CHAPTER 42: INTRODUCTION TO THE mitral or bicuspid valve- valve on the left side of the heart;
CARDIOVASCULAR SYSTEM composed of two leaflets or cusps
Cardiovascular System
- responsible for delivering oxygen and nutrients to all of
the cells of the body and for removing waste products for
excretion
- consists: 1. heart 2. pump3. interconnected series of tubes
THE HEART
- hollow, muscular organ divided into 4 chambers: atriums (
“porch” or entryway) and ventricles ( lower part)
- is the pump that keeps blood flowing through 60,000 miles
of tubes, constituting the cardiovascular system
*auricle- attached to each atrium; collects blood that is
pumped into the ventricles by arterial contraction
** a partition called a septum separates the right half of the
heart from the left. The right receives deoxygenated blood
from everywhere in the body through the veins ( vessels that
carry blood toward the heart) and directs that blood into the
lungs…
*** arteries- where aorta delivers blood into the systemic
circulation
- vessels that carry blood away from the heart
CARDIAC CYCLE
- … each period of the ventricles followed by a period of
systole= cardiac cycle…
* myocardium
- fibers of cardiac muscle
- form two intertwining networks called atrial and
ventricular syncytia
* Starling’s law of the heart
-occurs when muscle fibers of the heart are stretched by the
increase volume of blood that has returned🡺 spring back to
normal size; is similar to stretching a rubber band…
* Diastole
- the period of cardiac muscle relaxation where the heart
from the systemic and pulmonic veins, w/c flow into the
right and left…
* tricuspid- valve on the right side of the heart; composed
of 3 leaflets or cusps
CONDUCTIVITY
- where the specialized cells of the heart can conduct an
* systole
- the contraction of ventricles
* The heart’s series of one- way valves keeps the blood
flowing on the correct direction, as follows:
1. Deoxygenated blood: right atrium, though tricuspid valve
to right ventricle, through pulmonary valve to the lungs
2. Oxygenated blood: through the pulmonary veins to
ventricle, through aortic valve to the aorta
CONDUCTION SYSTEM OF THE HEART
- consist of:
1. SA node- located in top of the right atrium, acts as the
pacemaker of the heart
2. AV nodes- slows the impulse, allowing for the delay
needed for ventricular filling, and sends it from the atria into
the ventricles by way of the bundle of His
3. Bundle of His- w/c enters the septum and divides into
three bundle branches
4. Bundle branches- w/c conduct impulses through the
ventricles
5. Purkinje fibers- w/c delivers the impulse the ventricular
cells
***Sinoatrial (SA) node
AUTOMATICITY
- where the cells can generate action potentials or electrical
impulses without being excited to do so by external stimuli
5 phases:
1. Phase 0- points of stimulation; where: sodium gates open
along the cell membrane, and sodium rushes into the cell,
resulting in a positive state—an electrical potential🡺 called
depolarization
2. Phase 1- when Na ions concentrations are equal inside
and outside of the cell
3. Phase 2 (plateau stage)- cell membrane becomes less
permeable to Na🡺 Ca slowly enters the cell🡺 K slowly
leaves the cell
4. Phase 3- rapid repolarization 🡺 K rapidly moves out of
the cell
5. Phase 4- cell comes to rest as the sodium- potassium
pump returns the membrane🡺 spontaneous repolarization
begins again
impulse rapidly through the system so that the muscle cells
of the heart are stimulated at approximately the same time…
* absolute refractory period
***** SA node is the dominant influences most of the time,
keeping the resting heart rate at 70 to 80 beats per minute
* Sarcomere- the basic unit of the cardiac muscle
- made up of two contractile proteins: actin (thin filament)
and myosin (thick filament)🡺 kept apart by the protein
troponin
* Degree of shortening- determined by the amount of Ca
present—the more Ca is present, the more bridges will be
formed…
ARRYTHMIA OR DYSRYHTHMIA
- a disruption in cardiac rate or rhythm
- interfere with the work of the heart and can disrupt cardiac
output, which affects every cell in the body
- occurs when there is a shift in the pacemaker of the heart
from the SA node to some other sit, called ectopic focus
FIBRILLATION
- very serious arrhythmias arise when the combination of
ectopic foci and altered conduction set off an irregular,
uncoordinated twitching of the atrial or ventricular muscle
ELECTROCARDIOGRAPHY
-is a process of recording the patterns of electrical impulses
as they move through the heart
- an important diagnostic tool in the care of the cardiac
patients
ELECTROCARDIOGRAPHY MACHINE
- detects the patterns of electrical impulse generation and
conduction though the heart and translates that information
to a recorded pattern
ELECTROCARDIOGRAM
-a measure of electrical activity; provides no information
about the mechanical activity of the heart
The normal ECG pattern is made up of main waves:
1. P wave- formed as impulses originating in the SA node or
pacemaker pass through the atrial tissue
2. P wave- precedes the contraction of the atria
3. Ta wave- appear around the QRS complex
Critical points of the ECG are as follows :
1. P-R interval: reflects the delay of conduction at the AV
node
2. Q-T interval: reflects the critical timing of repolarization
of the ventricles
3. S-T segment: reflects the important information about the
repolarization of the ventricles
TYPES OF ARRHYTHMIAS
1. Sinus arrhythmias
- has a slower- than- to normal heart rate (usually less than
60 beats/ min) w/ Normal- appearing ECG pattern
2. Supraventricular Arrhythmias
- arrhythmias that originate above the ventricles but not in
the SA node
- feature an abnormally shaped P wave
- includes the following:
a. Premature atrial contractions (PAC’s)- reflect an ectopic
focus in the atria that is generating an impulse out of the
normal rhythm
b. Paroxysmal atrial tachycardia (PAT)- runs of rapid heart
originating in the atria
c. Atrial flutter- characterized b sawtooth- shaped P waves
reflecting a single ectopic focus that is generating a regular,
fast atrial depolarization
d. Atrial fibrillation- w/ irregular P waves representing
many ectopic foci firing in an uncoordinated manner
through the atria
3. Ventricular Arrhythmias
- impulses that originate below the AV node originate from
ectopic foci that do not use the normal conduction pathways
ATRIOVENTRICULAR BLOCK
- also called heart block
- reflects a slowing or lack of conduction at the AV node
-occur because of structural damage, hypoxia, or injury to
the heart muscle
- First degree of heart block= P-R interval beyond the
normal 0.16 to 0.20 seconds
CARDIOVASCULAR SYSTEM
CIRCULATION
- follows two courses:
1. Heart lung or pulmonary circulation: the right side of the
heart sends blood to the lungs, where carbon dioxide and
some waste products are removed from the blood and
oxygen is picked up by the red blood cells
2. Systemic circulation: the left side of the heart sends
oxygenated blood out to all of the cells in the body
* resistance system
- also referred as arterial system
- where the vessels can either constrict or dilate, increasing
or decreasing resistance, based on the needs of the body
* capillary system
- where blood from tiny arterioles flows
- connects the arterial and venous system
* capillary fluid shift
- shifting of fluid in the capillaries
- carefully regulated between hydrostatic (fluid pressure)
forces in the arterial end of the capillary and oncotic
pressure ( the pulling pressure of the large, vascular
proteins)
*Capacitance system
- also referred as venous system
- where the veins has the capacity to hold large quantities of
fluid
* sinuses of Valsalva
- where the myocardium receives its blood through 2 main
coronary arteries that branch off the base of the aorta
*coronary arteries
- these arteries encircle the heart in pattern resembling a
crown
*pulse pressure
- the pressure that fills the coronary arteries
- it is systolic minus diastolic blood pressure readings
* end- artery circulation
- a pattern of circulation
The main forces hat determine the heart’s use of oxygen or
oxygen consumption are as follows:
1. Heart rate: the more the heart has to pump, the more
oxygen it will require to do that
2. Preload ( amount of blood that is brought back to the
heart to be pumped around): the more blood that is returned
to the heart, the harder it will have to work to pump the
blood around. The volume of blood that is determinant of
preload
3. Afterload ( resistance against which the heart has to beat):
The higher the resistance in the system, the harder the heart
will have to contract to force open the valves and pump the
blood along. The blood pressure is measure of afterload
SYTEMIC ARTERIAL PRESSURE
* Hypotension
- occur if the blood pressure falls, either from the loss of
blood flowing from high- pressure to low pressure areas
- if severe, it can progress to shock and even death as cells
are cut off from their oxygen supply
* Hypertension
- excessive high blood pressure
- can damage the fragile lining of blood vessel
- cause disruption of blood flow to the tissues
- caused by neurostimulation of the blood vessels that cause
them to constrict and to raise pressure
* Vasomotor Tone
- work to dilate the vessels if more blood flow is needed in
an area
*Cardiovascular center
- the coordination of these impulses through the medulla
RENIN – ANGIOTENSIN SYSTEM
-determinant of Blood pressure
- activated when the blood flow to the kidneys is decreased
-…cells in the kidney release an enzyme called rennin
- Angiotensin I travels to lungs 🡺 Angiotensin- converting
enzyme (ACE) 🡺 reacts 🡺 Angiotensin II =
Vasoconstriction
(read: p. 635)
CONGESTIVE HEART FAILURE
- if the heart fails to do its job of effectively pumping
through the system, blood backs up and system becomes
congested
- results: hydrostatic pressure on the venous end of the
capillaries
 CHAPTER 43: DRUGS AFFECTING BLOOD PRESSURE α-adrenergic inhibit postsynaptic α1-adrenergic receptors, Drug-Drug Interactions
blockers ↓ sympathetic tone in the vasculature and - allopurinol = risk of hypersensitivity reactions ↑
- altering the body’s regulatory mechanisms causing vasodilation; diagnose and manage
- alter the normal reflexes that control BP episodes of pheochromocytoma Food-Food Interactions
- does not cure the disease but is aimed at maintaining the BP α1-blockers block postsynaptic α1-receptor sites, ↓ - food = absorption of oral ACE inhibitors ↓
within normal limits to prevent the damage that hypertension vasculature and causing vasodilation; do
can cause not block presynaptic α2-receptor sites Nursing Considerations
α2-agonists stimulate α2-receptors in the CNS and - encourage patient to implement lifestyle changes
Stepped-Care Approach to Treating Hypertension inhibit the CV centers, ↓BP; many adverse - administer on empty stomach, 1 or 2 hours before meals
- by the Seventh Joint National Committee on Prevention, CNS, GI effects, cardiac dysrhythmias - monitor fluid volume
Detection, Evaluation, and Treatment of Hypertension, from
the National Institute of Health Angiotensin-Converting Enzyme (ACE) Inhibitors Angiotensin II Receptor Blockers (ARBs)
- selectively bind the angiotensin II receptors in blood vessels
Step 1: Lifestyle Modifications - block the conversion of angiotensin I to angiotension II in the to prevent vasoconstriction
o weight reduction lungs - prevents the release of aldosterone in the adrenal cortex
o reduction of sodium intake - as monotherapy or combined with diuretics
o moderation of alcohol intake Prototype: losartan (Cozaar)
o smoking cessation Prototype: captopril (Capoten) - used alone or as part of combination therapy
o increased physical activity - for hypertension, congestive heart failure (CHF), diabetic - treatment of diabetic neuropathy with an elevated serum
neuropathy, left ventricular dysfunction after MI creatinine an d proteinuria
Step 2: Inadequate Response - associated with fatal pancytopenia, cough, GI distress
o continue lifestyle modifications Therapeutic Actions and Indications
o initial drug selection Therapeutic Actions and Indications - selectively bind with angiotensin II receptor sites in vascular
1. diuretic or β-blocker - ↓ BP and aldosterone release smooth muscle and in the adrenal gland to block
2. ACE inhibitor, calcium channel blocker, - indicated for treatment of hypertension, alone or with other vasoconstriction and aldosterone release
α-blocker, α- and β-blocker drugs - treatment of hypertension and for CHF in patients who are
intolerant to ACE inhibitors
Step 3: Inadequate Response Pharmacokinetics
o increase drug dose, or - well absorbed, widely distributed Pharmacokinetics
o substitute another drug, or - metabolized in liver, excreted in urine and feces - well absorbed, metabolized in liver
o add a second drug from another class - cross the placenta and associated with serious fetal - excreted in urine and feces
abnormalities - crosses the placenta, associated with serious fetal
Step 4: Inadequate Response abnormalities and death
o add a second or third agent or diuretic if not already Contraindications
prescribed - allergy Contraindications
- impaired renal function - allergy
Diuretics - pregnancy and lactation - pregnancy and lactation
- ↑ the excretion of sodium and water from the kidney
- first agents tried in mild hypertension Caution Cautions
- ↑ urination and disturb electrolyte and acid-base balances - CHF - hepatic or renal dysfunction
- salt/volume depletion - hypovolemia
Sympathetic Nervous System Blockers
- block the effects of the SNS Adverse Effects Adverse Effects
- useful in blocking many of the compensatory effects of the - effects of vasodilation and alterations in blood flow - headache, dizziness, syncope, weakness
SNS o reflex tachycardia, chest pain, angina, CHF, cardiac - hypotension, GI complaints
arrhythmias - symptoms of upper respiratory tract infections and cough
β-blockers block vasoconstriction; ↓ HR; ↓ muscle o GI irritation, ulcers, constipation, liver injury - rash, dry skin, alopecia
cardiac contraction; ↑ blood flow to kidneys; o renal insufficiency, renal failure, proteinuria
used in monotherapy in Step 2 o rash, alopecia, dermatitis, photosensitivity Drug-Drug Interactions
α- and β-blockers blocking of all receptors in SNS; patients - unrelenting cough - phenobarbital = risk of ↓ serum levels and loss of
complain of fatigue, loss of libido, inability to - associated with fetal pancytopenia and MI effectiveness ↑
sleep, GI and GU disturbances
Nursing Considerations - treatment of hypertensive crisis and maintain controlled ANTIHYPOTENSIVE AGENTS
- encourage patient to implement lifestyle changes hypertension during surgery
- administer without regard to meals; give with food - toxic levels cause cyanide toxicity - severe hypotension leads to shock
- suggest use of barrier contraceptives - sympathomimetic drug: first choice drug for treating shock
- monitor fluid volume Therapeutic Actions and Indications
- act directly on vascular smooth muscle to cause muscle Sympathetic Adrenergic Agonists
Calcium Channel Blockers relaxation, leading to vasodialtion and drop in BP - effects of a sympathetic stress response:
- prevent the movement of calcium into the cardiac and o ↑ BP
smooth muscle cells Pharmacokinetics o ↑ blood volume
- when the cells are stimulated - rapidly absorbed and widely distributed o ↑ strength of cardiac muscle contraction
- leading to loss of smooth muscle tone, vasodilation, ↓ - metabolized in the liver and excreted in urine
peripheral resistance - cross the placenta and enter breast milk only drug: midodrine (ProAmatine)
- ↓ BP - treat orthostatic hypotension
- very effective for treatment of angina Contraindications
- allergy Therapeutic Actions and Indications
Prototype: diltiazem (Cardizem, Tiamate) - pregnancy and lactation - activates alpha-receptors in arteries and veins to ↑ in
- sustained-release preparation - cerebral insufficiency vascular tone and BP
- treatment of hypertension - indicated for the symptomatic treatment of orthostatic
Cautions hypotension
Therapeutic Actions and Indications - peripheral vascular disease, CAD, CHF, tachycardia
- inhibit the movement of calcium ions across the membranes Pharmacokinetics
of myocardial and arterial muscle cells Adverse Effects - rapidly absorbed in GI tract
- related to changes in BP - metabolized in liver and excreted in urine
Pharmacokinetics - cyanide toxicity may occur with nitroprusside
- well absorbed, metabolized in liver, excreted in urine o dyspnea o imperceptible pulse Contraindications
- cross the placenta, enters breast milk o headache o absent reflexes - supine hypertension, CAD, pheochromocytoma
o vomiting o dilated pupils - acute renal disease
Contraindicaitons o dizziness o pink color - urinary retention
- allergy o ataxia o distant heart sounds
- heart block or sick sinus syndrome o loss of o shallow breathing Cautions
- renal or hepatic dysfunction consciousness - pregnancy and lactation
- pregnancy or lactation - visual problems
Nursing Considerations - renal or hepatic impairment
Adverse Effects - monitor BP and fluid volume
- CNS effects Adverse Effects
- GI effects Other Hypertensive Agents - related to stimulation of alpha-receptors
- CV effects o piloerection, chills, rash
- skin flushing, rash only drug: mecamylamine (Inversine) o hypertension, bradycardia
- ganglionic blocker that occupies cholinergic receptor sites of o dizziness, vision changes, vertigo, headache
Drug-Drun Interactions autonomic neurons, blocking the effects of acetylcholine at o problems with urination
- cyclosporine = ↑ serum levels and toxicity of cyclosporine both sympathetic and parasympathetic ganglia
- can cause Drug-Drug Interactions
Vasodilators o severe hypotension, CHF - risk of ↑ effects and toxicity of cardiac glycosides,
