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339 Cards in this Set
- Front
- Back
Diuretics are drugs that
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increase the output of urine
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Diuretics have two major applications:
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(1) treatment of hypertension and
(2) mobilization of edematous fluid associated with heart failure, cirrhosis, or kidney disease. |
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The nephron is...
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the basic functional unit of the kidney
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The kidney serves three basic functions:
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(1) cleansing of extracellular fluid (ECF) and maintenance of ECF volume and composition;
(2) maintenance of acid-base balance; and (3) excretion of metabolic wastes and foreign substances. |
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Diuretics most affect which function of the kidneys?
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Maintenance of ECF volume and composition is the function that diuretics affect most.
|
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Effects of the kidney on ECF are the net result of which three basic processes?
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(1) filtration, (2) reabsorption, and (3) active secretion.
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Where does filtration occur?
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Filtration occurs at the glomerulus.
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What is the first step in urine formation?
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filtration
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Virtually all small molecules present in plasma (electrolytes, amino acids, glucose, drugs, metabolic wastes) undergo filtration. Which elements remain behind in the blood?
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cells and large molecules (lipids, proteins)
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Filtration is a __________ process; therefore, it cannot regulate the __________ of urine.
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nonselective; composition
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How much of the water, electrolytes, and nutrients filtered at the glomerulus undergoes reabsorption?
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More than 99%
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Reabsorption of solutes (e.g., electrolytes, amino acids, glucose) takes place by way of __________ ; water then follows __________ along the osmotic gradient
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active transport; passively
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Most diuretics act by disrupting __________ .
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solute reabsorption
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Which ions are of greatest interest in kidney solute reabsorption?
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sodium and chloride ions
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What percentage of filtered sodium and chloride is reabsorbed at the proximal convoluted tubule?
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about 65%
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Which limb of the loop of Henle is freely permeable to water?
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The descending limb
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What is aldosterone and what does it do?
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It is the principal mineralocorticoid of the adrenal cortex, and it stimulates reabsorption of sodium from the distal nephron. At the same time, aldosterone causes potassium to be secreted.
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What basic mechanism of action do most diuretics share?
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blockade of sodium and chloride reabsorption
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Drugs that act ___________ in the nephron can block the ____________ amount of solute reabsorption. As a result, these agents produce the ___________ diuresis
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early; greatest; greatest
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diuretics that act at distal sites produce _____________ diuresis
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relatively scant
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What are the 3 major adverse effects diuretics can cause?
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hypovolemia, acid-base imbalance, and disturbance of electrolyte levels.
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What are the four major categories of diuretic drugs?
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(1) high-ceiling (loop) diuretics,
(2) thiazide diuretics, (3) osmotic diuretics, and (4) potassium-sparing diuretics. |
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The high-ceiling diuretics are the _________ (most/least) effective diuretics available.
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most
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What is the high-ceiling diuretic's site of action?
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the loop of Henle
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What is the most frequently prescribed loop diuretic?
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Furosemide
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Lasix
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Brand name of furosemide
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By blocking solute reabsorption, what does furosemide prevent?
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passive reabsorption of water.
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Furosemide is a powerful drug. What is it generally reserved for?
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situations that require rapid or massive mobilization of fluid
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Name 3 conditions that justify the use of furosemide.
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(1) pulmonary edema associated with heart failure (HF);
(2) edema of hepatic, cardiac, or renal origin that has been unresponsive to less efficacious diuretics; and (3) hypertension that cannot be controlled with other diuretics. |
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Which diuretics are effective even when renal blood flow and the glomerular filtration rate (GFR) are low?
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high-ceiling diuretics (in contrast to thiazide diuretics)
|
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Adverse effects of furosemide:
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Furosemide can produce excessive loss of sodium, chloride, and water, and severe dehydration can result. Dehydration can promote thrombosis and embolism.
Furosemide can cause a substantial drop in blood pressure. It can also cause potassium loss and may cause hearing impairment. |
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Loss of potassium is a special concern for patients taking which drug?
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digoxin
|
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The maximum diuresis produced by the thiazides is considerably ____________ (higher/lower) than the maximum diuresis produced by the high-ceiling agents.
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lower
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Which drug is the most widely used thiazide diuretic?
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Hydrochlorothiazide
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Hydrochlorothiazide promotes urine production by blocking the reabsorption of _____________ in the early segment of the _______________________.
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sodium and chloride; distal convoluted tubule
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The thiazides’ ability to promote diuresis depends on ____________________.
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adequate kidney function
|
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These drugs are ineffective when the GFR is low.
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thiazide diuretics
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The primary indication for hydrochlorothiazide is ________________, a condition for which thiazides are often drugs of first choice.
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hypertension
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Adverse effects of thiazide diuretics:
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Loss of sodium, chloride, and water can lead to hyponatremia, hypochloremia, and dehydration. The thiazides can cause hypokalemia from excessive potassium excretion. Thiazides can cross the placental barrier to produce fetal harm directly. Potential effects include electrolyte imbalance, hypoglycemia, jaundice, and hemolytic anemia.
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Two useful properties of the potassium-sparing diuretics:
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1. modest increase in urine production
2. substantial decrease in potassium excretion. |
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These drugs are often used to counteract potassium loss caused by thiazide and loop diuretics.
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potassium-sparing diuretics
|
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Spironolactone blocks the actions of ____________ in the ______________.
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aldosterone; distal nephron
|
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What effect does the inhibition of aldosterone have on the nephron?
