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Pharmacology Study Guide

Low protein levels Proteins are essential in the diet because they support cellular growth as well as maintain and repair body tissues. Patients with hypoproteinemia may be administered normal serum albumin to help restore blood protein levels. This occurs in patients with hepatic cirrhosis. Normal plasma albumin level - 3.5 to 5.0 g/dL Normal total serum protein - 6 to 8.4 g/dL Magnesium Sulfate Normal Levels: 1.8-3 mEq/L Second most abundant cation; majority found in bones so serum magnesium not accurate indicator of +/ Neuromuscular function; activates enzymes for breakdown of carbohydrates and proteins; Levels primarily controlled by kidney, so diuretics can cause significant loss. Magnesium disorders: cardiovascular and neuromuscular symptoms Hypomagnesemia: Few symptoms until level falls below 1 mEq, so often undiagnosed. Most critically ill patients Causes: Renal: kidney failure, Loop diuretic therapy GI: malabsorption, significant loss of body fluids (diarrhea, laxative abuse, nasogastric suctioning) Misc: Alcoholics, prolonged parenteral feeding with magnesium-free solutions Symptoms: weakness, dysrhythmias, HTN, loss of deep tendon reflexes, respiratory depression, muscle twitches, tetany, seizures. Pharmacologic: Magnesium supplements, oral or IV route usually. IM injections painful at site; symptoms are quickly reversed (30-60 min). Magnesium is sometimes given to prevent or terminate seizures assoc. with preeclampsia or eclampsia (anticonvulsant). Hypermagnesemia: Causes: Advance renal failure Symptoms: CNS depression, respiratory depression, hypotension, dysrhythmias, bradycardia, complete heart block, and coma. Pharmacologic: Infusions of calcium salts immediately reverse symptoms. If hypermagnesemia is minor, furosemide will increase urinary excretion which may be enough to reverse the hypermagnesemia. Extreme levels: neuromuscular blockade with respiratory paralysis, heart block & circulatory collapse. Potentially fatal. Deficiency must be severe to receive. Epson salts: diarrhea Contraindications: serious cardiac disease, undiagnosed abdominal pain, intestinal obstruction, fecal impaction. Drug Interactions: Neuromuscular blockers increase respiratory depression & apnea; CNS depressants Overdose signs: flush, sedation, confusion, intense thirst, muscle weakness. Overdose treatment: Calcium gluconate or gluceptate by IV Nursing Responsibilities: For IV - Monitor vitals every 10-15 min For parenterally - Moniter serum magnesium levels; monitor serum calcium & phosphorus. Assess for Toxicity - S/S carthartic effect, profound thirst, feeling of warmth, nausea, sedation, confusion; depressed DTR, muscle weakness. Cardiac arrest if excess of 25 mEq/L. Monitor respiratory rate, keep over 12/min.; Urinary output over 100mL over the 4 hours before each dose; Keep Calcium gluconate readily available in case of toxicity. Drink plenty of water (1-2 L/day) with oral drug to prevent loss of body water unless otherwise directed. To prevent hypomagnesemia - consume whole grain cereals, legumes, nuts, meats, seafood, milk, most green leafy vegetables, and bananas.

Potassium Supplement Prototype Drug: Potassium Chloride Therapeutic: Agent for Hypokalemia Effects and uses: Oral formulations of potassium chloride include tablets, powders, and liquids, and are usually flavored due to its unpleasant taste. Can cause peptic ulcers so it should be diluted with plenty of water. When given IV, it must be administered slowly to prevent possible cardiac arrest. Because pharmacotherapy with loop diuretics is the most common cause of potassium depletion, patients taking these drugs are usually prescribed PO potassium supplements to prevent hypokalemia. Adverse Effects : N/V, diarrhea, and abdominal pain are common because potassium chloride irritates the GI mucosa. Drug may be taken with meals to help reduce gastric distress. Hyperkalemia may occur if the patient takes potassium supplements concurrently with potassium sparing diuretics. Contraindications/Precautions: Patients with hyperkalemia, systemic acidosis, severe dehydration, extensive tissue breakdown as in severe burns, or adrenal insufficiency. Should be used with extreme caution in patients with chronic or acute renal failure. Drug Interactions: Not to be used with potassium sparing diuretics, or ACE inhibitors, which cause potassium retention. 3% NaCl > when serum sodium falls below 115 3% NaCl solution may be infused. > replacement solution for lost sodium > must be monitored frequently to avoid symptoms of hypernatremia, which includes lethargy, confusion, muscle tremor or rigidity. > When infusing 3% NaCl solutions, the nurse should continuously check for signs and symptoms of pulmonary edema. > Drug should not be administered to patients with hypernatremia, CHF, or impaired renal function. > pregnancy category C > No specific treatment for overdose. Diuretics may be administered to remove excess sodium ion and water to reduce pulmonary or peripheral edema. > Management of severe symptoms of hyponatremia including seizures, coma, and focal neurological signs. > A loop diuretic may be added to prevent sodium overload and enhance free water excretion

Blood Transfusion Blood products include whole blood, packed red cells, fresh frozen plasma, cryoprecipitate, and platelet infusions. A single unit of blood can be separated into specific constituents: erythrocytes, leukocytes, thrombocytes, plasma proteins, fresh frozen plasma, and globulins. Whole blood is indicated for the treatment of acute, massive blood loss (more than 30% of total volume). Whole blood is rarely administered otherwise, because there is no need to expose the patient to unnecessary components that could potentially trigger an adverse side effect. Most common complications of whole blood transfusion include febrile nonhemolytic and chill rigor reactions. Symptoms of an allergic reaction include back pain and low-grade fever and chills. Dizziness, urticaria, and headache may occur during or immediately after transfusion. Symptoms are generally mild and treated with acetaminophen and dihenhydramine (Benadryl). The most serious adverse side effect from administration of whole blood is an acute hemolytic transfusion reaction. This occurs when the patient develops antibodies against donor RBC antigens. This is very rare, but can be fatal. Another serious adverse side effect is acute lung injury. This occurs when the patient receives donor antibodies that attack normal granulocytes in the lung. Acute respiratory symptoms may develop and may be fatal. Whole blood despite being carefully screened also has the potential to transmit serious infections such as hepatitis, cytomegalovirus, malaria, or HIV.

Please refer to table 42.2 on page 689 for other blood products, descriptions, and indications.

