Pharmacology chapter 42(p-1-3)

Lecture Notes for 2nd year students

Digitalis Glycosides
inhibit the sodium potassium pump; causing increased intracellular sodium and increase influx of
calcium; result in muscle fibers contracting more efficiently.

Digitalis has three effects on heart muscle what are they>

1. Positive Inotropic action; increased myocardial contraction stroke volume. 2. Negative chronotropic
action; decreases heart rate. 3. Negative Dromotropic; decreases conduction of heart cells.

IV Inotropic agents for HF

IV inotropic agents (dopamine and dobutamine);

Cardiac glycosides can treat which dysrhythmias? How?

Afib and Aflutter; by using negative chronotropic effects (decreased heart rate) and negative
dromotropic effects (decrease conduction through AV node).

Adverse effects of Lomotil

dizziness and drowsiness

antidiarrheal drug
loperamide (Imodium)

Antidiarrheals MOA
Adsorbents: coat the walls of the GI tract
Anticholinergics: decrease intestinal muscle tone and peristalsis of GI tract
Intestinal flora modifiers (NIB): restores normal GI flora

Adsorbents
may prevent absorption of medications and nutrients

Antidiarrheal anticholinergic drugs

-reduce intestinal motility
-can have dangerous side effects

Antidiarrheals: opiates: MOA

-decrease bowel motility and relieve rectal spasms
-decrease transit time through the bowel, allowing more time for water and electrolytes to be
absorbed
-examples: paregoric, opium tincture, codeine, loperamide, diphenoxylate

Antidiarrheal agents; nursing implications

Do not give bismuth subsalicylate to children younger than age 16 or teenagers with chickenpox
because of risk of Reye's syndrome
Nausea and vomiting
most common and most uncomfortable complaints
vomiting is complex and is a defense mechanism

Nausea
unpleasant feeling that often precedes vomiting. Often accompanied with weakness, diaphoresis and
increased saliva

Emesis (vomiting)
forcible emptying of gastric, and occasionally, intestinal contents
-associated with many conditions

Antiemetic agents
used to relieve nausea and vomiting
centrally acting or locally acting
varying degrees of effectiveness

Emetics
Cause vomiting
No longer recommended for at-home poison control

VC
vomiting center

CTZ
Chemoreceptor trigger zone
-not protected

Treatment of N/V (antiemetics)

moderate to severe nausea treated

5-HT3 receptor blockers (serotonin blockers)

Ondansetron (Zofran)
-given prophylactically

Heart Failure - Syndrome

Syndrome - requires 3 symptoms
HF - heart is unable to pump adequate or sufficient amt of blood to the tissues

Heart Failure - symptoms

SOB, fatigue, exercise intolerance, venus overload, peripheral and pulmonary edema, JVD

Venus overload
too much fluid in the veins heard by ausculation, fluid in the lungs, crackling
JVD
Jugular Venus distension - assess in semi-fowlers 45 degree angle

heart failure early stage

can't see w/o ECG, will see thickening of walls of atria and ventricals but asymptomatic

cardiac remodeling
response to stress put on it hypertrophy, more spherical shape, rounder

hypertrophy
thickening of heart walls

cardiac remodeling leads to

changing the left ventricular ejection fraction
electrical conduction altered leading to dysrhythmia

CHF
hyperreninimic state - elevated renin goes out to angie - the AI comess out

CHF - lab tests

atrial natriuretic peptide (ANP) brain natriuretic peptide (BNP)

ANP/BNP test
when there is heart damage and cells die and lyce... contents are released into blood and measurable

BNP
Most sensitive test, best indicator for HF

Digoxin - TI
A-Fib have a higher TI Ventricular rate tells how effective Digoxin is working

Digoxin - Function
positive inotropic action strengthens contraction make it work smarter not harder
negative chronotropic decrease HR
negative dromotropic decrease conduction of electrical stimulus
increased stroke volume affected by BP

Digoxin - drug interactions

Diuretics (furosimide)
potassium loss, Glucocorticoids promote hypokalemia inducing Digoxin toxicity - antacid, decrease
effectiveness by changing Ph in stomach - space out by at least one hour separation, herbs, Anise
(black licorice) increases effects of Digoxin causing toxicity
Digoxin - Toxicity Signs/Symptoms
halos, bradycardia

Nursing Intervention w/Digoxin

check apical pulse before giving, teach accurate radial pulse, demonstrate BP, potassium lvl 3.5-5.3

Digoxin - Toxicity antidote

Digibind - bind it up to be excreted via urine

other HF treatments
ACE inhibitors (Angiotensin Concerting Enzyme) ARBs (Angiotensin II receptor blockers) - sartans, BBs,
Vasodilators - pull extra fluid

Digoxin assessment
measure - baseline, daily weight, lung sounds, pulses, radial pulse, educate drug interactions, Toxicity
(NVD, halos) grapefruit interaction, stress relief - relax, stop smoking, constricts vessels making the
heart work harder

angina
heart hurts

nitrates
sublingual usual route

nitrate side effects

headaches, hypotension, reflex tachycardia

calcium channel blocker - side effect

BP decreased, hypotension, headache, peripheral edema

BB - side effects
vasodialator

Nitrate - MOA
Dilates large myocardial arteries, rapid decrease in BP

Nitrates - routes and times

oral hr 1 hr -- sublingual 30/60 minutes -- translingual 30/60 minutes -- IV Immediate -- Topical 1hr --
transmucosal, 30 minutes

Beta Blockers
vasodilation resulting in decreased heart rate, decreased contraction
BB side effects
bradycardia

B1 side effect
decreased chronotropic - HR, inotropic - strength

B2 side effect
peripheral edema, headache, hypotension, skin flushing, dizziness

lab tests for CCB

serum enzyme lvls

Client teaching - CCB

faintness - report
grapefruit increases
concentration levels

During an intravenous (IV) infusion of amphotericin B, a patient develops tingling and numbness in
his toes and fingers. What will the nurse do first?
Discontinue the infusion immediately.

If a patient is taking fluconazole (Diflucan) with an oral anticoagulant, the nurse will monitor for which
possible interaction?
Increased effects of oral anticoagulants

The nurse is preparing an infusion of amphotericin B for a patient who has a severe fungal infection.
Which intervention is appropriate regarding the potential adverse effects of amphotericin B?
Before beginning the infusion, administering an antipyretic and an antiemetic drug

The nurse is administering one of the lipid formulations of amphotericin B. When giving this drug,
which concept is important to remember?
The lipid formulations are associated with fewer adverse effects than the older drugs.

The nurse is reviewing instructions for vaginal antifungal drugs with a patient. Which statement by the
nurse is an appropriate instruction regarding these drugs?
"Abstain from sexual intercourse until the treatment has been completed and the infection has
resolved."

A patient is infected by invasive aspergillosis, and the medical history reveals that the patient has not
been able to tolerate several antifungal drugs. The nurse anticipates an order for which medication to
treat this infection?
Caspofungin (Cancidas)

. A patient with a severe fungal infection has orders for voriconazole (Vfend). The nurse is reviewing
the patient's medical record and would be concerned if which assessment finding is noted?
History of cardiac dysrhythmias
During therapy with amphotericin B, the nurse will monitor the patient for known adverse effects that
would be reflected by which laboratory result?
Serum potassium level of 2.7 mEq/L

A patient has received a prescription for a 2-week course of antifungal suppositories for a vaginal
yeast infection. She asks the nurse if there is an alternative to this medication, saying, "I don't want to
do this for 2 weeks!" Which is a possibility in this situation?
A single dose of a fluconazole (Diflucan) oral tablet

A patient is taking nystatin (Mycostatin) oral lozenges to treat an oral candidiasis infection resulting
from inhaled corticosteroid therapy for asthma. Which instruction by the nurse is appropriate?
Let the lozenge dissolve slowly and completely in your mouth without chewing it."

The nurse is administering an amphotericin B infusion. Which actions by the nurse are appropriate?
(Select all that apply.)
Discontinuing the drug immediately if the patient develops tingling and numbness in the
extremities, Using an infusion pump for IV therapy, Monitoring the IV site for signs of phlebitis and
infiltration, Administering premedication for fever and nausea

n which of the following situations would blood be most likely to be rapidly relocated from central
circulation to the lower extremities?
A client is helped out of bed and stands up

A nurse is assessing the vital signs of a client. The client inquires about the functions of the arteries.
What should the nurse include in the client education about the function of arteries?
To carry oxygenated blood to the body cells

When describing Starling's law of the heart, the instructor compares this to:
stretching of a rubber band

When describing circulation, which would a nurse include?

