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NURS 3307: Nursing Pharmacology

Exam 4 Blueprint – Spring 2018


UNIT OBJECTIVES #

Cardiac Glycosides, Antianginals, 8


& Antidysrhythmics

Differentiate the actions of cardiac glycosides, antianginal drugs, and


antidysrhythmic drugs

Describe the signs and symptoms of digitalis toxicity

Compare the side effects and adverse reactions of nitrates, beta


blockers, calcium channel blockers, quinidine, and procainamide

Apply the nursing process, including patient teaching, related to


cardiac glycosides, antianginal drugs, and antidysrhythmic drugs

Diuretics 6
Compare the action and uses of thiazide, loop, and potassium-sparing
diuretics

Differentiate side effects and adverse reactions related to thiazide,


loop, and potassium-sparing diuretics

Explain the nursing interventions, including patient teaching, related to


thiazide, loop, and potassium-sparing diuretics

Apply the nursing process for the patient taking thiazide, loop, and
potassium-sparing diuretics

Antihypertensives 8

Differentiate the pharmacologic action of the various categories of


antihypertensive drugs

Compare the side effects and adverse reactions to sympatholytics,


direct-acting vasodilators, and angiotensin antagonists

Apply the nursing process related to antihypertensives including


nursing interventions and teaching

Describe the blood pressure guidelines for determining hypertension

Anticoagulants, Antiplatelets, 6
Thrombolytics

Compare the actions of anticoagulants, antiplatelets, and thrombolytics


Discuss the laboratory tests used to determine the therapeutic range of
anticoagulants differentiating between heparin and warfarin

Differentiate the side effects and adverse reactions of anticoagulants,


antiplatelets, and thrombolytics

Apply the nursing process, including patient teaching, for


anticoagulants and thrombolytics

Antihyperlipidemics 5
Describe the action of the two main drug groups: antihyperlipidemics
and drugs that improve peripheral blood flow

Compare the side effects and adverse reactions of antihyperlipidemics

Differentiate the side effects and adverse reactions of peripheral


vasodilators and blood viscosity reducer agents

Apply the nursing process, including patient teaching, for


antihyperlipidemics and blood viscosity reducer agents

Antipsychotics & Anxiolytics 6

Differentiate between antipsychotic and anxiolytic drug groups

Contrast the action, uses, side effects, and adverse effects of


traditional typical and atypical antipsychotics

Apply the nursing process to the patient taking an atypical


antipsychotic, a typical antipsychotic, and an anxiolytic

Antidepressants & Mood 6


Stabilizers

Contrast the various categories of different antidepressants

Apply the nursing process, including patient teaching, for


antidepressants (tricyclic antidepressants (TCAs), monoamine oxidase
inhibitors (MAOIs), selective serotonin reuptake inhibitors (SSRIs),
serotonin norepinephrine reuptake inhibitors (SNRIs), and atypical
antidepressants)

Explain the uses of lithium and its serum/plasma therapeutic ranges,


side effects and adverse reactions, and nursing interventions

Apply the nursing process to the patient taking lithium

Dosage Calculations 5

TOTAL 50
Ch 37-Cardiac Glycosides, Antianginals, & Antidysrhythmics: 8
Differentiate the actions of cardiac glycosides, antianginal drugs, and antidysrhythmic drugs.
Cardiac Glycosides
Digoxin/Digitalis
● Inhibits Na+/K+ pump → increase in intracellular Na+ → influx of Ca+ causes cardiac
muscle to contract more efficiently
● Positive inotropic: increases myocardial contraction (SV)
Negative chronotropic: decreases HR
Negative dromotropic: decreases conduction of heart cells
● Overall increases force/velocity of myocardial systolic contraction
● Corrects atrial fibrillation and atrial flutter; secondary drug for heart failure
● Therapeutic serum level (NARROW)
○ Dysrhythmias: 0.8-2.0 ng/mL
○ Heart failure: 0.5-1.0 ng/mL
● Potent diuretics (furosemide/hydrochlorothiazide) promote K+ loss → hypokalemia
increases effect of digoxin → digitalis toxicity
● Cortisones and antacids also can lead to hypokalemia
● Antidote for digitalis toxicity: Digoxin-immune Fab--only give if severe/life threatening
(may cause anaphylaxis)
Phosphodiesterase Inhibitors
● Positive inotropic response/vasodilation
● Milrinone Lactate: increase SV and CO/promotes vasodilation. HIGH ALERT
medication-causes harm when given inappropriately. Given IV over 48-72 hrs
Other drugs for HF
● Vasodilators, ACE Inhibitors, angiotensin II-receptor antagonists, diuretics (thiazides,
furosemide), spironolactone, some beta blockers
-Nonpharmacological measures to treat HF: limit salt intake, avoid alcohol/smoking, decrease
saturated fat intake, fluid intake may be restricted. Mild exercise recommended.
-ANH​: 20-77 ng/L
-BNP:​ <100 pg/mL
Antianginals
● Treat anginal pain: tightness, pressure in center of chest, pain radiating down left arm
● Increase blood flow: increase oxygen supply or decrease oxygen demand by
myocardium
● Classic (stable) angina​: predictable stress/exertion
Unstable (preinfarction) angina​: occurs frequently with progressive severity unrelated to
activity. Unpredictable. Emergency situation
Variant angina​: occurs during rest. Caused by vasospasm
● Classic & unstable: caused by narrowing/partial occlusion of coronary arteries
● Common for patient to have both classic and variant
● Nonpharm measures to decrease anginal attacks: Avoid-- heavy meals and smoking,
extreme weather changes, emotional upset. Moderate exercise may help.
Nitrates
● Vascular/coronary vasodilation
● Reduces myocardial ischemia
● Sublingual nitroglycerin: most commonly used nitrate-effects last 30 to 60 minutes.
● Others (long-acting): isosorbide dintrate, isosorbide mononitrate
● Ointment—only effective for 4-8 hrs. Patch—once daily
● Use for unstable and variant
Beta Blockers
● Block action of epinephrine/norepinephrine → decrease HR/BP. Most useful for stable
angina
● The -olol group
Calcium Channel Blockers
● Treat variant and stable angina
● Diltiazem, verapamil and the -pines
● Frequently given w/ nitrates
Antidysrhythmics
● Restore cardiac rhythym to normal
● Sodium Channel blockers-ventricular
○ Procainamide (used for CPR), lidocaine, mexiletine
● Beta Blockers-atrial and ventricular
○ -olols
○ Decrease HR/BP
○ More frequently prescribed than Na+ blockers
● Drugs that prolong repolarization-ventricular
○ Adenosine, amiodarone (stops your heart), dofetilide, ibutilide
○ Emergency treatment of ventricular dysrhythmias other antidysrhythmics are
ineffective
● Calcium Channel Blockers-atrial
○ Verapamil (CI for pt w/ AV block or HF)
○ Diltiazem
○ Negative inotropic action
○ For dysrhythmias and hypertension
○ Relax arteries