Peripheral neuropathy > mainly affects legs and feet. > frequently the cause of neuropathy cannot be identified and it is designated idiopathic. > Chief symptoms include weakness or clumsiness of movement, unusual or unpleasant sensations such as tingling or burning, reduction in the ability to feel texture, temperature, etc. and impaired balance when standing or walking. > Autonomic symptoms may also occur such as dizziness on standing up, ED, and difficulty controlling urination. > Diabetes and impaired glucose tolerance are the most common causes. > it progresses slowly over months to years. > treatment is aimed firstly at eliminating or controlling the cause if identified, secondly at maintaining muscle strength and physical function and thirdly at controlling symptoms of neuropathic pain. Enteric Coated Meds When crushed or opened, these drugs are exposed to stomach acid, which may destroy them, they are designed to dissolve in the alkaline environment of the small intestine. Some drugs are enteric coated because the agents will irritate the stomach mucosa and cause nausea and vomiting if they are dissolved in the stomach. Breakthrough Pain >Pain that comes on suddenly for short periods of time and is not alleviated by the patients normal pain management. It is common in cancer patients who often have a background level of pain controlled by medications, but whose pain periodically breaks through medication. All I could find on breakthrough pain. I remember seeing on a patient in the hospital having morphine as an IVP for breakthrough. Mild Pain Mild to moderate pain is usually treated with nonopioid analgesics: NSAIDs, acetaminophen, and a few centrally acting agents. NSAIDs such as aspirin and ibuprofen, are the drugs of choice for mild to moderate pain, especially for pain associated with inflammation. Many nonopioids are available OTC and are inexpensive, and there are several different formulations, including those for children. NSAIDs have antipyretic and anti-inflammatory activities as well as analgesic properties. Nonpharmacologic interventions may also be used to treat mild to moderate pain. These include: relaxation and imagery, meditation, distraction (art or music therapy), application of cold or heat, massage, TENS, acupressure and acupuncture, therapeutic touch, energy therapies, and biofeedback therapy. Verapamil Calcium Channel Blocker Slows myocardial conduction velocity and stabilizes certain types of abnormal heart rhythms. Causes vasodialation of arterioles which decrease BP and reduces cardiac workload. It also dialates coronary arteries an action that is important when the drug used is to treat angina. Its used off label as a migraine prophylaxis and acute mania. Acts by inhibiting the flow of calcium ions into both cardiac muscle cells and vascular smooth muscle cells. Blocking calcium entry causes vasodilation of the peripheral arterioles and reduced contractility of the myocardium. Adverse effects---most are extensions of its actions on the cardiovascular system. Flushed skin, headache, dizziness, light headedness, and peripheral edema. High doses & IV administrations may cause serious hypotension. Most serious adverse effects are cardiac related , worsening of CHF, bradycardia, reflex tachycardia and AV block. Confusion, drowsiness and mood changes have been reported. Verapamil is contraindicated in patients with AV heart block, sick sinus syndrome, severe hypotension, bleeding aneurysm, or those undergoing intracranial surgery. Patients with renal or hepatic impairment because it causes delayed clearance. Can elevate blood levels of digoxin Use with other antihypertensive drugs including ace inhibitors or beta-adrenergic blocker may cause additive hypotension or bradycardia. Verapamil with buspirone can triple the plasma concentration of buspirone Verapamil should not be administered with statins because the risk of myopathy increases significantly.

Grapefruit juice may increase verapamil levels. Use caution with herbal supplements such as hawthorn which may have additive hypotensive effects. High doses of calcium supplements may diminish the effects of CCBs. Treatment of overdose is aimed at reversing hypotension with vasopressors such as dopamine or dobutamine. Keep patient in recumbent position for at least 1 hour after dose is given to avoid hypotension. Take with a full glass of water to reduce gastric irritation Immediately report palpitations, weight gain or swelling of ankles and feet to HCP.

Beta Blocker & Amlodipine Amlodipine is a calcium channel blocker and should be used with caution in patients taking beta blockers. The combined effects of these drugs may cause partial or complete AV heart block, heart failure, or dysrhythmias. - Patients who are taking a beta blocker with amlodipine may be asked to take less and less of their beta blocker before stopping the medication completely. Stopping a beta blocker too quickly can cause serious heart problems that will not be prevented by amlodipine. Nifedipine Classification: calcium channel blocker, dihydropyridine type Effects and Uses: used for hypertension alone or with combinations of other hypertensive drugs. Important drug in the treatment of chronic stable or variant angina. At high doses the intermediate release form should be used in great cation because there is high risk for MI. Adverse Effects: is usually a well tolerated drug, but adverse effects such as hypotension, dizziness, headache, and flushing are usually related to the vasodilation action of the drug. Most common cardiovascular-related adverse effect is peripheral edema, which mostly occurs when other CCBs are being used. Other sever though rare effects include hepatoxicity, MI, congestive heart failure, sever hypotension, and confusion. Contraindications/ precautions: contraindicated in patients with hypersensitivity to nifedipine or other dihydropyridines. Caution must be taken in patients with bradycardia or CHF( congestive heart failure) because the drug may worsen these conditions. The drug causes blood pressure to fall so it should be used cautiously in patients with preexisting hypotension; patients with hepatic impairment are at risk for accumulation and toxcicity. Older adults are at greater risk for toxicity. Drug interactions: Nifedipine is a substrate for hepatic CYP3A4 and may interact with drugs that induce or inhibit this enzyme. Nifedipine with beta-adrenergic blocker increases the risk of CHF due to the additive negative inotropic and chronotropic effects. It may increases the serum levels of digoxin by 45% leading to bradycardia. Alcohol potentiated the vasodilation action of nifedipine and could cause rapid drop in blood pressure. Lisionpril Classification: ACE inhibitor Effects and Uses: treatment of heart failure, HTN and acute MI 2-3 weeks of use for maximum therapeutic outcome

Adverse Effects: c ough, headache, dizziness, orthostatic hypotension, rash, hyperkalemia Contraindications/precautions: hyperkalemia, history of angioedema Drug interactions: NSAIDs decrease antihypertensive activity Hyperkalemia w/ potassium supplements

Nursing Responsibilities: notify prescriber if: kidney or liver disease, CHF, diabetes, connective tissue disease Monitor B/P before and 30-60min after admin Keep pt in supine position notify HCP if hypotension occurs w/in 1-5 hrs

Make position changes slowly, drink 6-8 glasses of water a day, no alcohol, avoid OTC NSAIDs

Enalapril Ace inhibitors Approved for HTN, Heart Failure and asymptomatic left ventricular dysfunction in post MI patients. Has an extended half-life and is excreted by the kidneys and may require twice daily dosing. Enalapril is a prodrug being converted by hepatic enzymes to enalaprit. Most frequent adverse effect is hypotension which can be troublesome in patients with CHF. Adverse effects-cough, headache, orthostatic hypotension, rash, same as lisinopril Patients taking potassium sparing diuretics are at highest risk for hyperkalemia. Preg. Cat. D Use extreme caution in patients with hyperkalemia because they may experience serious and even fatal dysrhythmias. Patients with angioedema should not receive. HCTZ/Renal FunctionType: thiazide-type diuretic Effects and Uses: HTN, ascites,edema, heart failure, and nephritic syndrome. Off label indications include PMS, diabetes insipidus, hypercalciuria, and nephrolithiasis. Peak effect in 4h duration of action 6-12hr