A closed system

Fluid moves into the arterial end of a capillary due to:

Hydrostatic pressure

After teaching a group of students about circulation, the instructor determines that the teaching was
successful when the students identify it as:
a high to low pressure system.

A patient has a diminished flow of deoxygenated blood from the lower extremities. Which chamber of
the heart receives deoxygenated blood from the lower extremities?
Right atrium
As part of their orientation to a cardiac care unit, a group of recent nursing graduates is receiving a
refresher in cardiac physiology from the unit educator. Which teaching point best captures a
component of cardiac function?
"The diastolic phase is characterized by relaxation of ventricles and their filling with blood."

Pathologic changes in the structure of the capillary and venular endothelium can result in the
accumulation of fluid in interstitial space. What term refers to this accumulation?
Edema

The nurse assists and educates clients about blood pressure regulation. Based on this information, the
nurse asks the client what the number 80 in the blood pressure 120/80 represents. Which response
by the client demonstrates correct understanding of the basic concepts of blood pressure?
Diastolic pressure

The nursing instructor is explaining cardiac function to the senior nursing class. The instructor explains
that blood is ejected into the circulation as the chambers of the heart become smaller. The instructor
categorizes this action of the heart as what?
Systole

Which enzyme is produced in the kidney?

Renin

After explaining an electrocardiogram to a patient, which statement indicates that the patient
understands this test?
"It will show how impulses are moving through my heart."

If the production of actin is disrupted, what component of the human body will be affected?
Muscles

A client has been diagnosed with a problem associated with the heart's right atrium. Which statement
indicates the client
The top chamber, responsible for receiving blood from my body's veins, is the problem.

When explaining blood supply to the heart muscle, the nurse explains that the left circumflex artery
supplies the:
left ventricle.

The electrical impulses flow in the following manner:

Sinoatrial node, the atrioventricular node, bundle of His, right and left bundle branches, and
Purkinje fibers.

An instructor is describing the venous system, which is distensible and flexible and able to hold a large
amount of blood. The instructor is describing:
capacitancy.
When considering vital signs, which assessment is focused on the functioning of the body's resistance
system
Blood pressure

What primary event has occurred when a client experiences an ectopic focus?
The location of the heart's functioning pacemaker is no longer the sinoatrial (SA) node

Which client diagnosis is related to left-sided heart failure?

Pulmonary edema

A nurse is measuring the BP of a client. The client asks what the BP measures. What is the best
response by the nurse about the measurement of BP?
Pressure of blood within the arteries

The nurse is reviewing a patient's electrocardiogram and notes that the P waves are saw-toothed in
shape and there are three P waves for every QRS complex. The nurse would interpret this as
suggesting:
Atrial flutter

A client is diagnosed with an atrial septal defect (ASD) that has caused a hole between the two upper
chambers of the heart. What is the direct result of such a defect?
Deoxygenated and oxygenated blood will mix

An electrocardiogram (ECG) is prescribed for a client experiencing signs and symptoms associated
with a cardiac dysfunction. Which function of the heart will this diagnostic tool help evaluate?
Ineffective pumping

A client has severe aortic valve disease. When educating the client about anatomy, what would the
nurse include?
The aortic valve separates the left ventricle and aorta.

Considering the phases of the action potential of the cardiac muscle cell, what is the characteristic
event associated with phase 1?
Sodium is present in equal amounts both inside and outside of the cell

The capillary fluid shift is regulated by the balance between hydrostatic forces on the arterial end of
the capillary and:
Oncotic pressure

Which property is related to the ability of the heart cells to transmit an action potential of electrical
impulse?
Conductivity

Which is released initially when blood flow to the kidneys is decreased?

Renin
A client is diagnosed with a dysfunctional syncytia. What assessment finding supports this diagnosis?
The pumping of the heart's chambers of are not properly coordinated

A nurse is explaining blood flow through the heart to a patient who has experienced a myocardial
infarction. How would the nurse explain flow from the lungs to the heart?
Oxygenated blood from the lungs enters the left atrium through the pulmonary veins.

It is determined that a client's cardiac rhythm is being originated in the sinoatrial (SA) node. What
mechanism is responsible for the triggering of this node?
Specialized cells within the node itself

What structure makes it possible for the heart to be harvested for transplantation when donated by a
client who is declared "brain dead"?
sinoatrial (SA) node

Which teaching point should the nurse convey to a client being educated on the ability of the heart to
generate an electrical impulse?
"There are many different parts of your heart that can initiate an electrical impulse."

The critical care nurse is caring for a client with bradycardia after cardiovascular surgery. The nurse
knows that the heart rate is determined by myocardial cells with the fastest depolarizing rate. Under
normal circumstances, where are these cells located?
SA Node

A cardiovascular clinical nurse specialist describes the dysfunctional endothelium in relation to

cardiovascular disease. What is the major factor in the development of the dysfunctional
endothelium?
Atherosclerosis

A client who has been diagnosed with blood pressure problems is eager to know more about the
condition. What should the nurse explain is one of the internal processes that attempt to maintain
blood pressure within normal limits?
Special sensory receptors in blood vessel walls called baroreceptors are stimulated.

A nurse is assessing the vital signs of a client. The client inquires about the functions of the arteries.
What should the nurse include in the client education about the function of arteries?
To carry oxygenated blood to the body cells

A client has been declared "brain dead". The family asks the nurse to explain why their loved one's
heart continues to beat in spite of the damage to the brain. The nurse should provide what
explanation to the family?
The heart beats in response to impulses that are generated by specialized cells located in the heart
not the brain.

Several nursing students are creating a poster on the mechanism of the heart. What structure would
they label as separating the right half of the heart from the left?
Septum

A nurse is caring for a neonate born with a congenital heart anomaly. To better help the parents
understand the impact of this disorder, the nurse begins by describing the usual flow of blood through
the heart which takes what course?
Oxygenated blood from the lungs enters the left atrium through the pulmonary veins

A patient is scheduled to have a pacemaker implanted. The nurse knows pacemakers can be inserted
to correct what problem?
Malfunction of the sinuatrial (SA) node

What description of an artery, made by the nurse, is accurate?

Rigid resistance tubes

A 54-year-old man has a myocardial infarction, resulting in left-sided heart failure. The nurse caring
for the man is most concerned that he will develop edema in what area of the body?
Pulmonary

A patient, diagnosed with heart failure, would like the nurse to explain what the diagnosis means.
How will the nurse explain heart failure?
The heart muscle cannot pump effectively causing a backup of blood.

A patient who is on a ventilator has been declared brain dead. A family member asks the nurse how
the heart can still function if his father's brain is dead. What statement is an appropriate response by
the nurse?
The heart is self-controlled and does not depend on the brain to beat

The nurse is caring for a patient in the ICU; hypotension may be anticipated when the patient's body
produces insufficient quantities of what hormone?
Antidiuretic hormone (ADH)

The nurse is caring for a patient whose blood pressure is 120/78. What is the pulse pressure?
42

A patient is admitted to the cardiac unit with a diagnosis of a myocardial infarction (MI). The nurse
notes that the patient is having regular premature ventricular contractions (PVCs). Why would the
nurse be concerned?
Blood is not efficiently pumped from the heart with PVCs.

The nurse is caring for a patient whose damaged ventricle is reducing left ventricular filling and
causing a backup of blood into the left atrium. What valve is damaged in this patient?
Mitral

How would the nurse calculate the patient's pulse pressure?