Describe the signs and symptoms of digitalis toxicity.


● Bradycardia- pulse rate below 60/min
● Premature ventricular contractions
● Cardiac dysrhythmias
● Headaches, anorexia, nausea, vomiting
● Malaise
● Blurred vision, visual illusions (white, green, yellow halos around objects)
● Confusion and Delirium
● Older adults more prone
Compare the side effects and adverse reactions of nitrates, beta blockers, calcium channel
blockers, quinidine, and procainamide.
● Nitrates SE​: most common is headache (use Acetaminophen). Others: hypotension,
dizziness, weakness, fainting, tachycardia
○ Patches and ointment dose should be tapered to prevent myocardial ischemia
○ Ointment: don’t place where you may need to put defibrillator (explosive)
○ If nitro is given too rapidly, reflex tachycardia may occur
○ IV nitroglycerin may block effects of heparin
○ Store original container safely--not childproof
● Beta blockers SE:​ Bronchospasm, behavioral, psychotic response, hypotension,
hypoglycemia, dosage should be tapered for reflex tachycardia or cardiac dysrhythmias
● Calcium Blockers SE:​ Headache, hypotension, dizziness, flushing of the skin, reflex
tachycardia, peripheral edema, liver and kidney functions can change (check liver
enzymes)
● Quinidine SE​: can cause heart block, neurologic/psychiatric symptoms, nausea/vomiting,
palpitations, rash, dizziness, diarrhea, confusion, hypotension
● Procainamide SE:​ GI upset and hypotension. Less SE/cardiac depression than
Quinidine

Apply the nursing process, including patient teaching, related to cardiac glycosides, antianginal
drugs, and antidysrhythmic drugs.
● Glycosides​:
○ Check pulse rate with apical pulse for a full min-should be greater than 60
beats/min--DO NOT administer Digoxin if pulse is below 60
○ Monitor serum digoxin level 0.8-2 ng/ml and K+ levels 3.5-5 (report hypokalemia)
○ Eat foods high in K+
● Antianginals​:
○ Nitro​:
■ Give water before SL nitrates—dryness prevents correct absorption
■ Patient lying/sitting down when administering.
■ Use gloves when using ointment form.
■ Apply patches/rotate skins sites. Avoid hairy areas.
■ Store drug away from light, heat, and needs to be airtight--not childproof
■ If hypotension occurs, put pt in supine position w/ legs elevated
■ If pain does not get better in 5 min call 911
■ Avoid alcohol
■ Report if chest pain not alleviated (possible tolerance)
● Antidysrhythmics:
○ Monitor vital sign and get a baseline
○ Administer drug by IV push or bolus over a period of 2-3 min
○ Avoid, Caffeine, Alcohol, and tobacco
○ Usually only used during continuous cardiac monitoring in hospital setting
Ch 38-Diuretics: 6
● Two main purposes: to decrease hypertension and decrease edema in HF, renal or liver
disorders.
● Antihypertensive effect through Na+ and water loss
● 5 categories: Thiazide/thiazide-like, loop/high-ceiling, osmotic, carbonic anhydrase
inhibitors, potassium-sparing
● All diuretics are K+ wasting (except K+ sparing)
● Hypertension: BP greater than 140/90 mmHg