- produce relaxation of the vascular smooth muscle, ↓ o CNS symptoms of dizziness, syncope, weakness, beta-blockers, alpha-adrenergic agents, corticosteroids if
peripheral resistance and reducing BP vision changes taken with midodrine
- do not block reflex tachycardia o parasympathetic blocking symptoms of dry mouth,
- reserved for use in severe hypertension and hypertensive glossitis, nausea, vomiting, constipation, urinary Nursing Considerations
emergencies retention - monitor BP
o impotence - do not administer to bedridden patients
Prototype: nitroprusside (Nitropress) - monitor HR regularly
- used intravenously - monitor patients with visual problems
- encourage patients to void before taking drug
 CHAPTER 44: CARDIOTONIC
AGENTS
Congestive heart failure (CHF)
-condition where the heart fails to effectively
pump blood around the body
- called “dropsy’ or compensation
TREATMENTS OF CHF:
1. VASODILATORS
- used to treat CHF because they can decrease
the workload of the overworked cardiac
muscle
2. DIURETICS
- use to decrease blood volume, which
decreases venous return and blood pressure
- end result: decrease in afterload and preload
and a decrease in the heart’s workload
3. BETA- ADRENERGIC AGONISTS
- stimulate the beta receptors in the
sympathetic nervous system, increasing
calcium flow into the myocardial cells and
causing increased contraction, positive
inotropic effect
4. CARDIOTONIC DRUGS
- drugs that affect the intracellular calcium
levels in the heart muscle, leading to increased
contractility
- increase in contraction strength leads to
increased cardiac output, which causes
increased renal blood flow decreases rennin
release
-increases urine output
-decreased blood flow
- relieve CHF
- has two types:
A. CARDIC GYCOSIDES
- used for hundred of years
- derived form foxglove or digitalis plant
Drugs:
1. Digoxin (Lanoxin, Lanoxicaps)
-treatment of acute congestive heart failure,
atrial arrhythmias
* THERAPEUTIC ACTIONS
1.increase intracellular calcium and allow
more calcium to enter myocardial cells during
depolarization, causing following effects:
a. Increased force of myocardial contraction
b. Increased cardiac output and renal perfusion
c. Slowed heart rate
d. decreased conduction velocity through the
artrioventricular node
**PHARMACOKINETICS
1. absorbed widely
2. excreted unchanged in urine
3. caution w/ presence of renal impairements
4. not given during pregnancy
5. enters breast milk
*** CONTRAINDICATION
1. presence of allergy
2. tachycardia or fibrillation
3. heart block or sick sinus syndrome
4. idiopathic hypertrophic subaortic stenosis
(IHSS)
5. acute MI
6. renal insufficiency
7. electrolyte abnormalities
****CAUTION
1. pregnant or lactating women
2. **pediatric and geriatric patients
*****ADVERSE EFFECTS
1. headache, weakness, drowsiness and vision
changes
2. GI upset and anorexia
3. risk of arrhythmia development
*****DRUG-DRUG INTERACTION
1. taken with veramil, aminodarone, quinidine,
quinine, erythromycin, tetracycline or
cyclosporine = increased therapeutic effects
NURSING CONSIDERATION
DIAGNOSIS
1. Risk for deficient fluid volume related to
diuresis
2. Ineffective Tissue perfusion related in
cardiac output
3. Impaired Gas exchanged related to changes
in Cadiac Output
4. Deficient Knowledge regarding drug
therapy
IMPLEMENTATION
1. Consult with the prescriber about the end
for a loading dose when beginning therapy
2. Monitor apical pulse for 1 full minute
before administration of drugs
3. Monitor pulse for any change in quality or
rhythm
4. check for dosage and preparation carefully
5. Check pediatric dosage with extreme extra
care
6. follow dilution instructions
7.administer IV doses very slowly at least 5
minutes
8. Avoid IM administration
9. Arrange the patient to be weighed
10. Avoid administering oral drug with food or
antacids
11. Monitor patient digoxin level ( 0.5 to 3
ng/mL)
B. PHOSPHODIESTERASE INHIBITORS
- belong to a second class of drugs that act as
cardiotonic (intropic) agents
Drugs:
1. Inamripone (Inocor)
- treatment of adults with congestive heart
failure not responsive to digoxin, diuretics or
vasodilators
2. Milrinone (Pimacor)
- shorterm management of CHF in adults
receiving digoxin and diuretics
*THERAPEUTIC ACTIONS
1. block the enzyme phosphodiesterase
2. leads to an increase in myocardial cell
cyclic adenosine monophosphate (cAMP)
3. increases calcium levels in the cells
4. increased cellular calcium causes
contraction and prolongs effects of
sympathetic stimulation
5. indicated for shortterm CHF that has not
responded to digoxin or diuretics
**PHARMACOKINETICS
1. widely distributed after injection
2. metabolized in the liver
3. excreted in the urine
***CONTRAINDICATIONS
1. has allergy
2. w/ severe aortic or pulmonic valvular
disease
3. fluid volume deficit
****CAUTIONS
1. Elderly
2. pregnant or lactating women
***** ADVERSE EFFECTS
1. ventricular arrhythmias, hypotension and
chest pain
2. GI effects: nausea, vomiting, anorexia,
abdominal pain
3. Thrombocytopenia
4. hypersensitivity reactions: vasculitis,
pericarditis, pleurititis, and ascites
*******DRUG-DRUG INTERACTION
1. avoid Fluosemide ( Diuretics)
NURSING CONSIDERATIONS
DIAGNOSIS
1. decreased cardiac output related to
arrhythmias or hypotension
2. risk for injury related to CNS or
Cardiovascular effects
3. Innefective tissue perfusion related to
hypotension or arrythmias
4. Deficient knowledge regarding drug
therapy
IMPLEMENTATION
1. Protect drug form light
2. monitor input and output
3. monitor platelet count
4. monitor injection sites
 CHAPTER 45 - depress Phase 0 somewhat and actually shorten the - oral anticoagulants = ↑ risk for bleeding
ANTIARRHYTHMIC AGENTS duration of the action potential
o lidocaine (Xylocaine) Drug-Food Interactions
CORONARY ARTERY DISEASE (CAD) o mexiletine (Mexitil) - foods that alkalize urine (citrus juices, vegetables, antacids,
milk products) = ↑ quinidine levels and toxicity
- progressive growth of atheromatous plaques, or Class IC Drugs - grapefruit juice = ↑ serum levels and toxic effects
atheromas in the coronary arteries - markedly depress Phase 0, with a resultant extreme
→ plaques begin as fatty streaks in the endothelium slowing of conduction Nursing Considerations
→ they injure the endothelial lining o flecainide (Tambocor) - monitor cardiac rhythm
→ development of foam cells (by inflammatory o propafenone (Rythmol) - maintain life support equipment on standby
process) - give parenteral forms only if the oral form is not feasible
→ platelets, fibrin, other fats, and remnants collect on Therapeutic Actions and Indications - titrate the dose to the smallest amount needed
the injured vessel lining - binding to Na channels, depressing Phase 0 of action
→ cause atheroma to grow potential, changing the duration of action potential Class II Antiarrhythmics
→ blood vessel narrows and limits blood flow - have a local anesthetic effect
- injury to the vessel also causes scarring and thickening - treatment of potentially life-threatening ventricular - beta-adrenergic blockers that block beta receptors, causing
of cell wall arrhythmias a depression of Phase 4 of the action potential
- slow the recovery of cells, leading to slowing of conduction
✔ the softer, more lipid atheromas appear to be more likely Pharmacokinetics and ↓ automaticity
to rupture than stable, harder cores - widely distributed after injection of after rapid absorption
through the GI tract
- undergo hepatic metabolism Prototype: propanolol (Inderal)
ANTIARRHYTHMIC DRUGS - excreted in urine - used as an antihypertensive, antianginal, antimigraine
- cross the placenta and enter breast milk headache drug and as an antiarrhythmic to treat
- affect the action potential of the cardiac cells, altering their supraventricular tachycardias caused by digoxin or
automaticity, conductivity, or both Contraindicaitons catecholamines
- proarrhythmic: can also produce new arrhythmias - allergy
- used in emergency situations when the hemodynamics - bradycardia or heart block Therapeutic Actions and Indications
arising from the patient’s arrhythmia are severe and fatal - CHF, hypotension, shock - competitively block beta-receptor sites in the heart and
- may block reflex arrhythmias and help keep the CV system - electrolyte disturbances kidneys
in balance, or they may precipitate new, deadly arrhythmias - stabilize excitable cardiac tissue and ↓ BP
Cautions - indicated for the treatment of supraventricular tachycardias
Class I Antiarrhythmics - renal or hepatic dysfunction or PVCs
- pregnancy
- block the sodium channels in the cell membrane during an Pharmacokinetics
action potential Adverse Effects - absorbed from GI tract, hepatic metabolism, excreted in
- local anesthetics or membrane-stabilizing agents - associated with their membrane-stabilizing effects and urine
- preferable in situations such as tachycardia effects on action potentials - used only when the benefit to the mother outweighs the
o CNS effects risk to the fetus
Class IA Drugs o GI effects
- depress Phase 0 of the action potential and prolong the o CV effects Contraindications
duration of the action potential - respiratory depression and respiratory arrest - sinus bradycardia (rate less than 45 beats/min) and AV
o disopyramide (Norpace) - rash, hypersensitivity reactions, loss of hair, bone marrow block
o moricizine (Ethmozine) depression - cardiogenic shock, CHF, asthma, respiratory depression
o procainamide (Pronestyl) - pregnancy and lactation
o quinidine (Quinaglute) Drug-Drug Interactions
- digoxin, beta-blockers = ↑ risk for arrhythmias Cautions
Class IB Drugs - digoxin = ↑ digoxin levels and digoxin toxicity - diabetes and thyroid dysfunction
- cimetidine = ↑ serum levels and toxicity - renal and hepatic dysfunction
 Adverse Effects - related to their vasodilation of blood cells throughout the
Adverse Effects - related to the changes they cause in action potentials body
- related to the effects of blocking beta receptors in the SNS o nausea, vomiting, GI distress o CNS effects
o CNS effects o weakness and dizziness o GI effects
o CV effects o hypotension, CHF, arrhythmias - hypotension, CHF, shock, arrhythmias, edema
o respiratory effects - fever toxicity, ocular abnormalities, serious cardiac
o GI effects arrhythmias Drug-Drug Interactions
- loss of libido, ↓ exercise tolerance, alterations in blood - beta-blockers = ↑ risk of cardiac depression
glucose levels Drug-Drug Interactions - digoxin = additive AV slowing
- digoxin or quinidne = serious toxic effects - dogixin, carbamazepine, prazosin, quinidine = ↑ serum
Drug-Drug Interactions levels and toxicity
- verapamil = ↑ risk of adverse effects Class IV Antiarrhythmias - atracurium, gallamine, metocurine, pancuronium,
- insulin = ↑ hypoglycemia rocuronium, tubocurarine, vecuronium = ↑ respiratory
- block Ca channels in the cell membrane, leading to depression
Nursing Considerations (same as Class I Antiarrhythmics) depression of depolarization and a prolongation of Phases - calcium products or rifampin = ↓ effects
1 and 2 of repolarization, slowing automaticity and - given IV within 48 hours if IV beta-adrenergic drugs = risk
Class III Antiarrhythmics conduction of severe cardiac effects
- diltiazem + cyclosporine = ↑ serum levels and toxicity
- block K channels, prolonging Phase 3 of the action Prototype: diltiazem (Cardizem)
potential, which prolongs repolarization and slows the rate - administered IV Nursing Considerations (same as Class I Antiarrhythmics)
and conduction of the heart - treat paroxysmal supraventricular tachycardia
Other Drugs Used to Treat Arrhythmias
Prototype: sotalol (Betapace, Betapace AF) Therapeutic Actions and Indications
- indicated for the treatment of documented life-threatening - block the movement of Ca ions across the cell membrane, adenosine (Adenocard)
arrhythmias and maintenance of normal sinus rhythm depressing the generation of action potentials, delaying - convert supraventricular tachycardia to sinus rhythm
- proarrhythmic Phases 1 and 2 or repolarization, and slowing conduction - drug of choice for terminating supraventricular tachycardia
through the AV node. o very short duration of action (15 sec), picked up by
Therapeutic Actions and Indications - treatment of supraventricular tachycardia and to control the circulating RBCs, and cleared through the lvier
- block K channels and slow the outward movement of K ventricular response to rapid atrial rates o associated with very few adverse effects
during Phase 3 of the action potential
- indicated for Pharmacokinetics digoxin (Lanoxin, Lanoxicaps)
o life-threatening ventricular arrhythmias - well absorbed - slows Ca from leaving cell, prolonging the action potential
o conversion of recent-onset atrial fibrillation or atrial - metabolized in liver and excreted in the urine and slowing conduction and HR
flutter to normal sinus rhythm - used only when the benefit to the mother outweighs the - treatment for atrial arrhythmias
o maintenance of sinus rhythm after conversion of atrial risk to the fetus - positively inotropic, leading to ↑ cardiac output
arrhythmias
Contrindications Nursing Considerations (same as Class I Antiarrhythmics)
Pharmacokinetics - allergy
- well absorbed and widely distributed - sick sinus syndrome or heart block
- metabolized in the liver - lactation
- excreted in the urine - CHF or hypotension
- used only when the benefit to the mother outweighs the
risk to the fetus Caution
- idiopathic hypertrophic subaortic stenosis (IHSS)
Cautions - impaired renal or liver function
- shock, hypotension, respiratory depression, prolonged QTc
interval
- renal or hepatic disease
Adverse Effects
CHAPTER 46: ANTIANGINAL AGENTS
ANTIANGINAL DRUGS
- are used to help restore the supply- and- demand
ratio in oxygen delivery to the myocardium when
rest is not enough
- these drugs can work to improve blood delivery
to the heart muscle in 2 ways:
1. by dilating blood vessels ( e.i. increasing the
supply of oxygen)
2. by decreasing the work of the heart (i.e.
decreasing the demand of oxygen)
I. Nitrates
- are drugs that act directly on smooth muscle to
cause relaxation and to depress muscle tone
- decreases: preload, afterload, myocardial
contractility , oxygen demand
Prototype: Nitrogylcerin (Nitro-Bid, Nitrostat)
- treatment of acute angina attack; prevention of
anginal attacks
Therapeutic Actions and Indications
- direct relaxation of smooth muscle with a
resultant decrease in venous return and decrease in
arterial pressure, effects that reduce cardiac
workload and decrease myocardial oxygen
consumption
Pharmacokinetics
1. rapidly absorbed
2. metabolized in liver
3. excreted in urine
4. cross placenta
5. enter breast milk
Contraindications:
1. presence of allergy
2. w/ severe anemia
3. w/ head trauma or cerebral hemorrhage
4. during pregnancy and lactation
Caution
1. patients with hepatic or renal disease
2. w/ hypotension, hypovolemia, and conditions
that limit cardiac output
Adverse Effects
1. CNS effects: headache, dizziness, weakness
2. GI effects: nausea, vomiting, incontinence
3. cardiovascular problems: hypotension, reflex
tachycardia, syncope, angina
4. skin related effects: flushing, pallor, increased
perspiration
5. dermatitis and local hypersensitivity reactions
Dug- drug interaction
● ergot derivatives= risk of hypertension
and decreased anti- anginal effects
● heparin = decreased effects
Nursing Considerations:
1. Give SQ preparations in the tongue or in buccal
pouch, and encourage the patient not to swallow
2. ask the patient if the tablet “ fizzles” or burns
3. Give sustained- release forms with water and
caution the patient not patient not to chew or crush
them
4. Rotate the sites of topical forms
5. Make sure that transligual spray is used to under
the tongue and not inhaled
6. Break an amyl nitrate capsule and wave it under
the nose of the angina patient
7. Taper the dosage gradually
II. Beta- Blockers
- used to block the stimulatory effects of the
sympathetic nervous system
- block beta- adrenergic receptors and
vasoconstriction
- prevent the increase in heart rate and increased
intensity of myocardial contractility that occur with
sympathetic stimulation such as exertion or stress
- decrease the cardiac workload
Prototype: metoprolol (Toprol, Toprol XL)
- treatment of stable angina pectoris and
hypertension; prevention of reinfarction in MI
patients, and treatment of stable, symptomatic CHF
Therapeutic Actions and Indications
1. completely block- adrenergic receptors in the
heart and juxtaglomerular apparatus, decreasing
the influence of the sympathetic nervous system on
these tissues and thereby decreasing the
excitability of the heart, decreasing cardiac output,
decreasing cardiac oxygen compensation and
lowering blood pressure
Pharmacokinetics
1. absorbed from the GI tract and undergo hepatic
metabolic
2. found to increase bioavailability of propranolol,
but this effect has not been found with other beta-
adrenergic blocking agents
3. excreted in the urine
4. has teratogenic effects
Contraindications:
1. w/ bradycardia, heart block, cardiogenic shock,
asthma, or COPD
2. pregnancy and lactation
Caution:
1. with diabetes, peripheral vascular disease or
thyrotoxicosis
Adverse Effects
1. CNS effects: dizziness, fatigue, emotional
depression and sleep disturbances
2. GI problems: gastric pain, nausea, vomiting ,
colitis and diarrhea
3. Cardiovascular effects: congestive heart failure,
reduced cardiac output, and arrhythmias
4. Respiratory symptoms: bronchospasm, dyspnea,
and cough
Drug- Drug interaction 4. Skin effects: flushing and rash
1. beta blockers= paradoxical hypertension
2. w/ clonidine= withdrawal Drug-Drug interactions
1. toxicity of cyclosporines if taken w/ diltiazem
NURSING CONSIDERATIONS ( same with beta 2. increased risk of heart block and digoxin
blockers : Chapter 31) toxicity if combined with verapamil

