Pharmacology Blue Print 2 (Copy 1)

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inotropic durgs

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drugs that influence the force or energy of muscular contractions, particularly the contraction of the heart muscle

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positive inotropic effect

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an increase in the force and velocity of myocardial contraction without a corresponding increase in oxygen consumption-increased force

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negative inotropic effect

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a reduction in the force of a contraction

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chronotropic drugs

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drugs that influence the rate of the heart beat

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positive chronotropic effect

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increase the rate at which the heart beats

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negative chronotropic effect

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decrease the rate at which the heart beats

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Dromotropic dugs

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drugs that influence the conduction of electrical impulses within tissues

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positive dromotropic effect

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accelerate conduction of electrical impulses

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negative domotropic effect

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a decreased automaticity at the sa node

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conduction system of the heart

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the sinoatrial (SA) node, atrioventricular (AV)node, bundle of His, and the Purkinje fibers

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organophosphate insecticide exposure

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this can be treated with the administration of atropine a cholinergic antagonist drug (anticholinergic)

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Cholinergic blocking drugs/parasympatholytics/antimuscarinics/anticholinergic drugs

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drugs that block or inhibit the actions of acetylcholine at the muscarinic receptors in the parasympathetic nervous system which allows the sympathetic nervous system to dominate. They are largely competitive antagonists, have little effect on the nicotinic receptors except in high doses. The block of acetylcholine causes pupils to dilate, decrease GI motility, secretions, and salivation, and may cause an increase in heart rate. Can cause urinary retention, dry mucous membranes, and cause bronchial dilation.

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Atherosclerosis

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a common form of arteriosclerosis involving deposits of fatty, cholesterol containing material (plaques) within arterial walls

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How do nitrates/nitrites work?

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used in the prophylactic and treatment of angina and other cardiac problems by dilating all blood vessels. Vasodilation occurs as a result of relaxation of the smooth muscle cells that are a part of the wall structure of veins and arteries. venous dilation reduces venous return and in turn the left ventricular end-diastolic volume (pre-load), which results in lower left ventricular pressure, and myocardial oxygen demand. include: amyl nitrite, nitroglycerin, isosorbide dinitrate, and isosorbide mononitrate

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indications for nitrates and nitrites

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used to treat stable, unstable and vasospactic (printzmetal) angina. Long acting are used for prevention of angina, and rapid are for acute attacks.

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Adverse effects of nitrates/nitrites

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include headache, tachycardia and postural hypotension

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hyperkalemia

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an excessive serum potassium level exceeding 5.5 mEq/L and is often symptomless until very high levels are present in the blood. Eventually you will see muscle weakness, electrocardiographic abnormalities, and intractable cardiac rhythm disturbances leading to cardiac arrest. Can be treated with sodium polystyrene sulfonate, sodium bicarbonate, or insulin and glucose. Hemodialysis is also effective

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Sodium polystyrene sulfonate/Kayexalate
aka
cation exchange resin

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administered orally by NG tube or as an enema to treat hyperkalemia. it works in the intestine where potassium ions from the body are exchanged for sodium ions in the resin

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hypokalemia

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a deficiency of potassium which is normally caused by excessive potassium loss rather than from poor dietary intake. normal potassium levels are 3.5-5 mEq/L. symptoms include anorexia, hypotension, lethargy, mental confusion, muscle weakness, nausea, cardiac dysrhythmias, neuropathy, paralytic ileus, and secondary alkalosis. If diagnosed early may be treated with potassium-rich foods but in clinically significant cases oral or parenteral administration of a potassium supplement is needed.

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hyponatremia

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a condition of sodium loss or deficiency and occurs when the serum levels decrease below 135 mEq/L. Manifests with lethargy, hypotension, stomach cramps, vomiting, diarrhea and seizures. mild cases are treated with oral administration of soidum chloride tablest and/or fluid restictions. More serious cases are treated with NS or lactated Ringer's solution administered IV.