Compare the action and uses of thiazide, loop and potassium-sparing diuretics.
Thiazides
● Chlorothiazide--first thiazide
● Hydrochlorothiazide--prototype drug.
● Mild diuretics—​treat hypertension/peripheral edema
● Thiazides act on the distal convoluted renal tubule → promote Sodium, Chloride, and
water excretion.
● Not effective for immediate diuresis/don’t use in patients with severe renal dysfunction.
● Used primarily for patients with normal renal function.
● Promotes Ca+ reabsorption
● Hypercalcemia, hypokalemia, and hyperglycemia (caution w/ diabetes) can occur
● Hypercalcemia and hypokalemia → digitalis toxicity.
● Often combined with other drugs.
● Administer in the morning to prevent nocturia
● Divided into three categories: short-acting (less than 12 hours), intermediate acting
(12-24), and long-acting (greater than 24 hours)
Loop:
● Inhibit sodium reabsorption
● Can cause hypokalemia
● Can affect blood sugar and increase uric acid levels
● Extremely potent and may cause depletion of water and electrolytes
● Less effective as antihypertensive agents. Should not be prescribed if a thiazide can
alleviate body fluid excess.
● Furosemide​ is usually administered orally in the morning or IV when immediate removal
of body fluid needs to happen in case of acute heart failure or pulmonary edema.
● Used with end stage renal failure or if creatinine clearance is less than 30/min.
● Furosemide and bumetanide are derivatives of sulfonamides.
● Ethacrynic acid is a phenoxyacetic acid and is reserved for patients allergic to sulfa
drugs.
● Highly protein bound
● Used when other conservative measures, such as sodium restriction and use of less
potent diuretics, fail.
Potassium-sparing diuretics:
● Weaker than thiazides and loop diuretics. Used as mild diuretics or in combination with
other diuretics.
● Watch for hyperkalemia >5.3 mEq/L
● Act on the distal tubule and sodium-potassium pumps.
● Spironolactone​- blocks aldosterone and inhibits the sodium-potassium pump, effects
may take 48 hours, heart rate is more regular and the possibility of myocardial fibrosis is
decreased.
● Amiloride, triamterene-effective antihypertensive agents.
● Triamterene is useful in the treatment of edema caused by HF or cirrhosis of the liver.
● Spironolactone and eplerenone are effective for chronic HF.
● Don’t take with ACE inhibitors, angiotensin II blockers (ARBs) because they can
increase potassium levels.
● Common diuretics contain a potassium-sparing diuretic with hydrochlorothiazide.

Differentiate side effects and adverse reactions related to thiazide, loop and potassium-sparing
diuretics.
Thiazide SE:
● Hypokalemia, ​hypercalcemia​, hypomagnesemia, and bicarbonate loss (watch for digitalis
toxicity)
● Hyperglycemia, hyperuricemia, hyperlipidemia
● Other side effects include GI, hives (urticaria), blood dyscrasias, dizziness, headaches
Loop SE:
● Fluid and electrolyte imbalances result (hypo everything)
● Hypochloremic metabolic alkalosis may result, which can worsen hypokalemia
● Orthostatic hypotension
Potassium-sparing SE:
● Hyperkalemia, GI disturbances, and tingling of hands and feet can occur
● Watch for kidney function, urine output should be at least 600 mL/day
● If given with ACE inhibitors the likelihood of hyperkalemia is increased.

Explain the nursing interventions, including patient teaching, related to thiazide, loop, and
potassium-sparing diuretics.
Thiazide:
Assessment-
● Electrolytes (hypokalemia), glucose, and uric acid
● Check for pitting edema
Interventions-
● Monitor weight
● Digoxin toxicity with hypokalemia
● Signs of hypokalemia
● Note urine output
Teaching-
● Take hydrochlorothiazide in the morning to avoid sleep disturbance from nocturia
● Change positions slowly (orthostatic hypotension)
● Large doses can cause hyperglycemia
● Eat foods rich in potassium
● Take drugs with food to avoid GI upset.
Loop:
Assessment-
● Obtain drug history, ​furosemide is highly protein-bound and can displace other
protein-bound drugs such as warfarin.
● Note if patient is hypersensitive to sulfonamides.
Interventions-
● Urinary output should be at least 30 mL/h or 600 mL/24h
● Notify health care provider if urine output does not increase. Renal disorder may be
present
● Watch for drop in BP
● Administer IV furosemide slowly; hearing loss may occur if rapidly injected
● Watch for hypokalemia
Teaching-
● Take furosemide in the morning to avoid nocturia
● Arise slowly to avoid orthostatic hypotension
● Take with food to avoid nausea
Potassium-sparing:
Assessment-
● Note whether patient is taking potassium supplement or using a salt substitute
● Get vital signs, etc
Interventions-
● Because of long half-life spironolactone is usually administered once a day
● Monitor urine output, report if urine is < 30mL/h or <600 mL/h
● Watch for hypokalemia
● Administer spironolactone in the morning to avoid nocturia
Teaching-
● Take with meals
● Avoid exposure to direct sunlight, because drug can cause photosensitivity
● Avoid foods rich in potassium