Adverse effects: hypotension, dizziness, and headache, hypochloremia, hypomangnesemia, hypokalemia, and hyponatremia. May precipitate gout attacks. Blood dyscrasias such as leukemia, argranulocytosis, and aplastic anemia. Contraindications: anuria and prior hypersensitivity to thiazide diuretics or sulfonamide antibiotics. Serum glucose levels must be carefully monitored in pts with diabetes. Should not be used in jaundiced neonates. Drug interactions: may reduce the effectiveness of anticoagulents, sulfaureas, and antidiabetic drugs including insulin, they increase the risk of renal toxicity from NSAIDs Nursing Responsibilities: measure B/P before and after admin Take I&O ratios and check for edema Monitor serum postassium values and monitor for hyperglycemia

Decreased renal function Decrease in the kidneys ability to maintain electrolyte and fluid balance and excrete waste products. Primary treatment goal for patients with renal failure are to maintain blood flow through the kidneys and adequate urine output. The most basic diagnostic test of the kidney function is a urinalysis, which examines urine for the presence of blood cells, protein, pH, specific gravity, ketones, glucose, and microorganisms. Urinalysis can detect proteinuria and albuminuria, which are primary measures of structural kidney damage. Serum creatinine is an additional measure for detecting kidney disease Renal biopsy may be performed to obtain a more specific diagnosis The best marker for estimating kidney function is GFR, which is the volume of water filtered through the bowmans capsule per minute. The GFR can be used to predict the onset and progression of kidney failure and it indicates the kidneys ability to excrete drugs from the body. A progressive decline in GFR indicates a reduction in the # of functioning nephrons. When nephrons die the remaining ones compensate by increasing their filtration capacity. Because of this, patients with significant kidney damage may be asymptomatic until 50% or more nephrons have become nonfunctional and GFR has fallen to less than half its normal value. The most common cause of acute renal failure is renal hypoperfusion (lack of sufficient blood flow through the kidneys). Chronic renal failure, often patients have long standing HTN or DM.

Diuretics are given to increase urine output, and cardiovascular drugs are administered to treat HTN and heart failure

Spironolactone Type: Potassium-sparing diuretic/ aldosterone antagonist Uses and Effects: mild HTN good for patients who have a high risk for hypokalemia, reduces edema and sodium retention a/w CHF, nephritic syndrome, or liver disease. Short-term, preoperative treatment of primary hyperaldosteronism. Adverse Effects: hyperkalemia, muscle weakness, paresthesia, fatigue, bradycardia, flaccid paralysis of extremities, and shock. In men can cause gynecomastia, impotence, and diminished libido. In women mistral irregularities, hirsutism, and breast tenderness. Fertility may decrease during therapy. Contraindications: anuria, significant renal impairment, pregnancy, and hyperkalemia. Older patients and those with renal insufficiency or diabetes mellitus are at greater risk for hyperkalemia. Do not give to lactating pts. Drug Interactions: when combined with ammonium chloride acidosis may occur. Asprin and other salicylates may decrease the diuretic effect. When used with digoxin may decrease the effects of digoxin. With potassium supplements, ACEinhibitors, angiotensin receptor blockers or the potassium salts of other drugs severe hyperkalemia and dysrhythmias may result. Observe and report the onset of any mental changes, lethargy, or stupor in pts with liver disease. Monitor BP and asses for s/s of fluid and electrolyte imbalance

Chlorothiazide Diuril Diuretic & Antihypertensive, Short Acting. PO or IV (paranterally) Rapid onset of 1-2 hours, with a duration of action of 6-12. Thiazides act on Na+Cl symporter in the distal tubule to block Na+ reabsorption and increase K+ and water excretion. They are less effective than the loop diuretics because over 90% of the Na+ has already been reabsorbed by the time the filtrate reaches the distal tubule. Primary Indication: Mild to moderate HTN. They are not effective in patients with severe organ impairment. Chlorothiazide increases excretion of sodium and chloride in approximately equivalent amounts. Natriuresis may be accompanied by some loss of potassium and bicarbonate. Adverse effects: Dehydration and excessive loss of sodium, potassium, or chloride ions may occur with over treatment, which leads to hypokalemia and hypochloremia that can cause metabolic alkalosis. (dysrhythmias from hypokalemia) Careful monitering with digoxin to avoid dysrhythmias. Potassium supplements are sometimes prescribed. Also causes increase in blood glucose levels (and can increase serum levels of uric acid if patient has a history of gout). Serious adverse effects: Blood dyscrasias (blood containing permanent abnormal cellular elements) such as leukopenia (reduction in the # of WBC), agranulocytosis (deficiency of granulocytes causing increase vulnerability to infection), and aplastic anemia (failure of bone marrow dev. Causing deficiency of all types of blood cells). These are rare effects. Contraindications: Anuria, prior hypersensitivity to sulfonamide antibiotics. Preexisting hypovolemia or hypotention should be corrected first. Do not use on jaundiced neonates because it worsens the problem. Drug interactions: reduces effictiveness of anticoagulants, sulfonylureas, and antidiabetic drugs, including insulin. Increases risk of renal toxicity from NSAIDs. Cortocosteroids and amphotericin B increase potassium loss. Decreases the excretion of lithium and can lead to lithium toxicity. Do not use with calcium supplemts, Ginko biloba, oral aloe, hawthorn. Patient should be placed on a sodium-restricted diet of 8g or less per day. Treatment of Overdose: manifested by electrolyte depletion, treat with infusion of fluids containing electrolytes, also preventing dehydration and hypotension. Pregnancy Category B

Nursing Responsibilities: Obtain baseline serum electrolytes, CBCs, BUN, serum glucose, uric acid, CO2, and BP. Moniter I&Os. Check for edema. Effectiveness may be seen in 3-4 days, with full effects in 3-4 weeks. Provide ready access to restroom facilities. Weigh daily. Advise patient to eat potassium-rich foods daily. Teach symptoms of hypokalemia: muscle cramps or weakness. Make position changes slowly. Drug causes photosensitivity. Mannitol Type: osmotic diuretic Effects and uses: increase urine output in pts experiencing oliguria from acute renal failure. Mannitol ha d the abilitly to increase the osmolality of plasma and can reduce intracranial following head trauma. Administered concurrently with nephrotoxic drugs will speed them through the kidney to reduce damage to the walls of the renal tubules. IV onset: 1-3h 4-6hr duration

Adverse Effects: electrolyte imbalances(deficiencies or excesses) Pt may become hypovelemic or dehydrated other effects include fatigue, nausea, vomiting, dizziness, convulsions, and tachycardia. Contraindications: anuria, severe CHF, organic CNS disease or intracranial bleeding, severe dehydration, and shock. Test dose is admin. to check pts renal function( satisfactory if urine flow is at least 30 to 50 mL/h over 2 to 3 hours following test dose of 0,2 g/kg). Extreme caution should be used with pts who have high intracranial pressure. Drug Interactions: mannitol may increase the excretion of many drugs. This results in a decrease effect for drugs such as lithium, imipramine, salicylates, barbiturates, and potassium supplements.

Closely monitor serum and urine electrolytes and kidney function during therapy. do not breast feed on this med. Assess for thirst, muscle cramps or weakness, and paresthesias.

