases - Disadvantage: delays insulin administration until hyperglycemia occurs; results in large swings in glucose control Basal-Bolus Insulin Dosing: pg507 - Preferred method of treatment for hospitalized diabetic patients - Mimics a healthy pancreas by delivering basal insulin constantly as a basal and then as needed as a bolus - Basal insulin is a long-acting insulin (insulin glargine) – can not be NPO - Bolus insulin (insulin lispro or insulin aspart) – mimics boost of glucose - Blood glucose monitors frequently Oral Antidiabetic Drugs: - Used for type 2 diabetes - Treatment for type 2 diabetes includes lifestyle modifications => Diet, exercise, smoking cessation, weight loss - Oral antidiabetic drugs may not be effective unless patient also makes behavioral or lifestyle changes .5 – 1.5 kg per day Biguanides => metformin (Glucophage) Sulfonylureas => Second generation: glimepiride (Amaryl), glipizide (Glucotrol), glyburide (DiaBeta, Micronase) Glinides => repaglinide (Prandin), nateglinide (Starlix) Thiazolidinediones => pioglitazone (Actos), rosiglitazone (Avandia)Alpha-glucosidase inhibitors => acarbose (Precose), miglitol (Glyset) Dipeptidyl peptidase-IV (DPP-IV) inhibitors => sitagliptin (Januvia), saxagliptin (Onglyza), linagliptin (Tradjenta) Biguanides: metformin (Glucophage) - Decrease production of glucose by the liver - Decrease intestinal absorption of glucose - Increase uptake of glucose by tissues - Do not increase insulin secretion from pancreas (does not cause hypoglycemia) - lactic acidosis - alcoholism, hepatic disease, tissue hypoxia - diarrhea, fullness, abdominal bloating, nausea, cramping, feeling of fullness - dye used is can harm kidneys, metformin can not be used with contrast medium  not 48 hours before and after Sulfonylureas: - Stimulate insulin secretion from the beta cells of the pancreas, thus increasing insulin levels - Beta cell function must be present - Improve sensitivity to insulin in tissues - Result in lower blood glucose levels Glinides: - Action similar to sulfonylureas - Increase insulin secretion from the pancreas Thiazolidinediones: - Decrease insulin resistance => ―Insulin sensitizing drugs‖ - Increase glucose uptake and use in skeletal muscle - Inhibit glucose and triglyceride production in the liver Alpha-glucosidase inhibitors: - Reversibly inhibit enzyme alpha-glucosidase in the small intestine - Result in delayed absorption of glucose - Must be taken with meals to prevent excessive postprandial blood glucose elevations Dipeptidyl peptidase -IV (DPP-IV) inhibitors: - Delay breakdown of incretin hormones by inhibiting enzyme DPP-IV - Incretin hormones increase insulin synthesis & lower glucagon secretion- Reduce fasting & postprandial glucose concentrations Oral Antidiabetic Indications: Used alone or in combination with other drugs & diet, lifestyle changes to lower blood glucose levels in patients with type 2 diabetes Oral Antidiabetic Adverse Effects: Biguanides (metformin) Primarily affects GI tract: abdominal bloating, nausea, cramping, diarrhea, feeling of fullness May also cause metallic taste, reduced vitamin B12 levels Lactic acidosis is rare but lethal if it occurs Sulfonylureas Hypoglycemia, hematologic effects, nausea, epigastric fullness, heartburn, many others Glinides Headache, ***hypoglycemic effects, dizziness, weight gain, joint pain, upper respiratory infection or flulike symptoms Thiazolidinediones Moderate weight gain, edema, mild anemia Hepatic toxicity => monitor alanine aminotransferase (ALT) levels Alpha-glucosidase inhibitors Flatulence, diarrhea, abdominal pain Do not cause hypoglycemia, hyperinsulinemia, weight gain Dipeptidyl peptidase-IV (DPP-IV) inhibitors Upper respiratory tract infection, headache, and diarrhea Hypoglycemia can occur and is more common if used in conjunction with a