Ch 39-Antihypertensives: 8
Differentiate the pharmacologic action of the various categories of antihypertensive drugs.
-Biggest SE is orthostatic hypotension
-Nonpharmacologic control of hypertension:
-stress-reduction techniques, exercise, salt restriction, decreased alcohol & smoking
-Often more than one AH is used → fewer adverse effects
Diuretics
● They promote sodium depletion
● First line drugs to treat mild hypertension--hydrochlorothiazide=most frequently
prescribed
● Diuretics are usually prescribed together with antihypertensive agents because many of
them cause fluid retention
● Loop diuretics:​ usually recommended--does not depress renal blood flow
○ However don’t use if hypertension has RAAS involvement- they tend to elevate
the serum renin level immediately
● A combination of potassium wasting and potassium sparing diuretics should be useful
instead of a single thiazide drug--combination intensifies diuretic effect and prevents
potassium loss
● Thiazides can be combined with other AH drugs to increase effect
Sympatholytics (Sympathetic Depressants)
-halts fight or flight
● Beta adrenergic blockers:
○ May be used in combo w/ diuretic
○ Lowers BP/HR
○ Higher renin levels=greater hypotensive response
○ African Americans--must combine BB w/ diuretics
○ Cardio-selective BB preferred: act on B1 and lessen chance of
bronchoconstriction
○ Use w/ caution for pulmonary disease and preexisting bronchospasm
○ Lowers BP in pt with elevated renin level
● Centrally acting Alpha 2 Agonists
○ Decrease sympathetic activity
○ Vasodilation
○ Methyldopa, clonidine (avoid if pregnant)--given w/ diuretics
○ Guanfacine-- rebound hypertension less likely
● Alpha-Adrenergic Blockers
○ -zosin
○ Vasodilation, decreased BP
○ Useful for lipid abnormalities
○ Decrease VLDL and LDL
○ Safe for diabetes and don’t affect respiratory function
○ Can treat BPH
○ Prazosin= commonly prescribed
○ Terazosin, doxazosin normally given once at bedtime
○ Can cause edema
● Adrenergic Neuron Blockers (peripherally acting)
○ POTENT
○ Decrease in norepi
○ Reserpine=most potent, used for severe hypertension.
○ Last choice for chronic hypertension bc of ortho hypo
● Alpha1 and Beta1 Blockers
○ Labetolol
○ Alpha effect is stronger than beta- BP lowered and pulse rate is moderately
decreased
Direct-Acting Arteriolar Vasodilators
● POTENT
● BP decrease
● BB frequently prescribed with these
● Hydralazine, minoxidil
● Nitroprusside​: acute hypertensive emergency--very potent and rapid BP decrease
Angiotensin-Converting Enzyme Inhibitors (ACE)
● Inhibits angiotensin II (vasoconstrictor) and blocks aldosterone
● -pril
● African Americans and older adults don’t respond to these unless taken w/ diuretic
Angiotensin II Receptor Blockers (ARBs)
● Prevent release of aldosterone
● Vasodilation
● -sartan
● Valsartan: prototype--watch for hyperkalemia & rhabdomyolysis
Direct Renin Inhibitors
● Aliskiren
● Mild and moderate hypertension
● Not given to blacks
Calcium Channel Blockers
● Vasodilation
● Can use for blacks
● Verapamil, diltiazem, and -pines
● Reflex tachycardia prevalent with nifedipine--only use in hospital
Miscellaneous:
-​Beta blockers & ACE inhibitors--less effective for African Americans--use Alpha 1 blockers &
Calcium blockers
-African Americans don’t respond well to diuretics
-Asians twice as sensitive as white to beta blockers
Compare the side effects and adverse reactions to sympatholytics, direct-acting vasodilators,
and angiotensin antagonists.
Sympatholytics SE:
● Beta blockers:
○ Decreased pulse rate, decreased BP, bronchospasm.
○ Can also cause bradycardia, dizzy, insomnia, depression, fatigue, nightmares,
sexual dysfunction
○ Don’t abruptly stop → rebound hypertension, angina, dysrhythmias, MI
○ Use caution w/ diabetes mellitus → possible hypoglycemic symptoms
● Centrally acting Alpha 2 Agonists:
○ Don’t give with BB → bradycardia, rebound hypertension upon discontinuation
○ Drowsiness, dry mouth, dizzy, bradycardia
○ Methyldopa CI for impaired liver function, but used during pregnancy
○ Sodium/water retention=peripheral edema
● Alpha-Adrenergic Blockers:
○ Ortho hypo, nausea, headache, drowsy, nasal congestion from vasodilation,
edema, weight gain
● Adrenergic Neuron Blockers (peripherally acting):
○ Reserpine: ​Causes ortho hypo, vivid dreams, nightmares, suicidal ideation
● Alpha1 and Beta1 Blockers
○ Large doses increase airway resistance
○ Large doses CI for severe asthma
○ Ortho hypo, GI upset, nervousness, dry mouth, fatigue
○ Large doses of labetolol may cause AV heart block
Direct-Acting Arteriolar Vasodilators SE:
● Reflex tachycardia
● Hydralizine: reflex tachycardia, palpitations, edema, nasal congestion, lupus-like
symptoms, neurologic symptoms
● Minoxidil: similar, plus excess hair growth
Angiotensin-Converting Enzyme Inhibitors (ACE) SE:
● Constant, unproductive, irritated cough
● Hyperkalemia, tachycardia, first-dose hypotension
● Angioedema (higher incidence in blacks)
● Laryngeal edema--rescue epi
Calcium Channel Blockers
● Flushing, headache, dizzy, ankle edema, bradycardia, AV block
Apply the nursing process related to antihypertensives including nursing interventions and
teaching.
Diuretics
● Loop:​ most common SE- fluid/elec imbalances (hypokalemia, hyponatremia,
hypocalcemia, hypomagnesemia, hypochloremia). Pulls all electrolytes out.
○ Hypochloremic metabolic alkalosis may result which worsens hypokalemia
○ Orthostatic hypotension
○ Transient deafness if pushed too fast (Furosemide)
○ Thrombocytopenia & skin disturbances also rare
○ Digitalis toxicity if taken with digoxin
○ Need potassium replacement (food/supplements)--monitor levels
○ Observe for hypokalemia
Sympatholytics
● Centrally acting Alpha 2 Agonists:
○ Don’t abruptly stop=rebound hypertensive crisis
● Alpha-Adrenergic Blockers:
○ Do not take with antiinflammatories or nitrates → peripheral edema and faintness
can occur
○ Water retention--monitor weight gain
Direct-Acting Arteriolar Vasodilators
● Edema
Angiotensin-Converting Enzyme Inhibitors (ACE)
● Don’t give during pregnancy
● Give with food except for moexipril
● Don’t take with potassium sparing diuretics or w/ salt substitutes that contain potassium
(hyperkalemia)
● Monitor for renal impairment
● Warn of dizziness/lightheadedness in first week of captopril therapy
Calcium blockers:
● Amlodipine-don’t take if you have edema
Describe the blood pressure guidelines for determining hypertension.
Normal <120 / <80
Prehypertension 120-139/ 80-89
Stage 1 140-159/90-99
Stage 2 >160/ >100