Acetazolamide Diamox Edema, antiglaucoma, PO, IV, IM Carbonic anhdrase inhibitor. Produces mild diuresis. Used to reduce edema fluid in patients with CHF. Older drug, mostly replaced by thazide diuretics. increased excretion of sodium and bicarbonate. Also used as an anticonvulsant, to treat motion sickness, and to acclimatize people to high altitudes. Efective in treating open-angle glaucoma and for pre-op acute closed-angle glaucoma (but not drug of 1st choice). Lowers intraocular pressure. Adverse effects: Various electrolyte imbalances, including hyperchlremia and hypokalemia. Nausea, vomiting, diarrhea, anorexia, dizziness, fatigue, numbness in extremities, lips, or facial muscles. Metabolic acidosis. Contraindications: hypersensitivity to sulfonamides and thiazide diuretics. Patients with severe renal or hepatic impairment and adrenocortical insufficiency. Patients with preexisting electrolyte imbalances should be treated with caution. Drug interactions: Increased risk of hypokalemia with amphotericin B and corticosteroids. Renal excretion of many drugs may be decreased. Treatment of Overdose: treat metabolic acidosis by administering sodium bicarbonate. Electrolyte depletion and dehydration treat with infusions of fluids containing electrolytes. Pregnancy Category C Nursing Responsibilities: Baseline weight and weigh daily. Moniter for symptoms of metabolic acidosis and potassium loss (greatest early in therapy).

Daily I&Os. Baseline blood pH, blood gases, urinalysis, CVBC, and serum electrolytes. Encourage plenty of fluids to avoid kidney stones. Tell patient to report numbness, tingling, burning, drowiness, visual problems, sore throat or mouth, unuaual bleeding, fever.

Beta Blockers-beta-adrenergic antagonists p.251 All beta blockers have the ability to reduce the heart rate, decrease the force of myocardial contraction, and slow conduction velocity. Primary use is to treat HTN also therapeutic applications include angina pectoris and MI, dysrthythmias, heart failure, and migraines. Decreasing the heart rate and contractility also reduces cardiac output and lower systemic b/p Caution should be taken in pts w.asthma or heart failure. Heart rate and rhythm should be monitored regularly. This drug may worsen symptoms of ED You should taper this drug off over several weeks

Hydralazine Apresoline Antihypertensive, direct vasodialator, PO, IV, IM Rapidly absorbed, widely distributed For hypertensive emergencies, especially if associated with preeclampsia, though not a drug of choice for this. For acute heart failure because drug reduces workload on the heart. Peripheral vasodialation acts directly to relax arterial smooth muscle. Decreased peripheral resistance is accompanied by an increase in heart rate and cardiac output. All Direct Vasodialators cause reflex tachycardia (compensatory increase in heart rate due to sudden decrease in blood pressure). A fixed dose combination of isosorbide dinitrate + hydralazine (BiDil) is for the treatment of heart failure in African American patients. Patients should disconue hydralazine gradually because abrupt withdrawal may cause severe rebound HTN and anxiety. Adverse effects: Headache, tachycardia, palpations, flushing, nausea, and diarrhea are common. Orthostatic hypotension, fluid retention, and peripheral edema. Those who have renal impairment or are receiving high doses of hydralazine are at risk for lupuslike syndrome. Symptoms rash, uticaria, myalgia, fever, chills, and fatigue. Blood dyscrasias are rare (serious) but possible. Contraindications: Patients with Lupus, cerebrovascular disease or rheumatic heart disease. Caution with patients with Coronary Heart Disease (CAD) because it can cause angina attacks & acute MI. Drug interactions: MAOIs, other antihypertensives, hawthorm; NSAIDs may decrease the antihypertensive action. Heart rate should be carefully monitered to avoid bradycardia. May produce a false-positive Coombs test. Treatment of Overdose: Gastric lavage, activated charcoal and administration of a plasma volume expander to raise blood pressure. Tachycardia may need beta blocker. Pregnancy Category C Nursing Responsibilities: Baseline vitals, ECG, BUN, creatine clearance, uric acid, serum K, blood glucose. Determine antinuclear antibody titer before starting therapy and periodically. Moniter I&Os in patients with renal dysfunction.

Avoid alcohol. Take with full glass of water.

Hypertension classificationClassifies by stages, based upon degree of elevation in blood pressure. Normal range: 119/79 or less No antihypertensive indicated.

Prehypertensive: 120-139/ 80-89 No antihypertensive indicated.

Stage 1 Hypertension: 140-159/ 90-99 Thiazide diuretic (for most patients) other antihypertensives as needed

Stage 2 Hypertension: 160 or higher/ 100 or higher Two-drug comb antihypertensive

People who are prehypertensive are at a greater risk for becoming hypertensive. C & S technique (specimen collection) Culture & Sensitivity Technique (specimen collection) -- The process of isolating the infectious organism and identifying the most effective antibiotic is called culture & sensitivity (C & S) testing. Ideally, the pathogen should be identified before anti-infective therapy is begun. Midstream Clean Catch Specimen is the preferred type of specimen for culture 7 sensitivity testing. First clean the urethral area. Void first portion of urine stream into the toilet. The urine midstream is collected into a clean container.

Aminoglycosides -- Effective against aerobic gram-negative organisms but have to potential to cause ototoxicity and nephrotoxicity. Considered narrow spectrum drugs because they are normally reserved for serious systemic infections . Poorly absorbed by the GI system so must be admin. by IV Resistance can occur quickly and many things have been done to increase the effectiveness of this drug, such as, admin one large does per day. Excreted primarily by the kidney Clinical applications are limited due to the drugs potentially serious adverse effects: can impair hearing and balance, nephrotoxicity, direct injury the renal tubule cells Signs of toxicity can occur several weeks after the drug was d/c Regular evaluations of urinalysis, BUN, and serum creatinine are essential.

Augmentin Combination of amoxicillin and clavulanate potassium. Amoxicillin is a penicillin antibiotic used to fight bacteria in the body. Clavulanate potassium is a form of clavulanic acid; similar to penicillin but often effective at fighting bacteria that is resistant to penicillin and other antibiotics.