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sodium chloride

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primarily used as a replacement electrolyte for either the prevention or treatment of sodium loss, or as a diluent for the infusion of compatible drugs and in the assessment of kidney function after a fluid challenge. Contraindicated for those who are hypersensitive. Pregnancy category C. Adverse reactions: oral-gastric upset, parenteral- venous phlebitis, and death by cerebral edema if hypertonic saline (3% or 5%) is administered too rapidly.

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hypernatremia

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the condition of sodium excess with serum levels exceeding 145 mEq/L. Symptoms are water retention (edema), and hypertension, red, flushed skin; dry, sticky mucous membranes; increased thirst; temperature elevation; and decreased/absent urination.

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potassium supplements

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% of potassium is intracellular-outside the cells in the plasma normal range is 3.5-5 mEq/L. supplements are administered either to prevent or to treat potassium depletion. Oral forms include acetate, bicarbonate, chloride, citrate and gluconate salts. Parenteral forms include acetate, chloride, and phosphate. The dose will depend on the requirements of the patient. Potassium is contraindicated in patient with severe renal disease, severe hemolytic disease, Addison's disease, those with hyperkalemia, acute dehydration or extensive tissue breakdown from multiple traumas Preg A adverse reactions-orally- gi upset including bleeding and ulceration. IV dose usually painful at site, must be administered slowly or can cause cardiac arrest

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cryoprecipitate

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a blood produce used to manage acute bleeding- over 50% blood loss slowly or 20% rapidly

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Fresh Frozen Plasma- FFP

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a blood product used to increase the clotting factor levels in patients with a demonstrated deficiency. product is obtained by centrifuging whole blood and removing the cellular components. not recommended for routine fluid resuscitation, but may be used as an adjunct to massive blood transfusion for patients with coagulation disorders, has a plasma expanding capacity similar to dextran. Caution it may transmit pathogens.

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Packed Red Blood Cells- PRCBs

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a blood product used to increase oxygen-carrying capacity in patients with anemia, in patients with substantial hemoglobin deficits, and in patients who have lost up to 25% of their total blood volume. are obtained by the centrifugation of whole blood and the separation or RBC from plasma and other cellular elements. oxygen-carrying capacity is better than other blood products and are less likely to cause cardiac fluid overload. Disadvantages-high cost, limited shelf life, and fluctuating availability, as well as ability to transmit viruses, trigger allergic reactions, and cause bleeding abnormalities.

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plasma protein fractions- PPF

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a blood product used to manage acute bleeding- over 50% blood loss slowly or 20% rapidly

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Milrinone/Primacor

Pregnancy category c

IV only

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a phosphodiesterase inhibitor (PDI)-an inotropic dug which inhibits the action of the enzyme phosphodiesterase which results in increase cAMP, which is beneficial for pt with heart failure by providing a positive inotropic effect and vasodilation. Should be a used short-term, in contraindicated in cases of known allergy. main adverse effect is dysrhythmias. Adverse effects-cardiac dysrhythmias, hypotension, angina, hypokalemia, tremor, and thrombocytopenia.

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Inamrinone/amrinon

iv onlyf

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a PDI used for short term therapy for heart failure, causes more calcium to be available to help increase the force of contraction. adverse reactions- thrombocytopenia, dysrhythmias, nausea, and hypotension.

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Nitroprusside/Nipride

Pregnancy C

IV only

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relaxes arteriolar, venous smooth muscle resulting in reduction n cardiac preload/after-load, an decreases BP in hypertensive crisis
Adverse effects- dizziness, headache, twitching, can cause cyanide, thiocyanate toxicity, flushing. Black box- hypotension.
Food interactions-aconite will result in increased toxicity or death, licorice will decrease the hypertensive.
Monitor-BP, ECG, electrolytes, check weight, edema, CHF, dilute, keep away from light, if discolored discard. Teach patient to report headache, dizziness, loss of hearing, blurred vision, dyspnea, faintness

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metolazone/zaroxolyn

PO

Pregnancy B

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a thiazide diuretic that appears to be more potent than the thiazide diuretics, most visible in pt with renal dysfunction. it remains effective to a creatinine clearance as low as 10 mL/min. may be given in combo with other loop diuretics to produce potent diuresis in patients with severe symp. of heart failure. Increases risk of digoxin toxicity if taken together. adverse effects- dizziness, headache, decreased libido, gi issues, impotence, jaundice, agranulocytosis, photosensitivity, hyperglycemia. Electrolyte imbalances most common issue. reduces potassium levels, elevated calcium, lipids, glucose, and uric acid.

