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1

Antidysrhythmics, beta blockers, calcium channel blockers, itraconazole

negative inotropes and may worsen HF

2

cyclophosphamide (Cytoxin), daunorubicin (cerubidine), doxorubicin (adriamycin)

cardiotoxic and may worsen HF

3

androgens, estrogens, glucocorticoids, NSAIDS, rosiglitazone (Avandia), pioglitazone (Actos)

drugs that cause increased blood volume and may worsen HF

4

6 mechanisms of action against HF

adrenergic blockers
cardiac glycosides
phophodiesterase inhibitors
vasodilators
ACEI and ARBs
Diuretics

5

adrenergic blockers

treat HF by decreasing cardiac workload by slowing HR (B1) and decreasing BP (A1)
Carvedilol

6

Cardiac Glycosides

treat HF by increasing cardiac output by increasing the force of myocardial contraction
Digoxin

7

Phophodiesterase inhibitors

treat HF by increasing CO by increasing force of myocardial contraction
Milrinone

8

Carvedilol

adrenergic blocker-treats HF

9

Digoxin

cardiac glycoside treats HF

10

milrinone

phophodiesterase inhibitor treats HF

11

vasodilators

treat HF by decreasing cardiac workload by dilating vessels and reducing preload
isosorbide dinitrate with hydralazine

12

ACEI and ARBs

treat HF by increasing CO by lowering BP and decreasing blood volume
lisinopril

13

Diurectics

treat HF by increasing CO by reducing fluid volume and decreasing blood pressure
furosemide

14

isosorbide dinitrate with hydralazine

vasodilator to treat HF by decreasing cardiac workload by dilating vessels and reducing preload

15

lisinopril

ACEI or ARB that treats HF by increasing CO by lowering BP and decreasing blood volume

16

furosemide

diuretic that treats HF by decreasing fluid volume and BP to increase CO

17

nitrates
aspirin
clot-preventing drugs
beta blockers
statins
Calcium channel blockers

drugs to manage angina pectoris

18

Nitroglycerin

dilates veins and arteries
decrease myocardial workload
decrease preload (pooling of blood in periphery)
decrease myocardial ischemia to prevent vasospasm and dilates coronary arteries to increase perfusion
can be used for prevention of treatment

19

action of nitroglycerin

inactivate myosin and permissive vasodilation or relaxation of vessel tone occurs

20

Nitrates side effects/teaching

orthostatic hypotension
headaches, dizziness, vertigo, flushing, sweating

with the onset of angina, sit down and place on NTG tab under the tonge and wait 3-5 mins. If the angina has not subsided, take another tablet sublingually and wait 3-5 mins. If the angina has not subsided, take a third tablet and call 911 for help. Notify physician immediately.

21

Metoprolol, labetalol, propanolol

beta blockers for treatment of stable angina prevention
IV or PO
decrease HR, BP, contractility
cardioprotective
afterload of heart is reduced due to vasodilation
perfusion is improved through the coronaries bc of vasodilation and prolonged diastole
the heart can experience a greater Ejection Fraction due to prolonged diastolic filling time

22

Calcium Channel Blockers

diltiazem (Cardizem)
verapamil (Calan, Isoptin)
nifedipine (procardia, Adalat)
PO

23

Action of CCBs

decrease SA node automaticity and AV conduction to decrease HR and myocardial contractility

Decrease HR, BP, cause vasodilation, decrease preload and afterload, decrease myocardial oxygen needs

24

side effects of CCbs

Cardiovascular-hypotension, palpitations, and tachycardia
GI-constipation and nausea
Other-rash, flushing, and peripheral edema

25

Ranolazine (Ranexa)

can be used alone or with other angina meds, such as CCBs, beta blockers, or nitroglycerin

Unlike some other angine meds, Ranexa can be used with oral erectile dysfunction meds

Ranexa changes the metabolism of myocardium from fatty acid use for fuel to glucose, thereby decreasing metabolic needs

26

Treatment of Stable Angina

NTG, Beta Blockers, CCBs, ACEIs

27

treatment of unstable angina

NTG, heparin, clopidogrel, morphine, ASA

28

treatment of Prinzmetals angina

NTG and CCbs

29

Goals for treatment of MI (5)

reperfusion of blood supply to damage myocardium
reduce myocardial oxygen demand
control and prevent future myocardium dysrythmias
reduce post MI mortality
manage pain

30

10 drug classes to manage MI

thrombolytic agents
aspirin
ADP receptor blockers
Glycoprotein IIb/IIIa Inhibitors
anticoagulants
nitrates
beta blockers
ACEIs and ARBs
Pain management (morphine or demerol)
statins-post MI

31

OANM

oxygen
aspirin
nitroglycerin
morphine
treatment of MI

32

Thrombolytics

directly break up clots; give within 30 mins-12 hours following MI
enhance activation of plasminogen
streptokinase (Streptase)
alteplase (tPA, Activase)
anistrplase (Eminase)
reteplase (Retevase)
tenecteplase (TNKase)

33

thrombolytics contraindications

active bleeding or known bleeding d/o
Hx of hemorrhagic stroke or intracranial vessel malformation
recent major surgery or trauma
uncontrolled HTN
Pregnancy

34

enoxaparin (Lovenox)

LMWH
fibrinolysis should be started within 12 hrs to treat MI

35

Post MI care

ACEI/ARB
ASA or Antiplatelet agent
beta blocker or CCB
Statin

36

Captopril (Capoten)
Enalapril (Vasotec)
Benazepril (Lotensin)
Fosinpril (Monopril)

ACEI

37

Aspirin
Clopidogrel (Plavix)
Ticlopidine (Ticlid)-rarely used, neutropenia

antiplatelet agents

38

Prevent cardiac remodeling

beta blockers
Metoprolol (Lopressor)
Atenolol (Tenormin)
Propranolol
Esmolol
Labetalol

39

Amlodipine (Norvasc)
Diltiazem (Cardizem, Adalat)

CCBs

40

Statins action

lower cholesterol
lovastatin (Mevacor)
pravastatin (Pravachol)
simvastatin (Zocor)
atorvastatin (Lipitor)

