PSYCHIATRIC DRUGS

Anxiety Medications
1) Benzodiazepines
2)Barbiturates
3) Buspirone

1) Benzodiazepines
-lam
AlprazoLAM
MidazoLAM

-pam
TemazePAM
ClonazePAM
 The Benzodiazepines acts faster but are very dangerous because its Highly addictive hard
to come off (NOT for long term use)
 Never Abruptly or Suddenly STOP!

Mechanism of Actions:
Increase GABA Neurotransmitter which decrease neuron activity which reduces anxiety (As in
anxiety GABA reduces) PRETTY SIMPLE NA !!!

USES
 Anxiety
 Alcohol withdrawal
 Seizures

SIDE EFFECTS (Important)

 Heart (Low HR and BP)
 Respiratory depression (Tachypnea)
 Brain (Sedation)

ANTIDOTE: Flumazenil
2) Barbiturates
  Ending with - Barbital
 Like Phenobarbital

Good News
Last longer in body

Bad News
Take Longer to get out of the body (Toxicity RISK!!)

Mechanism of action:
Increase GABA in brain SAME as above

SIDE EFFECTS
Hypotension
Respiratory depression than ultimately to death

3) BusPirone
 2-4 Weeks to take affect
 NO sedation
 No withdrawal symptoms

DRUGS for BIPOLAR DISORDER

1. Carbamazepine
2. Valproic Acid
3. Lithium

1) Carbamazepine (Convul 200mg)

Uses
 Bipolar disorder
 Trigeminal Neuralgia
 Seizures
CAUSES
 Leukopenia
 LOOK FOR SIGNS OF INFECTION (Fever and Sore throat)
 Oral contraceptive ineffective
VALPORIC Acid (Dapakan 500 mg)
Remember VALLL

1. Liver toxicity
2. Low Platelet (LOOK FOR BLEEDING)
3. NOT Pregnancy safe
4. DONOT Stop abruptly
LITHIUM (BIG MAMA here)
Therapeutic Level 0.6 to 1.2 mEq/L
Remember Mnemonic “LITH”
L=Levels over 1.5 mEq/L huge toxicity
I= Increase Fluid and Sodium
 Never restrict and water and Sodium
 No Diuretic and drinks that causes diuresis
T =TOXIC signs
 Report Excessive Urination and extreme thirst
 Vomiting and Diarrhea
 Neuromuscular excitability (Tremors/ Myoclonic jerks)
H= HOLD NSAIDS (Ibuprofen and Naproxen)
NOTE These:
 DON'T Report Dry Mouth and Thirst
 Weight gain
 Drowsiness and Fatigue
 Weight gain and Weight Loss measures

ANTIDEPRESSANTS
4 Rules of Antidepressants
1) Antidepressants can increase suicidal thoughts in first few weeks
Notify Health care provider for any suicidal thoughts:
o Monitor for:
 New thoughts of suicidal
  Unusual Behavior
 Worsening depression
 Sudden change in mood
2) Slow Onset and SLOW taper off
 Never STOP abruptly
3) Never Mix
 SSRI + St. John's Wort
 MAOI + Antidepressant (TCA. SSRI, SNRI) leads to serotonin syndrome
 TWO WEEKS WASH UP periods before starting new antidepressant
4) ALL Psych drugs reduces BP
 Causes weight changes mostly weight gains

SSRI (SEROTONIN REUPTAKE INHIBITORS)

USES
1. Depression
2. Anxiety
3. PTSD

Most Common SSRI's

 Sertraline
 Citalopram
 Escitalopram (Cheer Up)
 Paroxetine and Fluoxetine (Flit)

MECHANISM OF ACTION
Selective Serotonin reuptake inhibitors works by stopping reuptake of serotonin from being
reused by Serotonin Transport
NOTE: side effects that improves after 3 months
 Weight gain
 Sexual dysfunction
Memory Mnemonic for SSRI
S Suicidal Risk Increased (18 to 24)
S Slow Onset and Taper off
S Sweaty and Hot and Fever
R Rigid muscles, Restlessness and Agitation
I Increased Heart rates or Tachycardia

SEROTONIN SYNDROME
S=Sweaty& Fever
R= Rigid muscles and Restlessness and Agitation
I= Increased Heart rate Tachycardia & Hypertension
Mydriasis (dilation of the pupil of the eye.)