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retention of potassium and increased excretion of sodium
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How long does it take for the effects of spironolactone to develop.
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up to 48 hours
|
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Spironolactone is used primarily for:
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hypertension and edema
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What drug(s) is spironolactone used most commonly in combination with & for what purpose?
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with a thiazide or loop diuretic to counteract the potassium-wasting effects of these more powerful diuretics.
|
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Why does spironolactone greatly reduce mortality and hospital admissions in patients with severe heart failure?
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Benefits derive from protective effects of aldosterone blockade in the heart and blood vessels.
|
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What are the adverse effects of spironalactone?
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hyperkalemia;
a variety of endocrine effects, including gynecomastia, menstrual irregularities, impotence, hirsutism, and deepening of the voice. |
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What can hyperkalemia result in?
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fatal dysrhythmias
|
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Why does spironolactone produce endocrine effects?
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It is a steroid derivative with a structure similar to that of steroid hormones.
|
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With what agents should spironolactone never be combined?
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potassium supplements, salt substitutes (which contain potassium chloride), or another potassium-sparing diuretic
[ACE inhibitors, ARBs, and direct renin inhibitors— should be combined with spironolactone only when clearly necessary.] |
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Triamterene can be used alone or in combination with other diuretics to treat ________________.
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hypertension and edema
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When combined with other diuretics, _______________ augments diuresis and helps counteract the potassium-wasting effects of the more powerful diuretic.
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triamterene
|
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What is the most significant adverse effect of triamterene?
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excessive potassium accumulation
|
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Relatively common side effects of trimterene:
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nausea, vomiting, leg cramps, and dizziness
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Maintenance of fluid volume and osmolality is primarily the job of the _____________.
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kidneys
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In the clinical setting, changes in osmolality are described in terms of the ___________ content of plasma.
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sodium
|
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Causes of isotonic contraction include...
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vomiting, diarrhea, kidney disease, and misuse of diuretics.
|
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Hypertonic contraction is defined as volume contraction in which loss of water ________ loss of sodium.
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exceeds
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Causes of hypertonic contraction include...
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excessive sweating, osmotic diuresis, and feeding excessively concentrated foods to infants.
|
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Hypotonic contraction is defined as volume contraction in which loss of sodium exceeds loss of water. In this case, both the _____________ and____________ of extracellular fluid decrease.
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volume; osmolality
|
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The principal cause of hypotonic contraction is...
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excessive loss of sodium through the kidneys.
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Volume expansion may result from...
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- an overdose with therapeutic fluids
- disease states (such as heart failure, nephrotic syndrome, or cirrhosis of the liver with ascites) |
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The principal drugs used to correct volume expansion:
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diuretics and the agents used for heart failure.
|
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Volume expansion
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an increase in the total volume of body fluid
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The respiratory system influences the pH through
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control of carbon dioxide (CO2) exhalation.
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The kidneys influence the pH by regulating __________. By retaining ________, the kidneys can raise the pH. Conversely, by increasing ____________, the kidneys can lower the pH and thereby compensate for alkalosis.
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bicarbonate excretion
bicarbonate bicarbonate excretion |
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Respiratory alkalosis is produced by ______________.
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hyperventilation
|
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Respiratory acidosis results from ______________________.
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retention of CO2 secondary to hypoventilation
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Primary causes of impaired ventilation:
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(1) depression of the medullary respiratory center
(2) pathologic changes in the lungs (e.g., status asthmaticus, airway obstruction) |
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Primary treatment of respiratory acidosis:
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directed at correcting respiratory impairment
|
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Common causes of metabolic alkalosis include:
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- excessive loss of gastric acid (through vomiting or suctioning)
- administration of alkalinizing salts (e.g., sodium bicarbonate). |
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In most cases, metabolic alkalosis can be corrected by infusing a solution of _____________________.
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sodium chloride plus potassium chloride
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Principal causes of metabolic acidosis are...
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1) chronic renal failure,
2) loss of bicarbonate during severe diarrhea 3) metabolic disorders that result in overproduction of lactic acid (lactic acidosis) or ketoacids (ketoacidosis). |
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Treatment of metabolic acidosis:
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+ correcting the underlying cause of acidosis
+ if the acidosis is severe, administering an alkalinizing salt (sodium bicarbonate) |
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Potassium is the most abundant ______________ cation.
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intracellular
|
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What role does potassium play in the body?
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Potassium plays a major role in conducting nerve impulses and maintaining the electrical excitability of muscle. Potassium also helps regulate acid-base balance.
|
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How are serum levels of potassium regulated?
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primarily by the kidneys
|
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What substance, produced by the body, increases renal excretion of potassium?
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aldosterone
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Extracellular acidosis promotes the ________ of potassium from cells, thereby causing extracellular _______________.
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exit
hyperkalemia |
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What is the definition of hypokalemia, and what is its most common cause?
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Hypokalemia exists when the serum potassium level falls below 3.5 mEq/L.
Its most common cause is treatment with a thiazide or loop diuretic. |
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Potassium depletion can be treated with ____________.
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potassium salts (The preferred salt is potassium chloride.)
|
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Hyperkalemia can result from:
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+ severe tissue trauma,
+ untreated Addison’s disease, + acute acidosis (which draws potassium out of cells), + misuse of potassium-sparing diuretics, and + overdose with IV potassium |
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The most serious consequence of hyperkalemia is ___________.