Broad Spectrum, (Aminopenicillen) Adverse effects include: Rash, pruritus, diarrhea, nausea, fever, anaphylaxis symptoms including angioedema, circulatory collapse and cardiac arrest, nephrotoxicity. The above adverse effects are listed for all penicillins from the table on pg 789. Ampicillin **Unasyn contains ampicillin and beta lactamase inhibitor sulbactam (by inhibiting penicillinase, these combined agents allow a greater percentage of aminopenicillin molecules to reach pathogens and affect cell wall synthesis. Beta lactamase inhibitors are ineffective when used alone and are therefore always used in a fixed combo formulation with other drugs. Broad spectrum penicillin Effective against gram + and certain gram bacilli (haemophilus influenza, E. coli, salmonella and shigella) Pharmacologic: Cell wall inhibitor: aminopenicillin Effects & Uses: Actions similar to that of penicillin G but has broader spectrum that includes enhanced activity over < Enterococci, E.Coli, Proteus Mirabilis, Neisseria gonorrhoeae, H. influenza, salmonella, shigella and bordatella pertussis> No longer drug of choice for treatment of gonococcal infections, childhood meningitis or salmonella / shigella enteritis. Mech. Of Action: Inhibits bacterial synthesis by binding PBPs. Drug is bacteriocidal and inactivated by penicillinase Adverse Effects: Rarely produces serious adverse effects. Rash and diarrhea are most common. Diarrhea occurs more frequently with ampicillin than with other aminopenicillins. Anaphylaxis is rare though potentially fatal. Analphylactic response may include: cardio collapse, edema of the mouth, tongue, pharynx and larynx; confusion; seizure and hallucinations. Pseudomembranous coloitis is an additional rare though serious, severe adverse effect. Extremely high doses may produce confusion and seizure.

Contraindications: Pt who are allergic to any drug in the penicillin class Used cautiously in those with hypersensitivity to cephalosporins Excreted primarily by the kidneys drug therapy closely monitored in patients with renal disease. Drug Interactions: Ampicillin decreases effectiveness of OCs Probenecid (Benemid) decreases excretion of ampillin can lead to antibiotic toxicity Penicillins antagonize actions of aminoglycoside antibiotics and must be administered at least 2 hours apart Antibacterial action of ampicillin is diminished when taken concurrently with chloramphenicol, erythromycin or tetracyclines

** Should be taken on an empty stomach Preg category: B Treatment of overdose: no specific therapy available: patients are treated symptomatically Nursing Responsibilities:

Perform an infection focused physical exam (VS, WBC count). Determine baseline signs and symptoms, indicating presence of infection. Obtain history prior to drug admin. (exposure, sensitivity/ allergies, known reaction to penicillin) Hypersensitivity reaction occur more often with parenteral than oral form so monitor pt closely for 30 min after parenteral admin. Obtain and assess culture and sensitivity (blood, urine, sputum, wound drainage and other body fluids) before starting therapy. Hypersensitity reaction may occur over a period of days to weeks and needs to be closely monitored. Evaluate renal, hepatic, hematologic function at regular intervals when pt is on high dose of medication. Inject med deeply into muscle mass, rotate sites.

Patient and Family education: Take with full 8 ounce glass of water on empty stomach 1 hour before or 2 hours after meal for maximum absorption (food decreases rate and extend of oral absorption) Take med around the clock and take full med prescribed (usually 10 day course of therapy) Immediately report sever of persistent diarrhea accompanied by fever to HCP (do not attempt to treat with OTC products) Immediately report signs of allery (rash, difficulty breathing, swelling of face/ lips/ throat) Contact HCP if signs of infection do not begin to improve after a few days of therapy meds Drugs similar: Amoxicillin Route: PO, IM, IV Absorption: 0% PO Distribution: Widely distributed; only small amounts cross the BBB; secreted in breast milk; plasma protein binding about 15-20% Primary Metabolism: Largely unmetabolized, 10% hepatic Primary Excretion: Renal Onset of Action: PO 30-60 min; IM 15-30 min Duration of Action: Half life 1-2 hrs

Gentamycin Pharmacologic: Protein synthesis inhibitor: aminoglycoside Effects and Uses: Used for treatment and prophylaxis of susceptible bacterial infections (prescribed primarily for serious infections caused by eerobic, gram negative bacilli (Enterobacter, E. Coli, Klebsiella, citrobacter, pseudomonas, and Serratia). Effective against a few gram + bacteria including some strain of MRSA. No activity against anaerobes. Drug is not absorbed PO route (topical formulation is available for infection of the external eye). Therapy is usually limited to those cases where a less toxic alternative is not available. Resistance to gentamicin is increasing (some pts show cross resistance to other aminoglycosides such as tobramycin. Sometimes given concurrently with beta lactam antibiotic such as a penicillin or cephalosporin to improve bacterial kill and delay resistance. Mech. Of Action: Inhibits bacterial protein synthesis by binding to the 30S ribosomal subunit. It is bacteriocidal by causing premature termination of the growing peptide chain. Adverse Effects: Rash, N/V, and fatigue are most common. Severe: ototoxicity can produce a loss of healing or balance with may be permanent with continued use ( tinnitus, vertigo, and persistent headache are early signs) Assoc with neuromuscular blockade and may cause severe neuromuscular weakness that lasts for several days (parathesias, twitching and seizure are early signs) Signs of reduced kidney funct. Include: (oliguria, proteinuria, and elevated BUN/ creatinine levels) Nephrotoxicity is a particular concern to patients with pre-existing kidney disease and may limit pharmacotherapy

Resistance to gentamicin is increasing cross resistance among aminoglycosides

Contraindications: Patients who are sensitive to aminoglycosides Drug therapy monitored closely in those with pre existing hearing loss and impaired renal function Should not be used in pregnant of breast feeding patients Drug interactions: Concurrent use with nephrotoxic drugs such as: acyclovir, amphotericin B, capreomycin, cisplatin, cyclosporine, salicylates, polymyxin B, or vancomycin increases risk of nephrotoxicity. Ethacrynic acid and furosemide will increase risk of ototoxicity if given concurrently with gentamicin. Penicillins can inactivate aminoglycosides if mixed in the same solution. Antiemetics (dimenhydrinate, meclizine, promethazine, and scopolamine may block nausea characteristics of vestibular toxicity or motion sickness, thus masking the signs of aminoglycoside-induced ototoxicity. Pregnancy Category: D (parenteral) Treatment of Overdose: Overdose can result in serious kidney damage and ototoxicity. No specific therapy is available Nursing Responsibilities: Complete health history including (allergies, drug history, drug interaction) Perform infection focused physical exam (VS, WBC count) Obtain C&S and renal func tests prior to first dose/ intermittently throughout (repeats C&S if improvement does not occur in 3-5 days) Determine creatinine clearance and serum drug conc. at specific intervals especially for pts with impaired renal func., infants due to immaturity, the elderly, pts receiving high doses/ therapy beyond 10 days, pts with fever or extensive burns/edema/obesity. Draw blood specimens for peak serum gentamicin concentrations 30 min to 1 hour after IM administration and 30 minutes after completion of a 30- and 60- minute IV infusion. Draw blood specimens for trough levels just before the next IM or IV dose. Check vestibular and auditory function before therapy and intermittently. Recheck function again 3 to 4 weeks after the drug is discontinued because this is when deafness is most likely to occur. Assess for dizziness, headache, vertigo, nausea and vomiting with motion, ataxia and nystagmus. Damage to auditory branch may also occur as (tinnitus, fullness of ears, roaring noises, and hearing impairment). Promptly report to prevent damage! Check baseline weigh and monitor I&O ratio. Maintain adequate hydration to prevent chemical irritation to renal tubule. Report oliguria, unusual appearance of urine, change in I&O ratio or pattern, and presence of edema bc drug prolongs elimination time. Monitor signs and symptoms of bacterial overgrowth or opportunistic infections caused by resistant or non-susceptible organisms. Give IM injections deeply into large muscle Avoid use of topical preparations to large denuded body surfaces due to systemic absorption and toxicity. Wash the affected area with mild soap and water, rinse, and dry thoroughly. Apply small amount of medication to lesion, then cover with sterile gauze Patient and Family Education: Avoid direct exposure to sunlight during and for several days after therapy is terminated If exposure to sunlight cannot be avoided, wear protective clothing, sunglasses and sunscreen Do not breast feed while taking this drug without without prior approval of HCP. This drug may affect teeth in a child. Immediately report changes in hearing and low urinary output to HCP Notify the health care provider if symptoms do not improve within 3-4 days Drugs Similar: Amikacin, Kanamycin, Neomycin, paromomycin, streptomycin, tobramycin