sulfonylurea Injectable Antidiabetic Drugs: Amylin agonist -Mimics the natural hormone amylin - Slows gastric emptying - Suppresses glucagon secretion, reducing hepatic glucose output - Centrally modulates appetite and satiety - Used when other drugs have not achieved adequate glucose control - Subcutaneous injection Incretin mimetic - Mimics the incretin hormones - Enhances glucose-driven insulin secretion from beta cells of the pancreas- Only used for type 2 diabetes - Exenatide: Injection pen device Injectable Adverse Effects: Amylin agonist: Nausea, vomiting, anorexia, headache Incretin mimetics: Nausea, vomiting & diarrhea, Rare cases of hemorrhagic or necrotizing pancreatitis, Weight loss Hypoglycemia: - Abnormally low blood glucose level (below 50 mg/dL) - Mild cases can be treated with diet (higher intake of protein and lower intake of carbohydrates) to prevent rebound postprandial hypoglycemia - Early signs: confusion, irritability, tremor, sweating - Late signs: hypothermia, seizures, coma, death Glucose Elevating Drugs: - Oral forms of concentrated glucose => Buccal tablets, semisolid gel - 50% dextrose in water (D50W) - Glucagon Nursing Implications: Before giving drugs that alter glucose levels: - Assess patient’s ability to consume food - Assess for nausea or vomiting - Hypoglycemia may be a problem if antidiabetic drugs are given and patient does not eat - If patient is NPO for a test or procedure, consult primary care provider to clarify orders for antidiabetic drug therapy ***Insulin order and prepared dosages are second-checked with another nurse*** Insulin: 521 - Check blood glucose level before giving insulin - Roll vials between hands instead of shaking them to mix suspensions - Only use insulin syringes, calibrated in units, to measure and give insulin - insulin good for 30 days - When drawing up two types of insulin in one syringe, always withdraw regular or rapid-acting insulin first Oral antidiabetic drugs:- Always check blood glucose levels before giving - Usually given 30 minutes before meals - Alpha-glucosidase inhibitors are given with the first bite of each main meal - Metformin is taken with meals to reduce GI effects - Metformin will need to be discontinued if the patient is to undergo studies with contrast dye because of possible renal effects, check with prescriber - Assess for signs of hypoglycemia Adrenal Drugs Ch 33 Adrenal medulla secretes catecholamines: Epinephrine, Norepinephrine Adrenal cortex secretes corticosteroids: Glucocorticoids, Mineralocorticoids (primarily aldosterone) Oversecretion => Cushing’s syndrome - moon face, fat distribution moves to abdomen Undersecretion => Addison’s disease Glucocorticoids => Topical, systemic, inhaled, nasal Mineralocorticoid => Systemic Adrenal steroid inhibitors => Systemic Hyper secretion – potassium loss - Most corticosteroids exert their effects by modifying enzyme activity o – 525 stimulating mass cells - Glucocorticoids differ in their potency, duration of action, and extent to which they cause salt, fluid retention - Glucocorticoids inhibit or help control inflammatory and immune responses Glucocorticoids: “one” beclomethasone (several formulations) fluticasone propionate dexamethasone hydrocortisone (several formulations) cortisone methylprednisolone (Solu-Medrol) prednisone (Deltasone, Sterapred, Liquid Pred) prednisolone triamcinolone Mineralocorticoid: fludrocortisone (Florinef) Adrenal steroid inhibitor: aminoglutethimide (Cytadren)Indications: - Adrenocortical deficiency - Cerebral edema ICP (headache) - Dermatologic diseases - GI diseases Antiadrenals (adrenal steroid inhibitors): aminoglutethimide (Cytadren) - Used in treatment of Cushing’s syndrome, metastatic breast cancer, adrenal cancer Adverse Effects: Heart failure, cardiac edema, hypertension (caused by electrolyte