III. CALCIUM CHANNEL BLOCKERS NURSING CONSIDERATIONS

-prevent the movement of calcium into the cardiac
and smooth muscle cells when the cells are
stimulated, interfering with their ability to contract
Prototype: diltiazem ( Cardizem, Cardizem SR)
- treament of prinzmetal’s angina, effort-
associated angina, chronic stable angina; used to
treat essential hypertension, paroxysmal
supraventricular tachycardia
1.monitor patient’s blood pressure, cardiac rhythm,
cardiac output while the drug is titrated or dosage
is being changed
2. Monitor blood pressure very carefully if the
patient is also taking nitrates
3. Periodically monitor blood pressure and cardiac
rhythm while the patient is using these drugs

Therapeutic Actions and Indications

● inhibit the movement of calcium ions across
the membranes of myocardial and arterial
muscle cells, altering the action potential and
blocking muscle cell contraction

Pharmacokinetics
1. well absorbed
2. metabolized in the live
3. excreted in urine
4. cross placenta and enter milk
5. fetal toxicity reported

Contraindications
1. presence of allergy
2. with heart block or sick sinus syndrome
3. with renal or hepatic dysfunction
4. during pregnancy and lactation

Adverse Effects
1. CNS effects: dizziness, light- headedness,
headache, fatigue
2. GI effects: nausea and hepatic injury
3. Cardiovascular effects: hypotension,
bradycardia, peripheral edema, and heart block
 CHAPTER 47
LIPID-LOWERING AGENTS
CORONARY ARTERY DISEASE (CAD)
- progressive growth of atheromatous plaques,
or atheromas in the coronary arteries
→ plaques begin as fatty streaks in the
endothelium
→ they injure the endothelial lining
→ development of foam cells (by
inflammatory process)
→ platelets, fibrin, other fats, and remnants
collect on the injured vessel lining
→ cause atheroma to grow
→ blood vessel narrows and limits blood flow
- injury to the vessel also causes scarring and
thickening of cell wall
✔ the softer, more lipid atheromas appear to be
more likely to rupture than stable, harder cores
ANTIHYPERLIPIDEMIC AGENTS
- often used in combination
- should be part of an overall health care regimen
that includes exercise, dietary restrictions, and
lifestyle changes to ↓ risk of CAD
Bile Acid Sequestrants
Prototype: cholestyramine (Questran)
- powder mixed with liquids and taken up to 6
times a day
Therapeutic Actions
→ bind with bile acids in the intestine to form a
complex that is excreted in the feces
→ liver must use cholesterol to make more bile
acids
→ ↓ serum levels of cholesterol and LDLs
Indications
- reduce serum cholesterol in patients with
primary hypercholesterolemia as an adjunct to
diet and exercise
- cholestyramine: treat pruritus associated with
partial biliary obstruction
- absorbed from GI tract
Pharmacokinetics - first-pass metabolism in liver
- form an insoluble complex - excreted through feces and urine
- excreted in feces - pregnancy category X
- not absorbed systematically
Contraindications
Contraindications - allergy
- allergy - active liver disease or history of alcoholic liver
- complete biliary obstruction disease
- abnormal intestinal function - pregnancy or lactation
- pregnancy or lactation
Caution
Adverse Effects - impaired endocrine function
- direct GI irritation
- ↑ bleeding times Adverse Effects
- vitamin A and D deficiencies - GI system
- muscle aches and pains - CNS effects
- ↑ concentration of liver enzymes
Drug-Drug Interactions - rhabdomyolysis with acute renal failure
- ↓ or delay the absorption of thiazide diuretics,
digoxin, warfarin, thyroid hormones, Drug-Drug Interactions
corticostreriods: - erythromycin, cyclosporine, gemfibrozil, niacin,
antifungal drugs = ↑ risk for rhabdomyolysis
Nursing Considerations - digoxin, warfarin = ↑ serum levels and resultant
- do not administer powdered agents in dry form toxicity
(mix with juices, soups, etc.) - oral contraceptives = ↑ estrogen levels
- ensure tablets are not cut, chewed, or crushed - grapefruit juice = ↑ serum levels and risk of
- give drug before meals toxicity
- administer oral medicatiosn 1 hour before or 5 to
6 hours after the bile acid sequestrant Nursing Considerations
- arrange for bowel program - administer drug at bedtime
- monitor serum cholesterol and LDL levels,
HMG-CoA REDUCTASE INHIBITORS (“statins”) including liver function, before and during
therapy
Prototype: atorvastatin (Lipitor) - arrange for ophthalmic medications
- associated with severe liver complications - ensure patient has attempted a
cholesterol-lowering diet and exercise program
Therapeutic Actions for at least 3 to 6 months before therapy
→ block the formation of cellular cholesterol - encourage patient to make lifestyle changes
→ ↓ serum cholesterol and LDLs, slight ↑ or no
change in HDLs Cholesterol Absorption Inhibitors
Indications Prototype: ezetimibe (Zetia)
- adjuncts with diet and exercise for the treatment
of ↑ cholesterol and LDL levels Therapeutic Actions
- slow the progression of CAD → works in the brush border of the small intestine
- prevent first MI to ↓ absorption of dietary cholesterol
→ drop in serum cholesterol levels
Pharmacokinetics
Indications → ↓ in lipoprotein and triglyceride synthesis and
- lower cholesterol level secretion
- treatment for homozygous familial
hypercholesterolemia - absorbed from GI tract
- reduce elevated sitosterol and campesterol - metabolized in liver
levels - excreted in urine