41

Dihydropyridine

treats MI?
nifdeipine (Adalat, Procardia XL)
blocks Calcium channels in the vascular smooth muscle decreasing the amount of intracellular calcium available for muscle contraction this results in the fall of BP
decrease myocardial oxygen demand due to the reduced afterload

42

Nondihydropyridines

verapamil (Calan, Isoptin)
Block l type calcium channels in vascular smooth muscle causing vasodilation
verapamil and diltiazem block calcium channels in the myocardium decreasing the rate of conduction reducing the HR reducing the contractility of the myocardium

43

benefit of Ranolazine (Ranexa)

effect on HR is minimal as the drug acts on myocardial metabolism

44

Nitrates adverse effects

secondary to vasodilation: headache, flushing, orthostatic hypotension
potential cardiovascular collapse if mixed with alcohol

45

nitrates disadvantage

tolerance builds quickly

46

What happens if you D/C a long acting nitroglycerin (Isosorbide dinitrate) abruptly?

vasospasm

47

nitrates contraindications

preexisting hypotension, head trauma (vasodilation would make these worse)
pericardial tamponade and constrictive pericarditis (vasodilation would make heart unable to maintain CO to maintain BP)
no sustained release tabs on pts with glaucoma (nitroglycerin may increase introcular pressure)
caution severe kidney/liver disease (toxic levels)
dehydration and hypovolemia should be corrected before nitroglycerin is administered (severe hypotension may occur)

48

Nitrate drug interactions

viagra none within 24 hrs before or after-cardiovascular collapse-->hypotension

ethanol, CCBs, antidepressants, phenothiazines, and anti HTN may cause additive Hypotension

sympathomimetics (EPI) antagonize vasodilation

49

Do you take beta blockers for Prinzmetals angina

no, they make it worse

50

Beta Blockers action in treating Angina

prevention
decrease HR, BP, contractility, workload
cardioprotective

51

Why beta blockers over nitrates for prevention of angina?

tolerance not an issue
possess antidysrythmic properties
ideal for common disorder combo of HTN and CAD
cardioprotective

52

when to DC beta blockers

gradually unless fatigue, lethargy, and depression occur
With long term care, the heart becomes more sensitive to catecholamines, which are blocked by beta blockers. when w/d abruptly, adrenergic receptors are activated and rebound excitation occurs. In pts with CAD, this can exacerbate angina, precipitate tachycardia, or cause an MI

53

beta blockers adverse effects at high doses?

SOB and respiratory distress secondary to bronchoconstriction therefore use caution with asthma and COPD pts

54

Beta blockers and diabetes?

beta blockers may mask the symptoms of hypoglycemia so diabetics should monitor blood glucose more closely

55

beta blockers contraindications

bradycardia (may lead to primary heart block)
cardiogenic shock
overt cardiac failure

56

Atenolol (Tenormin)

beta blocker (beta one selective)
anti anginal agent
treats HF, HTN, stable angina, and acute MI
PO 1/day
excreted 50% renal, 50% feces not metabolized!
anticholinergic may decrease GI absorption

57

beta blockers drug interactions

digoxin (and other antidysrythmics that depress myocardial conduction may lead to AV block)

58

adverse effects of beta blockers

bradycardia and hypotension

59

dyspnea on exertion, fatigue, pulmonary cogestion, peripheral edema

classic symptoms of HF

60

Why are ACEIs (or ARBs) a preferred drug in the treatment of HF?

ACEIs block the detrimental effects of angiontensin II and aldosterone on cardiac remodeling

61

Nesiritide (Natrecor)

has a limited role in HF treatment; ANP and BNP (Natrecor is BNP) cause diuresis, vasodilation, and decrease aldosterone secretion. Basically, Natriuretic peptides counteract the RAAS and SNS

give to patients with acutely decompensated heart failure

62

Patients at high risk for HF

make lifestyle changes
treat and control HTN, dyslipidemia, and diabetes
if htn, start ACEI

63

Patients with structural evidence of heart diseaes (MI or valvular disease) but no symptoms of HF

lifestyle, control of modifiable factors (HTN, lipids, diabetes)
ACEIs (ARBs)
Beta blockers if prior HF symptoms
Diurectics and salt restriction if fluid retention

64

Patients with structural evidence of heart disease with symptoms of HF such as fatigue, fluid retention, dyspnea

ACEI (ARB) and Beta Blocker
Add Digoxin and Spironolactone if needed to control sympotoms
If symptoms do not improve, add a loop or thiazide diuretic and a combo nitrate with hydralazine

65

3 goals of Pharmacotherapy of HF

reduce preload
reduce afterload (reduce vascular resistance-BP)
Inhibit RAAS and SNS (which are vasoconstrictors)

66

adrenergic blockers for HF

Carvedilol
decrease cardiac worload by slowing the HR (B1) and decreasing BP (alpha 1)

67

Vasodilators for HF

isosorbide dinitrate with hydralazine
decrease cardiac workload by dilating blood vessels and reducing preload

68

ACEI and ARBs for HF

lisinopril, captopril
increase cardiac output by lowering BP and decreasing blood volume

69

Phosphodiesterase Inhibitors for HF

Milrinone
increase cardiac output by increasing the force of myocardial contraction

70

Cardiac glycosides for HF

Digoxin
increase CO by increasing the force of myocardial contraction

71

Main ACEI adverse effects

hypotension (worse at beginning of treatment and when dose is changed) caution with Beta blockers and diuretics

renal insufficiency resultant of decreased blood flow or hyponatremia from diurectics

angioedema, cough, hyperkalemia

72

What is a risk associated with ACEI + spironlcatone?

hyperkalemia

73

Losartan (Cozaar)

ARB used for HF when ACEI is not tolerated

74

Diurectics Action

reduce peripheral edema
reduce pulmonary congestion
reduce blood volume
reduce BP
reduce cardiac workload
INCREASE CO
**only use diuretics in HF pts if fluid retention is present

75

Can you give loop diuretics to pts with renal insufficiency?

yes

76

examples of loop diurectics

furosemide (Lasix)
bumetanide (Bumex)
torsemide (demadex)

77

What diuretic is prescribed for mild-moderate HF and can be combined with loop diuretics?