imbalances: hypokalemia, hypernatremia), Convulsions, headache, vertigo, mood swings, nervousness, insomnia, steroid psychosis, Growth suppression, Cushing’s syndrome, menstrual irregularities, carbohydrate intolerance, hyperglycemia, Peptic ulcers with possible perforation, pancreatitis, abdominal distention, Fragile skin, petechiae, ecchymosis, facial erythema, poor wound healing, hirsutism, urticarial, Muscle weakness, loss of muscle mass, osteoporosis, Increased intraocular pressure, glaucoma, weight gain Nursing Implications: - Assess for contraindications to adrenal drugs, especially presence of peptic ulcer disease - Be aware drugs may alter serum glucose, electrolyte levels Corticosteroids - Inhibits immune response - Oral forms => given with food or milk to minimize GI upset - have patient rinses mouth to avoid oral fungus - After using an orally inhaled corticosteroid, instruct patients to rinse their mouths to prevent possible oral fungal infections - Patients should not take with alcohol (Barbs), aspirin (coumidins), or NSAIDs Bowel Disorder Drugs Ch 50 - 51 Gastric hyperacidity B12 – comes from plants Chocolate alcohol fatty meal s- hyperproduction – peptic ulcer Transfusion – needed for ulcer in GI – GI bleeding  Protonic – The parietal cells release positive hydrogen ions (protons) during HCl production. – 822  This process is called the proton pump  Bicarbonate excreted by stomach Acid rebound with peptil bismol  818 aluminum –  calcium and renal disease 824  sodium alkalosis Acute Diarrhea: Sudden onset, Lasts from 3 days to 2 weeks, Self-limiting, Resolves itself Causes: bacteria, virus, nutritional factors, drug induced Chronic diarrhea: Lasts for more than 3-4 weeks, Associated with recurring passage of diarrheal stools, fever, loss of appetite, nausea, vomiting, weight loss, chronic weakness Causes: tumors, diabetes, Addison’s disease, hyperthyroidism, irritable bowel, AIDS Antidiarrheals: Adsorbents Antimotility drugs (anticholinergics and opiates) Probiotics (bacterial replacement drugs) Adsorbents: - Coat walls of gastrointestinal (GI) tract - Bind to causative bacteria or toxin, which is then eliminated through stool Ex. bismuth subsalicylate (Pepto-Bismol), activated charcoal, aluminum hydroxide Antimotility drugs: anticholinergics - Decrease intestinal muscle tone and peristalsis of GI tract - Result: slows movement of fecal matter through GI tract Ex. belladonna alkaloids Antimotility drugs: opiates - Decrease bowel motility and reduce pain by relief of rectal spasms - Decrease transit time through bowel, allowing more time for water & electrolytes to be absorbed Ex. paregoric, opium tincture, codeine, loperamide (OTC), diphenoxylate Probiotics - Also known as intestinal flora modifiers and bacterial replacement drugs - Bacterial cultures of Lactobacillus organisms work by:Supplying missing bacteria to the GI tract Suppressing the growth of diarrhea-causing bacteria Ex. L. acidophilus (Bacid) Adverse Effects: Adsorbents: Increased bleeding time, Constipation, dark stools, Confusion, Tinnitus, Metallic taste, Blue tongue Anticholinergics: Urinary retention, impotence, Headache, dizziness, confusion, anxiety, drowsiness, confusion, Dry skin, flushing, Blurred vision, Hypotension, bradycardia Opiates: Drowsiness, dizziness, lethargy, Nausea, vomiting, constipation, Respiratory depression, Hypotension, Urinary retention, Flushing -Adsorbents decrease the absorption of many drugs, including digoxin, quinidine, and hypoglycemic drugs - Adsorbents cause increased bleeding time, bruising when given with anticoagulants (warfarin) - Toxic effects of methotrexate more likely when given with adsorbents Nursing Implications: - Do NOT give bismuth subsalicylate to children/teenagers with chickenpox or influenza because risk of Reye’s syndrome - Use adsorbents