SNRI (Serotonin and Non-epinephrine Reuptake inhibitor)

Mechanism of action: It works by increase serotonin and Nor-Epinephrine levels by inhibiting
their reuptake on receptors.
Nor- Epinephrine

In the brain, norepinephrine functions as a neurotransmitter, modulating various processes such as

attention, learning, and memory. It is involved in the regulation of mood, arousal, and vigilance, and has
been implicated in various psychiatric disorders, including depression, anxiety.

Dual- Oxetine
Double Purpose (Depression and Pain (Fibromyalgia means chronic body pain)
 Teach Patients regarding its dual action.

TCA (Tricyclic antidepressants)

Mechanism of Action:
The mechanism of action of TCAs involves their ability to block the reuptake of several
neurotransmitters, including serotonin and norepinephrine, from the synaptic cleft.
By blocking the reuptake of these neurotransmitters, TCAs increase the levels of serotonin and
norepinephrine in the brain, which helps to improve mood and reduce anxiety.
In addition to their effects on serotonin and norepinephrine reuptake, TCAs also have activity at
various other receptors in the brain, including histamine, muscarinic, and alpha-adrenergic
receptors. These effects contribute to the side effects commonly associated with TCAs, including
sedation, dry mouth, constipation, and blurred vision.
Drugs:
Amitriptyline and Imipramine
Because these drugs have effect on Muscarinic receptors that’s why causes
 Blurred vision
 Urinary retention
 Dry mouth
 Constipation
 Sedation
 Seizures
Sweating due to Nor Epinephrine increase
KEY CONCEPTS HERE
1. Orthostatic Hypotension (Slow position changes esp., Amitriptyline’s ---Amy trips on
things slow position changes) Due to effect of TCA on Alpha 1 receptors
2. Urinary retention (Imipramine--Inhibits my peeing)
3. Never take with MAOI
4. 2-week wash-out period
5. No MAOI + Antidepressants (TCA, SRRI, SNRI)

MAOI (Monoamine oxidase inhibitors)

1. Phenelzine (Brand Name: Nardil)
2. Seleginine
3. Isocaraboxazid

Mechanism of action
Increases Nor epinephrine +Serotonin+ Dopamine levels in blood
Memory Trick for MAOI
M= Massive HTN Crisis Risk
A = Avoid Tyramine (Wine &Cheese, Beer & Sausage, Salomi, Chocolates) Starting diet 2
weeks before and after MAOI to manage tyramine levels in the body
O = OTC drugs = HTN Crisis
O = Other Antidepressants SSRI MAOI TCA (Can Triger Serotonin Syndrome)
I = Increased suicide risk (First few week)

Atypical Antidepressant
Trazodone (Trazzzadone)
Indication:
Sleep Aid and treats depression
Key things to Note:
 Avoid Ethanol and Other Sedatives
 Take at night
 Slow Position change (To Prevent Orthostatic Hypotension)
 Piparism (If erection last longer than 4 hours contact hospital)

Bupropion SR (Sustained Release), XL (Extended Release)

 Depression
 Aids to stop smoking
Side effects
 Insomnia
 Headache
 Weight loss
Key things to note:
Never Crush chew or cut (Increases absorption leading to faster effects on the body)

Antipsychotics:
There are three generations of antipsychotic drugs:
Conventional or 1st generation antipsychotics
1. Fluphenazine (Flucate)
2. Thioxanthane (Cis isomer of injection Clopixol (Zuclopenthixol)
3. Haloperidol (Serenace)
Typical or Second-generation antipsychotics:
 1. Clozapine (Clozaril)
2. Risperidone (Risp, Dawn)
3. Olanzapine (Olanzia)
4. Quetiapine
5. Paliperidone (Invega) ((Its chemical similar to Risperidone, however is for an extended
release, so increase compliance.
Third generation antipsychotic:
1. Aripiprazole (Aripip)
Mechanism of action:
The major action of all antipsychotics in the nervous system is to block receptors for Dopamine
(D1, D2, D3, D4, D5) However, only D2,D3, D4 have been linked to mental illness. The
conventional or first-generation antipsychotics block all three of them. But blocking of D2
receptors causes extrapyramidal effects.
Newer, Atypical Second generation are relatively weak in blocking D2 receptors which may
cause lower incidence of extrapyramidal effects. In addition, they also inhibit reuptake on
Serotonin, as do some antidepressants. So effective against depression too.
The third generation are the dopamine stabilizers, these drugs thought to stabilize dopamine
output enhance dopaminergic transmission when it is too low and reduce it when it is too low.