Thiazide diuretics: chlorotiazide (Diuril), hydrochlorothiazide (HCTZ, HydroDIURIL)

78

Spironolactone (Aldactone)

potassium sparing and aldosterone antagonist diuretic
limited efficacy in HF pts bc low performing diuretic
blocks cardiac remodeling of aldosterone

79

when is it best to give ACEI for HF

within 36 hrs of onset

80

Diuretic cautions

dehydration and electrolyte imbalances
weigh self frequently
electrolyte tests (hypokalemia loop or thiazide especially when combined with digoxin)

81

If beta blockers, being negative inotropes, make HF worse, then why do we prescribe them to HF patients?

Beta Blockers stop the SNS compensatory response that makes HF worse and is a vicious cycle by blocking NE and other catecholamines that cause cardiac remodeling and disease progression. The result of beta blocker therapy is reduced HR and BP which leads to decreased cardiac workload.
After several mos of therapy, heart shape, size, and function can actually return to normal-> reverse remodeling

82

Which medication can cause reverse remodeling in HF patients?

beta blockers, carvedilol (Coreg) and metoprolol (Toprol), propranolol (nonselective)

83

How must beta blockers be administered to HF patients?

To prevent making HF worse, beta blockers must be given very specifically:
Initial doses must be 1/0-1/20 target dose and then doubled every two weeks until target dose is reached.

84

Beta Blockers are contraindicated for

COPD
bradycardia
heart block

85

beta blockers are used with caution on pts with

PVD, diabetes, or hepatic impairment

86

What lab tests do you monitor for pts on beta blockers?

liver function studies for signs of toxicity

87

How do vasodilator reduce symptoms of HF?

Vasodilators reduce preload or afterload

88

Hydralazine with isosorbide dinitrate

vasodilators: relax blood vessels and lower bp creating less workload for the heart;
use is limited due to risk of orthostatic hypotension and reflex tachycardia

89

Hydralazine

antiHTN acts on arterioles to decrease peripheral resistance, reduce afterload, and increase CO; not a first choice drug bc of hypotension and reflex tachycardia risks

90

Isosorbide Dinitrate

a long acting organic nitrate that reduces preload by directly dilating veins. not effective as monotherapy and tolerance develops quickly

91

what triggers the release of BNP in the body?

increased ventricular stretch releases BNP which then enhances diuresis and renal excretion of sodium (counteracts RAAS and aldosterone)

92

Patients with acutely decompensated heart failure are prescribed which vasodilator?

Nesiritde (BNP) and monitor this patient continuously bc hypotension may occur

93

What drug do you give to patients with supraventricular tachyarrythmias (afib)?

Digoxin-now a drug reserved for late stage HF
digoxin has antidysrythmic properties

94

Why are cardiac glycosides used in late stage HF only?

they have a narrow therapeutic window and severe side effects

95

When do you hold digoxin?

when HR is <60bpm

96

Two Primary classes of positive inotropic agents administered to pts with acute decompensated HF:

Beta AGONISTS
Phosphodiesterase Inhibitors

97

Beta Agonists

isoproterenol (Isuprel)
EPI, NE, Dopamine
Dobutamine (Dobutrex)** ability to rapidly increase myocardial contractility with min changes to HR and BP

98

two common adverse effects of beta agonists

tachycardia and dysrythmias

99

When do you give dopamine in HF?

when the pt has both HF and hypotension bc dopamine can increase myocardial contractility and activates alpha receptors to increase BP

100

How do phosphodiesterase III inhibitors work?

they block the enzyme which leads to increases in the amount of calcium available for myocardial contraction. Two benefits:
positive inotropic and vasodilation, thus CO is increaseed due to increased contractility and decreased in left ventricular afterload. There is little effect on HR

101

Prototype drug for phosphodiesterase III inhibitor

milrinone (Primacor)

102

ACEI action r/t HF

Lower peripheral resistance through inhibition of angiotensin II formation
reduce blood volume through inhibition of aldosterone
yields reduced arterial BP (afterload), increased CO, and dilated veins (preload)

103

digoxin action (4)

decreases SNS activity and increases PNS activity-can suppress SA node and slow conduction through AV node;

inhibits NaKATP Pump

increases intracellular calcium via sodium/calcium exchange pump

positive inotrope; by increasing mycardial contractility, digoxin increase CO and that improves exercise tolerance and urine production to restore fluid balance and decrease pulmonary congestion.

104

special considerations when administering digoxin

must give over a min of 5 mins, can dilute in 4-5mL
can give PO but NEVER IM or SC

105

Is digoxin highly protein bound?

Yes, so be aware of hypoalbumuria-toxic dig

106

Adverse effects of digoxin

ventricular dysrhythmias including sudden cardiac death. most common cause is hypokalemia from combined diuretic therapy; hypomagnesemia and hypo calcemia and impaired renal function are add'l risk factors. AV Block, atrial dysrhythmias, sinus bradycardia

107

Normal serum digoxin levels

0.5-1.5ng/dL drawn 6-12 hrs after last dose
toxicity often presents with flu like symptoms/ earliest sign is anorexia

108

H2antagonist

antagonist agent against histamine that decreases gastrin secretion

109

cathartic

agent with purgative action
Rapid, intense fluid evacuation of bowel.

110

surfactant

a surface active agent also known as a wetting agent, tension depressant, detergent and emulsifier

111

Methoscopalamine

blocks effect of Ach and relaxes smooth muscles
GI Stimulant
adjunct therapy for treating peptic ulcer disease

112

Dexpanthenol

minimizes risk of paralytic ileus when used post op

113

metoclopramide PO meal consideration and what does it treat?

take 30 mins before meals and at bedtime
dopaminergic blocker
treats v/n, and expedites gastric emptying

114

metoclopramide IV considerations

give 30 mins prior to chemo for antiemetic effect

115

GI stimulants

decrease reflux by increasing sphincter tone and enhancing acid clearance and decreasing gastric emptying.
Used for delayed gastric emptying caused by diabetic gastroparesis, GERD, or post op N/V
Stimulates gastric mobility w/o stimulating gastric, biliary, or pancreatic secretion

116

GI Stimulants contraindications

Hx seizure d/o, pheochromocytoma, PD (metoclopramide)
GI hemorrhage, obstruction or perforation
allergy to dextran, CHF, renal failure (dexpanthenol)
depression, HTN