The difference between the ejection and the resting pressures
The nurse takes the patient's pulse and finds a regular rate at 44 beats/min. What area of the heart is
controlling this patient's heart rate?
The sinuatrial (SA) node

The nurse is caring for a patient with severe coronary artery disease (CAD) who is experiencing chest
pain because the oxygen demand exceeds supply. What forces could potentially be lowered to reduce
oxygen consumption? (Select all that apply.)
B) Afterload
C)Stretch on the ventricles
D) Heart rate
E) Preload

The patient has edema resulting from heart failure (HF) in both ankles. The nurse interprets this to
mean the hydrostatic pressure is higher than what opposing pressure?
Oncotic pressure

The nurse is explaining the normal conduction pattern of the heart to an adolescent with a newly
diagnosed congenital heart anomaly. The nurse tells the patient that what serves as the pacemaker
for the heart?
The sinuatrial (SA) node

The nurse is caring for an older adult patient who is displaying alterations in the conduction of
impulses in the SA node which the nurse assesses as what?
Cardiac dysrhythmias

The nurse is caring for a patient with coronary artery disease and hypertension. The nurse explains to
the patient that coronary artery disease disables what process that controls blood pressure?
Ability of the arterioles to increase or decrease resistance

When a muscle acts as a pump what is a necessary property for the muscle to function efficiently?
Simultaneous contraction

The nurse is caring for a science professor with hypertension who asks for a more complete
explanation of blood pressure. The nurse begins by explaining that the phase when the ventricle
contracts and ejects blood out into the aorta is known as what?
Systole

When sodium gates open along the cell membrane and sodium rushes into the cell it results in the
membrane no longer having a positive or negative side but being electrically the same on both sides.
The nurse recognizes this period of the cardiac cycle as what?
Depolarized

The nurse explains the normal conduction pathway to the patient and evaluates the patient
understood when they provide what description of the conduction pathway in the heart?
SA node to AV node to bundle of His to Purkinje fibers
The patient has had a myocardial infarction. The nurse realizes the significance of this injury is
damage to what layer of the heart?
Myocardium

A very large, diverse group of eukaryotic, thallus-forming microorganisms that requires an external
carbon source
Fungi

Another of the major groups of antifungal drugs; includes ketoconazole

Imidazoles

A term for fungal infection of the mouth

Thrush

One of the older antifungal drugs that acts by preventing susceptible fungi from reproducing
Griseofulvin

The drug of choice for many severe, sys-temic fungal infections; also, the oldest antifungal drug
Amphotericin B

An antifungal drug commonly used to treat candidal diaper rash

Nystatin

An infection caused by fungi

Mycosis

Multicellular fungi characterized by long, branching filaments called hyphae, which entwine to form a
mycelium
Molds

An infant has thrush. The nurse expects to administer which drug for the treatment of thrush?
Nystatin

During an infusion of amphotericin B, the nurse monitors for which adverse effects? (Select all that
apply.)
Nausea
Fever
Malaise
Chills

A patient calls the gynecologic clinic because she has begun to menstruate while taking vaginal cream
for a vaginal infection. She asks the nurse, "What should I do about taking this vaginal medicine right
now?" Which is the nurse's best response?
"It's okay to continue to take the medication."

A patient will be receiving a one-dose treatment for vaginal candidiasis. The nurse expects to
administer which drug?
Fluconazole

The nurse is administering an antifungal drug to a patient who has a severe systemic fungal infection.
Which drug is most appropriate for this patient?
Amphotericin B

In an effort to prevent the complications associated with intravenous infusion of antifungal drugs such
as amphotericin B, the nurse will administer them over which time frame?
2 to 6 hours

The nurse is administering a new order for ampho-tericin B and reviews the patient's current
medications. Which medications, if also ordered, may cause an interaction with the amphotericin B?
(Select all that apply.)
Digoxin, a cardiac glycoside
Hydrochlorothiazide, a thiazide diuretic

Amphotericin B would be contraindicated in which patients? (Select all that apply.)

One with severe bone marrow suppression
One with renal impairment

What is the MOST important action for the nurse to complete before administration of intravenous
(IV) amphotericin B?
Check for premedication prescriptions.

Which antifungal drug can be given intravenously to treat severe yeast infections as well as a one-
time oral dose to treat vaginal yeast infections?
Fluconazole (Diflucan)
Fluconazole is an antifungal drug that does not cause the major adverse effects of amphotericin
when given intravenously. It is also very effective against vaginal yeast infections, and a single dose
is often sufficient to treat vaginal infections.

A client visits the health care provider for treatment of tinea pedis (athlete's foot). Which medication
would the nurse MOST likely instruct the client to take to treat this condition?
Terbinafine (Lamisil)
Terbinafine (Lamisil) is classified as an allylamine antifungal drug and is currently the only drug in its
class. It is available in a topical cream, gel, and spray for treating superficial dermatologic infections,
including tinea pedis (athlete's foot), tinea cruris (jock itch), and tinea corporis (ringworm).

The nurse would question a prescription for voriconazole (Vfend) if the client was taking which
medication?
Quinidine
The nurse would question a prescription for quinidine because both voriconazole and quinidine are
metabolized by the cytochrome P-450 enzyme system. The drugs will compete for the limited
number of enzymes, and one of the drugs will end up accumulating.

The nurse has provided education to a client about fungal skin infections. Further client teaching is
necessary when the client includes which condition in the discussion of fungal skin infections?
Impetigo
Impetigo is a bacterial skin infection and would not be classified as a fungal skin infection. If the
client included this in the discussion, further teaching is needed. All other skin infections listed are
fungal and would be treated with antifungal medications.

What are important for the nurse to monitor in a client receiving an antifungal medication? (Select all
that apply.)
Blood urea nitrogen, Daily weights, Creatinine, Intake and output
Nursing interventions appropriate to clients receiving antifungal drugs vary depending on the
particular drug. However, it is important for the nurse to monitor all clients for indications of
possible medication-induced renal damage so that prompt interventions can occur to prevent
further dysfunction. Monitoring intake and output amounts, daily weights, and renal function tests
will help prevent such damage.

What conditions are considered contradictions for use of antifungal medications? (Select all that
apply.)
Pancreatic failure, Liver failure

What is the MOST common drug used to treat oral candidiasis?

Nystatin (Mycostatin)
Nystatin is an antifungal drug that is used for a variety of candidal infections. It is applied topically
as a cream, ointment, or powder. It is also available as a troche and an oral liquid or tablet.

The nurse needs to know that major adverse effects are MOST common by which drug?
Amphotericin B (Amphocin)
The major adverse effects caused by antifungal drugs are encountered most commonly in
conjunction with amphotericin B treatment. Drug interactions and hepatotoxicity are the primary
concerns in clients receiving other antifungal drugs, but the IV administration of amphotericin B is
associated with a multitude of adverse effects.

what are the 4 ways that vomiting is triggered

the brain, ear, emotions and stomach

what are the 2 areas of the brain where vomiting is triggered?

the vomiting center-digestive track, inner ear and CTZ muscarinic receptors
Chemoreceptor trigger zone- impulses from drugs, toxins, vestibular center in ear
dopamine 2 receptors
5 HT receptors

what is the pathway of the ear receptor that triggers vomiting?

vestibular cochlear nerve--vestibular nuclei--histamine 1 receptors and muscarinic receptors--CTZ---
vomiting center

what is the pathway of the stomach receptors that trigger vomiting

enterochromaffin cells---serotonin--5HT receptors in the vagus nerve--vomiting center
what emotions trigger vomiting and how are they triggered?
pain, smells, sights, anxiety
trigger the muscarinic receptors in the brain

what are some non-pharmacologic methods to treat nausea and vomiting?

weak tea, flat soda, gelatin, Gatorade, Pedialyte, toast, crackers, ginger etc.

what are Anti-Histamines and what are the associated drugs

a non-prescription antiemetic used to treat motion sickness/ block receptors in the inner ear
dimenhydrinate
cyclizine hydrochloride
meclizine hydrochloride
diphenhydramine hydrochloride

side effects of non prescription ANTI histamines

drowsiness, dry mouth, constipation, urinary retention, blurred vision

bismiuth subsalicylate(pepto bismal)

non-prescription antiemetic ; acts directly on the gastric mucosa; helps with upset stomach and
diarrhea

phosphorated carbohydrate solution (Emetrol) and what is it cautioned in?

non-prescription antiemetic; hyperosmolar carbohydrate
decreases smooth muscle contraction
cautioned in diabetes mellitus(raises BS)

what are prescription Anti-histamines/anticholinergics and what are some drugs

prescription antiemetics that treat motion sickness act primarily on the vomiting center; they also act
by decreasing stimulation of the CTZ and vestibular pathways
hydroxyzine
promethazine
scopolamine

what are some side effects of prescription anticholinergics and antihistamines

drowsiness, dry mouth, blurred vision, tachycardia, constipation

what do Dopamine antagonists do and what are the drugs

block dopamine receptors in the CTZ
phenothiazines, butyrophenones, benzodiazepines

what are some side effects of dopamine antagonists?

extra-pyramidal symptoms(shuffling gait, tremors, rigidity)
hypotension,
extrapyramidal syndrome
what are Phenothiazines used for and what are some side effects
-zine, used to treat nausea and vomiting resulting from surgery, anesthetics, chemotherapy, and
radiation sickness
SE- drowsiness, EPS, anticholinergic SE

What are butyrophenones used for and what are some SE?
-idol
used to treat postop nausea and vomiting and emesis associated with toxins, cancer chemo, and
radiation therapy
SE-EPS, hypotension

Benzodiazepines use and major side effect

lorazepam; used for control nausea and vomiting that may occur with cancer chemotherapy
major SE-sedation

How do serotonin antagonists work?