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carbonic anhydrase inhibitors

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inhibit the activity of the enzyme carbonic anhydrase which is found in the kidneys,eyes, and other parts of the body. Their action primary takes place in the proximal tubule. Can induce metabolic acidosis which is beneficial in the prevention of certain seizures. Used to treat glaucoma, edema, and high-altitude sickness and rarely used as an antiepleptic. Most common is acetazolamide which can be used short term as a diuretic, for glaucoma, and high-altitude sickness.
Contraindicated for those with hyponatremia, hypokalemia, sever renal, or hepatic dysfunction, adrenal gland insufficiency, and cirrhosis. Adverse effects-metabolic acidosis, hypokalemia, drowsiness, anorexia, paresthesias, hematuria, urticaria, photosensitivity, and melena.

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Warfarin/Coumadin

Pregnancy X

PO only

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Class-oral anticoagulant MOA- antagonizes vitamin K which is needed for the synthesis of clotting factors which disrupts the coagulation cascade.
Uses- prophylaxis of thrombosis (Clot prevention), reduce the risk of MI, stroke, DVT, and Pulmonary embolism/PE, unstable angina, atrial fibrillation, use of indwelling devises like mechanical heart valves. will not have an effect on already formed clots.
Adverse effects- bleeding, fetal malformations, red-orange discoloration of urine, may cause skin necrosis and purple toes syndrome. DO NOT TAKE if there is a bleeding disorder, vitamin K deficiency, hypertension, or renal/liver disease
Nursing Implications- monitor prothrombin time (PT) and international normalized ratio (INR), normal INR is 1 second, on warfarin should be 2-3.5, PT 10-13, monitor for bleeding tendencies, TEACH-pt to decrease green leafy veggies.
VITAMIN K IS THE ANTiDOTE

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atrial fibrillation

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the most common cardiac dysrhythmia, affecting as many as 5-10% of people age 70 and over. Marked by rapid, irregular electrical activity in the atria, resulting in ineffective ejection of blood into the ventricles and an irregular ventricular response (apical pulse rate) May cause clot formation that may embolize

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Heparin

IV or Injection only

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Class-parenteral anticoagulant. MOA- enhances the inhibition of antithrombin factors which are needed for normal clotting, blocks the conversion of prothrombin to thrombin and fibrinogen to fibrin.
Uses- prevents and treats deep vein thrombosis (DVT), PE and emboli in atrial fibrillation, treats intravascular coagulation, preferred anticoagulant during pregnancy, prevents coagulation in heart-lung machines and dialyzers in patients after open-heart surgery.
Adverse effects- bleeding, hematoma, nausea, anemia, thrombocytopenia, fever, edema
Contraindications- bleeding tendencies, thrombocytopenia, eye, brain, spinal cord post operative patients
Nursing implications- monitor PTT normal 25-39 seconds, with heparin 45-70 , may overlap heparin and warfarin if changing medications, watch for bleeding!
ANTIDOTE-PROTAMINE SULFATE

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Diuretics

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drugs that accelerate the rate of urine formation via a variety of mechanisms resulting in the removal of sodium and water from the body. Are used in the treatment of hypertension by their hypotensive activity which causes direct arteriolar dilation which decreases peripheral vascular resistance, they reduce extracellular fluid volume, plasma volume, and cardiac output. May also be used in heart failure therapy. Include carbonic anhydrase inhibitors, loop diuretics, osmotic diuretics, potassium sparing diuretics, and thiazide/thiazide-like diuretics.
Assess before therapy- baseline vital signs, intake/output measurements, postural blood pressures, and labs. BUN, ALT, AST
Teach-proper nutrition and fluid intake, eat potassium rich foods unless using a potassium sparing diuretic, encourage changing positions slowly, report any dizziness, syncope, weakness or muscle aches, keep daily weight journal any more than 2-5 pounds should be reported, no the signs of hypokalemia, and should monitor blood glucose levels. take med early to prevent nocturia,

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Alpha 1 adrenergic recpetors

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cause pupil dilation, GI motility (decreases secretions), vasoconstriction of arterioles (increase BP, decrease blleding and nasal congestion), bladder contraction, prostrate contraction

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Alpha 2 Adrenergic receptors

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GI tract motility, vasoconstriction of arterioles (increase BP, decrease bleeding and nasal congestion.)