Pharmacokinetics vitamin B3
- absorbed well → inhibits release of free fatty acids from adipose
- metabolized in the liver and small intestine tissue
- excretion is through feces an urine → ↑ rate of triglyceride removal from plasma
→ ↓LDL and triglyceride level, ↑ HDL levels
Contraindications → also ↓ levels of apoproteins needed to form
- allergy chylomicrons
- pregnancy, lactation, severe liver disease (if in
combination with statin) - associated with intense cutaneous flushing,
nausea, abdominal pain, development of gout
Cautions - given at bedtime
- pregnancy or lactation - administer 4 to 6 hours after the bile acid
- elderly patients or with liver disease sequestrant

Adverse Effects Combination Therapy

- mild abdominal pain and diarrhea - if the patient shows no response to strict dietary
- headache, dizziness, fatigue, upper respiratory modifications, exercise, and lifestyle changes,
tract infection (URI), back pain, muscle aches and the use of lipid-lowering agent, combination
and pains of therapy may be initiated to achieve desirable
serum LDL and cholesterol levels
Drug-Drug Interations
- cholestyramine, fenofibrate, gemfibrozil,
antacids = ↑ risk of elevated serum levels of
ezetimibe
- cyclosporine = ↑ risk of toxicity
- fibrate = ↑ risk of cholethiasis
- ezetimibe = ↑ warfarin levels

Nursing Considerations
- monitor serum cholesterol, triglyceride, LDL
levels, liver function test before and during
therapy
- ensure patient has attempted a
cholesterol-lowering diet and exercise program
for several months before therapy
- encourage patient to make lifestyle changes

Other Drugs Used to Affect Lipid Levels

fibrates
→ stimulate the breakdown of lipoproteins from
the tissues and their removal from the plasma
 CHAPTER 48 – Drugs Affecting Blood Heparin, argatroban and bivalirudin block while Antithrombin
Therapeutic Actions: formationof thrombinfrom prothrombin. These drugs are used
Coagulation ● inhibit platelet adhesion and aggregation by blocking to treat thromboembolic disorders such as atrial fibrillation, MI,
receptor sites on the platelet membrane, preventing platelet- pulmonary embolus, and evolving dtroke and to prevent the
platelet interaction of the interaction of platelets w/ other formation of thrombi.
clotting chemicals
CARDIOVASCULAR SYSTEM
Prototype: Heparin (generic) half-life 30-180 minutes,
- is a closed system
Pharmacokinetics metabolize in the cells and excreted in the urine
● Consistently, the system must maintain an intricate balance
● well absorbed SQ onset 20-6- minutes, peak 2-4 hours, duration 8-12 hours
between the tendency to clot or form a solid state, called
● highly bound to plasma proteins IV – immediate onset, peak minute, duration 2-6 hours
coagulation, and the need to “unclot” or reverse coagulation
● metabolized in the liver Warfarin – effects last 4-5 days, onset of action in 3 days
to keep the vessel open and the blood flowing…
● excreted in urine
● increased bleeding Contraindications
● Blood coagulation
- is a complex process that involves vasoconstriction, platelet
Contraindications Contraindicated to known allergy to the drugs. They should not
clumping or aggregation, and a cascade of clotting factors
1. presence of allergy be use with conditions that can increase bleeding tendencies;
produced by the liver that eventually react to break down
2. during pregnancy and lactation hemorrhagic disorders, recent trauma, spinal puncture, GI
fibrinogen ( a protein also produced in the liver) into soluble
ulcers, recent surgery, intraunterine device placement,
fibrin threads .
Caution tuberculosis, presence of indwelling catheter, and threatened
1. Presence of Known bleeding disorder abortion.Contratindicated to pregnancy, lactation, renal or
● Vasoconstriction
2. recent surgery hepatic disease
- can seal off any break and allow the area to heal
3. closed head surgeries
Cautions
● Platelet aggregation
Adverse Effects
- causes platelets in the circulating blood to stick or adhere to
1. Bleeding ( increased bruising and bleeding while bruising the In patients with CHF, thyrotoxicocic, saenility, or psychosis,
the site of injury 🡺platelets release ADP (adenosine
teeth) diarrhea, fever
triphosphate- precursor of prostaglandin) and other chemicals
2. Headache, dizziness, and weakness
that attract other platelets, causing them to gather or aggregate
3. Nausea and GI distress may occur Adverse effects
and to stick as well🡺 thromboxane A2 cause local
4. Skin rash
vasoconstriction = platelet aggregation and adhesion
The most common adverse effect is bleeding (bleeding in gums
Drug- Drug interactions with tooth brushing to severe intrernal hemorrhage), clotting
● Hageman Factor
● risk of excessive bleeding increases if any of these drug is shoud be monitored. Nausea, GI upset, diarrhea, and hepatic
combined with another drug that affects blood clotting dysfunctiondue to toxicity. Warfarin can cause
ANTICOAGULANTS
alopecia,dermatitis, bone marrow depression and prolonged and
Nursing considerations painful
- are drugs that interfere with the normal coagulation process
1. provide small and frequent meals erections.
- affect the process at any step to slow or prevent clot formation
2. provide comfort measures and analgesia for headache
3. suggest safety measures, including the use of electric razor Drug to drug Interaction
I. ANTIPLATELET DRUGS
and avoidance of contact sports
4. provide increase precautions against bleeding Heparin + (oral anticoagulants, salicylates, penicillins,
- alter the formation of the platelet plug, or
5. Mark the chart of any patient teaching receiving this drug cephalosporins) =Increase bleeding
- decrease the formation of the platelet plug by decreasing the
6. Provide thorough patient teaching, including the name of the Heparin + nitroglycerin = Decrease coagulation
responsiveness of the platelet to stimuli that would cause them
drug, prescribed, measures to avoid adverse effects, warning
to stick and aggregate a vessel wall
signs of problems, the need for periodic monitoring and Nursing Considerations
- effectively to treat cardiovascular diseases that are prone to
evaluation
produce occluded vessels; for the maintenance of venous and
II. ANTICOAGULANTS -screen for allergy
arterial grafts; to prevent cerobrovascular occlusion, and
-evaluate for therapeutic effects of warfarin --prothrombin time
adjuncts to thrombolytic therapy in the treatment of MI and
Interfere with coagulation process by interfering with the (PT) 1.5 to 2.5 times control value or ratio of PT to INR
prevention of infarction
clotting cascade and thrombin formation (International Normalized Ratio) of 2 to 3
-Evaluate for herapeutic effects of heparin—whole blood
Prototype: Aspirin ( generic)
Therapeutic Actions and Indications clotting time (WBCT) 2.5 to 3 times control or activated
- reduction of the risk if recurrent TIAs or strokes in males with
partial thromboplastin time (APTT) 1.5 to 3 times the control
history of TIA due to fibrin or platelet emboli; reduction of
Anticoagulants interfere with the normal cascade of events value
death or nonfatal MI patients with history of infarction or stable
involved in the clotting process. Warfarin causes a decrease in - evaluate for signs of blood loss
angina; MI prophylaxis, also used as anti-inflammatory,
the production of vit. K—dependent clotting factors in the liver.
analgesics, and anti-pyretic
-maintain antidotes on standby (protamine sulfate for heparin,
vit, K for warfarin)
-monitor the patient when a drug is added or withdrawn from
the drug regimen of a patient receiving warfarin
-make sure patient receives regular follow up and monitoring
-provide health teaching, name of drug and its effects
Low Molecular-Weight Heparins
These drugs inhibit thrombus and clot formation by blocking
factors Xa and IIa. Because of size and nature of their
molecules, theses drugs do not greatly affect thrombin, clotting
or PT; they cause fewer adverse effects. They block
angiogenesis, process that allows cancer cells to develop new
blood vessels.
Prototype: Strptokinase (streptase, kabikinase)
Therapeutic actions and indications
Thrombolytic agents work to activate the natural clotting
system, conversion of plasminogen to plasmin, which in turn
breaks down fibrin threads in a clot to dissolve a formed clot.
They are indicated for the treatment of MI, to treat pulmonary
emboli and ischemic stroke and to open clotted IV catheter.
Pharmacokenetics
Must me injected and cleared from the body after liver
metabolism, crosses the placenta and have adverse fetal effects,
should not be used during pregnancies unless benefits to the
mother out ways the potential risks to the fetus. Cautions should
be used during lactation.
Contraindications and cautions
Contraindicated to allergy of these drugs, should not be used
with conditions that could worsen the dissolution of clots,
recent surgery, active internal bleeding, cerebrovascular
accident within the last two months, aneurysm, recent serious
GI bleeding, liver disease.
Adverse effects
The most common adverse effect is bleeding, cardiac
arrhythmias and hypotensions
Drug to drug interaction
Risk of hemorrhage increases if thrombolytic agents are used
with anticoagulant or antiplatelet drug.
Nursing consideration
-Discontinue heparin if given before administration of
thrombolytic agent, unless ordered for coronary artery infusion.
-evaluate for signs of blood loss (bleeding gums, bruises, dark
colored stools and urine, petechiae)
-institute treatment within 6 hours after the onset of symptoms
of acute MI
-arrange to type and cross match blood.
-monitor cardiac rhythm
-increase precautions against bleeding during invasive
procedures.
Drugs used to control bleeding
On the other end of the spectrum of coagulation problems are
various bleeding disorders: hemophilia, a genetic lack of
clotting factor that leaves the patient vulnerable to excessive
bleeding with injury.
Liver disease, clotting factors and proteins needed for clotting
are not produce.
Bone marrow disorders, insufficient platelets are formed.
Antihemophilic agents
Drugs used to treat hemophilia are replacement factors for the
specific clotting factors that are genetically missing.
Prototype: Antihemophilic factor (bioclate, others)
Therapeutic actions and indications
Replace clotting factors that are either genetically missing or
low in a particular type of hemophilia. Used to prevent blood
loss from injury or surgery and treat bleeding episode.
Pharmacokenetics
Replace normal clotting factors and are processed as such by
the body.
Contraindications and cautions
Contraindicated in the presence of known allergy to mouse
proteins. Factor IX is contraindicated in the presence of liver
disease with signs of Intravascular coagulation or fibrinolysis.
Coagulation factor VII is contraindicated with known allergies
to mouse, hamster or bovine products. Not recommended
during lactation and pregnancy.
Adverse effects
The most common is risks with the use of blood products, e.g.
hepatitis, aids. Headache, flushing, chills, fever and lethargy.
Nausea, vomiting and itching, stinging and burning at injection
site
Nursing consideration
-administer by IV only
-monitor clinical response and clotting factor levels regularly.
-monitor for sign of thrombosis
-decrease the rate of infusion if headache, chills, fever or
tingling occurs.
-arrange to type and cross match blood.
Systemic hemostatic agents
A used to stop bleeding. Some situation result in fibrinolytic
state with excessive plasminogen activity and risk of bleeding
from clot dissolution.
Prototype: Aminocaproic acid (amicar)
Pharmacokinetics
Parameters are different for each drug
Therapeutic actions and indications
Stop the natural plasminogen clot – dissolving mechanism by
blocking its activation or by directly inhibiting plasmin. These
drugs are used to prevent or treat excess bleeding in
hyperfibrinolytic states, including repeat CABG surgery.
Contraindications and cautions
Contraindicated to allergy to these drugs and with acute DIC.
Caution should be used in the following conditions: cardiac
disease, renal and hepatic dysfunction, pregnancy and lactation
Adverse effects
The most common is excessive clotting. CNS effects include
hallucinations, drowsiness, dizziness, headache and psychotic
states. GI effects including nausea, cramps, and diarrhea.
Drug to drug interaction
Increase risk of bleeding if combined with heparin
Nursing considerations
-monitor clinical response and clotting factor levels
-monitor for signs of thrombosis
-orient patients and offer support and safety measure if
hallucinations or psychoses occur.
Topical hemostatic agents
Used to injuries that involve damage to the small vessels in the
area that clotting does not occur and blood is slowly and
continually lost
Absorbable gelatin (gellfoam) and microfibrilar collagen
(avitene), are apllied directly to the injured area until the
bleeding stops
Thrombin (thrombinar, thrombostat) derived from bovine
sources and mixed with the blood
CHAPTER 49: DRUGS USED TO TREAT
ANEMIAS
BLOOD
- essential for cell survival
o contains oxygen and nutrients and
removes waste products that could be toxic
to the tissues
o contains clotting factors that help maintain
the vascular system and keep it sealed
o contains important components of the
immune system that protect the body from
infection
Blood Components
- composed of liquid and formed elements:
plasma, leukocytes, erythrocytes, platelets
Types of Anemia
1. Deficiency Anemia
- occurs when the diet cannot supply enough
of a nutrient, or enough of a nutrient cannot
be absorbed
2. Megaloblastic Anemia
- occurs when the bone marrow contains a
large number of megaloblasts, or large,
immature RBCs
- because these RBCs are so large, they
become crowded in the bone marrow and
fewer RBCs are produced
- patients usually have a lack of vitamin B12 or
folic acid
Iron Deficiency Anemias
- a negative iron balance
- occurs in situations in which blood is being lost
(such as heavy menstrual flow, internal
bleeding)
- only enough iron is absorbed to replace the
amount of iron lost each day
- only about 1 mg of iron is lost every day
Megaloblastic Anemias
- there is no sufficient folic acid or vitamin B12 to
adequately create the stromal structure needed
in a healthy RBC
Folic Acid Deficiency
- folic acid is essential for cell division in all types
of tissue
- deficiencies in folic acid are first noticed in
rapidly growing cells
- may occur in:
o certain malabsorption states (such as sprue
or celiac diseases)
o malnutrition that accompanies alcoholism
o repeated pregnancies
o extended treatment with certain antiepileptic
medications
- treated by the administration of folic acid or
folate
Vitamin B12 Deficiency
- vitamin B12 is used in minute amounts by the
body and is stored for use
- it is necessary for the health of the RBCs and for
the formation and maintenance of the myelin
sheath in the CNS
- vitamin B12 deficiency may occur in:
o strict vegetarians
o inability of the GI tract to absorb the needed
amounts of vitamin B12
- treated with vitamin B12 replacement therapy
Pernicious Anemia
- occurs when the gastric mucosa cannot produce
intrinsic factor and vitamin B12 cannot be
absorbed
- person may complain of fatigue, lethargy, and
CNS effects because of damage to the myelin
sheath
- treated with injections of vitamin B12 to replace
the amount
ERYTHROPOIETINS
- for patients who are no longer able to produce
erythropoietin in the kidneys
Prototype: epoetin alfa (Epogen, Procrit)
Therapeutic Actions
- acts like the natural glycoprotein erythropoietin
to stimulate the production of RBCs in the bone
marrow
Indications
- treatment of anemia with renal failure
- to ↓ the need for blood transfusion in patients
undergoing surgery
- treatment of anemias related to treatment for
AIDS
- treatment of anemia associated with cancer
chemotherapy (Procrit only)
Pharmacokinetics
- metabolized through the normal kinetic process
- half life of 4 to 13 hours
Contraindications
- presence of uncontrolled hypertension
- allergy
- lactation
Adverse Effects
- result of cellular response to glycoprotein: CNS
effects
- nausea, vomiting, diarrhea
- related to ↑ in RBC numbers: CV symptoms
Nursing Considerations
- confirm chronic, renal failure before drug
administration
- give epoetin alfa 3 times a week, IV or SQ
- do not mix with any other drug solution
- monitor access lines for clotting
- arrange for hematocrit reading before drug
administration
- evaluate iron stores before and during therapy
- maintain seizure precautions on standy
IRON PREPARATIONS
- iron deficiency anemia is common in certain
groups:
o menstruating women
o pregnant and nursing women
o rapidly growing adolescents
o persons with GI bleeding and slow bleeding
Prototype: ferrous sulfate (Feosol)
Therapeutic Actions
- elevate the serum iron concentration