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disruption of the electrical activity of the heart
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Treatment of hyperkalemia:
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1. withdrawal of potassium-containing foods and drugs that promote potassium accumulation
2. infusing a calcium salt to offset the cardiac effects of potassium 3. infusing glucose and insulin to promote potassium uptake by cells 4. infusing sodium bicarbonate if acidosis is present. |
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Low levels of magnesium may result from...
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diarrhea,
hemodialysis, kidney disease, prolonged intravenous feeding with magnesium-free solutions |
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Low levels of magnesium causes...
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increased muscle excitability (perhaps to the point of tetany)
|
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In the kidneys, hypomagnesemia may lead to
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nephrocalcinosis (formation of minuscule calcium stones within nephrons).
|
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Frank hypomagnesemia is treated with
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parenteral magnesium sulfate.
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Toxic elevation of magnesium levels is most common in patients with _________________.
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renal insufficiency
|
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Symptoms of mild intoxication:
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+ muscle weakness
+ hypotension + sedation + electrocardiographic (ECG) changes |
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Higher magnesium concentrations pose a risk of ______________.
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cardiac arrest
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Drugs recommended for the treatment of HF include:
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diuretics, inhibitors of the renin-angiotensin-aldosterone system (RAAS), beta blockers, and digoxin
|
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Heart failure is a syndrome in which...
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the heart is unable to pump sufficient blood to meet the metabolic needs of tissues.
|
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Heart failure is characterized by...
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signs of inadequate tissue perfusion (fatigue, shortness of breath, exercise intolerance)
and/or signs of volume overload (venous distention, peripheral and pulmonary edema). |
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The major underlying causes of HF are:
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chronic hypertension and myocardial infarction.
|
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Heart failure is a chronic disorder that requires _________________ treatment with drugs.
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continuous
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In the initial phase of failure, the heart undergoes _________ , a process in which the ventricles dilate (grow larger), hypertrophy (increase in wall thickness), and become more spherical (less cylindrical).
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remodeling
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The net result of the pathologic changes of heart failure is a progressive decline in _____________.
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cardiac output
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Water retention results from a reduction in renal blood flow, resulting in decreases in...
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the glomerular filtration rate (GFR), urine production, and activation of the RAAS.
|
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Levels of circulating _____________ are an important index of cardiac status in HF patients and thus can be a predictor of long-term survival.
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BNP
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In HF, if the cardiac output is insufficient to maintain adequate kidney function...
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renal retention of water progresses unabated.
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If cardiac output becomes too low to maintain sufficient production of urine, the resultant accumulation of water eventually is ___________.
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fatal
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The prominent signs and symptoms of HF are:
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Reduced exercise tolerance, fatigue, and shortness of breath
Tachycardia Increased heart size Pulmonary edema Peripheral edema Hepatomegaly (increased liver size) Distention of the jugular veins Weight gain resulting from fluid retention |
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HF is routinely treated with what types of drugs?
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(1) diuretics
(2) agents that inhibit the RAAS (3) beta blockers |
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_____________ are first-line drugs for all HF patients with signs of volume overload or with a history of volume overload.
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Diuretics
|
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Do diuretics prolong survival for HF patients?
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No, for the most part, the benefits of diuretics are limited to symptom reduction.
|
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The principal adverse effect of the thiazides is __________.
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hypokalemia, which increases the risk of digoxin-induced dysrhythmias
|
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Why are loop diuretics drugs of choice for patients with severe HF?
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Because they can mobilize large volumes of water and because they work when the GFR is low,
|
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Adverse effects of loop diuretics?
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hypokalemia (increasing risk of digoxin toxicity)
hypotension (due to excessive volume reduction) |
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Can agents that inhibit the RAAS prolong life in patients with HF?
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Yes, agents that inhibit the RAAS can be highly beneficial.
In the absence of specific contraindications, all patients with HF should receive one of these drugs. |
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ACE inhibitors block production of angiotensin II, reduce the release of aldosterone, and suppress degradation of kinins. How does this help the patient with HF?
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These actions improve hemodynamics and favorably alter cardiac remodeling.
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By suppressing production of angiotensin II, ACE inhibitors cause ___________ of arterioles and veins and reduce the release of ____________. Arteriolar dilation improves regional blood flow in the __________ and other tissues and, by reducing afterload, it __________ the stroke volume and cardiac output. Increased renal blood flow promotes ___________ of sodium and water.
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dilation
aldosterone kidneys increases excretion |
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Diuretics in HF--
Venous dilation reduces venous pressure, thereby reducing what? |
Pulmonary congestion, peripheral edema, preload, and cardiac dilation.
|
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(in heart failure clients)
With continued use, ACE inhibitors have a favorable impact on _______________. |
cardiac remodeling.
(Elevation of kinins is largely responsible. ) |
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The principal adverse effects of the ACE inhibitors are:
|
hypotension (secondary to arteriolar dilation), hyperkalemia (secondary to decreased aldosterone release),
intractable cough, and angioedema. |
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Because ARBs do not increase levels of ____________, their effects on cardiac remodeling are less favorable than those of ACE inhibitors.
|
kinins
|
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How can beta blockers improve a HF patient’s status?
|
improve the LV ejection fraction
increase exercise tolerance slow progression of HF reduce the need for hospitalization prolong survival |
|
Adverse effects of beta blockers in HF patients:
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(1) fluid retention and worsening of HF, (2) fatigue, (3) hypotension, and (4) bradycardia or heart block.
|
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Digoxin belongs to a class of drugs known as ___________, agents best known for their positive ________ actions (i.e., their ability to increase the myocardial contractile force).