117

nursing considerations for GI stimulants

monitor for possible hypernatremia and hypokalemia paricularly if pt has CHF or liver cirrhosis
monitor BP closely with metoclopramide IV

118

Client edu for GI stimulants

report signs of acute dystonia immediately
do not drive a few hours after taking metoclopramide
avoid humid environments with methoscopolamine

119

Anticholinergic and Antispasmodics

medications for decrease GI tone and motility
pylorospasm, ileitis, and IBS
give 30-60 mins before meals and at bedtime

120

Anticholinergic and Antispasmodics Contraindications

narrow angle glaucoma, obstructive GI disease, paralytic ileus, obstructive uropathy, adhesions between iris and lens, myocardial ischemia, and toxic megacolon.
Caution if renal dysfunction

121

Atropine may increase the effect of

phenothiazines

122

increased effects of atenolol with

anticholinergic drugs

123

what decreases absorption of anticholinergics

antacids

124

Cytotec (Misoprostol) contraindications

contraindicated if allergic to prostaglandins, pregnant, or lactating. May cause spontaneous abortion.
Prostaglandin Analog

125

Misc drug for PUD/GERD: Misoprostol (Cytotec)

protects against peptic ulcers caused by NSAIDS by reducing the secretion of gastric acid and by boosting the production of gastric mucus
Is a prostaglandin Analog

126

Carafate (Sucralfate)

butt paste; works locally in the stomach by rapidly reacting with Hcl to form a thick, paste-like substance that adheres to the gastric mucosa to form a protective acid resistant shield in the ulcer crater. In addition, stimulates prostaglandins, mucus, and bicarb; Protects the mucosa for up to 6 hrs
indicated for short term therapy, esp to treat ulcers r/t stress
**Not effective for ulcers r/t NSAIDS

127

Carafate (Sucralfate) danger

can result in aluminum toxicity in renally compromised patients when combined with aluminum salt antacids

128

carafate (Sucralfate) administration

1 hour before meals or 2 hours after meals; 2 hours after other po meds and not within 2 hours of antacids

129

cytotec nursing considerations

Pregnancy test prior to starting Cytotec and should be negative within 2 weeks of starting. Use contraception while on the med and for at least 1 month after stopping.

Cytotec take on empty stomach and not within 30 minutes (before or after) food intake

130

opioid related drugs, kaolin and pectin (in bananas) to treat diarrhea

Decrease peristalsis in the intestines.
Include:
Difenoxin
Diphenoxylate with Atropine (Lomotil)*
Loperamide (Imodium)- is an analog of Demerol

131

which opioid related drug treats long term diarrhea?

Loperamide is also used to treat chronic diarrhea

132

opioid related drugs adverse effects

GI distress
Lomotil- dizziness, lethargy, drowsiness; at high doses the anticholinergic effects may be observed (drowsiness, flushing, dry mouth & tachycardia); additive effects with other CNS depressants

133

antidiarrheal agents

paregoric/opium tincture
diphenoxylate (Lomotil®)
defenoxin (Motofen®)
loperamide (Imodium, Kaopectate®)
bismuth subsalicylate (Pepto-Bismol)
Octreotide acetate (Sandostatin)- profuse watery diarrhea, severe diarrhea associated with metastatic tumors

134

nursing indications of antidiarrheals

Do not give to clients with C. difficile
Typically do not use to treat diarrhea in children.
Avoid bismuth subsalicylate if allergic to aspirin. This medication may temporarily darken stools and tongue.

135

kaolin and pectin

Pharmacodynamics:
Bind with bacteria, toxins, and other irritants on the intestinal mucosa.
Pectin decreases the pH in the intestinal lumen which provides a soothing effect on the irritated mucosa.
Pharmacotherapeutics:
Used to relieve mild to moderate diarrhea.

136

osmotic laxatives

Work by drawing water into the intestine promoting bowel distention and peristalsis.
Include the following drugs:
Glycerin (Glycerol)
Lactulose (kristalose)
Polyethylene glycol (Miralax)
Saline compounds

137

PUD lifestyle treatments

Lifestyle changes
Stop tobacco use
Stop ETOH
Stop Caffeine
Weight control
Decrease use of NSAIDS, ASA*

138

PUD drug therapy

Aimed at either eradicating H. pylori or restoring balance between acid and pepsin secretions and the GI mucosal defense.
These drugs include: systemic antibiotics, antacids, Histamine-2 (H2)-receptor antagonists, proton pump inhibitors, and other peptic drugs such as misoprostol and sucralfate.

139

H2 Blockers

BLOCK the release of hydrochloric acid in the stomach in response to gastrin
"Tidines"
cimetidine (Tagamet®)
ranitidine (Zantac®)*
famotidine (Pepcid®)
nizatidine (Axid®)

140

Antacids

Interact with gastric acids at the chemical level to neutralize them
are inorganic compounds that contain aluminum, magnesium, sodium, or calcium to neutralized gastric acid and inactivate pepsin. They stimulate prostaglandin production and increase LES tone (reduces GERD)
therapeutic levels must increase stomach acid to at least 3.5

141

PPIs

Suppress secretion of hydrochloric acid into the stomach lumen
*Drugs of choice for PUD/GERD
Omeprazole (prilosec)
"prazoles"
bind irreversibly to enzymes that produce Hcl-long acting
take 2--30 mins before breakfast
no renal clearance (ok to give to pts with renal insufficiency)-metabolized in liver, excreted in urine/feces
long term therapy increases risk for osteoporosis (decrease calcium absorption)
other PPIs
Esmomeprazole (Nexium)
lansoprazole (prevacid)
pantoprozole (Protonix)
rabeprazole (AcipHex)

142

anticholinergics: Pirenzepine (Gastrozepine)
Misc drug for PUD/GERD

Reduce gastric motility
Adverse effects of dry mouth, constipation make this rarely prescribed now.