Extra pyramidal Side effects with antipsychotic drugs:

These serious neurological symptoms included Dystonia, Pseudoparkinosim, Akathisia.
Dystonia: Disorder characterized by involuntary muscle contractions that cause repetitive or
twisting movements and abnormal postures. The movements can occur in any part of the body
and can be painful and disabling. Acute muscular rigidity and cramping, a stiff or thick tongue,
laryngospasm or respiratory difficulties.
Pseudoparkinosim:
 Showing symptoms of parkinsonism
 Pill rolling of fingers ad thumb while at rest
 Cogwheel posture
 Drooling
 Mask Like-Face
 Stooped Posture
 Festinating gait: (FSG is described as; rapid, small steps, done in an attempt to keep the center
of gravity (COG) in between the feet while the trunk leans forward involuntarily and shift the
COG forward)

Akathisia: The client appears restless and agitated and urge to move. The internal feeling of
restlessness and the inability to sit still or rest often leads to client to discontinue medicine.
Neuroleptic Malignant Syndrome: Typical Antipsychotic (Haloperidol) cause this
lethal adverse effect. The major symptoms are rigidity, fever, autonomic instability such as
instable blood pressure, diaphoresis, pallor and elevated enzymes particularly creatine
phosphokinase.
HOLD This Drug immediately!! And Notify Health Care Provider (HCP)
Second generation antipsychotics
Hyper salivation
Weight gain
Key Points to Note:
1) Atypically antipsychotic can’t be given in dementia related psychosis as it causes death.
So, don’t give Risperidone in patient with dementia.
2) Clozapine can cause agranulocytosis
 Monitor WBS before treatment as a baseline
 During treatment every week
 And for 4 weeks after discontinuation of Clozapine
3) Ziprasidone (Geodon) contradicted in patients with history of QT Prolongation recent MI
or heart failure.

Diabetes Pharmacology
Insulin Tips
2. Peaks + Plates = Give FOOD during PEAKS
3. Deadly Hypoglycemia (70 or less)
4. No Peak No Mix = Long-Acting Inulin type (Glargine, Detereme)
5. IVP/IV Only= Regular Insulin.
 Draw Up: Clear to Cloudy (Regular insulin first than NPH Second)
6 Rotate locations---Best on Abdomen (near: Umbilicus, Naval, “belly button) Don’t
Massage, Draw plunger after injections.
7 DKA- Type 1 “Sick days”—Yes, we give Insulin without food but we closely monitor.

Insulins Types:
INSULIN TYPES
Peaks are priorities
Check BSL after 15 minutes of intervention
CSSI

Antidiabetics Oral agents

Classifications
1. Sulphonyl ureas
 Glipizide
 Glyburide (Glibenclamide)
2. Biguanides
 Metformin
3. Alpha- glucosidase inhibitors
 Acarbose & Precose
4. Thiazolidinedione (Insulin sensitizers)
 Pioglitazone
1 Sulphonyl ureas:
Glipizide & Glyburide
They trigger beta cells to stimulate insulin secretions from pancreatic beta-cells.
 1) Administer just prior to meals to avoid Hypoglycemia.
2) Instruct client to consult HCP before combining with OTC
3) Causes weight gains and Sun burns.
4) Glipizide and Glyburide bad for heart failure and MI history.
2 Biguanides
Inhibits Liver Glucose production & reduces intestinal glucose reabsorption.
Metformin (Glucophage):
 Hold 48 hours before contrast studies can cause contrast related Nephrotoxicity. Also,
metformin metabolites accumulate and causes lactic acidosis
 Most Common side effect is Bloating Nausea, Vomiting, Diarrhea. The Nurse should
inform the patient this disturbance is transient and lessen by taking Metformin with
food.
3 Thiazolidinedione (Insulin sensitizers)
Pioglitazone
Reduce glucose production and increase insulin receptors sensitivity
 Increased risk for Heart failure: Monitor daily weight for clients with any cardiovascular
problems
 Increased risk for macular edema: Teach clients to report changes in vision.
4 Alpha- glucosidase inhibitors
Acarbose
Inhibits absorption of glucose from intestine thus reducing postprandial (after meal) rise of blood
glucose. It has no effect on insulin receptors so doesn’t cause Hypoglycemia