carefully in elderly patients or those with decreased bleeding time, clotting disorders, recent bowel surgery, confusion -Do not administer anticholinergics to patients with a history of narrow-angle glaucoma, GI obstruction, myasthenia gravis, paralytic ileus, toxic megacolon - Teach patients to take medications exactly as prescribed and to be aware of their fluid intake and dietary changes - Assess fluid volume status, I&O, mucous membranes before, during, after initiation of treatment Constipation: Abnormally infrequent and difficult passage of feces through lower GI tract - Symptom, not a disease - Disorder of movement through the colon and/or rectum - Can be caused by a variety of diseases or drugs Types of Laxatives:- Bulk-forming - Emollient (stool softeners, lubricant laxatives) - Hyperosmotic - Saline - Stimulant - Peripherally acting opioid Bulk-forming: High fiber, Absorb water to increase bulk, Distend bowel to initiate reflex bowel activity Ex. psyllium (Metamucil), methylcellulose (Citrucel) Emollient: Stool softeners and lubricants, Promote more water and fat in stools, Lubricate the fecal material & intestinal walls Ex. Stool softeners: docusate salts (Colace, Surfak) Lubricants: mineral oil Hyperosmotic: Increase fecal water content, Results in bowel distention, increased peristalsis, and evacuation Ex. Polyethylene glycol (PEG), Sorbitol, glycerin, Lactulose (used to reduce elevated serum ammonia levels) Saline: Increase osmotic pressure within the intestinal tract, causing more water to enter the intestines, Results in bowel distention, increased peristalsis, and evacuation Ex. Magnesium hydroxide (Milk of Magnesia), Magnesium citrate (Citroma) Stimulant: Increases peristalsis via intestinal nerve stimulation Ex. senna (Senekot), bisacodyl (Dulcolax) Peripherally Acting Opioid Antagonists: Treatment of constipation related to opioid use and bowel resection therapy => Block entrance of opioid into bowel - Strict regulations for use - Allow bowel to function normally with continued opioid use Ex. methylnaltrexone (Relistor), alvimopan (Entereg) Indications: Bulk-forming: Acute and chronic constipation, irritable bowel syndrome, diverticulosis Emollient: Acute & chronic constipation, fecal impaction, facilitation of bowel movements in anorectal conditions Hyperosmotic: chronic constipation, diagnostic & surgical preps Saline: constipation, diagnostic & surgical preps Stimulant: acute constipation, diagnostic & surgical prepsLaxative Adverse Effects: Bulk-forming: Impaction, Fluid overload, Electrolyte imbalances, Esophageal blockage Emollient: Skin rashes, Decreased absorption of vitamins, Electrolyte imbalances, Lipid pneumonia Hyperosmotic: Abdominal bloating, Electrolyte imbalances, Rectal irritation Saline: Magnesium toxicity (with renal insufficiency), Cramping, Electrolyte imbalances, Diarrhea, Increased thirst Stimulant: Nutrient malabsorption, Skin rashes, Gastric irritation, Electrolyte imbalances, Discolored urine, Rectal irritation ***All laxatives can cause electrolyte imbalances*** Nursing Implcations: - Assess fluid and electrolytes before initiating therapy - Inform patients not to take a laxative/cathartic if experiencing nausea, vomiting, and/or abdominal pain - Healthy, high-fiber diet and increased fluid intake should be encouraged as an alternative to laxative use - Long-term use of laxatives often results in decreased bowel tone and may lead to dependency - Laxative tablets should be swallowed whole, not crushed or chewed, especially if enteric coated - Patients should take all laxative tablets with 6-8 oz of water - Patients should take bulk-forming laxatives as directed by the manufacturer with at least 240 mL (8 oz) of water - Give bisacodyl with water because of interactions with milk, antacids, and juices - Inform patients