Serotonin antagonists suppress nausea and vomiting by blocking the serotonin (5-HT3) receptors in
the CTZ and blocking the afferent vagal nerve terminals in the upper GI tract

What are the serotonin antagonists and what are some side effects?
end in setron (odansetron)
SE-headache diarrhea, constipation dizziness

Glucocorticoids (Corticosteroids) medications and uses

Dexamethasone and methylprednisolone effective in suppressing emesis associated with cancer
chemotherapy.

cannabinoids uses and side effects

Dronabinol and Nabilone; alleviate nausea and vomiting resulting from cancer treatment.
side effects- depressed mood, drowsiness, dizziness, headaches hallucinations, paranoid reactions

Metoclopramide (Reglan)
controls post-op NV and used for chemo and radiation
SE- sedation, diarrhea, EPS

animetics nursing interventions

check vital signs, bowel sounds, assess for dehydration, inform to not consume alcohol, avoid
driving, avoid in pregnancy

What do emetics do?

they are used to induce vomiting
don't use if caustic substances ingested

what are some things that cause diarrhea?

infection, drugs, inflammation, spicy foods, malabsorption

nonpharmacologic diarrhea treatment

avoid milk products, avoid high fat foods, clear liquids, Gatorade, Pedialyte, IV fluids with
electrolytes

how do opiates work and what are the side effects?

decrease intestinal motility which decreases peristalsis
side effects- drowsiness, dizziness, confusion, hypotension dry mouth

opiate medications, CI, and general antidiarrheal nursing interventions

diphenoxylate with atropine
difenoxin with atrophine
loperamide
assess vital signs
CI in c diff, pts who ingested toxins glaucoma, liver disorders, or ulcerative colitis, can cause CNS
depression
assess bowel sounds
check for s/s of dehydration
check electrolytes

What do adsorbents do?

coats the wall of the GI tract and absorb bacteria or toxins that cause diarrhea

what are the adsorbent drugs and what do they do?

kaolin, bismuth subsalicylate and pectin-binds to and absorbs toxic bacteria
Psyllum- absorbs large amounts of fluid to form bulkier stools
lactobacillus- correct altered GI flora

Octreotide (Sandostatin)
somatostatin analog; treats severe diarrhea asst. w/ some cancers by inhibiting secretions and
enhancing absorption
given IM/IV
SE- nausea, diarrhea, abdominal pain, gallstones, cholestatic hepatitis

types of laxatives
Osmotic (saline)
Stimulant (irritants)
Bulk-forming
Emollient (stool softeners)
chloride channel activators

what are laxatives used for?

constipation, fecal impaction, immobile patients, children, bowel obstruction, pregnant patients

Osmotic (Saline) Laxatives

draws water into intestines, distends the bowel, and causes peristalsis; used for acute constipation,
bowel prep and purging toxins
continued use can cause electrolyte imbalances and dehydration
adequate renal function is needed to excrete magnesium
examples of osmotic laxatives
lactulose
magnesium hydroxide
magnesium citrate
sodium phosphates
polyethylene gycol with electrolytes

what are stimulant laxatives and what are some examples?

causes irritation to intestines causing peristalsis and evacuation; used for acute constipation and
bowel prep
very rapid acting and shouldn't be used regularly
Bisacodyl
castor oil
senna

How do bulk forming laxatives work?

water retained in stool, which increases bulk and stimulates peristalsis; used for a more chronic
safe laxative, IBS
give with a full glass of water

Types of bulk forming laxatives

polycarbophil
psyllium hydrophillic mucilloid
polyethylene glycol
methylcellulose

what do Chloride channel activators do and what is the drug?

increases fluid secretions which increases motility in chronic idiopathic constipation; IBS in women
with constipation and opioid induced constipation
lubiprostone

Emollient laxatives
prophylactic to draw water and fat into stool but dont stimulate peristalsis
onset of action: 24-48 hrs

Emollients (Stool Softeners) medications

mineral oil and docusate sodium(colace)
dont use on patients on fluid restrictions

what are the contraindications of chloride channel activators?

GI obstruction
chrons disease
diverticulosis
severe diarrhea

side effects of laxatives

flatulence, diarrhea, abdominal cramps, nausea, and vomiting
nursing interventions of laxatives
check fluid intake and output, monitor vital signs, encourage fiber intake
assess BUN and CR
increase water intake with stimulants
monitor bowel sounds
mix bulk forming laxatives in water
avoid overusing laxatives

How do peptic ulcers form?

when there is a hypersecretion of hydrochloric acid and pepsin, which erode the GI mucosal lining

what are some predisposing factors of ulcers

H.Pylori
mechanical factors
genetic factors
environmental factors
drugs
stress ulcer following a critical situation

GERD
inflammation of the esophageal mucosa caused by reflux of gastric acid content into the esophagus

non pharmacologic measures to treat peptic ulcers

avoid tobacco, avoid alcohol,
avoid hot spicy and greasy foods
dont take NSAIDS, including aspirin with food
sit upright during meals
dont eat before bedtime
wear loose fitting clothes

What are the 8 antiulcer drugs?

tranquilizers,
anticholinergic
antacids
H2 receptor blockers
proton pump inhibitors
mucosal coating agents
GI prostaglandins
prokinetic agents

tranquilizers
rarely used; reduced vagal nerve stimulation
side effects include edema, ataxia, confusion, EPS, agranulocytosis

what do Anticholinergics do and what are the side effects

decrease GI motility and secretions; take before meals
side effect: dry mucus membranes, constipation, urinary retention, drowsiness, dizziness, decreased
secretions
what do antacids do and what are some side effects?
neutralize stomach acid and reduce pepsin
don't take for more than 2 weeks
take other meds 1 hour before or 2 hours after
SE-chalky taste, diarrhea, constipation

caution in antacids
sodium bicarbonate
calcium carbonate
magnesium hydroxide
aluminum hydroxide

H2 receptor antagonists and when should you take it

-tidine (cimetidine)
suppresses amount of gastric acid secreted
used in GERD, PUD, hypersecretory secretions, heartburn, prevention of stress ulcers
take with first meal or immediately after

H2 receptor antagonists side effects and drug interactions

headache, dizziness, constipation, confusion, restlessness, gynecomastia(cimetidine)
antacids
oral anticoagulants
vitamin b12
minerals

what are Proton Pump Inhibitors and when are they best taken?
-prazole, long term and most effective medication to inhibit gastric acid secretions for patients with
GERD, peptic ulcer, prophylactic or burns
best taken 30 minutes before first meal of the day

side effects and risks of proton pump inhibitors

diarrhea, headache, abdominal pain, N/V more at risk of pneumonia and Cdiff and risk for fractures,
and risk for minerals and vitamin b12 deficiency

what is the pepsin inhibitor drug and how long should you take it and when?
Sucralfate (Carafate); coats ulcer from high acidic environment
taken up to 8 weeks, 4x a day ac and hs
antacids 30 minutes before or after

pepsin inhibitors 3 side effects

constipation, dry mouth, dizziness

what do gastrointestinal prostaglandins do, some CI and SE?