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Beta 1 adrenergic receptors

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affect heart rate, contractility, automaticity, and conduction (increases heart rate and contractility)

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Beta 2 adrenergic receptors

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affect bronchodilation (improve breathing), heart rate and contractility, conversion of glycogen to glucose (cause hyperglycemia), uterus relaxation, and GI motility.

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Adrenergic agonist aka sympathomimetic agent

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stimulates any combination of alpha and beta receptors. If only a=Alpha they are alpha agonists and if only beta they are beta agonists. many adrenergic drugs are used to treat cardiovascular emergencies. Used for hemodynamic compromise, bronchospasm, and nasal/sinus congestion. They may be used for Hypotension. Side effects include cardiovascular and CNS interactions...Tachycardia, palpitations, hypertension, chest pain, and pulmonary edema, can cause nervousness, weakness, and tremors and anxiety. Mimic the action of the sympathetic nervous system fight or flight response.

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beta Blockers

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block stimulation of the beta receptors in the SNS by competing with norepinephrine and epinephrine, can be selective or nonselective, non selective block both beta 1 and beta 2 receptors.
Indications- angina (decrease demand for Myocardial oxygen), cardioprotective (protects the heart when things need to slow down), dysrhythmias, migraine headaches, antihypertensive, heart failure, and glucoma. Most end in -ol

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beta 1 receptors

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are cardio selective, located primarily on the heart, and beta blockers that are selective for this receptor are know as cardioselective beta blockers.

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beta 2 receptors

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located primarily on smooth muscle of the bronchioles and blood vessels

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Cardio-selective beta blockers

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selective for beta 1, reduce SNS stimulation of the heart, decrease heart rate, prolong SA node recovery, slow conduction rate through the AV node, decrease myocardial contractility reducing myocardial oxygen demand.

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Non-selective beta blockers

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target both beta 1 and beta 2, cause same effects on the heart as cardioselective, constrict bronchioles, resulting in narrowing of airways and shortness of breath, produces vasoconstriction of blood vessels.

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Beta Blockers-Adverse effects and contraindications

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contraindicated for uncompensated heart failure, cardiogenic shock, heart block or bradycardia, pregnancy, severe pulmonary disease and Raynaud's disease. Must tritrate off due to risk of rebound hypertension,
Adverse effects- agranulocytosis, thrombocytopenia, AV block, bradycardia, heart failure, peripheral vascular insufficiency, dizziness, mental depression, lethargy, hallucinations, unusual dreams(nightmares), GI upsest, impotence, rash, alopecia, bronchospasm (if not cardio selective)
TOXICITY- TREAT with ATROPINE for bradycardia, and TREAT with DIAZEPAM for seizures
Interactions, may mask signs of of hypoglycemia, Digoxin (enhanced bradycardia), antacids, diuretics, other drugs affecting the heart

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Cholinergic drugs aka Cholinergic agonists aka parasmpathomimetics

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drugs that stimulate the parasympathetic nervous system (the rest and digest actions) by mimicking the effects of the PSNS neurotransmitter acetycholine (ACh) Increases SLUDGE- Salivation, Lacrimation, Urinary incontinence, Diarrhea, Gastrointestinal cramps, Emesis. Stimulates intestine and bladder with increase gastric secretions, increased gastrointesintal motility, and urinary frequency, causes pupil constriction (miosis) and reduces intraocular pressure, increased salivation and sweating, Cardio slows down.
Contraindications-GI obstructions, bradycardia, defectss in cardiac impulse conduction, hyperthyroidism, epilepsy, hypotension, chronic obstructive pulmonary disease, and parkinsons.
Adverse reactions- SLUDGE

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Cholinergic receptors

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nicotinic receptors (kind of like the bad guy), and muscarinic receptors (can be the good guy but in large amount). Nicotinic receptors are located in the ganglia of PSNS and SNS and are stimulated by the alkaloid nicotine. Muscarinic receptors are located in the effector organs of the PSNS (smooth muscle, cardiac muscle, and glands) they are stimulated by the alkaloid muscarine.