Ch 40-Anticoagulants, Antiplatelets, Thrombolytics: 6


Compare the actions of anticoagulants, antiplatelets, and thrombolytics.
Anticoagulants
● Prevent clots from forming given prophylactically. Prevents it in veins
● Heparin:​ prevents formation
○ Rapid effect for DVT, PE, or evolving stroke
○ Used in open-heart surgery & in critically ill pt w/ DIC
○ Given subcu for prophylaxis & IV for acute thrombosis
○ Antidote for hemorrhage: protamine sulfate
○ Must be given in hospital
● LMWH: Enoxaparin​: hip/knee replacement--DO NOT RUB--bruising. Given subcu 1 or
2x daily. Usually started in hospital within 24 hrs of surgery. Usually given in abdomen
● Direct-Acting Thrombin Inhibitors:
○ Argatroban: used if pt has heparin-induced thrombocytopenia (HIT)
○ Also can use bivalirudin
● Oral Anticoagulants
○ Warfarin: prevent thrombophlebitis, PE, embolism formation by a fib (stroke).
Watch for external/internal bleeding signs. Long term therapy. Don’t use during
pregnancy. Control external bleed by applying pressure 5-10 min
■ Antidote for warfarin OD: vitamin K--takes 24-48 hrs to kick in
● Anticoagulant Antagonists
○ Phytonadione--used for warfarin overdose/uncontrollable bleeding (vitamin K1)
Antiplatelets
● Used to prevent thrombosis by suppressing platelet aggregation
● Used in Arteries
● Mainly for prophylactic use in prevention of MI/stroke (history, prevention of repeat, for
TIAs)
● Low dose aspirin therapy (discontinue week before surgery)
● Clopidogrel--used after MI/Stroke to prevent a second event. Often used w/ aspirin
Thrombolytics
● Clot buster--clot disintegrates
● Administer within 3-4 hrs or within 30 min of arriving at hospital, can give up to 12 hrs
● Alteplase (tPA), tenecteplase (TNK tPA)=commonly used

Discuss the laboratory tests used to determine the therapeutic range of anticoagulants
differentiating between heparin and warfarin.
● Heparin is PTT & APTT (Partial Thromboplastin Time/Activated Partial Thromboplastin
time)
● Warfarin is PT (Prothrombin time) and INR
● PT is the time it takes for blood to clot w/ certain clotting factors which warfarin affects
○ PT performed immediately before admin the next drug dose until therapeutic
level is reached
● International Normalized Ratio (INR) normal INR is 1.3 -2, patients on warfarin need to
be at 2-3. (If patients have mechanical heart valve or systemic embolism the levels
should be 2.5-3.5 possibly to 4.5)
Differentiate the side effects and adverse reactions of anticoagulants, antiplatelets, and
thrombolytics.
● BLEEDING for everything!!!!
Anticoagulants
-Avoid these until thrombolytic effect has passed
● Heparin
○ Decrease platelet count → thrombocytopenia
○ Do not take antiplatelet drugs with anticoagulants
○ LMWH: CI for stroke, peptic ulcer, blood anomalies, eye, brain or spinal injury
● Warfarin
○ BLEEDING
○ Use acetaminophen instead of NSAIDS--don’t use oral hypoglycemic drugs
Thrombolytics
● Allergic reactions/anaphylaxis, facial/throat edema, rhabdomyolysis
● Hemorrhage: use aminocaproic acid to stop bleeding
● Watch for 24 hrs after therapy stops for bleeding
Apply the nursing process, including patient teaching, for anticoagulants and thrombolytics.

Ch 41-Antihyperlipidemics: 5
Describe the action of the two main drug groups: antihyperlipidemics and drugs that improve
peripheral blood flow.
Antihyperlipidemics
● (Bile-acid sequestrants, fibrates, nicotinic acid, cholesterol absorption inhibitors)-don’t
need to know, hepatic 3-hydroxy-3-methylglutary-coenzyme A reductase inhibitors
(STATINS)
● Cholestyramine​-a bile-acid sequestrant that reduces LDL. Effective against
hyperlipidemia type II
● Fibric Acid Agents- gemfribrozil
● COLESEVELAM-​has less side effects and less effect on the absorption of fat soluble
vitamins making it good.
● Nicotinic Acid/niacin​-many side effects, but used properly it is very effective
● Ezetimibe​-cholesterol inhibitor and usually combined with a statin.
● hs-CrP lab values are used to monitor cardiovascular disease risk.
Statins (HMG-CoA Reductase Inhibitors)​-decrease cholesterol, LDL, and slightly increases
HDL (good cholesterol).
● Statins all end in -statin
● Serum liver enzymes monitored
● Annual eye examinations because cataract formation can occur
● Patient should report any muscle aches or weakness because rhabdomyolysis can occur
● GI, muscle cramps, fatigue, headache
● Patients will be on drugs for the rest of their lives
● Abruptly stopping can cause a threefold rebound effect that may cause death from an
acute MI
● You want your cholesterol levels less than 200.
● Use continuously
Peripheral Blood Flow drugs:
Peripheral Vasodilators
● Used to treat peripheral vascular disease
● More effective in conditions resulting from vasospasm (Raynaud’s) instead of vessel
occlusion
● Cilostazol: antiplatelet and vasodilation properties-used to treat intermittent claudication.
It’s a direct acting vasodilator.
● Pentoxifylline-this is a blood thinner
○ Decrease blood viscosity and improves flexibility of erythrocytes
○ Used to improve microcirculation in the capillaries
○ Used in patients with intermittent claudication and has been prescribe for those
with Buerger’s disease resulting from arterial occlusions
○ Avoid smoking- it causes vasoconstriction

Compare the side effects and adverse reactions of antihyperlipidemics.