misoprostol; decreases the acidic environment and increases mucosa
prevents PUD
contraindicated in pregnancy
SE- diarrhea and abdominal cramps
what are the 3 types of drug cocktails to prevent H. pylori
PPI, clarithromycin, amoxicillin
PPI, clarithromycin, metronidazole
PPI, bismuth subsalicylate, metronidazole, tetracycline

what is normal blood glucose

60 to 100 fasting and up to 140 after eating

What is diabetes mellitus and what are some major symptoms?

deficient glucose metabolism
Type 1 is insulin dependent
Type 2 is insulin resistance
MS- polyuria, polydipsia and polyphagia

secondary diabetes
can be caused by medications like glucocorticoids, thiazide diuretics and epinephrine
pregnancy's
or illnesses like cystic fibrosis, pancreatic cancer and celiac disease

How does insulin work?

released by beta cells in pancreas; lowers blood glucose by facilitating uptake of glucose and coverts
to glycogen for future glucose needed in the liver and muscle

what are the types of insulin and what are some things to remember?
rapid-acting
short-acting
intermediate acting
long acting
combination
rotate sites to prevent lipodystrophy; changes required in times of stress; has to be administered
subcut (besides Humulin R)

rapid acting insulin onset/peak/duration and medications and food

insulin lispro insulin aspart, insulin glulisine
onset-5 to 15 min
peak- 30 min to 1 hour
duration- 2 to 4 hours
you want the meal in front of the patient as you administer

short acting insulin (clear) medication, peak/onset/duration

Humulin R and Novolin R
onset- 30 to 60 minutes
peak- 2 to 3 hours
duration- 3 to 4 hours

intermediate acting (cloudy) insulin onset peak and duration

insulin isophane (Humulin N, Novolin N)
onset- 2 to 4 hours
peak- 4 to 12 hours
duration- 18 to 24 hours

what are the 3 long acting insulins and what are their onset peak and duration
insulin glargine(peakless, onset 1 hr, duration 24 hrs, hs)
insulin detemir- similar to glargine but peak 8 hours
insulin degludec(duration 42 hours)

Combination insulin
composed of short and intermediate acting or rapid and intermediate acting
isophane NPH 70% regular 30%(Humulin 70/30)

insulin interactions with drugs

increased hypoglycemia with aspirin, oral anticoagulants, alcohol, oral hypoglycemics, beta blockers,
TCA, MAOIs, tetracyclines
increased chance of hyperglycemia with thiazides glucocorticoids, oral contraceptives', thyroid drugs,
smoking

Hypoglycemia (insulin reaction) signs and symptoms

headache, dizziness, confusion, slurred speech, tremors, tachycardia, seizures

how do you treat hypoglycemia

bs <60 and conscious patient, give fast acting sugar
bs <60 and unconscious patient, give D50 IV or glucagon subcut w/ OJ
repeat blood sugars every 15-20 minutes until stable

Hyperglycemia symptoms and how to treat

extreme thirst, dry mucous membranes, poor skin turgor, polyuria, fruity breath kussmaul
respirations
treat with fluids and insulin

other diabetic events

lipodystrophy, somogyi effect, dawn phenomenon, insulin shock, diabetic ketoacidosis

Nursing Interventions for insulin

monitor VS, glucose level, teach patient how to check blood glucose, how administer insulin, if patient
is NPO, dose reduction and holding, teach diet and exercise, rapid or fast acting-make sure food is in
room

how to prevent errors with insulin

match bottles with orders, have another nurse check, swirl to mix, inject air into vial first, no
aspiration, store in fridge,

what are some other methods of insulin administration

insulin pumps; insulin pen injectors, insulin jet injectors

sliding scale insulin

adjusted doses depending on blood glucose
done before eating and at bedtime
rapid or short acting insulin

how to store insulin

keep in fridge
remove from fridge 30 minutes before injection
avoid storing in sunlight or at high temperatures

first and second generation sulfonylureas

only used to treat type 2 diabetes and increases tissue response to insulin and decreases glucose
production

what are the first generation sulfonylureas medications?

short acting- tolbutamide
intermediate acting- tolazamide
long acting- chlorpropamide

second generation sulfonylureas

glimepiride
glipizide
these work more effectively and have a greater hypoglycemic potency so monitor for hypoglycemia

SE of sulfonylureas and cautions

GI distress(N/V/D)
dermatological responses
hypoglycemia
caution in ETOH(alcohol) because it causes disulfiram like reaction
contraindicated in type 1 diabetes

biguanide: Metformin action and side effects

decreases hepatic production of glucose from stored glycogen
decreases the absorption of glucose from the small intestine
SE- diarrhea, lactic acid, bitter taste
monitor renal function, avoid alcohol

alpha-glucosidase inhibitors
acarbose inhibits digestive enzyme in SI responsible for release of glucose in the diet

acarbose interventions
can combine with sulfonylureas, will not cause hypoglycemia when given alone
administer with first bite of food

thiazolidinediones
-glitazone
lowers glucose by decreasing hepatic glucose production and target cell response to insulin
thiazolidinediones side effects and cautions
headache, dizziness, blurred vision, weight gain, edema
CI in symptomatic heart disease class III and IV CHF

meglitinides action and nursing interventions

repaglinide stimulate beta cells to release insulin
short acting(less chance of hypoglycemia)
take with meals
CI- liver dysfunction

incretin modifiers (DPP 4 inhibitors)

-gliptin
increase level of incretin hormones, insulin secretion and glucagon secretion to reduce BS
no weight gain
teach families how to administer

SLT 2 inhibitors
-gliflozin
Dapagliflozin
blocks reabsorption of glucose in kidneys causing glucose to be eliminated through urine
no hypoglycemia
SE-UTI, yeast infection

Incretin Mimetics
-tide
enhance insulin secretion, suppress glucagon, slow gastric emptying and reduce food intake so good
with weight loss

incretin mimetics nursing interventions and SE

refrigerated injectable pen for subcut use
take within 60 min before breakfast and dinner
SE- headache, dizziness, jitteriness, GI distress

amylin analogue
Pramlintide acetate; improves post prandial glucose control in patients using insulin but unable to
maintain glucose control
vials; given before meals
for type 1 and type 2
SE- dizziness, anorexia, N/V fatigue

Hyperglycemic drugs- Glucagon

used to treat insulin induced hypoglycemia when other methods aren't available
parenteral routes
Onset- 5 to 20 min
teach families how to administer

hyperglycemic drugs-diazoxide
increases BS by inhibiting insulin release and stimulating epinephrine
treats chronic hypoglycemia due to hyperinsulinism caused by islet cell cancer/hyperplasia
The nurse is caring for a patient in a state of shock. The family asks the nurse why the patient is so
sick. What is the nurse's best response?
Low blood pressure means inadequate supply of oxygen to the body's tissues.

The nurse is caring for a patient with chronic renal failure. The patient asks the nurse how his kidney
disease causes hypertension. What is the nurse's best response?
When blood flow to the kidney declines, cells in the kidney release renin.

The nurse is assigned to watch the cardiac monitors in the constant care unit and notes four different
patients displaying arrhythmias. Which arrhythmia is the nurse's highest immediate priority?
Ventricular fibrillation

How does the nurse describe the cardiac action potential to a new coworker?
The cycle of depolarization and repolarization

The nurse teaches a class on the systems that control blood pressure and includes what systems in
the discussion? (Select all that apply.)
B) Aldosteroneantidiuretic hormone (ADH)
D) Stimulus from the sympathetic system
E) Reflex control of blood volume

A patient presents at the clinic complaining of shortness of breath, fatigue, and difficulty performing
activities of daily living (ADLs). The nurse notes the bluish color around the patient's mouth and
fingernail beds. What would the nurse expect the patient has?
Heart failure

The nurse explains how the myocardium receives oxygen to the new graduate nurse beginning work
in the constant care unit; she tells the new nurse the coronary arteries receive blood when?
During diastole

The nurse explains that the reason the left ventricle is so much larger than the right ventricle is what?
The left ventricle needs to pump blood through the entire body.

The nurse is caring for a patient with hypertension and recognizes this will have what impact on
afterload?
Increased afterload

The patient's blood pressure is low due to shock and vasodilation of the blood vessels. The nurse
recognizes this will have what impact on preload?
Preload will increase.