143

Mucosal barrier protectants

Coat any injured area in stomach to prevent further injury from acid

144

Lactulose (kristalose)

osmotic laxative
given in renal disease too
pulls amonia into gut and you poop it out

145

H2 Blockers Indications

PUD
GERD
Reflux esophagitis
Prevention of aspiration pneumonia
Prevention of stress ulcers in critically ill clients, and as combination therapy to treat H pylori infection

146

H2 Blockers Nursing considerations

Avoid antacid use within 1 hour of po administration.*
IV preparations should not be mixed with other medications.
Once a day dosing should be at bedtime; more often five before meals.
Use cautiously in clients with renal or hepatic function impairment.

147

PUD

the incidence of PUD is associated with the following risk factors:
H. pylori infection
Family hx of PUD
corticosteriods, NSAIDS, ASA, platelet inhibitors
Blood group O (H. pylori may bind to this antigen)
Smoking tobacco
excessive caffeine
stress

148

NSAID related ulcers are usually where? (PUD)

gastic ulcers
less common
anorexia, weight loss, vomiting

149

H. pylori related ulcers are usually where? (PUD)

duodenal ulcers
gnawing or burning upper abdominal pain that occurs 1-3 hrs after a meal. Pain is worse in empty stomach and often disappears with ingestion of food. (presence of food closes the sphincter and keeps acid in stomach) red vomit, black tarry stools.

150

what contributes to stress ulcers? (PUD)

vasoconstriction secondary to SNS involvement causes decreased blood flow to small intestine

151

ZES (Zollinger-Ellison Syndrome)

less common cause of PUD
caused by a tumor that secretes gastrin (gastrin increases Hcl secretion)
results in too much acid

152

GERD

persistent Heartburn, dysphagia, dyspepsia, chest pain, nausea, belching
symptoms worsen following large meals, exercise, and when reclining

153

What makes GERD worse?

caffeine, alcohol, citrus fruits, tomato based products, onions, carbonated beverages, spicy food, chocolate, smoking, pregnancy, and obesity

154

Which meds make GERD worse?

nitrates, benzodiazepines, anticholinergics, beta blocker, alpha blockers, estrogen, progesterone, iron, CCBs, NSAIDS, tricyclic antidepressants, opioids, levodopa, biposphonates, and some chemo agents

155

Warning s/sx of GERD

unexplained weight loss, early satiety, anemia, vomiting, initial onset of symptoms after age 50, prolonged anorexia or dysphagia

156

Goals of PUD pharmcotherapy

provide immediate relief, promote healing of ulcer, prevent complications, prevent future recurrence

157

for PUD patients with H. pyloria

antibiotics are key to pharmacotherapy

158

Drugs to provide relief for PUD/GERD

neutralizing gastric acid
PPIs
H2 blockers
Antacids
*long term acid suppression leads to deficiency in folic acid, iron, and vit B12**

159

H2 blockers

"Tidines"
cimetidine (Tagamet)
famotidine (Pepcid)
nizatidine (Axid)
ranitidine (Zantac)

160

Sodium antacids disadvantages

avoid if sodium restricted diet or have HTN, HF, and renal impairment bc they cause fluid retention

161

Magnesium antacid disadvantages

hypermagnesemia (fatigue, hypotension, dysrhythmias)
laxative effect in large intestine

162

Calcium antacid disadvantages

constipation risk and may cause/aggravate kidney stones
hypercalcemia, renal failure at high doses
calcium carbonate antacids with milk or vit D can cause milk-alkali syndrome

163

s/sx of hypercalcemia and milk-alkali syndrome

HA, urinary frequency, anorexia, nausea, fatigue

164

Aluminum antacids disadvantages

constipation
aluminum carbonate and aluminum hydroxide may interfere with dietary phosphate absorption to cause hypophosphatemia

165

bicarb antacid disadvantages

may provoke metabolic alkalosis (fatigue, mental status changes, muscle twitching, depressed RR)
bicarb combines with gastric acids to form CO2-causes bloating and belching

166

drug interactions with antacids

increase stomach pH-affect solubility and absorption of many PO meds

acidic drugs will have a lesser therapeutic effect and basic drugs will have a more intense effect

enteric coated or delayed release drugs are designed to dissolve in the alkaline environment of the small intestine-antacid use may cause these drugs to dissolve early in the stomach and the drug may then irritate stomach lining
antacids bind to tetracyclines and digoxin

by changing urine pH, antacids delay the elimination of basic drugs (amphetamines) and speed the elimination of acidic drugs (aspirin)

167

Acidic drugs

NSAIDs, sulfonylureas, salicylates, warfarin, barbiturates, isonizaid, digoxin (decreased action with antacid)

168

basic drugs

morphine sulfate, antihistamines, tricyclic antidepressants, amphetamines, quinidine (increase action with antacid)

169

To decrease potential for antacid-drug interactions, what should the nurse advise her patients to do?

other meds should be taken at least 1 hour before or 2 hours after an antacid

170

Pharmacotherapy of H. Pylori

Omeprazole (PPI), clarithromycin (Biaxin), amoxicillin

or
add metronidazole (Flagyl), bismuth subsalicylate (peptobismol) and tetracycline

171

how does bismuth compound work to treat H pylori?

inhibit bacterial growth by disrupting cell walls and prevent h pylori from adhering to gastric mucosa

172

how do PPIs treat h pylori?

suppress h pylori, and the increased pH creates a hostile environment for H pylori, thus enhancing effectiveness of antibiotics

173

Misc drug for PUD/GERD: bismuth compounds (Kaopectate or PeptoBismol)

contains both bismuth and salicylate which stim mucosal bicarb and prostaglandin production and inhibits H pylori from adhering to ulcerated tissue. causes cell wall death to h pylori.

turns stool black-normal side effect

174

childrens pepto

contains calcium carbonate but no salicylates due to increased risk of developing Reye's syndrome with salycylate use under age 19

175

Misc drug for PUD/GERD: Metoclopramide (Reglan)

more commonly prescribed to treat n/v associated with chemo, but used for PUD/GERD when pts dont respond to first line drug therapy

Causes muscles in the upper intestine to contract, resulting in aster emptying of the stomach

Decreases esophageal relaxation and blocks food from entering the esophagus (GERD benefit)

176

adverse effects of metoclopramide (Reglan)

drowsiness, fatigue, confusion, insomnia

uncommon: parkinsonism (bradykinesia, akathisia, and tardive dyskinesia)

177

which two antacid compounds may cause constipation?

aluminum and calcium antacid compounds may cause constipation
Sodium compounds may cause flatulence
Magnesium compounds may cause diarrhea

178

What adverse effects should a nurse monitor for in pts taking ranitidine (Zantac)?

blood dyscrasisas have been reported, especially neutropenia, and thrombocytopenia so the nurse should performed periodic blood counts

179

Bulk forming laxatives
calcium polycarbophil (FiberCon, Equalactin)
methylcellulose (Citrucel)
psyllium mucilloid (Metamucil, Naturacil)

absorb water, thus adding to the size of fecal mass (the larger the fecal mass, the greater the neural stimulus for defecation)
take with plenty of water or you could obstruct your esophagus!!
Bulk forming laxatives are the treatment of choice for chronic constipation and may be taken on a regular basis without ill effects.