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cardiac glycosides
inotropic |
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Does digoxin prolong life in patients with HF?
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Although digoxin can reduce symptoms of HF, it does not prolong life.
|
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Major risk of digoxin use?
|
cardiac dysrhythmias
|
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When using digoxin, what levels need to be monitored closely?
|
potassium
|
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Digoxin use--As a result of increased cardiac output, three major secondary responses occur:
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(1) sympathetic tone declines, (2) urine production increases, and (3) renin release declines.
|
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Some patients taking digoxin may require an antidysrhythmic drug, such as:
|
phenytoin or lidocaine
|
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Patients who develop bradycardia or AV block while using digoxin can be treated with ___________.
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atropine
|
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In addition to dysrhythmias, digoxin can cause __________ effects and ___________ effects. These effects often precede dysrhythmias and therefore can provide advance warning of serious toxicity.
|
gastrointestinal (GI)--(anorexia, nausea, vomiting)
central nervous system (CNS) -- (fatigue, visual disturbances |
|
Patients should be warned about digoxin-induced dysrhythmias and instructed to take their medication ______________.
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exactly as prescribed
|
|
the process by which the body makes red blood cells, white blood cells, and platelets.
|
hematopoiesis
|
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In all patients, erythropoiesis stimulating agents (ESAs) may increase the risk of ...
|
stroke, heart failure, blood clots, myocardial infarction (MI), and death
|
|
a growth factor produced by recombinant DNA technology
|
Epoetin alfa
|
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Epoetin alfa is used to treat ______________-induced anemia in patients with nonmyeloid malignancies.
|
chemotherapy
|
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Because ESAs can shorten survival time in all cancer patients, epoetin is indicated only when the goal of cancer therapy is ____________.
|
palliation
|
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Epoetin may be given to increase ___________ levels in anemic patients scheduled for elective surgery. The drug should be used only when significant____________ is anticipated; however, it should not be used before ___________ or vascular surgery.
|
erythrocyte
blood loss cardiac |
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The most significant adverse effect of epoetin alfa:
|
hypertension
|
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When given to preoperative patients to reduce the need for RBC transfusion, ESAs have increased the risk of...
|
deep vein thrombosis
|
|
filgrastim, pegfilgrastim, and sargramostim are all...
|
leukopoietic growth factor --stimulate production of leukocytes (white blood cells)
|
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Filgrastim has two principal uses:
|
elevation of neutrophil counts in cancer patients and treatment of severe chronic neutropenia.
|
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Filgrastim is given to reduce the risk of infection in patients undergoing ______________. It does this by stimulating _______________________.
|
cancer chemotherapy
neutrophil production |
|
The principal adverse effects of filgrastim are ____________ and ____________ .
|
bone pain; leukocytosis
|
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Thrombopoietic growth factors are endogenous compounds that stimulate production of ______________.
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platelets
|
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At this time, ___________ is the only thrombopoietic growth factor available.
|
oprelvekin
|
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Oprelvekin is given to stimulate ____________ production in patients undergoing myelosuppressive chemotherapy for _____________.
|
platelet
nonmyeloid cancers |
|
Adverse effects of oprelvekin:
|
retention of sodium and water by the kidneys;
anemia, due to expanded plasma volume; tachycardia, atrial fibrillation, and atrial flutter; severe allergic reactions, including anaphylaxis |
|
the cells responsible for insulin synthesis and release into the bloodstream
|
pancreatic beta cells
|
|
develops when hypoglycemia becomes severe and is allowed to persist
|
Ketoacidosis
|
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Most long-term complications of diabetes occur secondary to disruption of blood flow because of ____________ or ______________ damage.
|
macrovascular; microvascular
|
|
Levels of ________ reflect average blood glucose levels over the previous 2 to 3 months.
|
A1c
|
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Name some long-term complications of diabetes.
|
CVD, retinopathy, kidney disease, and amputations
|
|
4 elements of glycemic control (keeping blood glucose levels in normal range around the clock):
|
diet modification,
self-monitoring of blood glucose (SMBG), exercise, and insulin replacement. |
|
Oral antidiabetic agents are helpful for patients with which type of diabetes?
|
Type 2
|
|
Which drugs are preferred agents for managing diabetic hypertension and can help protect against diabetic nephropathy?
|
An ACE inhibitor or an ARB
|
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To reduce high levels of LDL cholesterol, ____________ are preferred drugs
|
statins
|
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Clinical experience has shown that ______________, by themselves, often normalize insulin release and decrease insulin resistance.
|
dietary measures
|
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Target values for blood glucose are ____________ mg/dL before meals and _________________ mg/dL at bedtime.
|
90 to 130
100 to 140 |
|
What is the principal stimulus for insulin release?
|
a rise in blood glucose
|
|
Insulin lispro, insulin aspart, and insulin glulisine are ___________ acting and ______ duration insulins.
|
rapid; short
|
|
Lispro insulin's effects begin within __________ minutes of subcutaneous injection and persist for_________ hours.
|
15 to 30; 3 to 6
|
|
Regular insulin is unmodified human insulin; its effects begin in ___________ minutes, peak in _________ hours, and last up to _____________ hours.
|
30 to 60; 1 to 5; 10
|
|
Neutral Protamine Hagedorn (NPH) insulin is injected ___________ daily to provide glycemic control between _____________ and during _________.
|
twice;
meals; the night |
|
These insulins are supplied as cloudy suspensions that must be gently agitated before administration.