The patient has a diagnosis of atherosclerosis. When a branch of the coronary artery becomes
completely blocked, what event will the nurse expect to occur?
Myocardial infarction
The patient has an excessive production of antidiuretic hormone (ADH). The nurse expects what
change in the patient's blood pressure?
Increase in blood volume will cause increase in blood pressure

What are 5-HT3 blockers (Serotonin blockers) primarily used for

N/V for patients receiving chemo, radiation and postoperative nausea and vomiting.

Anticholinergics/Antihistamines
diphenhydramine, scopolamine

anticholinergics/antihistamines recommended uses

for n/v associated with motion sickness or inner ear problems.
Take before travel

Antimetics, phenothiazines and phenothiazide-like drugs prototype drug

prochloperazine (Compazine)

Phenothiazines
prochlorperazine (Compazine)
promethazine (Phenergan)
-also used for intractable hiccups

Phenothiazines recommended uses

treatment of N/V, esp assoc with anesthesia and severe vomiting

Nonphenothiazine
metoclopramide (Reglan)
-stimulates peristalsis in the GI tract
-also used for GERD, delayed gastric emptying

scopolamine (Transderm-Scop)
used to treat motion sickness; prophylaxis
-patch

Substance P/Neurokinin 1 receptor antagonists

newest class of drugs for N/V
-approved for highly emetogenic antineoplastic chemotherapy

Emetics (inducing vomiting)

should only be used in emergency situations only when directed

Nursing implications
-assess complete nausea and vomiting history, including precipitating factors
-assess current medications
-assess for contraindications and potential drug interactions
**most are more effective when given prophylactically

Role of the nurse: antiemetic therapy

-patient safety is a concern because of drowsiness
-assess risk for falls
-prevent aspiration

Antiemetics education
-many agents cause severe drowsiness; warn patients about driving or performing any hazardous
tasks
-Taking with alcohol may cause severe CNS depression
-Teach patients to change position slowly to avoid hypotensive effects
-many agents should be administered 30 minutes prior to meals or treatments (for chemo, often
given 30 minutes to 3 hours prior to chemo treatment)
-incorporate nonpharmacological measures also

Cornea
The clear tissue that covers the front of the eye

Watch for scratches

Pupil Dilation
Sympathethic motor nerve fiber

Caused by dim lights

Mydriatic Agents

Pupil Constriction
Parasympathetic motor nerve fibers

Caused by bright lights

Miotic agents

Glaucoma
Abnormal elevation of intraocular pressure (IOP) caused by:
1. Excessive production of aqueous humor
OR
2. Diminished ocular fluid outflow

Increased pressure → compresses retina & optic nerve → BLINDNESS

Eye Exam Recommendations

Ages 40 to 64: every 2 to 4 years

After age 65: every 1 to 2 years

For African-Americans: increased frequency

Tonometry
Procedure eye care professionals perform to determine the intraocular pressure (IOP), the fluid
pressure inside the eye.

Norms: 10-23 mm Hg

(average ~ 16 mm Hg)

3 Types of Glaucoma
1. Primary
-Open angle
-Closed angle

2. Secondary
-eye surgery
-disease

3. Congenital

Open Angle Glaucoma

Drains are blocked, gradual, build up of pressure.

Most common type (90%)

Usually bilateral

S/S:
Decreased peripheral vision
Frontal headache
Eye pain, brow pain
Tunnel vision with white halos

3Ps of Blindness due to Open Angle Glaucoma

Preventable
Painless
Permanent

Closed Angle Glaucoma

This condition involves sudden blockage of the outflow of aqueous humor (sudden increase in IOP)

10% of cases

S/S: Severe eye pain (bulging iris)

Severe headache

Nausea & vomiting

Tunnel vision with white halos

EMERGENCY
Treatment for Glaucoma
Goal: ↓ IOP & prevent blindness

Surgical: lasers; trabeculoplasty; shunts

Medical: Medications
-Miotics
-Meds that inhibit production of aqueous humor

Drug Class: Carbonic Anhydrase Inhibitors

Action: inhibition of carbonic anhydrase results in decreased production of aqueous humor & ↓IOP

Examples:
acetozolamide (Diamox) po
dorzolamide (Tusopt) ophthalmic sol'n.

Use: Closed and open angle glaucoma

Side Effects: gastric irritation, electrolyte imbalance (↓Na, K, Cl)

Nursing Implications:
√ electrolytes
√ allergy to SULFA
Contraindicated in pregnancy

Drug Class: Cholinergic Agents

Example: pilocarpine (Isopto-Carpine, Pilopine HS)

Action: cholinergic → miosis (ciliary body contraction) → IOP↓

Side effects:
↓ Visual acuity @ night
Blurred vision 1-2 hr. after admin.
Headache/conjunctival irritation

Serious Side Effects- may be signs of excessive administration→toxicity:

Bradycardia/Hypotension
Diaphoresis/Salivation/Abdominal discomfort

Nursing Implications:
√ heart rate
Block inner canthus 3-5 minutes
Safety (blurred vision)

Note: These drugs must be administered 4 x day. Use is ↓ due to side effects and preference for
drugs that need either daily or bid administration.

Drug Class: Alpha Adrenergic Agents

Example: phenylephrine (Prefrin, Mydfrin)

Action: mydriasis; ↑ outflow of aqueous humor, ↓ production of aqueous humor

Use: mydriasis for ophthalmic diagnostic procedures
↓IOP in open angle
lowers redness from irritation

Side effects:
Systemic: ↑ HR, ↑ BP
Sensitivity to light
Conjunctival irritation/lacrimation

Nursing Implications:
√ HR, BP
Block inner canthus
Sunglasses
Use with caution in patients with bronchial asthma

Drug Class: Beta-Adrenergic Blocking Agents

Examples: betaxolol (Betoptic); timolol (Timoptic)

Use: first line drugs for open-angle glaucoma

↓IOP

Action: unknown (? ↓ production aqueous humor)

Side effects:
Systemic: BP↓ HR↓

Nursing Implications:
√ BP, HR @ specific intervals
Block inner canthus 3-5 minutes
√ interactions (other BB)

Drug Class: Prostaglandin Agonists

Examples: latanoprost (Xalatan); travoprost (Travatan); bimatoprost (Lumigan)

Action: ↑ outflow of aqueous humor→ ↓ IOP

Dosage: usually once daily; don't exceed dosage

Side effects:
Mild irritation, stinging
Eye pigment changes (Blue>Brown)
Eyelash growth

Nursing Implications: Teaching

Side effects
Do not admin. with contacts
Avoid products with Thimerosol

Drug Class: Anticholinergic Agents

Example: Mydriacyl

Use: mydriasis & cycloplegia (extreme dilation for eye exams)

Contraindication: closed angle glaucoma

Side effects: light sensitivity; ↑ IOP

Drug Class: Antifungals

Example: natamycin (Natacyn)

Use: yeasts such as Candida, Aspergillus

Side effects: photosensisitivity; blurred vision

Teach: symptoms should improve in a few days; notify physician if worsening or no improvement

Drug Class: Antivirals

Example: trifluridine

Use: herpes keratitis

Side effects: light sensitivity, blurring, stinging, tearing

Teaching: notify physician if no improve-ment in 7 -14 days

Drug Class: Ophthalmic Antibiotics

Example: erythromycin

Uses:
bacterial infections
prophylaxis for gonorrhea & chlamydia blindness in newborns

Teach: prolonged use can cause hypersensitivity & resistant organisms

Drug Class: Corticosteroids

Examples:
dexamethasone
(Dexasol)- ointment; (Maxidex)-suspension

Uses: Allergic reactions of the eye/ acute, non-infectious inflammatory conditions.

Prolonged ocular steroid therapy may cause glaucoma and cataracts

Drug Class: Ophthalmic Anti-Inflammatory Agents

Example: Flurbiprofen sodium, Diclofenac sodium, nepafenac and bromfenac

Action: anti-inflammatory, antipyretic, and analgesic by inhibiting biosynthesis of prostaglandins

which ↑intraocular inflammation & pressure. Also inhibit miosis .