Indications
- treatment of iron deficiency anemias
- adjunctive therapy in patients receiving epoetin
alfa
Pharmacokinetics
- absorbed from small intestine
- transported in the blood
- used during pregnancy and lactation
Contraindications
- allergy
- hemochromatosis (excessive iron)
- hemolytic anemias
- normal iron balance
- peptic ulcer, colitis, regional enteritis
Adverse Effects
- direct GI irritation
- with increasing serum levels, iron can be CNS
toxic, causing coma and death
- parenteral iron: severe anaphylactic reactions,
local irritation, staining of the tissues, phlebitis
Drug-Drug Interactions
- antacids, tetracyclines, cimetidine = ↓ iron
absorption
- ciproflaxin, norfloxacin, ofloxacin = ↓
anti-infective response
- chloramphenicol = ↑ iron levels
- levodopa = ↓ effects of levodopa
Drug-Food Interactions
- antacids, eggs, milk, coffee, tea = iron is not
absorbed
Nursing Considerations
- confirm deficiency anemia before drug
administration
- administer with meals
- have patients drink solutions through a straw
- caution patient that stool may be dark or green
- administer IM only through Z-track technique
- arrange for hematocrit and hemoglobin
measurements before and during therapy
FOLIC ACID DERIVATIVES AND VITAMIN B12
Folate deficiencies usually occur
o secondary to ↑ demands Adverse Effects
o absorption problems in the small intestine - pain and discomfort at injection sites
o secondary to the malnutrition of alcoholism - nasal irritation with the use of nasal sprays
Prototype: folic acid (Folvite)
- parenteral drugs are preferred for patients with Nursing Considerations
potential absorption problems - confirm the nature of megaloblastic anemia
- give both types of drugs in pernicious anemia
Vitamin B12 deficiencies usually occur - parenteral Vitamin B12 must be given IM each
o with poor diet or increased demand day for 5 to 10 days, then once a month for life
o lack of intrinsic factor in the stomach - arrange for nutritional consultation
- monitor for hypersensitivity reactions
Prototype: hydroxocobalamin (Hydro-Crysti 12) - arrange for hematocrit and hemoglobin
- given IM everyday for 5 to 10 days, then once measurements before and during therapy
a month for life
- used in states of ↑ demand or dietary
deficiency
Therapeutic Actions
- folic acid and vitamin B12 : for cell growth and
division, and production of strong stroma in
RBCs
- Vitamin B12: maintenance of the myelin sheath in
nerve tissue
Indications
- replacement therapy for dietary deficiencies
- replacement in high-demand states (such as
pregnancy and lactation)
- treat megaloblastic anemia
- folic acid: rescue drug for cells exposed to some
toxic chemotherapeutic agents
Pharmacokinetics
- well absorbed after injection
- metabolized mainly in liver
- excreted in urine
- highly protein bound
- considered essential during pregnancy and
lactation
Contraindication
- allergy
Cautions Chapter 50 - Introduction to the
- pregnant or lactating who have anemias
- nasal cyanocobalamin
Kidneys and the Urinary Tract
- presence of nasal erosion or ulcers
Renal system:
⮚ Aldosterone-a hormone produced
● Urinary tract b.) Secretion – actively removing
● Ureters components from the capillary the adrenal gland
● Urinary bladder system and depositing them into - is released into the
● Urethra the tubule circulation in response to
● the high potassium levels,
4 major functions of the renal system: c.) Absorption – removing from the sympathetic stimulation, or
● Maintain the value and tubule to return them to the angiotensin III
composition of the body fluids capillary system and circulation - stimulates Na-K exchange
w/in normal range >about 99% of the water filtered at pump in the cells of the
● Regulating vitamin D activation the glomerulus is reabsorbed distal tubule, w/c reabsorbs
● Regulating blood pressure >the filtrate components include Na in exchange for K, as a
● Regulating red blood cell the vitamins, glucose, electrolytes, result Na is reabsorbed into
production sodium bicarbonate, and sodium the system and K lost in the
● chloride filtrate
>the kidneys are two small organs that >precision of the reabsorption ⮚ Natriuretic Hormone- probably
receive about 25% of the cardiac output process allows the body to
maintain the correct extracellular produced by the hypothalamus
fluid volume and composition - causes decrease in Na
Nephron
reabsorption from the distal
● the functional unit of the kidneys
Maintenance of Volume and composition tubules w/ a resultant dilute
● is composed of the Bowman’s
of Body Fluids urine or increase volume
capsule, proximal convoluted
- is released in response to
tubule, loop of Henle, distal
Sodium Regulation the fluid overload or
convoluted tubule, and collecting
Sodium hemodilution
duct
Countercurrent Mechanism
● ⮚ Is one the body’s major
Renal Processes ⮚ in the medullary nephrons allow
a.) Filtration - straining fluid into the cations(positively charged ions)
for the concentration or dilution of
nephron ⮚ Reabsorbed via transport system urine under the influence of ADH
>approximately 125 mL of fluid is secreted by the hypothalamus
that functions under the influence
filtered each minute, or 180L/day
if the catalyst carbonic
>99% of the filtered fluid is Potassium Regulation
anhydrase, 🡪 carbonic acid 🡪
returned to the bloodstream Potassium
sodium bicarbonate
>approx. 1% of the filtrate, less
2 hormones that influence sodium levels ⮚ is another cation that ios vital to
than 2 L of fluid is excreted each
in the filtrate:
day in the form of urine proper functioning of the nervous
 system, muscles, and cell
✔ Fine tuning reabsorption occurs in
membranes
the distal convoluted tubule.
⮚ 65% is filtrated at the glumerulus
is reabsorbed at the Bowman’s
capsule and proximal convoluted
tubule
⮚ 25%-30% is r5eabsorbed at the
Urinary Tract
loop of Henle
Urinary Bladder- is the muscular pouch
Chloride Regulation that stretches and holds
Chloride the urine until it is
⮚ Is an important negatively charged excreted from the body.
Uterus- have smooth endothelial lining
ion that helps to maintain electrical and circular muscular linings.
neutrality with the movement of
● The female urethra is very short
cations across the cell membrane
and leads to an area populated by
⮚ Primarily absorbed in the loop of normal flora including e.coli.
Henle, where it promotes the ● The male urethra is much longer
movement of sodium out of the and passes through the prostate
cell gland.
*the kidneys play a role Prostate Gland- a small gland that
produces an acidic fluid that is
Sodium Regulation important in maintaining the sperm
and lubricating the tract.
Calcium
✔ Is important in muscle function,
blood clotting, bone formation,
contraction of cell membranes and
muscle movement.
✔ Filtered at the glomerulus and
mostly reabsorbed in the proximal
convoluted tubule and ascending
Loop of Henle.