180

Stimulant laxatives
bisacodyl (Correctol, Dulcolax)
castor oil (Emulsoil, Neoloid)

promote peristalsis by irritating the bowel; rapid acting and more likely to cause diarrhea and cramping than bulk forming laxatives.

do not use frequently: laxative dependence, abdominal cramping, and fluid/electrolyte imbalances may occur

used as a bowel prep prior to bowel exams/surgeries

181

Surfactant laxatives / stool softeners
docusate (Colace)

cause more water and fat to be absorbed in stool
ineffective in treating constipation but are most often used to prevent the condition.

182

Saline/Osmotic Cathartics
magnesium hydroxide (Milk of Magnesia)
polyethylene glycol (MiraLAX)
sodium biphosphate (Fleet Phospho-Soda)
Glycerin (Glycerol)
Lactulose (kristalose)
Saline compounds

pull water into the fecal mass to create a more watery stool

can produce a BM very quickly

do not use long term due to risk of dehydration and electrolyte depletion

Saline laxatives are important for colonoscopy prep or for purging toxins from body

183

mineral oil as a laxative

should not be used bc it interferes with absorption of fat-soluble vitamins

184

opioids are the most effective drugs for controlling

severe diarrhea (codeine, Difenoxin
or diphenoxylate with atropine (Lomotil)*
caution use with MAOIs (hypertensive crisis may ensue)

185

loperamide (Imodium)

analog of meperidine (Demerol)
antidiarrheal agent
no analgesic actions, no issues with dependence

186

what do you administer to counteract an od of Lomotil (opioid)?

Naloxone

187

Ocreotide (Sandostatin) as an antidiarrheal

treats severe diarrhea associated with cancer
prevents release of serotonin and other active peptides that promote diarrhea; directly inhibits intestinal secretions and enhances absorption
long term therapy usually causes gallstones or cholestatic hepatitis

188

Treat IBS with

immunosuppressants and anti-inflammatory drugs
1. 5-ASA (sulfasalazine, olsalazine, balsalazide, mesalamine)
2. oral coritcosteriods (prednisone)
3. (Immunosuppressants) azathioprine (Imuran), mercaptopurine (Purinethol), methotrexate- onset 3 mos effective at expanding time between relapses
4. TNF inhibitor (Remicade), adalimumab (Humira)

189

Budesonide (Entocort-EC)

corticosteriod that is first line for treatment of IBS bc it is encapsulated so it is not absorbed in stomach or duodenum (not GI irritation)

Drug is slowly released and reaches a high concentration in the terminal ileum and proximal colon (2 most affected sites for IBD)

almost entirely removed by liver in first pass metabolism-nill on side effects

190

treat n/v with

antiemetics
1. cannabinoids
2. serotonin blockers (antipsychotics)

antihistamines and anticholinergics
antacids
herbal supplements peppermint, ginger

191

Phenothiazines: prochlorperazine (Compazine), metoclopramide (Reglan), perpehenazien (Phenazine, Trilafon)

treat psychoses and antiemetic
EPS are a concern with long term therapy

192

Benzodiazepines lorazepam (Ativan)

anxiety and antiemetic

193

Cannabinoids dronabinol (Marinol)

like marijuana

194

Corticosteriods dexamethasone (Decadron) and methylprednisolone (Solu-Medrol)

prevent chemotherapy induced and post surgical n/v

195

serotonin (5-HT3) receptor antagonists: dolestron (Anzemet), granisetron (Kytril), ondansetron (Zofran)

most widely prescribed for treating n/v induced by chemo

196

Pancrelipase (Creon, PAncreaz, Zenpep)

used as replacement therapy for patients with pancreatitis or cystic fibrosis

197

The client who is taking sulfasalazine (Azulfidine) develops a sore throat, bruising, and severe fatigue. The nurse determines that the client is most likely experiencing drug induced

blood dyscrasias

198

The nurse teaches the client taking procholperazine (Compazine) to dc the medication immediately if what occurs?

facial twitching, tremors, muscle spasms, pacing

199

A nurse should question the order for pancrelipase for a client

with a pork allergy

200

A healthcare provider orders magnesium hydroxide (Mil of Magnesia) for a client with constipation. Before administering the drug, what should the nurse assess?

bowel sounds to make sure no obstruction

201

drugs used for weight management affect

appetite or the absorption of fats

202

lipase inhibitors (Orlistat/Alli/Xenical) cause weight loss

by interfering with the absorption of fats
indicated for those with BMI>30
only effective if taken with meals containing lipids; omit med if the meal has no lipid content

203

Anorexians

drugs used to induce weight loss by suppressing appetite and hunger

204

Lactulose

Lactulose is used to treat constipation and decrease ammonia* production and absorption from the intestines in liver disease.

205

Mineral Oil (lubricant laxative)

May impair the absorption of many oral medications such as fat-soluble vitamins (A,D,E,K )*, oral contraceptives, and anticoagulants*.