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Types of Cholinergics

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direct acting- bind to cholinergic receptors, activating them
Indirect-acting- inhibit the enzyme acteylcholinesterase which breaks down ACh, resulting in more ACh being available at the receptors
Desired effects come from the stimulation of the muscarinic receptors and many undesirable effects are caused by stimulation to the nicotinic receptors.

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Bethanechol/Urecholine

PO or Sub Q

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a direct-acting cholinergic drug used for post-surgical atony(tone or strength) of the bladder and GI tract, relaxes sphincters in the bladder and GI tract to allow them to empty, increases the tone and motility of the bladder and GI tract, chronic refractory heartburn, familial dysautonomia, and used to dx infantile cystic fibrosis.
Contraindications- Allergy, hyperthyroidism, peptic ulcer bronchial asthma, cardiac disease, CAD, epilepsy, obstructions, COPD, bradycardia, hypotension. LIFETHREATENING-TRANSIENT COMPLETE HEART BLOCK. Interacts with acetylcholinesterase inhibitors as it will enhance the adverse effects
Adverse-hypotension, tachycardia, headache, seizure, GI upset, asthmatic attacks
Nurse implications-monitor BP and pulse for 1 hour after injection, report early signs of OD (sweating, salivation, flushing, cramps, nausea) monitor respiratory status, supervise ambulation, change position slowly, do not drive, may cause blurred vision

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Atropine Sulfate

PO, parenteral, and Ophthalmic

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naturally occurring anticholinergic (extraction from the potato). Used for preoperative control of secretions, bradycardia, severe diarrhea or IBS, Reverses toxic effects of cholinergic drugs, anticholinesterase effect for organophosphate or carbamate poisoning (pesticides).
Contraindications-angle closure glaucoma, certain types of asthma, adhesions between the iris and the lens, advanced hepatic and renal dysfunction, intestinal atony, obstructive GI or GU conditions, severe ulcerative colitis.
Adverse effects- increase heart rate, dysrhythmias, flushed skin, headache, fatigue, ventricular fibrillation, dry mouth, NV/constipation, urinary retention
Nurse implications-monitor vitals and IO, frequent mouth care, have pt void before giving atropine, risk of heatstroke

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Physostigmine (Antiliruim) Injectable only IV or IM

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indirect-acting cholinergic works to increase acetylcholine. Used for treatment of myasthenia gravis as it improves muscle strength, an antidote for toxic exposure to organophosphate insecticides, and TCA overdose, atropine overdose.
Contraindicated-severe cholinergic reactions, asthma, gangrene, hyperthyroidism, obstructions of GI and GU tracts, allergy, CV disease
Adverse effects- SLUDGE, life threatening- acute toxicity, collapse, respiratory paralysis
Nursing implications-monitor vitals and LOC, stop if salivation, emesis, urinary frequency or diarrhea develop, sweating or nausea occur with dosage

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Cholinesterase

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an enzyme that is responsible for breaking down acetylcholine, it is an indirect acting cholinergic drug that works by inhibiting the action of acetyl cholinesterase

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Tolterodine (detrol)

PO only

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anti-cholinergic/muscarinic receptor blocker used to treat urinary frequency, urgency, and urge incontinence;
Contrainidications- angle-closure glaucoma, urinary retention, and cautiously use in the presence of decreased hepatic or renal function
Adverse effects- blurred vision, dry mouth, and sensitivity to light
Nursing implications-dry mouth incidence if low, used only for adults, notify dr. if has eye pain, rapid heart rate, difficulty breathing, skin rash or hives, or incoordination.