|
NPH
|
|
Insulin glargine is a modified human insulin with a prolonged duration of action (at least ___ hours). Insulin glargine achieves blood levels that are relatively _______ over _____ hours.
|
24;
steady; 24 |
|
Only ______________ insulin is appropriate for mixing with short-acting insulins.
|
NPH
|
|
Why is insulin infusion employed to treat hyperkalemia?
|
It can promote cellular uptake of potassium and lower plasma potassium levels.
|
|
The principal indication for insulin is _____________.
|
diabetes mellitus
|
|
Responsibility for managing diabetes rests with the _____________.
|
patient
|
|
Main cause of insulin excess:
|
overdose
|
|
signs and symptoms of hypoglycemia
|
Rapid fall in glucose levels--tachycardia, palpitations, sweating, and nervousness (SNS)
Gradual decline in glucose--headache, confusion, drowsiness, and fatigue (CNS) |
|
In conscious patients, glucose levels can be restored with __________. In cases of severe hypoglycemia, ___________ is the preferred treatment. Parenteral __________ is an alternative treatment.
|
a fast-acting oral sugar
IV glucose glucagon |
|
What can sulfonylureas, glinides, beta-adrenergic blocking agents, and alcohol do when combined with insulin?
|
Drugs that lower blood glucose levels can intensify hypoglycemia induced by insulin.
|
|
When combined with insulin, what is the effect of thiazide diuretics, glucocorticoids, and sympathomimetics.
|
Drugs that raise blood glucose can counteract the desired effects of insulin.
|
|
What is the diabetic patient's concern when taking beta blockers?
|
Can delay awareness of and response to hypoglycemia by masking signs that are associated with stimulation of the sympathetic nervous system.
|
|
How do sulfonylureas, glitazones, and glinides work?
|
These drugs actively drive blood glucose down.
|
|
How does metformin work?
|
It doesn’t drive blood glucose down, but modulates the rise in glucose that happens after a meal.
|
|
What is the drug of choice for initial therapy in most patients with type 2 diabetes?
|
metformin
|
|
Metformin lowers blood glucose and improves glucose tolerance in three ways: It inhibits glucose production in the ______, it reduces glucose absorption in the ____ slightly, and it ________ insulin receptors in target tissues (fat and skeletal muscle), increasing glucose uptake in response to available insulin.
|
liver; gut; sensitizes
|
|
Why does metformin not pose a risk of hypoglycemia when used alone?
|
It does not stimulate insulin release from the pancreas.
|
|
Metformin is used to lower blood sugar in patients with type 2 diabetes who have not responded adequately to __________________.
|
diet modification and exercise
|
|
What are the most common side effects of metformin?
|
decreased appetite, nausea, and diarrhea
|
|
Metforminin must never be used by patients with ______________.
|
renal insufficiency
|
|
The thiazolidinediones, also known as glitazones or TZDs, reduce glucose levels primarily by __________________.
|
decreasing insulin resistance
|
|
Sulfonylureas act primarily by______________________ .
|
stimulating the release of insulin from pancreatic islets
|
|
The most common reactions to pioglitazone are:
|
upper respiratory tract infection, headache, sinusitis, and myalgia
|
|
Glinides—also known as meglitinides—are hypoglycemic agents that have the same mechanism as the sulfonylureas: ______________________________.
|
stimulation of pancreatic insulin release
|
|
Over time, repaglinide can lower _____ by about 1.7%. The drug is approved for ______ diabetes only.
Repaglinide is approved for monotherapy or combined therapy with ______ or ______. |
A1c;
type 2; metformin; a glitazone |
|
The alpha-glucosidase inhibitors—acarbose and miglitol—act in the ______ to delay ______.
|
intestine;
absorption of carbohydrates |
|
Acarbose frequently causes ___________. These responses result from bacterial fermentation of unabsorbed carbohydrates in the _________.
|
flatulence, cramps, abdominal distention, diarrhea, and borborygmus;
colon |
|
Acarbose can decrease absorption of ______, posing a risk of ______. Long-term, high-dose therapy may cause ______ dysfunction.
|
iron; anemia; liver
|
|
The combination of _______ and acarbose should probably be avoided. Both drugs cause significant ______ side effects, and the combination could be very unpleasant.
|
metformin
GI |
|
Gliptins promote glycemic control by...
|
suppressing postprandial release of glucagon.
|
|
Sitagliptin's most common side effects are
|
respiratory tract infection, headache, and inflammation of the nasal passages and throat
|
|
There are three other injectable drugs for diabetes.
|
Pramlintide, exenatide and liraglutide
|
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Exenatide was the first ______.
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incretin mimetic
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Adverse effects of exenatide:
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nausea and hypoglycemia
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Risks of exenatide--
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pancreatitis; renal impairment
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The most severe manifestation of insulin deficiency
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DKA
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Treatment of DKA--
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Correct hyperglycemia and acidosis,
replace lost water and sodium, and normalize potassium balance. Begin with IV fluids and electrolytes, followed as soon as possible by IV insulin. |
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What do thyroid hormones affect?
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metabolism, cardiac function, growth, and development
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Thyrotropin-releasing hormone (TRH) from the ______ causes the ______ to release thyroid-stimulating hormone (thyrotropin, TSH), which causes the ______ to make and release T3 and T4, which then act on the ______ to suppress further release of TSH.
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hypothalamus; pituitary; thyroid ; pituitary
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Hypothyroidism in adults requires ______ with thyroid hormones. In almost all cases, treatment must continue ______.