Uses:
Flurbiprofen (Ocufen) - inhibits miosis during Cataract surgery
Diclofenac sodium(Voltaren), nepafenac (Nevanac) and bromfenac (Xibrom)- treat postoperative
inflammation after cataract extraction
Ketorolac tromethamine (Acular) - relieves ocular itching with seasonal allergic conjunctivitis
Drug Class: Antihistamines
Example: Patanol (olopatadine)

Uses:
Relief of Sx associated with allergies

Administration:
For best results, administer before exposure to allergens

Drug Class: Antiallergic

Action: Inhibit release of histamine

Examples: Bepreve, Crolom, Alomide, Alamast

Use: Treat allergic ocular disorders

(ie.vernal keratoconjuctivitis)

Drug Class: Diagnostic Agent Sodium Fluorescein

Used for:
Identifying foreign bodies, abraded, & ulcerated areas
Fitting contact lenses

Topical - 2% topical solution (strips)

10% & 25% for injection into aqueous humor

*An abraded cornea

is highly susceptible to infection*

Drug Class: Artificial Tear Solutions

Example: Tears Naturale, Murine

Used for:
Dry eyes
Artificial eyes
Decreased protective reflexes

Caution: sensitivity to preservatives

Drug Class: Ophthalmic Irrigants

Example: Eye-Stream, Blinx, Optigene

Uses:
Cleansing the eye
Foreign bodies
Chemical exposure

Eye wash station

Macular Degeneration
Deterioration of the macula- small area in retina. Age-related macular degeneration. (AMD)

Symptoms: blurriness, dark areas, distortion. Peripheral vision NOT affected.

"Dry" (atrophic) AMD
Caused by aging and thinning of the macular tissues.

Vision loss is gradual

Most common form of AMD

"Wet" (exudative) AMD

Abnormal blood vessels form underneath the retina at back of the eye. Leak fluid or blood and blur
central vision.

Vision loss may be rapid and severe

Drug Class: Vascular Endothelial Growth Factor Antagonist

Examples: pegaptanib (Macugen) (q 6 weeks)
and ranibizumab (Lucentis) (q month)

Action: antagonists that bind to VEGF to prevent it from forming new blood vessels which contribute
to wet form of AMD

*Watch for redness, light sensitivity, pain, ↓vision.

Report immediately to ophthalmologist*

Ophthalmic Med Administration

Should be labeled "For Ophthalmic Use"

Gloves & sterile technique

Cleanse eyelashes & eyelids (with separate gauze)- inner canthus outward

Drops should be @ room temperature

Positioning

For Systemic medications:

Pre-medication assessment
Hold pressure @ inner canthus 3-5 minutes

If >1 eye med is ordered, wait at least 5 minutes between meds.

DROPS > OINTMENT

Don't remove impaled objects

Post-operative restrictions
Prevent Increase in IOP

Head position

No: bending,
coughing, Valsalva maneuver

The nurse is teaching a patient with open-angle glaucoma about the disease and its treatment. Which
statement by the patient best indicates that teaching has been successful?
A. "I need to use my eye drops regularly if I want to regain my vision."
B. "I will use a separate bottle of eye drops for each eye so I can't spread the infection."
C. "I will refill my eye drop prescription a few days ahead of time so I am certain not to run out."
D. "I won't touch my eyes because it increases the pressure in them."
C. "I will refill my eye drop prescription a few days ahead of time so I am certain not to run out."

What is the best measure of drug effectiveness in the treatment of open-angle glaucoma?

A. Intraocular pressure
B. Visual acuity
C. Speed of convergence
D. Change in peripheral vision
A. Intraocular pressure

Which ophthalmic medication does the nurse expect to administer when preparing a patient for
cataract surgery?

A. Ketorolac tromethamine (Acular)

B. Timolol maleate (Timoptic)
C. Diclofenac sodium (Voltaren)
D. Flurbiprofen sodium (Ocufen)
D. Flurbiprofen sodium (Ocufen)

A patient admitted to the eye clinic has been diagnosed with "wet" macular degeneration (exudative)
in the right eye. Which medication does the nurse anticipate the ophthalmologist will order for this
patient?

A. Latanoprost (Xalatan)
B. Metipranolol (OptiPranolol)
C. Ranibizumab (Lucentis)
D. Tropicamide (Mydriacyl)
C. Ranibizumab (Lucentis)

A patient is taking bimatoprost (Lumigan) and timolol maleate (Timoptic) eye drops. How does the
nurse instruct the patient to administer the drops?

A. At the same time

B. At least 1 minute apart
C. At least 5 minutes apart
D. At least 30 minutes apart
C. At least 5 minutes apart

When digoxin does not convert Afib which medication/s are used?
CCBs (verapamil) with warfarin; this is to slow heart rate down and decreasing chance of
thromboemboli.
ANP lab range? Why is it excreted? What does it represent? What does it do?
20-77 pg/mL; excreted because of over expansion of atria; vasodilation and increases GFR causing
large amounts of urine to decrease blood volume and pressure; if high indicated HF

BNP lab range? What is the purpose of the lab when identifying HF? What age related consideration
should be considered?
<100 pg/mL; it helps identify if a person is experiencing dyspnea from lung conditions or HF; it is more
accurate than ANP for Dx of HF. It can be higher in women over 65 years old.

Protein binding for digoxin is? rate of absorption for digoxin?

30%; 70-90%.

Half life of digoxin? Where is it excreted?

30-40 years; 30% metabloized by liver and the rest is from kidneys unchanged.

Therapeutic serum level for digoxin? For HF what therapeutic level should be maintained and also
for dysrhythmias.
0.8-2.0 ng/mL; HF should have lower end of therapeutic level; dysrhythmias should have higher level
of therapeutic serum.

Major symptoms of digoxin toxicity

Bradycardia, PVCs, dysrhythmias, visual illusions

Three reasons why ventricular dysrhytmias are induced with digoxin toxicity
1; suppression of AV conduction. 2. increased automaticity. 3. decreased refractory period in
ventricular muscle

Which drugs are effective for treating digoxin toxicity? What is the antidote for Cardiac/Digitalis
Glycosidees
Licocaine (ST) and phenytoin; Digoxin immune Fab (ovine, Digibind; for severe toxicity)

Digitalis toxicity can cause ______ degree, _______ degree, or ________ heart block.
first; second; complete

Which medications have interactions with digitalis? How are these interactions avoided?
Cortisone/potassium wasting diuretics (due to causing hypokalemia); Antacids (which cause
decreased absorption)...Eat foods high in potassium or potassium supplements; stagger antacid
doses with digoxin.

Phosphodiesterase Inhibitors; what is the name of one of these meds; how does it work; how is it
administered and how long; what are important considerations?
Positive inotropics; milrinone lactate; increases stroke volume, caridac output, and vasodilation.
Works by inhibiting phsophodiesterase. It is administered IV no longer than 48-72 hours. Important
nursing considerations are close cardiac/ECG monitoring for dysrhythmias.
What are the three ways Arteriolar dilators work?
Reduce after load and increase cardiac output; dilate arterioles of kidneys for fluid loss; improve
circulation to skeletal muscles.

Nursing interventions digoxin

Check apical pulse for one minute and make sure it is above >60 bpm before admin; determine signs
for pulmonary and peripheral edema (HF); monitor serum digoxin (0.8-2) and serum potassium (3.5-
5).

Diet for Digoxin

high in potassium; fresh/dried fruits, fruit juices, vegetables (potatoes)

Herbal interactions with Digoxin (8)

Ginseng ↑ false digoxin levels; St. Johns Wart ↓ absorption of digoxin; Psyllium ↓ digoxin
absorption; Hawthrom ↑ effect of digoxin; Licorice ↑ potasssium loss; Aloe ↑ potassium loss; Ma-
huang or ephedra ↑ toxicity; Goldenseal ↓ effects of digoxin and antidysrhythmics

ACE inhibitors for HF; how do they work; what major drug interactions and side effects can cause
problems
Usually prescribed; dilate venules and arterioles, moderately reduce aldosterone (↓ sodium and fluid
retention); Can increase serum potassium levels especially with potassium sparing diuretics.

Angiotensin II receptor blockeres (ARBs); name main drugs; why are they used
valsartan (Diovan) and candesartan (Atacand); approved for HF; used when ACE inhibitors are
contraindicated.

Potassium sparing diuretic; name of drug;how does it work; recommended dose; nursing
considerations; what does it treat
spironolactone (Aldactone); blocks the production of aldosterone (↑ sodium/water excretion and ↓
potassium excretion). Decreases myocardial fibrosis; RDA 12.5-25 mg/day; hyperkalemia occurs with
>50 mg/day, but levels should still be monitored.