to contact their prescriber if they experience severe abdominal pain, muscle weakness, cramps, and/or dizziness, which may indicate possible fluid or electrolyte loss Irritable Bowel Syndrome: - Chronic intestinal discomfort characterized by cramps, diarrhea, and/or constipation - Patients usually cope with symptoms by avoiding irritating foods and/or taking OTC laxatives & antidiarrheal drugs - Perform a general assessment and additional assessment of liver functioning as well as assessment for any underlying cardiac diseaseIBS Drugs: tegaserod (Zelnorm), lubiprostone (Amitiza), alosetron (Lotronex) Antiemetic/Antinausea Drugs Ch 52 - Most work by blocking one of vomiting pathways, thus blocking stimulus that induces vomiting Antiemetic drugs => Used to relieve nausea, vomiting Types of Antiemetic/Antinausea Drugs: - Anticholinergic drugs - Antihistamines (histamine 1 [H1] receptor blockers) - Antidopaminergic drugs - Prokinetic drugs - Serotonin blockers - Tetrahydrocannabinoids Indications: Anticholinergic drugs (ACh blockers) - Bind to and block acetylcholine (ACh) receptors in inner ear labyrinth - Block transmission of nauseating stimuli to CTZ - Block transmission of nauseating stimuli from reticular formation to VC scopolamine (Transderm-Scōp, Scopace) Antihistamine drugs (H1 receptor blockers) - Inhibit ACh by binding to H1 receptors - Prevent cholinergic stimulation in vestibular and reticular areas, thus preventing nausea and vomiting - Used for motion sickness, nonproductive cough, allergy symptoms, sedation Ex. dimenhydrinate (Dramamine), diphenhydramine (Benadryl), meclizine (Antivert) Antidopaminergic drugs - Block dopamine receptors in CTZ (Chemoreceptor trigger zone) - Also used for psychotic disorders, intractable hiccups Ex. prochlorperazine (Compazine), promethazine (Phenergan), droperidol => controversial because of associated cardiac dysrhythmia Prokinetic drugs - Block dopamine receptors in CTZ - Cause CTZ to be desensitized to impulses it receives from the GI tract- Stimulate peristalsis in GI tract, enhancing emptying of stomach contents - Used for gastroesophageal reflux disease (GERD), delayed gastric emptying Ex. metoclopramide (Reglan) Serotonin blockers - Block serotonin receptors in the GI tract, CTZ, VC - Used for nausea/vomiting in patients receiving chemotherapy & for postoperative nausea, vomiting Ex. dolasetron (Anzemet), granisetron (Kytril), ondansetron (Zofran), palonosetron (Aloxi) Tetrahydrocannabinoids - Major psychoactive substance in marijuana - Inhibitory effects on reticular formation, thalamus, cerebral cortex - Alter mood & body’s perception of its surroundings => may help relieve nausea/vomiting Ex. dronabinol (Marinol) => Used for nausea/vomiting associated with chemotherapy, and anorexia associated with weight loss in AIDS patients Antinausea Drugs: phosphorated carbohydrate solution (Emetrol) => Mint-flavored oral solution, Used off label for treatment of morning sickness aprepitant (Emend) => Used for prevention of nausea/vomiting associated with highly emetogenic cancer chemotherapy regimens Herbal Products: Ginger: Used for nausea and vomiting, including that caused by chemotherapy, morning sickness, and motion sickness Adverse effects => Anorexia, nausea and vomiting, skin reactions Drug interactions => May increase absorption of oral medications, Increase bleeding risk with anticoagulants Nursing Implications: - Many of these drugs cause severe drowsiness; warn patients about driving or performing any hazardous tasks - Taking antiemetics with alcohol may cause severe CNS depression - Teach patients to change positions slowly to avoid hypotensive effects - For chemotherapy, antiemetics are often given 30 to 60 minutes before chemotherapy begins [Show More]

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