Statins-
● Can cause a dose related increase in liver enzymes
● Avoid if patient has acute hepatic disorder
● Rhabdomyolysis can occur
● Cataracts can occur
● Cholestyramine-constipation, peptic ulcer
● Niacin- many SE

Differentiate the side effects and adverse reactions of peripheral vasodilators and blood
viscosity reducer agents.
● Peripheral Vasodilators/Cilostazol-lightheadedness, dizziness, tachycardia, palpitation,
and GI distress
● Pentoxifylline-flushing of the skin, faintness, sedation, and GI disturbances. Take with
food

Apply the nursing process, including patient teaching, for antihyperlipidemics and blood
viscosity reducer agents.
Antihyperlipidemics-Statins:
Assessment
● Assess vital signs and lab values
● CI in patients with liver disease or are pregnant
Interventions
● Monitor lipid levels
● Monitor liver function and GI upset
Teaching
● It may take several weeks to see lipid levels decline
● Have serum liver enzymes monitored
● Have annual eye examination
● Watch for bleeding if taking oral anticoagulant
● Watch blood sugar
● Large doses of nicotinic acid can cause vasodilation, producing dizziness and faintness
● Statins-watch for muscle weakness or pain, rhabdomyolysis can occur
● Do not abruptly stop taking statins as rebound effect might occur
Vasodilators: Cilostazol
Assessment
● Look for signs of inadequate blood flow to extremities: pallor, coldness, and pain
Interventions
● Vitals, tachycardia and orthostatic hypotension can be a problem
Teaching
● Therapeutic effect may take 1.5-3 months
● Don’t smoke
● Avoid aspirin
● Change position slowly because of orthostatic hypotension
● Avoid alcohol- hypotensive reaction can occur

Ch 22-Antipsychotics & Anxiolytics: 6


Differentiate between antipsychotic and anxiolytic drug groups
Antipsychotic-aka neuroleptics and psychotropics
Divided into two groups: typical and atypical antipsychotics
Typical Antipsychotics
● Phenothiazines and Nonphenothiazines
● Block the action of dopamine and sometimes norepinephrine
● Blocking the D2 receptor promotes EPS.
● Okay for treating positive symptoms of schizophrenia instead of negative
● Phenothiazines-three groups: aliphatic, piperazine, and piperidine which differ mostly in
their side effects
○ Aliphatic-​produce a strong sedative effect, decreased BP, and may cause EPS.
○ Chlorpromazine hydrochloride is an aliphatic and may produce orthostatic
hypotension
■ Psychosis, schizophrenia, hiccups
○ Piperazine​-produce more EPS than other phenothiazines, cause dry mouth,
urinary retention, and agranulocytosis
○ EX-fluphenazine, and perphenazine...look for -phenazine
■ For psychotic disorders, to control severe nausea and vomiting, and
hiccups
■ CI for patients who have glaucoma
■ Crosses the BBB and placenta
■ Avoid use with other antihypertensives and antacids should be given 1
hour before or 2 hours after taking the drug if on antacids
○ Piperidine​-strong sedative effect, cause few EPS
○ Thioridazine-for psychosis only when unresponsive to other medications. Can
cause life threatening dysrhythmias
○ All phenothiazines may cause pinkish to red-brown urine color.
○ Full therapeutic effect may take 3-6 weeks, but an observable effect may take
7-10 days.
○ Liquid is preferred route
● Nonphenothiazines​-4 groups: butyrophenone, dibenzoxazepines, dihydroindolone, and
thioxanthene
○ Butyrophenone​: ​haloperidol​ is frequently prescribed and behaves like
phenothiazines
○ Long acting preparations (haloperidol decanoate and fluphenazine decanoate)
are given for slow release via injection every 2-4 weeks.
○ Use large-gauge needle to help prevent soreness and inflammation because of
the viscosity of the liquid
○ Do not rub the injection site, and the site should be rotated.
○ The medication should not remain in a plastic syringe for longer than 15 minutes
○ Haloperidol alters dopamine leading to sedation and EPS.
■ Used to decrease psychoses and decrease agitation
■ Has anticholinergic activity so be be careful with patients who have
glaucoma
■ Skin protection may be needed as photosensitivity can occur
○ Dibenzoxazepine​: loxapine has a moderate sedative effect and orthostatic
hypotension and strong EPS effects.
○ Dihydroindole​: molindone has low sedative and orthostatic hypotensive effects
and a strong EPS effect
○ Thioxanthenes​: thiothixene-low sedative effect and orthostatic hypotension and a
strong EPS
Atypical (Serotonin/Dopamine Antagonist) Antipsychotics
● Effective in treating both positive and negative symptoms of schizophrenia
● Two advantages: effective in treating negative symptoms and they are not likely to cause
EPS, including tardive dyskinesia.
● Have a greater affinity to blocking serotonin than dopamine so EPS is not as big of an
issue
● Common side effects: weight gain, drowsiness, unsteady gait, headache, insomnia,
depression, diabetes mellitus, and dyslipidemia
● Clozapine​-used to treat schizophrenia, especially in patients who don’t do well with other
meds
○ Serious adverse reactions are seizures and agranulocytosis.
○ Monitor WBC for leukopenia, if levels fall below 3000 mm^3 then discontinue
drug
● Risperidone​-for management of schizophrenia
○ Used to treat positive and negative symptoms of schizophrenia
● Ziprasidone​-be careful of use if patient has cardiac dysrhythmias
○ CI in patients with a history of prolonged Q-T interval or with other drugs known
to prolong Q-T interval
○ Watch for hypoglycemia
● Aripiprazole​: prototype drug-for schizophrenia
○ If symptoms occur the healthcare provider should check the medications
○ Is in a new class-dopamine antagonist stabilizer….
Anxiolytic-aka anti-anxiety or sedative hypnotics
● Primarily used to treat anxiety and insomnia
● Major group is benzodiazepines (enhance the action of GABA)
● Anxiolytics are given for primary anxiety (anxiety not caused by a medical condition)
● Secondary anxiety is caused by a medical condition...drugs typically not given, but could
be given for a short period to alleviate acute anxiety attacks.
● Benzodiazepines are used for severe or prolonged anxiety.
● Look for -azepam (suffix for most benzos)
● Lorazepam ​is frequently prescribed.
○ Lipid-soluble and rapidly absorbed in the GI tract
○ Acts on the limbic, thalamic, and hypothalamic levels of the CNS
○ Don’t use for more than 3-4 months because of tolerance
● Miscellaneous Anxiolytics: buspirone hydrochloride binds to serotonin and dopamine
receptors.
● Has an interaction with ​grapefruit juic​e that can lead to toxicity
● Side effects: drowsiness, dizziness, headache, nausea, nervousness, and excitement