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replacement therapy
lifelong |
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What is the most common cause of excessive thyroid hormone secretion?
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Graves’ disease
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How is hyperthyroidism treated?
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Reducing the production of thyroid hormones by
(1) surgical removal of thyroid tissue, (2) destruction of thyroid tissue with radioactive iodine, and (3) suppression of thyroid hormone synthesis with an antithyroid drug (methimazole or propylthiouracil). |
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Symptoms & treatment of thyrotoxic crisis:
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Profound hyperthermia (105°F or even higher), severe tachycardia, restlessness, agitation, and tremor
High doses of potassium iodide to suppress thyroid hormone release, beta blocker to slow the heart rate, sedation, cooling, glucocorticoids and IV fluids. |
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Levothyroxine
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a synthetic preparation of thyroxine (T4) & the drug of choice for most patients who require thyroid hormone replacement
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When should levothyroxine be taken?
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in the morning, at least 30 to 60 minutes before breakfast, on an empty stomach
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Levothyroxine has a _______ therapeutic range
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narrow
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How is therapy with levothyroxine evaluated?
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via measurement of the serum TSH
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What condition do methimazole and propylthiouracil (PTU) treat & what do they do?
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hyperthyroidism; suppress synthesis of thyroid hormones.
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Name a first-line drug for hyperthyroidism.
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Methimazole
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Once therapy with methimazole has begun, why may it take 3 to 12 weeks to produce a euthyroid state?
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Methimazole prevents thyroid hormone synthesis, but does not destroy existing stores of thyroid hormone.
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Who should avoid takine methimazole?
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women who are pregnant or breast feeding
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What conditions can methimazole cause?
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Methimazole can cause neonatal hypothyroidism, goiter, and even cretinism.
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What is Iodine-131 (131I) used for?
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destroying thyroid tissue in patients with hyperthyroidism
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What is the objective in Iodine-131 therapy?
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to produce clinical remission without causing complete destruction of the gland
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Advantages of Iodine-131 therapy:
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(1) low cost; (2) patients are spared the risks, discomfort, and expense of thyroid surgery; (3) death from 131I treatment is extremely rare; and (4) no tissue other than the thyroid is injured.
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Who is a candidate for 131I therapy?
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patients over age 30,
patients who have not responded adequately to antithyroid drugs or to subtotal thyroidectomy |
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Who should not undergo 131I therapy?
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young children; women who are pregnant or breastfeeding
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Working together, the _____________ and _____________ help regulate practically all bodily processes.
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hypothalamus; pituitary
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The anterior pituitary produces six major hormones:
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growth hormone, corticotropin, thyrotropin, follicle-stimulating hormone, luteinizing hormone, and prolactin.
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The posterior pituitary produces only two hormones,
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oxytocin and antidiuretic hormone.
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The _____________ is primarily responsible for regulating the release of hormones from the anterior pituitary.
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hypothalamus
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The only treatment for GH deficiency is replacement therapy with...
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human GH itself.
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Treatment of gigantism requires...
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surgical removal of the pituitary.
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Antidiuretic hormone (ADH), also known as_______________, acts on the kidneys to cause reabsorption (conservation) of __________.
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vasopressin
water |
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When ADH replacement therapy is started, the patient must be warned to reduce _________, because failure to do so can cause _______________.
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water intake
water intoxication |
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Vasopressin can cause what side effects?
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adverse cardiovasculareffects; vasoconstriction.
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Diabetes insipidus may be treated with...
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desmopressin
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The two most familiar forms of adrenocortical dysfunction are __________, caused by adrenal hormone excess, and ______________, caused by adrenal hormone deficiency.
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Cushing’s syndrome
Addison’s disease |
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The adrenal cortex produces three classes of steroid hormones:
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glucocorticoids, mineralocorticoids, and androgens
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Glucocorticoids influence...
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carbohydrate metabolism and other processes
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Mineralocorticoids modulate ...
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salt and water balance
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Adrenal androgens contribute to...
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expression of sexual characteristics.
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Of the several glucocorticoids produced by the adrenal cortex, _______ is the most important.
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cortisol
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The mineralocorticoids influence renal processing of sodium, potassium, and hydrogen; ____________ is the most important.
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aldosterone
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In the absence of aldosterone, renal excretion of sodium and water is greatly _____________, whereas excretion of potassium and hydrogen is _______________.
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increased
reduced |
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Secretion of aldosterone is regulated by _____________.
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the renin-angiotensin-aldosterone system (RAAS)
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The treatment of choice for adrenal adenoma and carcinoma is __________________.
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surgical removal of the diseased adrenal gland
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The role of drugs in treating Cushing’s syndrome is limited; benefits derive from suppression of corticosteroid synthesis. The most effective agent is ____________, an antifungal drug that also blocks glucocorticoid synthesis.
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ketoconazole
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_______________ causes hypokalemia, metabolic alkalosis, and hypertension and can increase the risk of heart failure
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Hyperaldosteronism
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Chronic adrenal insufficiency requires lifelong replacement therapy with appropriate _____________. All patients require a ________________. Some may require a ____________ as well.
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corticosteroids
glucocorticoid mineralocorticoid |
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_______________ is a drug of choice among the glucocorticoids available to treat Addison's disease.
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Hydrocortisone
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At times of ___________, patients must increase their glucocorticoid dosage.
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stress
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If additional mineralocorticoid activity is needed for treatment of Addison's, ___________ can be added to the regimen.