Gastro-Intestinal Pharmacology
Antiemetics
The drugs that stop Nausea & Vomiting
Ondansetron: Works by blocking the Serotonin receptors
Before Chemotherapy to prevent Nausea Vomiting
Before and After pain meds that cause Nausea (Onset +Tramadol etc.)
Can cause Serotonin Symptoms: Muscle rigidity, Tachycardia, Hypertension, Headache
Side effects:
Priority: Torsade pointes
Headache dizziness

METCLOPRAMIDE:
Works to treat Nausea and Vomiting but also Gastroparesis (Delayed gastric emptying)
It’s a prokinetic agent. Increase intestinal motility so delaying gastric emptying.
Contraindication: It is contradicted in GI Bleed (As it affects GI motility)
KEY POINTS
Extrapyramidal side effects:
Tardive Dyskinesia which is a neurological disorder characterized by involuntary movements of
the face, tongue, and other parts of the body. TD can manifest in different ways, but some
common symptoms include repetitive facial movements such as grimacing or eye blinking, lip
smacking, tongue protrusion, and involuntary movements of the limbs and trunk. Like:
 Lip smacking
 Puffing of cheeks
 Tongue protrusions
Inform HCP if these signs are observed

Constipation
Laxative & Stool Softeners:
1. Bulk forming laxative: Ispaghul husk
2. Osmotic Laxative: Lactulose
3. Stool Softeners: Sodium discoute

Contraindicated in Bowel Obstruction huge risk for death

Psyllium Husk Fiber

Milk of Magnesia (Antacid and Laxative)
Sodium Docusate (stool softener)
Increase fluid, walking and fiber
Lactulose
LAC
L=Laxative
A= Ammonia level decrease
C= Cognition improved
Decrease ammonia level in their body and helps in Hepatic Encephalopathy.
KEY POINTS

1. 2-3 soft stools per days

2. Ammonia level decrease
3. Improve mental status

Sodium Polystyrene Sulfonate (Kayexalate)

 Reduces Body Potassium K+

 Given for Hyperkalemia
 Per Oral is most effective also can give enema
Ensure:

 Normal Bowel function before administering

 Bowel patterns and frequency
 Drink fluids after administration
 Monitor for signs and symptoms of Hypokalemia

Antidiarrheal
Loperamide (Imodium)
Opioid antidiarrheal agent
Mechanism of action: Decrease the motility & movements of intestine, also increase the absorption of
water and sodium.
Can Cause Constipation
FDA has prohibited this medicine
Dicyclomine
Given in the patient with IBS (Irritable Bowel Stool)
Who have more than 20 loose stools a day
Helps gets bowel on regular cycle
Mechanism of action:
It is antispasmodic and anticholinergic. It dries everything up so cause Urinary retention, blurred vision,
constipation.
Key Points
Not for Paralytic ileus or Bowel obstruction
Not for Narrow angle glaucoma
Not Full bladder more than 400ml
dicyclomine means Dry Cycle

Sulfasalazine
It is used in Inflammatory Bowel Disease (IBS)
Crohn disease and Ulcerative colitis
Those autoimmune disease that causes to destroy itself. Reduces inflammation by blocking
prostaglandins
It is considered as immunosuppressants
Normal signs:
 Yellow or orange discoloration of Skin and Urine
Major concern:
Mnemonic: SULF
S=Sun Dried, Photosensitivity
 Wear Sun Block and avoid direct Sun exposure
U= Urine Crystals (Kidney stones)
L=Low urine output high specific gravity (Normal 1.003-1.030)
F=Fluid and Folic acid
 Folic acid 1mg/ day with it
 Fluid 8 glasses per day
Expected findings: Bloody diarrhea and raised inflammatory markers. Don’t STOP the meds.

Acid Prevention
1. Antacid
2. H2 Blockers
3. PPI
Mucosal Protection
Sucralfate

1. Antacids
 Never take antacid with other meds
Mnemonic: SCAM as they provide short term relief
1. Sodium Bicarbonate
2. Calcium Carbonate
3. Aluminum Hydroxide
4. Magnesium Hydroxide (Milk of Magnesium)
Aluminum and Calcium
They cause constipation
Magnesium Hydroxide
Can Upset Stomach and liquid Bowel Movement ( diarrhea)
Key Points:
 Never taken with other meds
 Take 1 hour BEFORE or AFTER other Meds!
 Don’t take OTC for heart failure patients. These guys have sodium or other electrolytes
disturb body chemistry.