CHAPTER 51: Diuretic Agents
Diuretic Agents
- drugs that increase the amount of urine
- the greater significance of diuretics is their ability to
increase sodium excretion.
Therapeutic actions and indications:
- prevent the cell’s lining the renal tubule from
reabsorbing an excessive proportion of the sodium
ions in the glomerular filtrate.
- as a result, sodium and other ions are lost in the
urine instead of being return to the blood, where they
would cause increase intravascular volume and
therefore increase hydrostatic pressure, which could
result in leaking of fluids at the capillary level.
- Indicated for the treatment of edema associated with
congestive heart failure, acute pulmonary edema,
liver disease, and renal disease, and for the treatment
of hypertension.
- Also use to decrease fluid pressure in the eye
(intraocular pressure), which is useful in treating
glaucoma.
- Diuretics that decrease potassium levels may also be
indicated in the treatment of conditions that cause
hyperkalemia.
Contraindications and cautions:
- presence of allergy to any of the drugs given
- fluid and electrolyte imbalances
- severe renal disease
- caution should be used with systemic lupus
erythematosus (SLE)
- glucose tolerance abnormalities or diabetes mellitus
- gout
- liver disease
- pregnancy and lactation
Adverse effects:
- the most common adverse effects seen with diuretics
include GI upset, fluid and electrolyte imbalances,
hypotension, and electrolyte disturbances.
Drug- drug interactions:
drugs that altered the actions of diuretics:
- antiarrhythmics (digoxin), drugs that depend on a
particular electrolyte balance for their therapeutic
effects.
- Quinidine, drugs that depend on urine alkalinity for
proper excretion.
- Antihypertensive ad antidiabetic agents, depend on
normal reflexes to balance their effects.
THIAZIDE AND THIAZIDE- LIKE DIURETICS
- Hydrochlorothiazide (hydroDIURIL), the most
frequently used of the thiazide diuretics, often used
in combination with other drugs for the treatment of
hypertension.
- Chlorothiazide (Diuril), the oldest of this class, and
considered the prototype.
- Bendroflumethiazide (Naturetin)
- Hydroflumethiazide (Diucardin)
- Methyclothiazide (Aquatensen)
- Trichlormethiazide (Diurese)
*Thiazide- like drugs
- Chlorthalidone (Hygroton)
- Indapamide (Lozol)
- Metolazole (Mykrox)
- Quinethazone (Hydromox)
Therapeutic actions and indications:
- Thiazide diuretics belong to a chemical class of
drugs called sulfonamides.
- Thiazide- like diuretics has a slightly different
chemical structure but work in the same way that
thiazide diuretics do.
- Their action is to block the chloride pump.
- Usually indicated for the treatment of edema
associated with CHF or with liver or renal disease.
- Also used as monotherapy or as adjuncts for the
treatment of hypertension.
Pharmacokinetics:
- onset of action: 1-3 hours
- metabolize in the liver and excreted in the urine
- well absorbed in the GI tract
Contraindications and cautions:
- contraindicated with allergy to thiazides or
sulfonamides, fluid or electrolyte imbalances and
renal and liver disease.
- Additional cautions include: gout, SLE, diabetes,
hyperparathyroidism, bipolar disorder, and
pregnancy and lactation.
Adverse effects:
- Hypokalemia (weakness, muscle cramps, and
arrhythmias)
- Decrease calcium excretion, which leads to increase
calcium level.
- Decrease uric acid excretion (gout, high level of uric
acid)
- Urine will slightly alkalinized
Drug- drug interactions:
- decrease absorption of this drugs if combined with
cholestyramine or colestipol, if combination is used,
it should be taken separated by at least 2 hours.
- Risk of digoxin toxicity increases due to potential
changes in potassium levels; serum potassium level
should be monitored if this combination is used.
- Decrease effectiveness of antidiabetic agents may
occur related to the changes in glucose metabolism;
dosage adjustment of those agents may be needed.
- Risk of lithium toxicity may increase if these drugs
are combined. Serum lithium levels should be
monitored and appropriate dosage adjustment made
as needed.
LOOP DIURETICS
-work in the loop in henle
- Furosemide (Lasix), most common less powerful
than new loop diuretics.
- Bumetanide (Bumex)
- Torsemide (Demadex)
- Ethacrynic acid (Edecrine)
Therapeutic action and indications:
- referred to as high-ceiling diuretics because they
cause greater degree of diuresis.
- Block the chloride pump in the ascending loop of
henle, where normally 30% of all filtered sodium is
reabsorbed.
- These drugs work even in the presence of acid- base
disturbances, renal failure, electrolyte imbalances, or
nitrogen retention.
- A drug of choice when rapid and extensive diuresis
is needed.
 - In case of severe edema, it is important to remember
that these drugs can have an effect only on the blood
the nefron.
- In pulmonary edema, this fluid then circulates back
to the lungs pulls fluid out of the interstitial spaces
by its oncotic pull, and delivers fluid to the kidneys
where the water is pulled out completing the cycle.
- Commonly indicted for treatment of acute CHF,
pulmonary edema, edema associated with CHF or
with renal or liver disease and hypertension.
Pharmacokinetics:
- metabolized and excreted through urine.
- They should not be used during pregnancy, unless
the benefit to the mother far outweigh the potential
risk, it enters in the breastmilk.
- Safety for use in children younger than 18 years of
age, has not been establish.
- If one of this drug is used for a child, carefully
monitor child’s fluid and electrolyte balance is
needed.
Contraindication and cautions:
- allergy to loop diuretics, electrolyte depletion,
anuria, severe renal failure, hepatic coma, pregnancy
and lactation.
- Caution on patient with SLE, gout, and/or diabetes
mellitus.
Adverse effect:
- hyperkalemia is a very common adverse effect.
- Alkalosis (a drop in serum pH to an alkaline state.)
- Hypotension, dizziness, ototoxicity, deafness.
- This may occur in conduction of fragile nerve in
CNS.
Drug- drug interactions:
- risk for ototoxicity increase with amino glycosides
or cysplapin.
- Anticoagulation effect may increase with
anticoagulant.
- Decrease loss of sodium and decrease
antihypertensive effect with indomethacin,
ibuprofen, salicylates, or another NSAIDs.
CARBONIC ANHYDRASE INHIBITOR
- relatively mild diuretics.
- Used to treat glaucoma
Acetazolamide (Diamox)
Methazolamide (Meptazane)
Therapeutic Actions and Indication
- the enzyme carbonic anhydrase is a catalyst for the
formation of sodium bicarbonate.
-This diuretics lacks the effects of carbonic anhydrase that
slows down the movement of hydrogen ions, as a result
more sodium and bicarbonate are lost in the urine
- Use as a drug adjuncts to other diuretics when a more
intense diuresis is needed
- Acetalozamide is used to treat mountain sickness
Pharmacokinetics
-rapidly absorbed widely distributed excreted in the urine
- another method of feeding the infant should be used if
one of this drugs is needed during lactation.
Contraindicaions and Cautions
-Allergy to drugs or antibacterial sulfunamides or thyazide or
chronic noncongestive angle closure glaucoma
-cautios use is recommended in patients who are
breastfeeding, who have fluid imbalances, renal or hepatic
disease, adrenocortical insufficiency, respiratory acidosis
or COPD
Adverse Effects
- metabolic acidosis
- hypokalemia
- paresthesias (tingling), confusion and drowsiness
Drug to Drug Interaction
- there maybe an increase excretion of salicylates and lithium if
they are combined with this drugs
Potassium- Sparring Diuretics
- These drugs are used for patients wha are at risk for
hypokalemia associated with diuretic use.
- Retain potassium instead of wasting it.
Amiloride (Midamore)
Spironolactone (Aldactone)
Triamterene (Dyrenium)
Therapeutic Actions and Indication
- These drugs are often used as adjuncts with thiazide
or loop diuretics.
- Spironolactone is the drug of choice for treating
hyperaldosteronism, a condition seen in cirrhosis of
the liver and nephronic syndrome.
Pharmacokinetics
- These drugs are well absorbed, protein bound and
widely distributed.
- These drugs cross the placenta and enter breast milk.
Contraindicaions and Cautions
- Allergy to the drug
- Hyperkalemia
- Renal disease
- Anuria
- Patients who are taking Amiloride or triamterene
Adverse Effects
- Hyperkalemia
OSMOTIC DIURETICS
- Pull water into the renal tubule without sodium loss.
- Drug of choice for Increase cranial pressure or acute
renal failure.
Glycerin (osmoglyn)
Mannidol (Osmitrol)
Urea (ureaphil)
Therapeutic Actions and Indication
- It acts to pull large amounts of fluid into the urine by
the osmotic pull of the large sugar molecule.
- These drugs are often used in acute situation .
- Prevent oliguric phase of renal failure, and to
promote of toxic substances through the kidneys.
Pharmacokinetics
- These drugs are freely filtered at the renal
glomerulus, poorly reabsorbed by the renal tubules
and not secreted by the tubule, and resistant to
metabolism.
Contraindications and Cautions
- Renal disease and anuria from sever renal disease,
pulmonary congestion, intracranial bleeding,
dehydration and CHF.
Adverse Effects
- Sudden drop of fluid levels
- Cardiac decompensation and even shock
 ● Methenamine (Hiprex)- undergoes
metabolism in the liver and is Drug interactions that can
excreted in the urine occur are very specific to the drug
● Methylene blue (Urolene Blue)- being used.
is widely distributed,
metabolized in the tissues, and
excreted in urine, bile, and Urinary Tract Antispasmodics
feces
DRUGS:
ACTION:
● Flavoxate (Urispas)- prevent
Chapter 52- Drugs affecting the The urinary anti-infectives act smooth muscle spasm
Urinary Tract and the Bladder specifically within the urinary tract specifically in the urinary
to destroy bacteria, either through a tract, but it is associated
direct antibiotic effect or through with CNS effects (blurred
Urinary Tract Anti-Infectives acidification of the urine. vision, dizziness, confusion)
that make it less desirable to
DRUGS: PHARMACOKINETICS: use in certain patients
● Oxybutynin (Ditropan)- is a
2 types: antibiotics & anti infectives Because these drugs are from potent urinary antispasmodic,
works to acidify the urine several different chemical classes, but it has numerous
the pharmacokinetic data are different anticholinergic effects, making
Antibiotics for each drug. it undesirable in certain
CONTRAINDICATIONS: conditions or situations that
● Cinoxacin(Cinobac)- interferes might be aggravated by
with the DNA replication in These drugs are contraindicated decreased sweating, urinary
gram negative bacteria in the presence of any of these drugs. retention, tachycardia, and
● Norfloxacin (Noroxin)- a newer They should be used with caution in changes in the GI activity.
and more broad spectrum drug, the presence of renal dysfunction, ● Tolterodine (Detrol,Detrol LA)-
is effective against even more which could interfere with the is a newer agent that blocks
gram negative strains than excretion and action of these drugs, muscarinic receptors,
cinoxacin and with pregnancy and lactation preventing bladder contraction
because of the potential for adverse and spasm
● Fosfomycin (Monurol)- has the
effects on the fetus or neonate. ● Trospium (Sanctura)- is the
convenience of only one dose.
It is not recommended for newest drug approved to block
ADVERSE EFFECTS: urinary tract spasms. It also
patients younger than 18 years
of age specifically blocks muscarinic
● nausea, vomiting, diarrhea, receptors and reduces the
● Nalidixic (NegGram)- is an
anorexia, bladder irritation, muscle tone of the bladder. It
older drug that is not
and dysuria is specifically indicated for
effective against as many
strains of gram-negative ● infrequent symptoms include the treatment of overactive
bacteria as the other pruritus, urticaria, headache, bladder with symptoms of urge
antibiotics used for UTIs dizziness, nervousness, and urinary incontinence, urgency,
confusion and urinary frequency.
● Nitrofurantion (Furadantin)- is
another older drug with a very ● GI irritation caused by the
agent, which is alleviated if ACTION:
short half-life (20-60 minutes)
Anti-infective works to acidify urine drug is taken with food
Inflammation in the urinary
DRUG-DRUG INTERACTIONS: tract, such as cystitis, prostatics,
urethritis, and The risk of toxic effects of
euthrocystitis/urethrotrigonitis, Urinary Tract Analgesic this drug increases if it is combined
causes smooth muscle spasms along the with anti-bacterial agents used for
urinary tract. Irritation of the DRUGS: treating UTIs. If this combination is
urinary tract leading to muscle spasm used, the phenazopyridine should not
also occurs in patient with neurologic ● Phenazopyridine (Azo-Standard, be used for longer than 2 days.
bladder. Baridium, and others) is a dye
that is used to relieve pain.
PHARMACOKINETICS: ACTION:

These drugs are rapidly When phenazopyridine is

absorbed, widely distributed, excreted in urine, it exerts a direct,
metabolized in the liver, and excreted topical analgesic effect on the
in urine. Caution should be used in urinary tract mucosa. It is used to
the presence of hepatic or renal relieve symptoms related to urinary
impairment because of the potential of tract irritation from infection,
alterations in metabolism or excretion trauma, or surgery.
of the drugs.
PHARMACOKINETICS:
CONTRAINDICATIONS:
Phenazopyridine is rapidly
These drugs are contraindicated absorbed and has a very rapid onset of
in the presence of any allergy to action. It is widely distributed,
these drugs; with pyloric or duodenal crossing the placenta and entering
obstruction or recent surgery because breast milk. It is metabolized in the
anticholinergic effects can cause liver and excreted in the urine.
serious complications.
CONTRAINDICATIONS:
ADVERSE EFFECTS:
This drug is contraindicated in
● adverse effects of urinary the presence of any allergy to the
antispasmodics are related to drug and serious renal dysfunction,
blocking of the parasympathetic which would interfere with the
system excretion and effectiveness of the
● nausea and vommitng, dry mouth, drug.
nervousness, tachycardia, and
vision changes ADVERSE EFFECTS:

DRUG-DRUG INTERACTIONS: ● GI upset, headache, rash,

reddish-orange coloring of
Decreased effectiveness of urine
phenothiazines and haloperidol has ● Hepatic toxicity, this drug
been associated with the combination should not be used for longer
of these drugs with oxybutynin. If any than 2 days because the toxic
such combinations must be used, the effects may be increased.
patient should be monitored closely
and appropriate dosage adjustments DRUG-DRUG INTERACTIONS:
made.