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Transfusion reactions

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my occur immediately or within 2 weeks after the transfusion. Symptoms include apprehension, restlessness, increased pulse, and respiratory rate, fever chills, shortness or breath, chest pain, headache, back pain, rash, jaundice, hypotension, hematuria, pulmonary edema, cyanosis. If patient complains of neck or back hurting during infusion it should be discontinued. Must be aware of possibility of bacteria and pathogens from the donor and incompatible blood. 2 nurses much check the product before administration.

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Antidysrhythmic therapy

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Contains a group of drugs that work by correcting abnormal cardia electro-physiologic functioning. Class I works by stabilizing the membrane, class II include beta-adrenergic blockers, Class III increase the action potential duration by prolonging depolarization in phase 3, Class IV are calcium channel blockers work to inhibit the calcium channels which reduces the influx of calcium ions during action potentials.
Assess-baseline ECG, vitals, postural blood pressures, apical-radial pulses, jugular vein distention, complete blood counts, assess for bleeding, and emphasize reaction with grapefruit juice,
Implementation- monitor pulse rates-lower than 60 dr. should be notified; ECG and vitals, oral dosages take with food and fluids, any chest pain, hypotension, sever gi distress, dizziness, syncope, blurred vision, and change in respiratory status or edema should be reported. , do not stop taking drug abruptly. change positions carefully, carry medical alert tag/bracelet.

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Effects of high blood pressure

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risk ractor for cardiovascular disease (CVD), Coronary artery disease (CAD), and death. Monitor kidney function, and retinophathy in fundus blood pressure consistently 140/90.

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dipyridamole/persantine
Pregnancy B
PO, IV

Back 59

anti-platelet used as an adjunct in warfarin therapy in the prevention o postoperative thromboembolic complications, produces coronary artery dilatation , inhibits platelet aggregation, absence of ischemic attacks and reinfarction. Prevention of coronary bypass graft occlusion with aspirin.
may be used for 2-3 months to reach continuous therapeutic effects,
Contraindicated for children under 12, pregnant or breastfeeding women.
MAY INCREASE DIGOXIN TOXICITY
NURSE IMPLICATIONS-monitor BP, assess cardiac status, use ECG to check for dysrhythmias, watch for bronchospasms and chest pain, give with water on an empty stomach, store at room temp.
TEACH-do not double dose, change positions slowly, do not use alcohol or OTC medications, avoid hazardous activities until stabilized on meds
OD-IV phenylephrine

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Thrombolytic therapy

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used to lyse (break down/destroy) existing clots by converting plasminogen in the blood to plasmin. plasmin digest or dissolves fibrin clots wherever they exist and wherever they can be reached by plasmin. Used for acute pulmonary embolism (PE), DVT, MI, CVA.
DO NOT GIVE TO- pt at risk for uncontrolled bleeding ex. aneurysm, severe hypertension (200/120 or greater), recent surgery, brain tumor, or recent CNS. Pt with a CVA should have a CT scan to rule out bleeding before administration. Get baseline vitals and labs, CBC, PT/aPTT, electorlytes and ATIII.
Monitor for bleeding at iv sites, hemoptysis, hematuria, occult blood in stools, flank and abdominal pain, and change in neurological status.

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Anticoagulant therapy

Back 61

stay with what you are eating eating, importance of keeping appointments for having lab work done, teach the signs and symptoms of bleeding, and watching dietary intake, patient should report any unusual bleeding, apply direct pressure to site of bleeding,Vitamin K intake should be monitored as large amounts will reduce the effects of the anticoagulation therapy.
Certain herbals should be avoided like capsicum (red pepper), feverfew, garlic, ginger, ginkgo, licorice, passion flower, red clover and willow.
Report any edema, reduced urination, ringing in the ears, clay colored stools, rash, abdominal pain.

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LDL

Back 62

low density lipoproteins, carry 60-70% of total cholesterol and is the most harmful. LDL should be less than 100mg, borderline to high is between 130-159 and high risk is >160 mg.