206

condansetron (Zofran®) antiemetic of choice in US

Doesn’t affect dopamine receptors, so no extrapyramidal effects*

207

absorbant drugs for OD treatment

Most commonly used adsorbent drug is activated charcoal.*

208

simple partial seizure

one hemisphere, manifestations include alterations in motor function, sensory signs, or sensory or autonomic symptoms

209

complex partial seizures

temporal lobe, may be preceded by an aura
impaired loc, repetitive, non-purposeful movements such as lip smacking, picking or aimless walking
amnesia is common

210

generalized partial seizure

both hemispheres

211

absence seizure

generalized, last 5-30 seconds, sudden cessation of motor activity and blank stare, can occur occasionally or up to 100x/day, eyelid fluttering and lip smacking, more common in children than adults

212

Tonic-clonic seizure

AKA grand mal
most common seizure
may be proceded by aura or have no warning
typically begins with loss of consciousness and sharp muscle contractions
pt falls to floor and may have urinary and/or bowel incontinence
breathing ceases and cyanosis develops during tonic phase
clonic phase follows with alternating muscle contraction and relaxation in al extremities, hyperventilation, eyes rolled back in head
postictal period: pt is relaxed with quiet breathing, unconscious, unresponsive, gradually regaining consciousness and may have transient confusion and disorientation

213

Diazepam (Valium)

Benzodiazepine
for seizures
most serious side effect is cardiovascular collapse; assess for hypotension, tachycardia, and edema
treat od with Flumazenil (Romazicon) reverses CNS depression
listed on Beers List of potentially inappropriate drugs for the older adult
hold drug if BP drops 20mmHG (orthostatic hypotension)
Assess respiratory status for depression (rate, rhythm, depth)

214

Phenytoin (Dilantin)

Hydantoin
prevents seizures (except absence seizures)
loading doses common; can be very toxic (nystagmus, confusion, ataxia, coma, seizures), monitor closely
gingival hyperplasia (use soft bristle toothbrush)
do not DC abruptly-risk for seizure
assess for blood dyscrasias (sore throat, bruising, nosebleeds)
Monitor serum glucose closely as Dilantin may inhibit insulin release-risk for hyperglycemia

215

therapeutic range of Phenytoin (Dilantin)

10-20 mcg/mL

216

Carbamezepine (Tegretol)

antiepileptic
risk for Stevens Johnson syndrome (fever, sore throat, fatigue)
treat OD with activated charcoal and gastric lavage

217

Valproic Acid (Depakote)

GABA Agonist
adverse effects of photosensitivity and pulmonary edema
treat OD with Naloxone (Narcan); hemodialysis can lower drug serum levels. Caution must be used when administering Narcan bc it can reverse the anitseizure action of Depakote

218

Therapeutic level of Valproic Acid (Depakote)

50-100mcg/mL

219

Muscle Spasm Medications

Carisoprodol (Soma)
Cyclobenzaprine (Amrix, Flexeril)
Diazepam (Valium)
Metaxalone (Skelaxin)
Methocarbamol (Robaxin)

220

Diazepam (Valium) uses besides seizures

anxiety, acute alcohol w/d, treat tetanus

221

Nursing considerations for muscle spasm meds

blood studies (CBC, WBC with differentials)
assess for CNS depression, dizziness, drowsiness, and psychiatric symptoms

222

myasthenia gravis

occurs when antibodies attack nicotinic synapses on skeletal muscles resulting in symptoms of extreme fatigue, double vision, and difficulty chewing or swallowing. The most obvious symptom is ptosis. Diagnosis is accomplished by clinical symptoms and presence of antibodies to Ach.

223

Pyridostigmine (Reganol)

treats myasthenia gravis

224

Edrophonium (Tensilon)

diagnose Myasthenia Gravis; administer IV rapidly while observing pt repsonse. works 1x; toxic to liver and loses efficacy the more you use it

225

pyridostigmine (Reganol) side effects

severe cholingeric response (excessive salivation, sphincter relaxation, diarrhea, vomiting)

226

pyridostigmine (REganol) nursing considerations

assess repiratory
give w/ meals on time to keep in therapeutic range (short half live)

227

Levodopa and Carbidopa (Sinemet); Pramipexole (Mirapex); Benztropine (Cogentin)

treat parkinsons disease

228

levodopa and carbidopa (SInemet)

dopamine replacement agent
carbidopa makes levodopa more effective at smaller doses by inhibiting its breakdown in the intestine and peripheral tissues (more reaches brain); levodopa treats tremor, bradykinesia, gait and muscle rigidity

imbalance, sensory problems, sexual dysfunction and constipation do not respond well to levodopa

229

pramipexole (Mirapex)

dopamine receptor agonist

230

benztropine (Cogentin)

cholinergic antagonist

231

Dietary restrictions assoc with levodopa and carbidopa (SInemet)

avoid food high is pyridoxine (vit B6) (Beef, liver, ham, pork, egg yolks, whole-grain or fortified cereals, or multivitamins)-they will decrease medicinal effects

do not take with foods high in protein-neg effect on absorption

the full therapeutic effect of meds may take several months to appear

232

What's another drug that is used synergistcally with levodopa to treat PD?

Pramipexole (Mirapex)
Watch for hallucinations, dizziness, drowsiness, and nausea
orthostatic hypotension
EPS (tongue rolling, confusion, jerking)
fainting, mood changes, muscle cramps/spasms, increased tremors, swelling of ankles/feet, chest pain, vision changes, dysrhythmias
BUN/cr

233

How do you combat EPS in Pramipexole drug therapy

pair with Cogentin (Benztropine)

234

adverse effects of Benztropine (Cogentin)

paralytic ileus, tachycardia, cardiovascular collapse, anaphylactic shock, can cause some psych conditions to worsen so monitor closely

235

Nursing responsibilities r/t Cogentin

use caution in hot weather, avoid using mechanical/heavy machinery (dizziness/drowsiness), avoid OTCs and alcohol

236

Alzheimers treatment

Donepezil (Aricept)
reversible cholinesterase that causes elecated Ach levels in the cortex, which slows the neuronal degradation of Alzheimers disease
adjust dosage no more frequently than q6wks

237

Donepezil (Aricept) Contraindications

DC if jaundiced
urinary frequency and incontinence common
A fib possible
assess BP to hypotension
monitor liver function studies

238

Patient education r/t Donepezil (Aricept)

report side effects of twitching, n/v/d, or rash
do not increase or decrease dosage abruptly
stop smoking