Chapter 53 – Introduction to
the Respiratory System
The respiratory system’s function is to
supply the blood with oxygen in order for
the blood to deliver oxygen to all parts
of the body. The respiratory system does
this through breathing, thus allowing gas
exchange to occur. The normal functioning
of the respiratory system depends on an
intricate balance of the nervous system,
cardiovascular, and musculoskeletal
systems. It is composed of two parts
namely the upper respiratory tract and
the lower respiratory tract.
THE UPPER RESPIRATORY TRACT
The upper respiratory tract or conducting
airways is composed of the nose, mouth,
pharynx, larynx, trachea, and the upper
bronchial tree. In here, air usually
moves into the body through nose and into
nasal cavity. The structures of the upper
respiratory tract are moist with mucus
(which are produced by the goblet cells
in the epithelial lining of the nasal
cavity) and are lined with cilia
(microscopic hair-like projections of the
cell membrane). The cilia constantly move
and direct mucus and any trapped
substances down toward the throat.
Pairs of sinuses (air-filled spaces,
communicating with the nasal cavity,
within the bones of the skull and face)
open into the nasal cavity. From the
sinus, the mucus drains into the throat
and is swallowed into the
gastrointestinal tract, where stomach
acid destroys foreign materials.
Air moves from the nasal cavity into the
pharynx and larynx. The larynx contains
the vocal chords and the epiglottis
(which closes during swallowing). From
the larynx, air proceeds to the trachea,
the main conducting airway to the lungs.
The trachea divides into two main
bronchi, which further divide into
smaller and smaller branches. These
bronchial tubes are composed of three
layers: cartilage, muscle, and epithelial
cells. All of these tubes contain
mucus-producing goblet cells and cilia.
The cilia in these tubes moves the mucus
up to the trachea and into the throat,
where again it is swallowed.
The walls of the trachea and conducting
bronchi are highly sensitive to
irritation. When receptors in the walls
are stimulated, a central nervous system
reflex is initiated and a cough reflex
results, which causes air to be pushed
through the bronchial tree to clean out
any foreign irritant. This reflex, along
with the sneeze reflex, forces foreign
materials directly out of the system.
Around the airways, many macrophage
scavengers freely move about
epithelium and destroy invaders. Mast
cells are present in abundance
release histamine, serotonin,
adenosine triphosphate (ATP), and other
chemicals to ensure rapid and intense
inflammatory reaction to any cell injury.
The end result of these various defense
mechanisms is that the lower respiratory
tract is virtually sterile-an important
protection against respiratory infection
that could interfere with essential gas
exchange.
THE LOWER RESPIRATORY TRACT
The lower respiratory tract is composed
of the smallest bronchioles and alveoli
which both are the functional units of
the lungs. Within the lungs are network
of bronchi, alveoli, and blood vessels.
The lung tissue receives its blood supply
from the bronchial artery, which branches
directly off the aorta. The alveoli
receives unoxygenated blood from the
right ventricle via the pulmonary artery.
This delivery of blood to the alveoli is
referred to as perfusion.
Gas exchange or ventilation occurs in the
alveoli where carbon dioxide is lost from
the blood and oxygen is to the blood. The
alveolar sac holds the gas, allowing
needed oxygen to diffuse across the
respiratory membrane into the capillary
while carbon dioxide, which is more
abundant in the capillary blood, diffuses
across the membrane and enters the
alveolar sac to be expired.
The respiratory membrane is made up of
the capillary endothelium, the capillary
basement membrane, the interstitial
space, and the surfactant layer. The sac
is able to stay open because of the
surface tension of the cells is decreased
by the lipoprotein surfactant which is
produced by the type II cells in the
alveoli. Absence of surfactant leads to
alveolar collapse.
The oxygenated blood is returned to the
left atrium via the pulmonary veins; from
there it is pumped throughout the body to
deliver oxygen to the cells and to pick
up waste products.
the RESPIRATION
The central nervous system controls the
and respiration or the act of breathing. The
and respiratory center in the medulla
stimulates the inspiratory muscle to
contract, it also receives input from
chemoreceptors and increase the rate of
depth and/or rate of respirations to
maintain homeostasis.
The vagus nerve, a predominantly
parasympathetic nerve, plays a key role
in stimulating diaphragm constriction and
inspiration. Vagal stimulation also leads
to bronchoconstriction or tightening. The
sympathetic system also innervates the
respiratory sytem by increasing rate and
depth of respiration and dilation of the
bronchi.
RESPIRATORY PATHOLOGY
UPPER RESPIRATORY TRACT CONDITION
● The Common Cold
Common cold is caused by a number of
different viruses that invade the upper
respiratory tract, initiating the release
of histamine and prostaglandins and
causing an inflammatory response. As a
result, mucous membranes become engorged dyspnea, fever, cough, hypoxia, and It is characterized by reversible
with blood, the tissues swell, and the changes in chest wall movement. bronchospasm, inflammation and
goblet cells increase the production of hyperactive airways. The hyperactivity is
● Pneumonia triggered by allergens or nonallergic
mucus. These effects cause the person to
inhaled irritants or by factors such as
complain sinus pain, nasal congestion, exercise and emotions. The triggers cause
runny nose, sneezing, watery eyes, Pneumonia is an inflammation of the lungs
caused either by bacterial or viral an immediate release of histamine, which
scratchy throat, and headache. In result in bronchospasm in about 10
invasion of the tissue or by inspiration
susceptible, this swelling can block the of foreign substances into the lower minutes. The later response (3 to 5
outlet of Eustachian tube, which may lead respiratory tract. The respiratory tract hours) is cystokine-mediated
to an ear infection (otitis media). leads to a localized swelling, inflammation, mucus production, and edema
engorgement, and exudation of protective contributing to obstruction. The extreme
sera. The respiratory membrane is case of asthma is the status asthmaticus
● Seasonal Rhinitis which can be life-threatening because
affected, resulting in decreased gas
exchange. Patients complain of difficulty bronchospasm does not respond to usual
Seasonal rhinitis or commonly called as breathing and fatigue, and they present treatment and occludes air flow into the
hay fever occurs when the upper airways with fever and noisy breath sounds, and lungs.
respond to specific antigen with vigorous poor oxygenation.
inflammatory response, resulting in nasal ● Chronic Obstruction Pulmonary
congestion, sneezing, stuffiness, and Disease (COPD)
● Bronchitis
watery eyes.
Acute bronchitis occurs when bacteria, COPD is a permanent, chronic obstruction
● Sinusitis
viruses, or foreign materials infect of airways, often related to cigarette
inner layer of the bronchi. The person smoking. It is caused by two related
Sinusitis occurs when the epithelial with bronchitis may have a narrowed disorders, emohysema and chronic
lining of the sinus cavities becomes airway during the inflammation; this bronchitis. Emphysema is characterized by
inflamed. The resultant swelling often condition can be very serious in a person loss of elastic tissue of the lungs,
causes severe pain. The danger of sinus with obstructed or narrowed airflow. destruction of the alveolar walls, and a
infection is that, if left untreated, Chronic the bronchi that does not clear. resultant hyperinflation and tendency to
microorganisms can move up the sinus collapse with expiration. Chronic
● Bronchiectasis
passages and into brain tissue. bronchitis is a permanent inflammation of
Pharyngitis and Laryngitis Pharyngitis and the airways with mucus secretion, edema,
Laryngitis are infections frequently Bronchiectasis is a chronic disease that and poor inflammatory defenses. Persons
caused by common bacteria or viruses. involves the bronchi and bronchioles. It with COPD are characterized by both
These conditions are frequently seen with is characterized by dilation of the disorders.
influenza. bronchial tree and inflammation of the
bronchial passages. With chronic
● Cystic Fibrosis
inflammation, the bronchial epithelial
LOWER RESPIRATORY TRACT CONDITIONS cell membranes, combined with the
dilation of the bronchial tree, leads to Cystic fibrosis is a hereditary disease
chronic infections in the now unprotected that results in the accumulation of
● Atelectasis
lower areas of the lung tissue. Patients copious amounts of very thick secretions
with this condition often have an in the lungs. Eventually, the secretions
Atelectasis, the collapse of underlying medical condition that makes obstruct the airways, leading to
once-expanded lung tissue, can occur as a them more susceptible to infections. destruction of the lung tissue. Treatment
result of outside pressure against the Patients present with the signs and is aimed at keeping the secretions fluid
alveoli or pleural effusion. Atelectasis symptoms of acute infection, including and moving and maintaining airway patency
most commonly occurs as a result of fever, malaise, myalgia, arthalgia, and a as much as possible.
airway blockage, which prevents air from purulent, productive cough.
entering the alveoli, keeping the lung ● Respiratory Distress Syndrome (RDS)
expanded. This condition occurs when a Obstructive Pulmonary Diseases
mucus plug, edema of the bronchioles, or
Respiratory distress syndrome is
a collection of pus or secretions
● Asthma frequently seen in premature babies whose
occludes the airway and prevents movement
lungs are not yet fully developed and
of air. Patients may present rales,
their surfactant levels are still very
low. Surfactant is necessary for lowering
the surface tension in the alveoli so
that they can stay open to allow the flow
of gases. Treatment is aimed at
instilling surfactant to prevent
atelectasis and to allow the lungs to
expand. Adult respiratory distress
syndrome (ARDS) is characterized by
progressive loss of lung compliance and
increasing hypoxia. This syndrome occurs
as a result of severe insult to the body.
Chapter 54- Drugs Acting on the Upper
Respiratory Tract
These drugs work to keep the airways open
and gas to move freely.
⮚ Antitussives- blocks the cough reflex
⮚ Decongestants- decrease the blood flow to the
upper respiratory tract and decrease the
overproduction of secretions
⮚ Antihistamines- block the release or action of
histamine, a chemical released during
inflammation that increases secretions and narrows
airways.
⮚ Expectorants- increase productive cough to
clear the airways.
⮚ Mucolytics- increase or liquefy respiratory
secretions to aid the clearing of the airways.
Antitussives
- Drugs that suppress the cough reflex.
- Act directly on the medullary cough center
of the brain to depress the cough reflex.
- Acts as a local anesthetic on the respiratory
passages, lungs, and pleurae, blocking the
effectiveness of the stretch receptors that stimulate
a cough reflex.
- Contraindicated for patients w/
postoperative and those who have undergone
abdominal or thoracic surgery.
- Caution should be used in patients who are
hypertensive or have a history of addiction to
narcotics
- T ½ of 2-4 hrs; metabolized in liver and
excreted in urine
- Side effects include: dizziness, respiratory
depression and dry mouth
Drugs in this class:
benzonatate(Tessalon); codeine(generic); P
dextromethorpan(Benylin);
hydrocodone(Hydocan)
Implemetation:
- teach the pt. the proper administration of the
drug to ensure therapeutic effect
- caution pts. not to use the drug longer than 5
days to facilitate detection of the underlying
medical conditions that may require treatment.
- provide safety measures if dizziness occurs
to prevent patient injury
- offer support and encouragement to help the
patient cope with the disease and the drug regimen
Decongestants
- Drugs that cause local vasoconstriction
- Decrease the blood flow to the irritated and
dilated capillaries of the mucous membranes lining
the nasal passages and sinus cavities.
● Topical Nasal Congestants
- are sympathomimetics
- cause vasoconstriction, leading to decreased
edema and inflammation of the nasal membranes
- caution in patients with lesions or erosions
in the mucous membranes.
- T ½ of 0.4-0.7 hr; absorbed systematically,
metabolized in the liver and excreted in the urine.
- Side effects include: disorientation,
confusion, light headedness, nausea, vomiting,
fever, dyspnea, rebound congestion
Drugs in this class: P ephedrine(Kondon’s Nasal);
oxymetazoline(Afrin, Allerest);
phenylephrine(Coricidin); trahydrozoline(Tyzine);
xylometazoline(Otrivin)
● Oral Decongestants
-decrease nasal congestion related to common
colds,sinusitis,and allergic rhinitis.
-relieve pain and congestion of otitis media
- shrink the nasal mucous membrane by
stimulating the alpha-adrenergic receptors in the
nasal mucus membrane,promoting drainage of the
sinuses and improving air flow.
-Pseudoephedrine peak levels- 20 to 45 minutes.
-ask the patient to void before taking the drug.
-contraindicated to patient with
glaucoma,hypertension,diabetes,thyroid
disease,coronary disease and prostate problems.
-Adverse effects: rebound
congestion,anxiety,tenseness
tremors,hypertension,arrythmias,sweating,and
pallor.
-encourage patient not to use this drug for more
than 1 week.
● Topical Nasal Steroid Decongestants
- treatment for allergic rhinitis,been found to
be effective in patient that doesn’t respond with
other decongestants.
- Has an anti-inflammatory action that
produce direct local effect.
- Onset of action may not be immediate, and
may require up to a week to cause any changes.
- If no effects after 3 weeks , discontinue the
drug.
- Relieve inflammation after removal of nasal
polyps.
- Contraindicated with Candida Albicans
infection,caution to those with TB,chickenpox,and
measles.
Drugs in this class: P flunisolide, Beclomethasone
(Beclovent), Budesonide (Rhinocort)
,Dexamethasone (Decaderm),Fluticasone
(AeroBid),Triamcinolone ( Kenacort)
Antihistamines
-blocks the effect of histamine 1 receptor sites,
bringing relief to the patient to patients suffering
from itchy eyes,swelling,congestion,and drippy
nose.
-treatment for seasonal and perennial allergic
rhinitis,uncomplicated urticaria,angioedema
-also has anticholinergic effects and antipruritic
effect.
-most effective if used before the onset of
symptoms.
-Onset of action 1-3 hours.
-caution to those with arrythmias and prolonged
Q-T intervals.
-Adverse effects: drying of the respiratory and GI
mucous membranes,GI upset ,
nausea,dysuria,urinary hesitancy,and skin eruption
and itching associated with dryness.
-increase effect if taken with MAOI,
ketoconazole,and erythromycin.
-administer drug in an empty stomach
-have patient void before each dose
-Avoid alcohol
Drugs in this class: P Diphenhydramine (Benadryl)
T ½ of 2.5-7 hours
1st generation: Azelastine
(Astelin),Brompheniramine, Buclizine ( Bucladin
S),Cetirizine(Reactine),Chlorpheniramine
(Aller-chlor),Clemastine (Tavist),Cyclizine
(Marezine),Cyproheptadine(Periactin),Dexclorphe
niramine(Dexchlor),Dimenhydrinate
(Dimentabs),Hydroxyzine (Vistaril),Meclizine
(Bonine),Phenindamine
(Nolohist),Promethazine(Phenergan).
2nd generation : Desloratadine
(Clarinex),Fexofenadine (Allegra),Loratadine (
Claritin).
Expectorants
-liquefy lower respiratory tract secretions,reducing
viscosity of these secretions, and making it easier
for patient to cough them out.
-reduces adhesiveness and surface tension of
secretions,movement of less viscous secretions
-more productive cough, decreased frequency of
coughing.
-P Guaifenesin (symptomatic reliefof respiratory
condition characterized by dry, nonproductive,
cough, and in the presence of mucus in respiratory
cough)
-adverse effects:
Nausea,vomiting,headache,dizziness,rash.
-Not to use this drug for more than 1 week.
-Advise the use of small,frequent meals.
Mucolytics
-aid in high –risk respiratory patient in
coughing up thick secretions,tenacious secretions.
-for COPD, cystic
fibrosis,pneumonia,tuberculosis,atelectasis,diagnos
tic bronchoscopy,
Postoperative patients with tracheostomy.
-administer through instillations or
nebulization.
-caution with acute brochospasm,peptic
ulcer,and esophageal varices.
-splits links in mucoproteins contained in
secretions,decreasing viscosity.
Drugs in this class : P Acetylcysteine
(Mucomyst) T ½ 6.25 hr ,Dornase alfa
(Pulmozyme)