Route: IM, IV, topical Absorption: Not absorbed PO; readily absorbed IM

Distribution: Distributed to most of the body tissues and fluids, except the CSF; concentrates in the kidneys and inner ear; crosses the placenta; small amounts secreted in breast milk Primary metabolism: Not metabolized Primary excretion: Renal Onset of Action: Rapid Duration of Action: Half-life 3-4 hours Metronidazole Nitroimidazole agent. Prototype medication for amebiasis being effective against both the intestinal and hepatic phases of the disease. Amebiasis is an infection of the intestines caused by the parasite Entamoeba histolytica. Drug of choice for giardiasis (off-label) and trichomoniasis. Antiprotozoan agent. Strong activity against anaerobic bacteria and may be given PO or IV to treat a number of serious respiratory, bone, skin and CNS infections. Topical forms (MetroGel, MetroCream, MetroLotion) are used to treat rosacea, a condition characterized by skin reddening and hyperplasia of the sebaceous glands, particularly around the nose and face. Adverse Effects: anorexia, nausea, vomiting, diarrhea, abdominal pain, dizziness, and headache. Contraindication/Precautions: Although rare, may cause bone marrow suppression. Thus it is contraindicated in patients with dyscrasias. CBCs should be monitored to prevent leucopenia. Crosses blood brain barrier so should be contraindicated in patients with CNS pathology. Discontinue if signs of CNS toxicity appear. Liver function tests should be carefully monitored in patients with alcoholism or hepatic impairment, as metronidazole is extensively metabolized in the liver. The injectable form of metronidazole contains significant amounts of sodium which can lead to edema in patients with heart failure. Drug Interactions: Concurrent administration with PO anticoagulants can potentiate hypoprothrombinemia; thus warfarin doses may require adjustment. Alcohol use may require a disulfiram like reaction. Concurrent use with disulfiram can induce acute psychosis. Including cough remedies that contain alcohol. Metronidazole may elevate lithium levels therefore doses of lithium need to be decreased to avoid toxicity. XR form should be taken on an empty stomach. Pregnancy Category B Nursing Responsibilities: Obtain complete health Hx including allergies, drug history, and possible drug interactions. Initiate infection control interventions, hand washing. Monitor other patients on the unit for symptoms of parasitic infection. Discontinue immediately and notify prescriber if CNS symptoms develop such as seizures or peripheral neuropathy as noted by numbness and paresthesia of extremities. Monitor lab tests for WBC counts before, during and after therapy. Monitor for elevated lithium levels if the patient is on lithium. Assess for SOS of sodium retention such as weight gain, swelling, or edema, especially in patients with chronic heart failure or who are taking corticosteroid therapy. Assess for candidiasis and report infection to the prescriber. Obtain repeat fecal examinations for three months to determine the effectiveness of the treatment. Patient and Family Education: Follow the therapeutic regimen exactly as prescribed by the health care provider w/o interruption or changing the dose. Refrain from sexual intercourse during therapy for trichomoniasis. Report sexual contacts to health care provider so that they may receive concurrent treatment. Asymptomatic trichomoniasis in the male may cause reinfection of the female. Avoid drinking alcohol for at least 48 hours after treatment is completed.

Note it is normal for the urine to become dark or reddish brown during therapy, especially with higher than recommended doses. Report symptoms of candidiasis such as vaginitis, milky vaginal discharge, proctitis, furry tongue, glossitis, or stomatitis. Do not breast feed w/o approval from the health care provider while taking this drug. Isoniazid - Pharamocolgic: Mycolic acid inhibitor - Effects and Uses: Prototype antituberculosis drug (superior safety profile and most effective single drug for the disease). Used exclusively for the treatment and prophylaxis of mycobacterial infections. May be used alone for chemoprophylaxis or in combination with other antituberculosis drugs for treating active disease. When used for prophylaxis, therapy may continue for as long as a year. While resistance can occur during therapy, the incidence is only about 10%. Main route of metabolism is through enzymatic acetylation in the liver. Acetylation is the general biochemical process that adds a 2 carbon chain to a drug molecule, which renders the medication less effective or allows it to be excreted more easily. Not all people acetylate at the same rate due to genetic differences. Those of Japanese and Inuit descent often have increased enzyme activity and are known as fast acetylators. Those with decreased activity slow acetylators- are most commonly of scandanavian, north African or jewish descent. The half life ranges from 70 minutes in fast acetylators to 2-5 hrs in slow. Drug is safe across a wide range of doses and variations do not result in toxicity. Doses should be lowered in those who are slow acetylators to avoid adverse effects and increased in those who are fast to keep plasma levels consistently within therapeutic range. Dosage reductions should occur in pts with significant hepatic impairment because of diminished acetylation. Mech. Of Action : Acts by inhibiting the synthesis of mycolic acid, an essential component of mycobacteria. Because mycolic acids are unique to mycobacteria, isoniazid has no activity for other microbial species. It is bacteriocidal for rapidly dividing organisms but bacteriostatic for dormant mycobacteria. Adverse Effects: Few adverse effects (major reason why tit is a drug of choice for mycobacterial infections). Neurotoxicity is a concern during therapy and patients may exhibit paresthesia of the feet and hands, convulsions, optic neuritis, dizziness, coma, memory loss and various psychoses. Major factor responsible for neurotoxicity is the ability of the drug to cause a deficiency of activated pyridoxine (vit B6) which is required for synthesis of the neurotransmitter gamma aminobutyric acide (GABA). Pyridoxine is usually prescribed during isoniazid therapy to prevent the development of peripheral neuropathy. Pyridoxine is considered the antidote for reversing acute nervous system effects of isoniazid overdose. Common adverse effects are rash and fever. Although rare, hepatotoxicity is a serious and sometimes fatal adverse effect; thus pt should be monitored carefully for jaundice, fatigue, elevated hepatic enzymes or loss of appetite. Liver enzyme tests are usually performed monthly to identify early hepatotoxicity (usually appears in the first 1-3 months of therapy but may occur at any time during treatment). Older adults at greatest risk for developing hepatoxicity. Blood dyscrasias such as granulocytosis and aplastic anemia may occur, although they are uncommon. Contraindications: No absolute contraindication other than previous allergy to drug. Therapy is monitored closely in patients with a history of chronic hepatic disease bc the liver metabolizes the drug and fatal hepatitis has been reported. Serum aspartate transaminase (AST) levels should be monitored regularly for high risk pts. (If AST levels rise to 3 times the baseline levels, liver damage is likely and isoniazid should be discontinued. Pts with renal failure require lower doses because kidneys excrete the drug. Pts with seizure disorder should be carefully monitored bc this drug can increase the risk of seizure activity (pt with seizure history will usually receive pyridoxine during therapy) Drug Interactions:

Isoniazid is a potent inhibitor of the hepatic metabolic enzymes (CYP2C19 and CYP3A4) and is assoc. with numerous drug interactions. Before adding additional drugs, nurse should consult a drug guide for potential interactions. Aluminum containing antacids should not be administered concurrently bc they decrease absorption of iso. Disulfiram can create lack of coordination or severe psychotic reactions with taken with iso. Ethanol use should be avoided due to increase risk of hepatotoxicity Iso inhibits the metabolic breakdown of phenytoin which may cause anticonvulsant to build to toxic levels, an effect that occurs more often in slow acetylators. Iso can increase serum levels of carbomezapine and cause carbomezapine toxicity. Food decreases absorption

Pregnancy Category: C Treatment of Overdose: Iso overdose may be fatal and treatment is mostly symptomatic. Pyridoxine may be infused in a dose equal to that of iso to prevent seizures and to correct metabolic acidosis. Dose may be repeated several times until pt regains consciousness. Nursing Responsibilities: Obtain health history (allergies, drug history, possible drug interactions) Assess for presence / history of: positive TB skin test, positive sputum culture / smear, immunosuppressant drug therapy, alcohol abuse, liver or kidney disease, close contact with person recently infected with TB, HIV, or AIDS Assess pts ability to adhere to long term medication therapy Initiate drug therapy after C&S test to determine possible bacterial resistance Monitor serum drug levels (remember the inactivation of iso. is genetically determined) Be aware that slow inactivation leads to high plasma drug levels and increased risk of toxicity. Monitor hepatic func throughout. Isoniazid hepatitis can be fatal (especially in pts 35 or older who ingest alcohol daily). Usually develops within first 3-6 months but can develop at anytime. Administer pyridoxine (vit b6) supplementation (10-50 mg). Isoniazid induced pyridoxine depletion results in neurotoxic effects such as peripheral neuropathy. Monitor BP during period of dosage adjustment to prevent orthostatic hypotension during position change Monitor serum levels in pts with diabetes. Loss of glycemic control can occur due to drug therapy. Monitor therapeutic effectiveness (may be observed within the first 2-3 weeks of initiating therapy). 90% of patients have negative sputum culture but the 6th month. Patient and Family Education: Continue therapy until all doses are taken. Infection may worsen if directions are not followed correctly. If allergic reaction occurs (usually within first 3-7 weeks) discontinue immediately and report to HCP. Discontinue medication and report: dark urine, jaundice, clay colored stool (symptoms may indicate possible liver toxicity) Avoid tyramine containing foods such as: aged cheeses and smoked fish (these foods cause flushing, palpation and BP elevation. Avoid histamine containing foods such as: tuna, sauerkraut in juice, and yeast extracts. Foods may result in an exaggerated drug reaction such as headache, sweating, itching, flushing, hypotension, palpitation, or diarrhea. Avoid alcohol increased risk of liver toxicity Do not breast feed while taking this drug Keep all appts for follow up care because relapse can occur Drugs Similar to Isoniazid: Rifampin, Rifapentine, pyrazinamide, ethambutol, combination agents of these.

Route: PO, IM (only is PO is unavailable) Absorption: Readily absorbed Distribution: Widely distributed (can even enter the necrotic lung tubercles that are characteristic of TB); crosses the placenta, enters the CNS, secreted in breast milk; about 60% bound to plasma proteins Primary metabolism: metabolized by acetylation in the liver

Primary excretion: Renal (75%) Onset of action: Rapid Duration of Action: Half-life 1-4 hours Leprosy treatment Cronic infection caused by M. leprae. Rare in the US. 6 million worldwide. Presents with macular skin lesions that can become large. Organism invades peripheral nervous tissue, causing nerve thickening that results in loss of sensation or paresthesia. If left untreated, infection causes extreme disfigurement and bone resorption, resulting in loss of digits. Diagnosed by skin biopsy. May be infectious or noninfectious, depending on stage of disease. Mode of transmission unclear. Likely spread by respiratory route. May have very long incubation period, months to years. Two presentations of Leprosy: Lepromatous leprosy: patient with defective cell-mediated immunity, slow progressive development of nodular skin lesions and nerve involvement. Because patient has impaired immune system, the mycobacteria may disseminate through the body and cause death. Initial 3 drug regimen: dapsone, clofazimine (Lamprene), and rifampin (Rifadin) given for 2-5 years. Tuberculoid leprosy: less progressive and may have long periods of remission followed by reactivation with more severe nerve involvement; patient has intact cell-mediated immune response so disease is more benign and less often fatal. Initial 2-drug regimen: dapsone and rifampin for 6-12 mo., followed by dapsone alone for 2-3 years. Substitute antibacterials if patient intolerant of above: Ofloxcin, clarithromycin, minocycline During first year of therapy, skin lesions may actually worsen because of immune response. Edema and new lesions may appear on normal skin because immune cells are attacking antigens released by the mycobacteria. If this happens, corticosteroids such as predinisone are added to reduce the severe inflammation. Patients are examined monthly. Follow up may continue for several ears after completion of pharmacotherapy. Close contacts of leprosy patients normally do not receive chemoprophylaxis, though they will need follow up examinations to ensure they have not acquired the infection. Drug of choice: Dapsone (DDS), antileprosy. Inhibits folic acid metabolism. PO. Adverse Effects: Dose-related hemolysis and methemoglobinemia with cyanosis. Toxic hepatitis has been reported. Drug concentrates in the skin, causing reactions including photosensitivity and toxic epidermal necrolysis. Colicky abdominal pain, nausea, and vomiting. Drowsiness and dizziness. Serious Adverse effects: GI bleeding, bone and joint pain, dimished vision. Contraindications: Hypersensitivy to sulfonamides; caution with patients with preexisting blood disorders. Frequent blood assessments conducted, as well as liver enzyme testing to watch for hepatoxicity. Drug interactions: Rifampin and St. Johns wort decrease levels of dapsone. Pregnancy Category C Treatment of Overdose: Acute overdose may result in cyanosis, treated by slow IV administration of 1-2 mg/kg of methylene blue. Nursing Responsibilities: Lab tests, white blood count (WBC), serum electrolytes, albumin and liver function. Assess for reddish-brown discoloration of skin, cornea, conjunctiva, and body fluids. This adverse effect occurs in 75-90% of patients within a few weeks of treatment. Minimize use of soap; rinse thoroughly, especially if skin is dry. Immediately report changes in vision or hearing, dark urine, unusual fatigue, unusual bruising or bleeding, bluish fingernails, or yellowing of the eyes or skin. Mycobacterium Avium Complex treatment