Contrast that action, uses, side effects, and adverse effects of traditional typical and atypical
antipsychotics.
EPS:
● Parkinson like symptoms
Acute dystonia:
● Facial grimacing, involuntary upward eye movement, muscle spasms, laryngeal spasm
Akathisia:
● Restless, trouble standing still, paces the floor, feet in constant motion
Tardive dyskinesia: (does not always resolve with discontinuation of drug)
● Protrusion and rolling of the tongue
● Sucking and smacking lips
● Chewing motion, facial dyskinesia
● Involuntary movements of the body
-If patient has neuroleptic malignant syndrome the medication needs to be discontinued
immediately. It’s a life threatening condition
Traditional Typical:
● The most common is drowsiness
● Some have anticholinergic effects: dry mouth, increased HR, urinary retention, and
constipation
● BP decreases
● EPS can occur
● High dosing or long term use can cause blood dyscrasias or agranulocytosis
● Monitor WBC and watch for leukocytopenia
● Dermatologic side effects: pruritus and photosensitivity
● Interact with anticonvulsants
● Atropine counteracts EPS and potentiates antipsychotic effects
● Do not give multiple antipsychotics at once...if one doesn’t work replace it with another
one
● Do not abruptly stop
● STANCE-Sedation and photosensitivity, Tardive dyskinesia, Anticholinergic and
agranulocytosis, neuroleptic malignant syndrome, cardiac arrhythmia, EPS
Atypical Antipsychotics:
Benzodiazepines
● Sedation, dizziness, headaches, dry mouth, blurred vision, rare urinary incontinence and
constipation
● Leukopenia
● Do not abruptly stop, withdrawal can occur
Plan nursing interventions, including patient teaching, for the patient taking antipsychotics and
anxiolytics.
Phenothiazines/Nonphenothiazines
● Assessment:
○ Mental status, cardiac, eye, and respiratory disorders, continue daily assessment
● Interventions:
○ Orthostatic hypotension is likely
○ Stay with patient when taking medication, many patients will hide their drugs to
avoid taking them
○ Avoid skin contact with liquid concentrates to prevent contact dermatitis. Liquid
must be protected from light and should be diluted with fruit juice.
○ Check BP 30 minutes after giving the drug
○ Observe for EPS
○ Assess for symptoms of NMS: increased fever, pulse, and bp, muscle rigidity,
WBC
● Teaching:
○ Medication might take 6 weeks to achieve full effect
○ Do not consume alcohol or other CNS depressants
○ Stop smoking, maintain good hygiene
○ Talk with doctor if planning on starting a family
○ Phenothiazine pass into the breast milk thus affecting the infant
○ Monitor WBC every 3 months
○ Side effects: drowsiness, orthostatic hypotension
Benzodiazepines:
● Assessment
○ Assess for suicidal ideation, patient’s support system, and anxiety reactions
● Interventions:
○ Monitor vital signs, bp and pulse as hypotension may occur
○ Drug tolerance can occur
● Teaching:
○ Sedation is a common side effect so avoid driving motor vehicles
○ Don’t consume alcohol or CNS depressants
○ Teach how to control excess stress
○ Rise slowly because of orthostatic hypotension

Ch 23-Antidepressants & Mood Stabilizers: 6


Contrast the various categories of different antidepressants.
Tricyclic antidepressants (TCA)-used to treat major depression
● Block the uptake of nepi and ser
● Clinical response after 2-4 weeks
● Avoid polydrug therapy
● Amitriptyline, doxepin, or trimipramine for agitated depressed person because of
sedation effects
● Usually given at night because of highly sedative effects (decreases insomnia)
● Imipramine is used for treatment of enuresis (involuntary discharge of urine in sleep in
children)
● Drugs include: amitriptyline, imipramine, trimipramine, doxepin, desipramine,
nortriptyline, clomipramine (NMS)
● Amitriptyline is highly protein bound → may lead to EPS
● Ends in -itriptyline or -ipramine

Selective serotonin reuptake inhibitors (SSRIs)


● Block the reuptake of serotonin
● Used more often than TCA’s because they have less side effects
● Primary used for MAJOR depression
● Also used for anxiety
● Fluvoxamine is used for OCD.
● Fluoxetine (prototype)-​-effective in treating 50-60% of patient who do not respond to
TCA
● Sertraline is most commonly prescribed
● AVOID grapefruit juice
● Fluoxetine has been approved for a weekly dose of 90 mg, but before taking it the
patient should take the daily maintenance dose of 20 mg/d without serious effects
● Fluoxetine is highly protein bound, therapeutic effect between 1-4 weeks
● Fewer SE than TCAs