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fludrocortisone
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What are the symptoms of adrenal crisis (acute corticosteroid deficiency)?
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hypotension, dehydration, weakness, lethargy, and gastrointestinal (GI) symptoms
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Hydrocortisone, a synthetic steroid, has a structure identical to that of _______, the principal glucocorticoid produced by the adrenal cortex.
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cortisol
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Hydrocortisone is a preferred drug for all forms of __________________.
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adrenocortical insufficiency
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______________ is the only mineralocorticoid available and is the drug of choice for chronic mineralocorticoid replacement.
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Fludrocortisone
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Patients taking fludrocortisone should be monitored for ...
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weight gain, elevation of blood pressure, and hypokalemia.
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Why is calcium important?
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Calcium is critical to blood coagulation and to the functional integrity of bone, nerve, muscle, and the heart.
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Absorption of calcium takes place in the ______________. Absorption is increased by ____________________.
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small intestine
parathyroid hormone (PTH) and vitamin D |
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Calcium excretion is primarily ___________.
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renal
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How does PTH increase serum calcium levels?
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PTH (1) promotes calcium resorption from bone, (2) promotes tubular reabsorption of calcium that had been filtered by the kidney glomerulus, and (3) promotes activation of vitamin D and thereby promotes increased absorption of calcium from the intestine.
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Both vitamin D and PTH __________ plasma calcium levels. Vitamin D differs from PTH in that vitamin D _________ plasma levels of phosphate, whereas PTH __________ levels of phosphate.
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increase
elevates reduces |
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Calcitonin, a hormone produced by the thyroid gland, ________ plasma levels of calcium. Hence, calcitonin acts _________ PTH and vitamin D.
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decreases
in opposition to |
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Oral calcium preparations are used to treat ___________. In addition, calcium salts are taken as________________.
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mild hypocalcemia
dietary supplements |
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People who may need supplemental calcium:
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adolescents, the elderly, and postmenopausal women
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Hypercalcemia is most likely in patients who are receiving large doses of calcium and____________.
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vitamin D
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Signs and symptoms of hypercalcemia:
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GI disturbances, renal dysfunction, and CNS effects
may also cause cardiac dysrhythmias and deposition of calcium in soft tissue |
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Vitamin D is an important regulator of ___________ and _____________ homeostasis.
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calcium
phosphorus |
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Vitamin D is obtained through...
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food, supplements, and exposure to sunlight.
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Calcitonin has two principal actions:
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(1) it inhibits the activity of osteoclasts, thereby reducing bone resorption, and (2) it inhibits tubular resorption of calcium, thereby increasing calcium excretion.
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Calcitonin-salmon, given by nasal spray or injection, is indicated for treatment of _____________________—but not for prevention.
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established postmenopausal osteoporosis
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Benefits of calcitonin-salmon derive from suppressing ___________. The treatment program should include supplemental ____________ and adequate intake of vitamin D.
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bone resorption
calcium |
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carvedilol's trade name
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Coreg
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Carvedilol is a _______________ used as an adjunct to treat ____________.
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beta blocker
heart failure |
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carvedilol's MOA
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reduces cardiac output and tachycardia, causes vasodilation, reduces blood pressure and cardiac workload
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carvedilol's contraindications
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asthma; severe bradycardia
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D/D interactions for carvedilol
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amiodarone; beta blockers; digoxin; CCBs
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If giving carvedilol to a HF patient, also expect to give ____________.
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digoxin, a diuretic, & an ACE inhibitor
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Abrupt stoppage of carvedilol in hyperthyroid patients could precipitate ______________.
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thyroid storm
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Desmopressin (DDAVP) is an ______________ given to treat ______________.
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antidiuretic; diabetes insipidus
available as a nasal spray |
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desmopressin's MOA
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increases permeability of renal collecting ducts, thus enhancing water reabsorption
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Contraindications for desmopressin
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renal impairment; hyponatremia
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Nursing consideration when giving desmopressin--
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Monitor pt closely for signs of hyponatremia (headache, N/V, restlessness, fatigue, changes in mental status)
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digoxin
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Lanoxin
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Digoxin is an ________________.
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antiarrhythmic
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Digoxin is given to treat:
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heart failure, atrial flutter, a-fib
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digoxin's MOA
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increases force and velocity of myocardial contraction (positive inotropic effect)
decreases conduction rate (antiarrhythmic effect); slows heartrate |
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Patient teaching for digoxin:
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take as prescribed, same time each day, take pulse before administration, watch drug/drug, notify Dr. of GI distress or pulse changes
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Enalapril
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Vasotec
|
|
Enalapril is an _____________ used to control _______________ and to treat ________________.
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ACE inhibitor
hypertension heart failure |
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Enalapril's MOA
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Decreases vascular tone & pressure (inhibits aldosterone release, reducing sodium & water reabsorption-->lower BP)
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Drug/Drug for enalapril
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potassium-containing salt substitutes (risk of hyperkalemia)
alcohol (added hypotensive effect) |
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Nursing considerations--enalapril
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use caution in pts with impaired renal function; watch for hypotension; watch for angioedema of face, lips, tongue
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exenatide
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Byetta
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exenatide is an ________________ drug
|
antidiabetic
|
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route for exenatide
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subQ
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D/D exenatide
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oral antidiabetics (hypoglycemia); warfarin (bleeding)
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exenatide MOA
|
spurs insulin synthesis; suppresses glucacon secretion
|
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Nursing considerations for exenatide
|
monitor for pancreatitis; monitor blood glucose levels; administer within 60 min before morning & evening meals
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epoetin alfa
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Epogen
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Epoetin alfa is an ________________ drug.