2. H2 receptor Antagonist
Famotidine, Ranitidine
 It turns down volume of acid production
 Take 30 minute before meal
 GERD and Ulcer
Mechanism of action: Blocks H2 receptors in stomach thus blocks histamine so histamines
doesn’t bind parietal cells so reducing acid production in the stomach.

3. Proton Pump Inhibitors (PPI)

 Omeprazole
 Esomeprazole
 Pantoprazole
KEY POINTS:
  Prevents Holes
 Prophylaxis for ulcers
 30 minutes before meal
 Porous bones, long tern side effects. So, take Calcium and Vit D & do Regular bone
testing)
 Possible GI infections (Clostridium difficile)
 Heart Burns

Mucosa Protectors:
Sucralfate
Mechanism of action: It made thick protective layer over the ulcer provide physical barrier on
ulcer
 Taken on empty stomach
 1-2 hours before food or after taking meds or food
 Taken at bed time

BLOOD THINNERS
1. Antiplatelet Small guys
2. Anticoagulants Medium
3. Antiplatelets Large Guys

ANTIPLATELETS
1. Clopidogrel
2. Abciximab
Indications:
Prevent MI and Stroke who have acute coronary syndrome
Used after PCI
Side effects:
o Bleeding
o With clopidogrel GI Upset and rash
o With Abciximab Hypotension and Dysrhythmias
Nursing Care:
1. Asses for bleeding
2. Monitor Platelets count 150k to 400k and Hematocrit and Hemoglobin levels below 7.
 3. But with Abciximab monitor EKG and vital signs because of its side effects of
Hypotension and Dysrhythmias

ANTI COAGULANTS
1. Heparin
2. Warfarin
HEPARIN: Injectable rapidly acting prolongs clotting time of blood by preventing fibrin
formation:
 Increase activity of antithrombin which inhibits conversion of Prothrombin to Thrombin.
So, no conversion of Fibrinogen to Fibrin. NO CLOT with fibrin.
 Prevention of new clots and growth of existing clots. Works quickly within 20 minutes.
aPPT= 46-70 Therapeutic range
Antidote: Protamine Sulphate
LOW MOLECULAR WEIGHT HEPARIN (Enoxaparin, Deltaparin)
 Lessen the risk for bleeding
 Prevention of DVT after surgery
Administration:
o Subcutaneous at 90-degree angle 2 inches from Umbilicus only
o Never aspirate SQ injections
o Never rub the site
MAJOR CONSIDERATIONS HERE:
Don’t administer if H & H (Hematocrit and Hemoglobin) is even slightly low
Open fractures (As we don’t know who much he has bleed)’
Measure: We measure for low platelet counts not coagulation studies like aPPT or INR
Platelet count= 150k to 400k
Hold the med if any platelet less than 50k
MAJOR MAJOR Consideration for Heparin:
It causes HIT (Heparin induced thrombocytopenia) after starting for 24 hours Alert HCP

WARFARIN:
Coagulation factors 2,7,9,10 produced in liver and activate by Vitamin K produces in the GI. So,
warfarin is it antagonist blocking and causing anticoagulation.
 Both Heparin and Warfarin together. This allows time for warfarin to kick in as warfarin
takes 5 days to start its affect, we use warfarin for long term use
Measure: INR = 2 to 3
For heart valve replacement = 2.5 to 3.5
Antidote= Vitamin K
Vitamin K Foods: This vitamin is present in very specific foods:

1. Liver
2. Green Leafy vegetables (Broccoli, Spinach)

Key Patient Teaching: Don’t increase or decrease its intake just keep in moderation and
consistency.
Nice to Know Thing:
Antibiotics increases risk on bleeding because it decreases INR. This is because antibiotics kills
in the intestinal bacteria that actually produces Vitamin K.
Indications:

1. It is given lifelong to prevent clots

2. Patient with atrial fibrillation
3. Mechanical valve replacements

Frequent blood test obviously to check its therapeutic range

FONDAPARINUX
Major advantage is no risk for HIT (Heparin Induced thrombocytopenia)
Major disadvantage is it can cause Epidural bleed
Don’t give to the patient with:
 Lower back pain
 Decrease LOC Level of Consciousness
 Paralysis
KEY TERMS HERE:
 No Fondaparinux for atleast 6 hours after surgery (Because patient has decrease level of
conscious.
 No anticoagulant while spinal epidural catheter in place
  Huge risk for Epidural Bleed