Mycobacterium Avium Complex infections are common in patients with impaired immune function. MAC is the most common cause of lung disease due to atypical mycobacterial infections MAC is an expected complication in patients with AIDS. Found in higher incidences in patients with COPD. The infection is caused by M. avium, M.intracellulare, or a combination of atypical mycobacteria. Treatment of MAC should include two drugs (and often three or four) because monotherapy has been shown to promote the emergence of resistant strains. Treatment is prolonged and relapse rates for treating pulmonary MAC approach 20%. Drugs for MAC include: Macrolide antibiotics (clarithromycin and azithromycin). Ethambutol (Myambutol) used for TB. Rifabutin (Mycobutin) This is effective if a third drug is needed. Griseofulvin Fulvicin. Antifungal; disrupts microtubule aggregation during mitosis. PO only, because it cannot penetrate the deeper skin levels. Deposited in keratin where it protects against fungal invasion. Once entering the fungal cell, inhibits mitosis, preventing replication.

Oral therapy for inflammatory lesions. Severe cases of tinia corporis (ringworm) that occurs in the groin, perineum, and perianal region; tinia pedis (the most common dermatomycosis, athlete's foot), tinia cruris (jock itch), and tinea capitis, involving the hair, eyebrows or eyelashes (primarily affecting children 4-14 yo). Trichophyton (genus of fungi that cause various infections of the skin, hair and nails. It utilizes keratin as a source of nourishment) is responsible for more than 90% of cases.

Typical regimen: 10 mg/day for 8-10 weeks. To reduce GI adverse effects and increase its bioavailability, it is available as a microsize particles (Grisfulvin V) and ultramicrosize particles (Gris-PEG). Grifulvin V is 25-70% absorbed. Gris-PEG is almost 100% absorbed. Side Effects: headache; Rare side effects of hepatitis and neutropenia with prolonged therapy. Pregnancy Category C Greater relapse rate than other superficial antifungals. You should not use if you are allergic to it (wheezing, itching, swelling, SOB), or if you have liver failure, porphyria, or if you are pregnant. Caution for patients with liver disease, heart disease, lupus, or allergy to penicillin. Avoid exposure to sunlight or tanning beds. Drinking alcohol can increase certain side effects of griseofulvin. Human Growth Hormone (HgH) GH is produced and secreted by the anterior pituitary gland. Major targets are bone and skeletal muscle. GH stimulates many types of cells to increase in size and replicate. Anabolic hormone. Increases the length and width of bone. Stimulates cartilage growth. Stimulates growth and development of visceral and endocrine organs, skeletal and cardiac muscle, and skin and connective tissue. Enhances cellular uptake of amino acids and increased protein synthesis. Increases use of fatty acids for fuel with decreased use of glucose; impairs glucose tolerance and insulin resistance in peripheral tissues. Many effects of GH are dependent upon IGF (insulin-like growth factor) produced in the liver. Regulation of serum GH levels resides in the hypothalamus with secretions of GHRH and GHIH. Exercise and sleep influence release of GH. In children GH deficiency results in dwarfism.

Adult GH deficiency is associated with reduced muscle mass, increased muscle mass, increased cardiovascular mortality, central adiposity and increased visceral fat, insulin resistance and dyslipidemia.

Lispro Insulin Humalog. Rapid acting; Onset 5-15 min; PEAK: 1-1.5 hrs; Duration 3-4 hrs; SubQ 5-10 min. before meal or right after; can be given with NPH draw lispro up first and give immediately. Clear color. Purpose is to help control rise in blood glucose brought on by meal; normally given with intermediate or long-acting agent that provides a basal coverage of insulin. Does not require mixing. Cannot be given IV. Often used with insulin infusion pumps. Antihypertensive monitoring (general) Theraputic lifestyle changes recommended for all patients with hypertension. Maintaining optimum weight is priority. 10-20lb weight loss produces measurable decrease in BP, even inobese patients. Weight loss may eliminate the need for meds. Non-pharmacologic methods for controlling HTN: Limit alcohol Restrict sodium Reduce fat & cholesterol, increase consumption of fruits and veg. Increase aerobic activity Discontinue tobacco Deal with stress Maintain optimum weight Pharmacologic mgt of HTN is individualized to the patients risk factors, comorbid conditions, and degree of BP elevation. The JNC-7 report recommends thiazide diuretics as drugs of choice for mild to moderate HTN. Patients may benefit from a second drug in combination with or to replace. There are 9 different drug classes for HTN. In most cases, low doses of the initial drug are prescribed and the patient is reevaluated after an appropriate time period. As therapy continues, dosage is adjusted to maintain optimum BP. The following drug classes are considered primary antihypertensive agents: Diuretics Antiotensin-converting enzyme (ACE) inhibitors Angiotensin II receptor blockers (ARBs) Calcium channel blockers (CCBs) Beta-adrenergic antagonists If a patient doesnt respond to the initial medication, a drug from a different antihypertensive class may be added. Additive/synergistic. Especially if BP is particularly high. Advantage is lower doses of each, resulting in fewer adverse effects and better patient adherence. They may be combined into a single pill. Alternative antihypertensive drug classes: Alpha1-adrenergic antagonists Alpha2-adrenergic agonists Direct-acting vasodialators Peripheral adrenergic antagonists African Americans have a significantly higher incidence of HTN. An aggressive antihypertensive therapy may be necessary. Thiazide diuretics and CCBs seem to provide the greatest BP reduction in this population. Hypoglycemia Def- abnormally low serum glucose (Normal serum glucose, 60-100mg) Causes Metabolic acidosis Too much insulin Uncontrolled DM Failure to eat at regular intervals Increased exercise Medication adjustments

Oral antidiabetic agents Changes in the insulin injection site Alcohol consumption (by decreasing gluconeogenisis)

S/S Pallor, cold clammy skin, increased pulse, headache, tremors, blurred vision; because the brain relies on continuous supply of glucose, falling levels may lead to headache, difficulty concentrating, confusion, behavior changes, leading to seizures and coma. The body tries to increase the level by the release of catecholamines (epinephrine and norepinephrine). This causes tachycardia, anxiety, sweating, and the constriction of surface vessels, leading to cool, clammy skin. Can lead to brain damage or death. Very rapid onset.

Patients who have had diabetes a long time may develop hypoglycemic unawareness (the inability to recognize symptoms) Beta-adrenergic blockers interfere with sympathetic symptoms of hypoglycemia, making it difficult to recognize symptoms and for the body to correct the low glucose levels. Treatment: Always glucose (15-20 g); if unconscious, gel or spray to buccal mucosa; IV immediately effective. Alternative therapy is glucagon (which increases glycogenolysis, making actions dependent on presence of adequate liver glycogen stores).