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antianemic
|
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Who takes epoetin alfa?
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renal failure, HIV, and chemo patients (in danger of anemia)
also pre-surgery |
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D/D for epoetin alfa
|
don't mix with any other drug
antihypertensives; heparin; iron supplements |
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contraindications for epoetin alfa
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uncontrolled HTN
|
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Nursing implications for epoetin alfa
|
don't shake--denatures protein & inactivates drug
target hemoglobin not to exceed 12 g/dl take seizure precautions |
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filgastrim
|
Neupogen
|
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Filgastrim is an ________________ given to prevent ________________ and ________________.
|
antineutropenic, hematopoietic stimulator
neutropenia infection |
|
Patients who might receive filgastrim:
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chemotherapy, bone marrow transplant patients
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Nursing implications for filgastrim
|
monitor CBC, hematocrit, & platelet count
don't shake |
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fludrocortisone
|
Florinef
|
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Fludrocortisone is given to treat ________________
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chronic adrenocortical insufficiency
|
|
fludrocortisone MOA
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similar to aldosterone--enhances sodium reabsorption, hydrogen & potassium excretion, and water retention
|
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nursing implications--fludrocortisone
|
monitor for signs of heart failure, monitor BP & fluid status, weight
Don't stop taking abruptly |
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furosemide
|
Lasix
|
|
glipizide
|
Glucotrol
|
|
Glipizide is a ________________ used to control blood glucose levels in ________________.
|
sulfonylurea
type 2 diabetes |
|
glipizide MOA
|
stimulates insulin release from beta cells in pancreas
increases peripheral tissue sensitivity to insulin |
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Glipizide--Increased risk of hypoglycemia in patient with ________________
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renal, hepatic, pituitary, or adrenal insufficiency
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Hydrocortisone is a ________________ used to treat ________________.
|
glucocorticoid
severe inflammation or acute adrenal insufficiency |
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hydrocortisone's MOA
|
suppresses inflammatory & immune responses
|
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Nursing considerations for hydrocortisone
|
Avoid sudden withdrawal after long-term therapy--could precipitate adrenal crisis. Reduce dosage gradually.
Client should avoid people with infections. |
|
Kayexalate is an ________________ drug given to treat ________________.
|
antihyperkalemic
hyperkalemia |
|
Nursing considerations--Kayexalate
|
Use cautiously in pts with HF, hypertension, or marked edema. Not for treatment of acute, life-threatening hyperkalemia (takes hours to work). Monitor for hypokalemia. Watch for cramps, N/V.
|
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levothyroxine
|
Synthroid
|
|
Levothyroxine teachings
|
separate iron & calcium supplements from levothyroxine with 4 hours or more; may need weeks to take effect
|
|
Signs of hypermagnesemia
|
bradycaria; dyspnea; decreased deep tendon reflexes; hypotension; vomiting; weakness
|
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metformin
|
Glucophage
|
|
Metformin reduces ________________ in ________________.
|
blood glucose levels; type 2 DM
|
|
Nursing considerations--metformin
|
Give with food (reduces GI upset).
Withhold if pt has diarrhea, GI obstruction, or vomiting. Monitor blood glucose levels. Report signs of lactic acidosis. |
|
Methimazole is an ________________ drug used to treat ________________.
|
antithyroid; hyperthyroidism
|
|
octreotide
|
Sandostatin
|
|
Octreotide is a ________________ used to treat ________________.
|
hormone suppressant;
symptoms of acromegaly |
|
route for octreotide
|
injection only
|
|
Considerations for octreotide
|
orthostatic hypotension; possible pancreatitis; diabetic--take extra care of blood glucose levels
|
|
hydrochlorothiazide
|
HydroDIURIL
|
|
Nursing considerations for hydrocholrothiazide
|
Give in morning & early evening to avoid nocturia.
Monitor I&O, daily weight, BP, and serum electrolye levels (esp. K+). Advise pt to eat foods rich in potassium. |
|
Why take morphine sulfate to relieve HF?
|
as an adjunct to treat pulmonary edema caused by left-sided heart failure
|
|
repaglinide
|
Prandin
|
|
Repaglinide is an ________________ used to achieve ________________ in type 2 DM.
|
antidiabetic; glucose control
|
|
repaglinide MOA
|
Stimulates release of insulin from functioning pancreatic beta cells.
|
|
Contraindications for repalinide
|
gemfibrozil therapy; DKA; severe hepatic or renal impairment
|
|
Nursing considerations for repaglinide
|
Shouldn't be used with NPH insulin--risk of angina
|
|
sitagliptin
|
Januvia
|
|
sitagliptin MOA
|
slows inactivation of incretin hormones (which stimulates work of insulin)
|
|
Somatropin is a ________________ used to treat ________________ caused by ________________.
|
growth hormone; growth failure; hormone deficiency
|
|
Adverse effects to watch for with somatropin
|
Although uncommon, intracranial hypertension is possible. (headache, nausea, vision changes)
|
|
Spironolactone (Aldactone) is an ________________ used to treat ________________ caused by ________________.
|
aldosterone antagonist/diuretic
edema heart failure |
|
spironolactone's MOA
|
competes with aldosterone in nephron, causing sodium and water excretion (reducing blood volume and BP)
|