FACTOR XA INHIBITORS:
1. Rivaroxaban
2. Endoxaban
3. Apixaban

RIVAROXABAN
Work as anticoagulant by blocking Factor Xa Inhibitors and causes the blood to flow like River
Side effects:
o Risk for bleeding
o Possible elevated liver enzymes
o Don’t Abrupt stop
o Risk for neurological bleeding (Rock band causes bleeding due to their stupid Music)
Nursing Care:
1. Monitor liver function
2. Monitor hemoglobin and Hematocrit level
3. Avoid Aspirin with Rivaroxaban or avoid any other NSAIDS or over the counter meds
that causes bleeding

OTHER THROMBIN INHIBITORS:

Dabigatran, Argatroban
Key Terms:
 Used to prevent clots in high risk A Fib patients
 Don’t stop the med for Gi issues Normal side effects
 Not Crushed, taken whole (Slowly showing is affect)
 STOP if black tarry Stools (Gi bleeding)
 Hold before surgery

THROMBOLYTICS
1. Tissue Plasminogen Activator, or tPA (Alteplase)
2. Streptokinase
3. Urokinase
KEY TERMS:
 3-4.5 hour from onset of sign and symptoms
  Massive risk for bleeding
 NO IV, Sub Q, NO IM, No ABG’s
 Only given thorough peripheral IV that can be compressed not Central lines because you
can’t compress it
CONTRAINDICATION:
1. Active Bleeding
2. Hemorrhagic CVA or Peptic Ulcer
3. Uncontrolled HTN 180/110+
4. Recent surgery within 2 weeks

PHARMACOLOGY FOR URINARY SYSTEM

Bethanechol
Bethanechol it is typically used for Neurogenic bladder. It helps to treat functional urinary
retention.
It works by activating Parasympathetic system, stimulating Cholinergic receptors. (Cholinergic
Secretions)
Common side effects:
 It activates the Parasympathetic system which causes:
 Urinary urgency
 Sweating
 Low Heart rate & Low Blood Pressure

Oxybutynin and Tolterodine

It is anticholinergic drug. And it is anti-secretion. It deactivates Parasympathetic system
Uses:
 Given to treat an overactive bladder.
 Decrease Nocturia, Urgency and frequency.
 It is used for patients with urinary urgency.
Side effects
 Blurred vision
 Urinary retention
  Constipation
 Dry Mouth
Important Key information:
Avoid giving this to bowel obstruction disorder (due to constipation side effect)
Urinary retention
 No urination all day Must report to HCP
Avoid Hyperthermia= avoid sun exposure
Slow position changes to prevent Orthostatic hypotension

Finasteride
 Given in BPH. It shrinks the prostate gland.
Mechanism of action: Finasteride is a medication that is used to treat hair loss and prostate
enlargement in men. It works by inhibiting the activity of an enzyme called 5-alpha-reductase,
which converts testosterone to dihydrotestosterone (DHT) in the body.
Thus, increasing Testosterone level. So, it shrinks prostate causing urination.

Terazosin and Tamsulosin

Urinary retention in clients with BPH
Mechanism of action: Alpha-1 adrenergic receptors are present in bladder neck, prostate gland,
and peripheries, which helps in the regulation of smooth muscles works by blocking these
muscles and make easier to pass urine.
Side effects:
 Headache
 Orthostatic Hypotension by relaxation of smooth muscles
Patient Teaching for this:
1. Slow position changes (To avoid orthostatic hypotension)
2. Avoid Viagra.
3. Grapefruit juice is okay with this drug.

PHARMACOLOGY FOR CARDIAC SYSTEM

Antihypertensive
ACE Inhibitors:
 It works on RAAS system by blocking ACE inhibitors, thus blocking the conversion of
Angiotensin 1 into Angiotensin 2. The Angiotensin causes vasoconstriction and stimulate adrenal
gland to release aldosterone (which actually retains Na and water).
Ends with “pril” Example: Captopril, Lisinopril, Enalapril
TWO ACTIONS BY THIS DRUG:
1. Blocks conversion of Angiotensin 1 to Angiotensin 2
2. Increase level of Bradykinin (Basically ACE enzymes plays important role in breaking
down Bradykinin (Plays its role in vasodilation, inflammation and pain). Increase in its
level can causes Cough and Angioedema as its side effects