Serotonin norepinephrine reuptake inhibitors (SNRIs)


● Inhibit the reuptake of serotonin and nepi
● Used for MAJOR depressive disorders
● Also for anxiety and social anxiety disorders
● Venlafaxine, duloxetine, and desvenlafaxine
● Venlafaxine will interact with St. John’s wort to increase the risk of serotonin syndrome
and neuroleptic malignant syndrome (drowsy, dizzy, insomnia, headache, euphoria,
amnesia, blurry vision, ejaculation dysfunction, hypertension, tachycardia, angioedema,
seizures, suicidal ideation)

Atypical antidepressant-second generation antidepressant


● Used for major depression, reactive depression, and anxiety
● Amoxapine, maprotiline, nefazodone, trazodone
● Do not take with MAOIs or within 14 days of discontinuing MAOI use
● Ketoconazole, ritonavir, and indinavir may interact with trazodone leading to increased
trazodone levels

Monoamine oxidase inhibitors (MAOIs)


● The enzyme monoamine oxidase inactivates nepi, dop, epi, and ser
● Tranylcypromine sulfate, isocarboxazid, selegiline, and phenelzine sulfate
● As effective as TCAs for depression, but are not the drug of choice bc of adverse effects
● Usually prescribed if pt does not respond to TCA’s or atypical
● Do not take with TCAs
● Can be used for mild, reactive, and atypical depression
● Blood pressure monitoring is essential
● Patients on MAOIs must avoid certain foods that contain tyramine (cheese, meat,
alcohol)
● Watch out for OTC drugs and interactions

Describe the side effects and adverse reactions of antidepressants.


TCAs
● Orthostatic hypotension, sedation
● Anticholinergic effects, cardiotoxicity (dysrhythmias), and seizures
● Amitriptyline may to lead to EPS
● Clomipramine may cause neuroleptic malignant syndrome
● Seizure threshold is decreased by TCAs.
● Therapeutic serum range is 100-200
SSRIs
● Dry mouth, blurred vision, insomnia, headache, nervousness, anorexia, nausea,
diarrhea, suicidal ideation
● Sexual dysfunction may occur--a lot of males stop taking these bc of this/women
anorgasmic
● Side effects often decrease over the 2-4 weeks of waiting for the therapeutic effect to
start
SNRIs
● Drowsiness, dizziness, insomnia, headache, euphoria, amnesia, blurred vision,
photosensitivity, ejaculation dysfunction
● Adverse effects: hyponatremia, bleeding, hypertension, angioedema, blood dyscrasias,
suicidal ideation, Stevens-Johnson syndrome
MAOIs
● CNS stimulation (agitation, restlessness, and insomnia)
● Orthostatic hypotension and anticholinergic effects

Plan nursing interventions, including patient teaching, for antidepressant (tricyclic


antidepressants (TCA), monoamine oxidase inhibitors (MAOIs), selective serotonin reuptake
inhibitors (SSRIs), serotonin nepi reuptake inhibitors (SNRIs), and atypical antidepressants).
Assessments:
● TCA’s should be avoided if patient has CVD and hypertension
● Check liver and renal function
● Secure drug history
Interventions:
● Observe for signs of depression
● Watch for orthostatic hypotension, check for anticholinergic like symptoms
● Watch for suicidal tendencies
● Watch for foods containing tyramine as it can cause hypertensive crisis if taken with
MAOIs
● Frequently monitor BP with MAOIs
Teaching:
● Effectiveness may take 1-2 weeks
● Many herbal products will react with antidepressants
● Avoid driving, etc until stabilized on the drug
● Don’t abruptly stop the drug (withdrawal)
● Take drug at bedtime to decrease dangers from sedative effects

Explain the uses of lithium and its serum/plasma therapeutic ranges, side effects and adverse
reactions, and nursing interventions.
Lithium:
● Used to treat bipolar affective disorder
● Has a calming effect, but may cause some memory loss and confusion
● Expect to be on it for a long time
● Therapeutic serum range 0.5-1.5 mEq/L
● Levels greater than 1.5-2 mEq/L are toxic
● Monitor levels bi-weekly until therapeutic level has been met and then monthly
afterwards
● Watch for hyponatremia as lithium causes excess sodium excretion.
● Adequate fluid intake needs to occur
● Be careful if taking a diuretic (might be best to stop lithium)
Side Effects:
● Dry mouth, thirst, increased urination (loss of water and sodium)
● Weight gain, bloated feeling, metallic taste, and edema (ankle and hands)
● May have teratogenic effects, can’t be on if patient is pregnant
● Avoid NSAIDs and lithium usage together
● Watch for thyroid issues
● Do not take if patient has cardiac “sick sinus syndrome”

Apply the nursing process to the patient taking lithium, carbamazepine, and valproic acid.
Assessment:
● Watch for suicidal ideation
● Neurological status
● Watch for signs of toxicity...1.5-2 can cause nausea, vomiting, diarrhea, tinnitus, and
blurred vision
● Toxicity of 2-3.5 causes dilute urine, tremors, muscular irritability, mental confusion,
giddiness
● Toxicity about 3.5 is life threatening and may result in impaired consciousness, seizures,
nystagmus, MI
Interventions:
● Watch for orthostatic hypotension
● Draw blood and monitor lithium levels
● Watch for suicidal tendencies
● Watch urine output and weight
● Check patient’s cardiac status
Teaching:
● Check with provider before using OTC drugs

Dosage Calculations: 5