Beta Blockers HF
Should be started very low doses and gradually increased; improve cardiac performance; one to three
months for therapeutic effect to develop.

Nesirtide (Natrecor)
Natriuretic peptide hormone; inhibits ADH and increases sodium loss. Causes vasodilation, natiuresis,
and diuresis. Usesful for acute decompensated HF with dyspnea.

BiDil
Combo of hydralazing (BP) and isosorbide dinitrate (dilator for heart pain); uses specifically for African
Americans.

Nonpharmacologic ways to avoid angina attacks

avoid heavy meals, smoking, extreme weather changes, stenuous exercise, emotional upset
Antianginal Drugs for Variant angina
Use CCBs and/or nitrates; BBs can affravate.

Antianginal Drugs for Unstable Angina

Medical emergency; nitrates given sublingually or IV; if the pain is not relieve then give BBs IV; if
patient cannot tolerate give CCBs.

How do Calcium channel blockers work to help angina

Dilate arterioles to decrease afterload and O2 demand. Only Verapamil and diltiazem decrease HR
and contractility

How do Beta Blockers work to help angina

Decrease HR and contractility

Sublingual Nitroglycerin
Absorbed into the internal jugular vein; 40-50% of nitrates inactivated by liver if administered via GI.

Nitroglycerin Pharmacodynamics
Acts directly on smooth muscle; decreases preload (amount of blood in ventricle at the end of
diastole); and decreases afterload (peripheral vascular resistance); and reduces myocardial O2
demand.

Onset of action of Nitro; Sublingual; transdermal.

SL (1-3) minutes; transdermal (30-60 minutes)

Duration of action of nitro ointment?

6-8 hours.

What happens with abrupt withdrawal of nitro? What happens with rapid admin of nitro?
Myocardial ischemia; reflex tachycardia (HR increases because of overcompensation of cardiovascular
system)

Drug interactions of Nitro

BBs, CCBs, Vasodilators, and Alcohol enhance nitro effect; IV nitro antagonize effects of heparin

BBs are best for what kind of angina

Stable

Abrupt discontinuation of BBs

reflex tachycardia and angina

Conditions that are contraindication to use BBs

Decreased HR or BP, and second or third degree AV block
Nonselective BBs; name some medications; what do they do
pindolol, nadolol, propanolol; decrease HR and cause bronchoconstriction act strongly on beta 1.

Selective BBs; name some meds; what angina do they control best
metoprolol, atenolol; best for controlling angina pectoris

Half life of propanolol? Half life of atenolol? Half life of Metprolol?

3-6 h; 6-7h; 3-7

Propanol and metprolol are excreted where? Where is atenolol excreted from? IV BBs are excreted
where?
Metabolized and excreted by liver; 50% excreted unchanged in feces; 85% excreted in urine within 24
hours.

Onset,Peak and duration of non selective BBs? Of cardioselective? Of selective metoprolol

NS; 30 min, 1-1.5 h, 4-12 h; CS; 60 m, 2-4 h, 24 h. SM; 15 m, duration 6-12 h

Side effects/adverse reactions of BBs? Any nursing considerations

Nonselective can cause bronchospasm, psychotic response, taper off for 1 to 2 weeks and monitor
vitals closely.

CCVs used for long term treatment of angina

verapamil, nifedipine, diltiazema

Absorption of CCBs and bioavailability if they are metabolized

80-90% absorbed through GI; first pass decreases the availability to; 20% (Verapamil), 45-65%
(diltiazem), 35-40% (nifedipine).

Are CCBs protein bound? What is the half life of main LT drugs
Highly protein bound; 2-9 hours.

The most potent CCB is and which CCB causes bradycardia as the most common problem
Nifedipine; Verapamil

Onset of action and duration of; verapamil, nifedipine, and diltiazem.

verapamil; 10 m, 3-7h. nifedipine and diltiazem; 30 m, 6-8 h

Nursing considerations CCBs

Assess for peripheral edema, assess serum liver enzymes.

Drug alert Nifedipine (immediate release capsules)

SCD; only used in hospital
Nitroglycerin not used for marked __________ or ____________ __________- ___________
hypotension; acute myocardial infarction

Nursing interventions nitro

give sips of water before SL (dry mouth can ↓ absorption), place patient in supine position with legs
elevated if hypotension from SL results.

Constipation facts
-it's a symptom, not a disease
-can be caused by a variety of diseases or drugs
-it's about consistency not quantity

Constipation causes
-ignore urge
-low residue diet
-decreased activity
-stress
-excessive laxative use
-decreased fluids

Ideal laxative function

-non irritant
-non toxic
-rapid action with normal stool
-one stool with no residue
-work in lower GI tract - descending colon
-not interfere with nutrient absorption

Laxative therapy
-bowel prep
-cardiovascular disease (decrease strain)
-parasites
-poisoning
-constipation
-any condition where straining is to be avoided

Actions of Drugs Used to Affect Motor Activity of the GI Tract

-speed up or improve movement
-increase the tone of the GI tract
-decrease movement along the GI tract

three ways laxatives work

-chemical stimulation
-bulk or increased fluid in the lumen
-lubrication of the intestinal bolus

Laxatives indications
-short term relief of constipation
-diagnostic procedures
Types of laxatives
Stimulants
Bulk forming
saline cathartics (Osmotic)
lubricants

Stimulant laxatives
-chemical irritation
-selective action on wall of intestine
-effects whole tract
-decreases absorption of digoxin, nitofuration, salicylates, tetracycline, oral anticoagulants
-laxative dependence
-often produce a watery, diarrheal stool

Most common stimulant laxative

bisacodyl (Dulcolax) (OTC)

Bulk laxatives MOA

bulk forming; absorbs water, distends bowel to initiate reflex bowel activity

Bulk forming laxatives

-safest laxative
-large volume of fluids needed, ALWAYS
-decreases absorption of digoxin, nitofuration, salicylates, tetracycline
-more likely to produce "normal" stool

Saline (osmotic) laxatives

-draw water through cell walls
-systemic effect
-used for rapid bowel evacuation
-toxicity, renal insufficiency CV disease, dehydration

GoLYTELY
-used for bowel preps
-moves large amount of H2O into colon
-complete cleanse in 4 hours
-GI procedures

Lactulose
-water drawn into colon
-ammonia from blood passes to colon

Lubricants
lubricate the fecal material and intestinal walls

Example of lubricant
mineral oil
Stool softeners
-promote more water and fat in the stools
-non irritant
-do not stimulate peristalsis
-non dependent

common stool softener

colace (Surfak)

Side effects of laxatives

all laxatives can cause electrolyte imbalances

Laxatives: Nursing Implications

-fluid intake should be encouraged
-long term use of laxatives often results in decreased bowel tone and may lead to dependency
-all laxative tablets should be swallowed whole with 8oz of water

Enemas
-may cause laxative/enema dependence

Suppositories
usually contain stimulant drugs
-common suppository is bisacodyl

Role of the nurse: laxative therapy for bowel evacuation

-peristalsis must be restored prior to laxative therapy
-assess for colon cancer, esophageal obstruction, intestinal obstruction, fecal impaction, undiagnosed
abdominal pain
-if diarrhea occurs, discontinue laxative use
-take with 1-2 glasses of water
-educate patients about proper use

Gastrointestinal stimulant
metoclopramide (Reglan) (leads to increased GI activity and rapid movement of food through the
upper GI tract PO, IV, IM) (prokinetic agent)

contraindications of GI stimulants
increased GI activity can cause GI obstruction

Diarrhea
-it's a symptom
-abnormal passage of frequent watery stools
-untreated diarrhea may cause malnutrition, fluid and electrolyte imbalance and exhaustion

Acute Diarrhea
-sudden onset
-lasts from 3 days to 2 weeks

Chronic Diarrhea
lasts for more than 3 weeks

Pharmacotherapy for severe diarrhea

opioids

Medications for mild diarrhea

loperamide (Imodium)
Probiotic supplements (lactobacillus)

Antidiarrheal therapy
-assess fluid and electrolyte status
-assess patient's ability to get out of bed safely

Actions and indications of antidiarrheal therapy

slow the motility of the GI tract
relief of symptoms

Antidiarrheals; opioids prototype drug

Lomotil