Indications:
 Lower Blood Pressure
 Heart failure patients (Systolic dysfunction)
 Post MI (Limit effects on heart)
Side Effects: Mnemonic: ACE
 Angioedema
 Cough
 Elevated Potassium (K+)
 Avoid Pregnant pts
NURSING CARE FOR PATIENTS ON ACE INHIBITORS
 Monitor K+ levels, Urinary output more than 30ml/hr
 Avoid foods reach in potassium (Potatoes, Banana, Oranges, Pork, Spinach, Avocados,
Tomatoes)
 Contact HCP if and persistent Dry cough and can’t tolerate
 Angioedema

ANGIOTENSIN 2 BLOCKERS (ARBS)

It works by blocking angiotensin 2 receptors thus inhibiting the effect of angiotensin 2. This
causes Vasodilation (Decrease SVR and BP). Excrete Na+ and increase K+ Level.
End with “sartan” Example: Valsartan, Losartan
Used for:
 Hypertension
 Heart Failure (↓preload +↓afterload)
 Type 2 Diabetic Nephropathy. Patient having kidney disease causes protein leak so higher
blood pressure can increase Proteinuria (↓ BP so ↓Proteinuria)
Side effects:
  Hypotension and Dizziness
 Elevate Potassium
Patient education:
1. Don’t abruptly stop the meds
2. Missed medicines taking method
3. Avoid diet high in Potassium
4. Avoid salts
5. Monitor BP Regularly
6. Avoid in pregnancy

BETA BLOCKERS
Beta 1 in heart (one heart) and in Kidneys in juxta medullary apparatus producing Renin
Beta 2 in Lungs (there are two lungs) also present in GI system, Vascular smooth muscle,
skeletal muscle and ciliary body of eye.
End with “lol”
Selective: Target Beta 1 receptors
Atenolol, Metoprolol, Esmlol etc
Non-Selective: Target Beta 1 and Beta 2
Propranolol (Inderal), Sotalol, Timolol

Mechanism of action: It blocks these beta receptors in the cardiac tissue. This inhibition of
Catecholamines results in decrease in heart force of contractions, heart rate and eventually blood
pressure, reducing cardiac oxygen demand (So helpful in MI and relives angina pain). Also,
blocks renin from juxtaglomerular apparatus thus inhibiting RAAS system.
Non selective beta blockers help in relieving intraocular pressure by contraction of intraocular
muscles but also can cause bronchospasm (Can use it in asthma patients).

Used for:
 Hypertension
 Stable angina
 Glaucoma
 Dysrhythmias
 Migraines and anxiety
Side effects:
 Bradycardia
  Hypotension
 Bronchoconstriction (Non elective beta blockers)
 Mask the effect of Hypoglycemia (Because Hypoglycemia causes in increase in heart rate
but it actually has lowering heart, avoided in hypoglycemia patients most of the time).
 Peripheral vasoconstriction (Causing erectile dysfunction, and cold calmy skin on
peripheries) that’s why prevented in people with peripheral vascular disease.
Nurse Responsibilities:
1. Monitor Heart rate and Hypotension
2. Exacerbate heart failure Because can cause negative inotropic affects
3. Taper off
4. Asthma and COPD (Don’t give non selective beta blockers)
5. Monitoring blood sugar closely

CALCIUM CHANNEL BLOCKERS

Blocks the calcium channels:
1. Vascular smooth muscles (Coronary arteries and peripheral arteries)
2. Cardiac myocytes (strength of heart contractions)
3. Cardiac nodal tissue (S.A and AV nodal tissues)
So, it causes coronary arteries to relax causing more oxygen to heart muscles and peripheral
arteries causing vasodilation and reducing Blood pressure, so helpful in heart attack)
Reduces strength of contraction and heart rate (Negative Chronotropic and Inotropic affects)
Reduces speed of contraction through AV node so, beneficial in Supraventricular tachycardia
(SVT)
Types of Calcium channel blockers:
Dihydropyridines (More vascular selective)
 Amlodipine, Nifedipine, Felodipine
Mainly for HTN and angina
Non Dihydropyridines (Myocardium selective)
 Verapamil
 Diltiazem
Mainly for Antiarrthymias, HTN, Angina
Side effects and Nursing care
1. Monitor bradycardia, Hypotension
2. Orthostatic hypotension (slow position change)
 3. Worsen heart failure
4. Avoid grapefruit
5. Also have to take fibers for constipation
6. Good Oral care as it causes gingival hyperplasia