Chapter 55 - Drugs Used To Treat
Obstructive Pulmonary Disease
Bronchodilators/
Antiasthmatics-dilating airways
Xanthines
-main treatment for bronchospasm and
asthma.
-has direct effect on the smooth muscles
of respiratory tract,both in the bronchi and
in the blood vessels.
- stimulate 2 prostaglandins resulting in
smoothe muscle relaxation, which then
increase the vital capacity.
- inhibit the SRSA.
- Unlabeled use: stimulation in
respiration Cheyne Stokes respiration.
- Peak levels within 2 hours.
- Caution with patient with GI
problems,coronary disease,respiratory
dysfunction,renal or hepatic lung
disease,alcoholism,hyperthyroidism.
- Increases with nicotine.
Drugs in the class: P Theophylline (
Sio-bid ,Theo Dur)
T ½ of 3-15 hr (nonsmoker),4-5 hr
(smoker),
Aminophylline(Truphylline), Caffeine,
Dyphylline (Dilor).
-administer drug with food or milk.
Sympathomimetics
-mimic the effects of the sympathetic
nervous system.
-dilates the bronchi and increased the rate
and depth of respiration.
-beta2 selective adrenergic agonists.
-Adverse effects: increase
BP,HR,vasoconstriction,decreased renal
and GI bloodflow.
-rapidly absorb after injection.
Half life of < 1 hour.
-Caution on those with cardiac
disease,vascular
disease,diabetes,hyperthyroidism,
pregnancy and lactation
- avoid combination with
bronchodilators,general anesthetics
cyclopropane,and halogenated
hydrocarbon.
- administer with small frequent meals.
Drugs in this class: P Epinephrine (Sus
–Phrine, EpiPen), Albuterol(Proventil),
Bitolterol (Tornalate),
Ephedrine,Formoterol (Foradil),
Isoetharine(Bronkosol), Isoproterenol
(Isuprel), Levalbuterol (Xopenex),
Metaproterenol (Alupent).
Anticholinergic Bronchodilators
-not as effective as sympathomimetics but
can provide some relief to those patient
who could not respond to other drugs.
-has an effect in the vagus nerve,which
block or antagonize the action of the
neurotransmitter acetylcholine at
vagal-mediated receptor sites, leading to
relaxation of smooth muscles by
bronchodilation.
Drugs in this class: P Ipratropium with an
onset of action of 15 minutes when
inhaled.Peak of 1-2 hours,Thiotropium
has rapid onset and longer duration with
half life of 5 to 6 days.
-Encourage client to void before each
dose.
-Provide small frequent meals and
sugarless lozenges.
-Caution patient not to use inhalator for
more than 12 inhalations in 24 hours.
Inhaled Steroids
-very effective for treatment of
bronchospasm.
-decrease inflammatory response in the
airway,thus increasing air flow and
facilitate respiration.
-Has 2 effects:

⮚ Decreased swelling associated with
inflammation and promotion in the beta
–adrenergic receptor activity.
⮚ Inhibit bronchoconstriction.
-used for prevention and treatment of
asthma,treat chronic steroid-dependent
bronchial asthma.
-should be taken 2-3 weeks to achieve
effects.
-Adverse effects: sore throat,coughing,dry
mouth,and pharyngeal and laryngeal
fungal infection.
-have patient use decongestant drops
before using inhaled steroid.
-Have patient rinse his mouth after inhaler.
Drugs in this class include:P Flunisolide
(AeroBid) T ½ of 1-2 hours.,
beclomethasone (beclovent),Budesonide
(Pulmicort),Fluticasone
(Flovent),Triamcinolone (Azmacort).
Leukotriene Receptor Anatagonist
-selectively,and competitively blocks the
receptor for production of leukotrienes D4
,E4 components of SRSA.
-blocks many signs and symptoms of
asthma,such as neutrophil,eosinophil
migration,neutrophil,and monocyte
aggregation,leukocyte adhesion,increased
capillary permeability,and smooth muscle
contraction.
-prophylaxis for bronchial asthma and in
patients younger than 12 years of age.Not
indicated for treatment of acute asthma
attack.
-metabolized via cytochrome P450 and
excreted in feces.
-Abverse effects:
headache,dizziness,myalgia,nausea,diarrhe
a,elevated liver
enzymes,vomiting,fever,pain.
-Increased toxicity if taken with
propanolol,theophylline,and warfarin
Drugs in this class : P Zafirlukast
(Accolate),Montelukast(Singulair),Zileuto
n (Zyflo).
-administer drug in an empty stomach.
-Caution patient not to stop meds in
symptom –free periods.
Lung Surfactant
-naturally occurring substance lipoproteins
containing lipids, and apoproteins that
reduce the surface tension within the
alveoli for gas exchange.
-used to replace the surfactant that is
missing in lungs of neonates with RDS.
-begin to act immediately on instillation
into the trachea.
-No contraindications
-Adverse effects: patent ductus arteriosus
in infants,hypotension,intraventricular
hemorrhage,pneumothorax,pulmonary air
leak,hyperbilirubinemia,and sepsis.
Drugs in this class: P Beractant
(Survanta),Calfactant(Infasurf),Colfosceril
(Exosurf, Neonatal ),
Poractant (Curosurf).
-suction the infant immediately before
administration,but do not suction for 2
hours after administration.
Mast Cell Stabilizers
-prevent release of inflammatory and
bronchoconstricting substances when mast
cells are stimulated to release these
substances because irritation.
Drugs in this class: P Cromolyn T ½ of
80 min(inhibit release of histamine and
SRSA,and is inhaled in a capsule but may
not reach its peak effect for 1
week).Nedocromil (inhibit mediators of
inflammatory cells including
eosinophils,neutrophils,macrphages,and
mast cells.
-treatment of mild-moderate bronchial
asthma of >12 years old patients.
-Cromolyn not recommended for children
younger than 2 years old,and nedocromil
not recommended for children younger
than 12.
-Adverse effects:
headache,dizziness,nausea,sore
throat,dysuria,cough and nasal congestion.
-Administer oral drug 30 minutes before
meals and at bedtime.
-Instruct patient not to wear contact
lenses if using Cromolyn eye drops.
-Dizziness and fatigue common problem
in takinh Nedocromil.

CHAPTER 56 – INTRODUCTION TO
THE GASTROINTESTINAL SYSTEM
The gastrointestinal (GI) system is the
only system in the body that is open to the
external environment. The GI system is
composed of one continuous tube that
begins at the mouth; progresses through
the esophagus, stomach and small and
large intestines; and ends at the anus. The
pancreas, liver and gallbladder are
accessory organs that support the
functions of the GI system.
Composition of the Gastrointestinal Tract
The GI tube is composed of
four layers:
● The Mucosa – provides the inner
lining of the GI tract
● The Muscularis Mucosa – is made
up of muscles. It helps the tube
open and squeezing the tube to aid
digestion and motility. It also helps
propel the gastrointestinal contents
down the tract.
● The Nerve Plexus – these gives the
GI tract local control of movement,
secretions, and digestion.
● The Adventitia – outer layer of the
GI tract, serves as a supportive
layer and helps the tube maintain
its shape and stay in position.
Gastrointestinal Activities
The system has four major activities:
● Secretion
● Absorption
● Digestion
● Motility
Secretion – secretes various compounds to
aid the movement of the food bolus
through the GI tube, to protect the inner
layer of the GI tract from injury and to
facilitate the digestion and absorption of
nutrients.
- Saliva – contains water and
digestive enzymes and
facilitate swallowing by
making bolus slippery
- Histamine 2 receptors –
gastrin and
parasympathetic system
stimulates it, causing the
cells to release
hydrochloric acid into the
lumen of the stomach.
- Bile – contains detergent
like substance that breaks
apart fat molecules so that
they can be processed and
absorbed.
- Gallstones – develop when
the concentrated bile
crystallizes.
Digestion – process of breaking food into
usable, absorbable nutrients.
Absorption – active process of removing
water, nutrients and other elements from
the GI tract and delivering them to the
bloodstream for use for the body.
Motility – GI tract depends on this to keep
things moving through the system.
- Peristalsis – basic
movement in the
esophagus. It is a constant
wave of contraction that
moves from the top to the
bottom of the esophagus.
- Swallowing – response to a
food bolus in the back of
the throat stimulates the
peristaltic movement that
 directs the food bolus into
the stomach.
- Segmentation – involves
contraction of one segment
of small intestine while the
next segment then relaxes,
and the relaxed segment
contracts.
Other local GI reflexes:
● Ileogastric reflex
● Intestinal-intestinal reflex
● Peritoneointestinal reflex
● Renointestinal reflex
● Vesicointestinal reflex
● Somatointestinal reflex

Central Reflexes
Two centrally mediated reflexes -
Swallowing reflex and Vomiting reflex –
are very important to the functioning of
the GI tract.
Local Gastrointestinal Reflexes
● Gastroenteric reflex: stimulatiuon ⮚ Swallowing – is a centrally
of the stomach by stretching, the mediated reflex that is important in
presence of food, or cephalic delivering food to the GI tract for
stimulation causes an increase in processing. It is controlled by the
activity in the small intestine. It is medulla and involves a complex
thought that this prepares the small series of timed reflexes.
intestine for the coming chyme.
● Gastrocolic reflex: stimulation of ⮚ Vomiting – is controlled by the
the stomach also causes increased chemoreceptor trigger zone (CTZ)
activity in the colon, again in the medulla or by the emetic
preparing to empty any contents to zone in immature or injured brains.
provide space for the new chime. The CTZ is stimulated by several
● Duodenal-colic reflex: the different processes and initiates a
presence of food or stretch in the complex series of responses that
duodenum stimulates colon first prepare the system for
activity and mass movement, again vomiting and then cause a strong
to empty the colon for the new backward peristalsis to rid the
chime. stomach of its contents.