D DIURETICS
Loop Diuretics:
 Frusemide (Lasix)
It works by blocking the absorption of Sodium and water in ascending Loop of Henule, Also
increase the excretion of Potassium, Calcium, Magnesium.
Used for
 Pulmonary edema
 Heart failure edema
 Hypertension
 Liver and Kidney disease
Side effects:
 Hypotension
 Hypokalemia
 Hyponatremia
 Hypocalcemia
 Hypomagnesaemia
 Ototoxicity
 Hyperglycemia (Frusemide causes liver to produce more glucose and also lowered
potassium can possibly cause insulin resistance)
Nursing Care with this medication:
1. Administer during the day
2. Administer slowly at the rate of 20mg per minute
3. Monitor Intake Output, Electrolytes
4. Increase intake of potassium containing foods (Potato, Tomatoes, Banana)

Thiazide diuretics:
Hydrochlorothiazide
Indications:
Treat Hypertension
Helps to treat renal calculi associated with Calcium
Edema related to Heart failure Liver and Kidney disease
Mode of action
Blocks the reabsorption of Sodium (N+) and water at distal convoluted tubules
Side effects:
 Hypotension
 Dehydration
 Hypokalemia
 Hyponatremia
 Hypercalcemia
 Hyperglycemia
 Hyperuricemia

Potassium Sparing diuretics:

Types:
Epithelial sodium Channel inhibitors
 Amiloride
Aldosterone antagonist

 Spironolactone

Mode of action: It works by blocking sodium channel and also as antagonist of aldosterone.
Excreting sodium and retaining potassium in the blood.
Indications:
 Hypertension
 Hypokalemia due to potassium wasting diuretics
 Hyperaldosteronism
 These are weakest diuretics so used in conjunction with loop of thiazide diuretics
Side effects & Nursing teaching:
1. Dehydration
2. Hypotension
3. Electrolytes (Hyperkalemia) Monitor for its symptoms
4. Avoid foods high in potassium
5. Also Take caution with ACE inhibitors, Arbs, Lithium
6. Spironolactone cause antiandrogen effects in body so cause gynecomastia
Dilators (Vasodilators)
They produce relaxation of vascular smooth muscles thus decreasing the blood pressure, also it
activates K+ channels that causes efflux of potassium resulting in membrane
HYPERPOLARIZATION and reducing calcium influx=arteriolar relaxation.
HYDRALAZINE
It works by relaxation of vascular smooth muscles
Side effects:
 Flushing
 Palpitations
 Headache
 Tachycardia
 Nasal congestion

SODIUM NITROPRUSSIDE:
It acts directly on arterial and venous vascular smooth muscles to produce vasodilation
It is used in Hypertensive emergencies
It can be also used in controlled Hypotension to minimize bleeding during the surgeries
ANTI ANGINAL
1. Nitrites and Nitrates
2. Beta blockers
3. Calcium Channel Blockers
Nitroglycerin (Isosorbide dinitrate and mononitrate)
They work by relaxing vascular smooth muscles, resulting dilation of veins causing pooling of
blood thus reducing preload and dilation of arterioles and causing decrease in afterload and blood
supply to heart by increasing diameter of coronary arteries.
Side effects:
Headache: Due to vasodilation in cerebral vessels
Skin flushing: Due to vasodilation in skin vessels
Postural hypotension: due to peripheral vasodilation
Tachycardia: Reflexly due to hypotension
Nursing actions and teaching:
 1. Can only give three tablets on five minutes interval if angina pain is not relieving (But
not more than three tablets) Give Sublingually
2. Store the medicine in tightly close container
3. Decreasing tolerance of drug by Nitrate- free interval (Giving interval in giving
medicines)

GLYCOSIDES
Digoxin
It is positive inotropic by increasing calcium influx and negative chronotropic by vagal
stimulation.
Indications:
First line treatment of heart failure with atrial fibrillation

Digoxin Toxicity:
GI upset Nausea and Vomiting
Sudden fatigue and weakness
Vision changes (Everything looks green)
Nursing actions:
Don’t give if pulse below 60
Monitor therapeutic ranges 0.5 -1.2
Causes Hypokalemia. Monitor its level closely
Antidote: Digiband
Class 1 Sodium channel blockers:
Ligocaine, Phenytoin
Class 2 Beta blockers
Class 3 Drugs that prolongs refractory timing
Amiodrarone
Clas 4 Calcium channel blockers
Verapamil
Heart Failure Pharmacology
A ACE & ARBS
Beta Blockers
Calcium Channels blockers
Digoxin
Dilators
Diuretics