239

Sharp, stabbing, dull, aching-

nociceptive pain

240

Burning, tingling=

neuropathic pain

241

peripheral nociceptors analgesics

local anesthetics
Anti-inflammatory drugs

242

peripheral nerve analgesics

local anesthetics

243

Dorsal horn analgesics

local anesthetics, opioids, alpha2 agonists

244

brain analgescis

opioids, alpha 2 agonists

245

Endocet

oxycodone HCl + acetaminophen

246

norco

hydrocodone + acetaminophan

247

Percocet

oxycodone HCl + acetaminophen

248

Percodan

oxycodone + aspirin

249

Vicodin or Lortab

hydrocodone + acetaminophen

250

Vicodin HP

hydrocodone + acetaminophen

251

opium

morphine + codeine

252

activation of mu receptor

responsible for the analgesic properties of the opioids as well as some of the adverse effects such as respiratory depression and physical dependence (opioid agonists)

253

opioid agonist

activate both mu and kappa receptors
morphine, codeine

254

mixed opioid agonist-antagonist

occupy one receptor and block (or have no effect) on the other
pentazocine (Talwin)
butorphanol (Stadol)
buprenorphine (Buprenex)

255

Opioid Antagonist

block both mu and kappa receptors
naloxone (Narcan)

256

kappa binding only

analgesia, sedation, decreased GI motility

257

Mu binding

analgesia, sedation, decreased GI motility
respiratory depression, euphoria, physical dependence

258

**general actions of opioids

Analgesia
Respiratory depression
*Constipation (decrease GI motility)
*Urinary retention
*Cough suppression
Emesis
Increased ICP
Indirect through CO2 retention
Euphoria/Dysphoria
Sedation
Miosis
Pupil constriction
decreased Preload & afterload
Watch for hypotension!

259

promethazine (phenergan)
ondansetron ( Zofran)

antiemetic drugs usually used to combat nausea/vomiting r/t opioid use

260

clinically used opioids for analgesia

fantanyl, morphine

261

clinically used opioids for cough suppression

codeine, Dextromethorphan

262

clinically used opioids Antidiarrheal

(Diphenoxylate,Loperamide)

263

clinically used opioids Acute Pulmonary edema

(Morphine)

264

clinically used opioids anesthesia

(Fentanyl)

265

clinically used opioids Opioid Dependence or adjunct in chronic pain

(Methadone)

266

highly effective opioids

fentanyl
hydromorphone
levorphanol
meperidine
methadone
morphine
oxymorphone
**risk for respiratory failure!!

267

moderately effective opioids

codeine
hydrocodone
oxycodone
percocet
**Hepatotoxicity, respiratory depression, circulatory collapse, coma

268

opioids wit mixed agonist-antagonist effects

buprenorphine (mu agonist, kappa blocker) *resp depression
burorphanol (weak mu blocker, kappa agonist)
nalbuphine weak mu blocker, kappa agonist)
pentazocine (weak mu blocker, kappa agonist)

269

morphines respiratory depressive action may be used to treat

SOB assoc end stage cancer
HF
pulmonary edema

270

advantages of morphine therapy

no upper end dose limit and pts develop tolerance to all the adverse effects except constipation

271

morphine drug interactions

alcohol, skeletal muscle relaxants, MAOIs (increased sedation)
kava, valerian, chamomile (increase CNS depression)
St John's Wort may decreased analgesic action

272

duramorph

a preservative free morphine sulfate commonl used for IV, epidural, and intrathecal use (PCA pumps)

273

nursing responsibilities for morphine

Nursing implications
Baseline vital signs (BP will be lower, RR, O2 sat, pain rating) monitor output (ensure no urinary retention), watch for falls, d/c all previous orders for pain meds, administer by micro-drip and infusion pump
Predetermined dose and lockout interval

274

hydromorphone (Dilaudid)

7-10 time effect of morphine
faster onset, but shorter duration of action
high abuse potential

275

hydrocodone

often paired with tylenol (Vicodin) or aspirin (Lortab)
increased risk of hepatotoxicity (no vicodin for pts with hepatitis)

276

Meperidine (Demerol)

duration of action is shorter than morphine
good for pts with GI pain (pancreatitis, biliary colic) *does not increase biliary tract pressure
Patients with pain and acute asthma
Less likely to produce histamine release

277

contraindications for meperidine (demerol)

Cautions/Contraindications
Neurotoxicity with sickle cell, burn injuries, or cancer
Severe/fatal reaction if given to patient taking MAOI
Produces a vagolytic effectincrease HR
In COPD may result in resp. depression
In increased ICP, may mask neuro parameters
If given IM, rotate sites as tissue irritation is common

278

Methadone

more potent that morphine
used for detox and maintenance programs
cautions: OTC drugs may potentiate action, orthostatic hypotension is common side effect and can last several weeks
**no euphoria prod by other opioids

279

oxycodone

pproximately 10 times more potent than codeine
Examples
Percocet, Tylox- with acetaminophen
Percodan- with aspirin

280

fentanyl

Brands
Sublimaze, Innovar, Duragesic
Uses
premed, with anesthesia, post anesthesia

281

Propoxyphene (Darvocet)

less potent that morphine
Darvon (ASA)
Darvocet (acetaminophen)
not a good choice for older adults
caution history of alcohol abuse

282

Butorphanol (Stadol) mixed opioid
Cautions:

hypertensive clients, contraindicated in MI ( cardiac workload), may increase CSF (monitor ICP)

283

Pentazocine (Talwin) mixed opioid
Caution

cardiac function

284

Nalbuphine (Nubain) mixed opioid
uses

preeop as adjunct to anesthesia; obstetric analgesia

285

opioids to avoid for older adults

Meperidine (Demerol), propoxyphene (Darvon),and pentazocine (Talwin) are more toxic in older adults and should be avoided
Diminished circulation, which results in slower absorption of IM or SQ drugs

286

Tramadol (Ultram)

centrally acting non opioid analgesic
no GI ulceration like NSAIDs
no respiratory depression of opioids
bind to pioid mu receptor (weak mu agonist) 10Xinhibits NE and serotonin reuptake in spinal neurons (inhibits pain transmission)

287

Tramadol adverse effects

vertigo, dizziness, HA, n/v, constipation, and lethargy
nervousness, tremor, anxiety, agitation, confusion, visual impairment, and hallucinations
seizures if also taking antidepressants

288

adjuvant analgesics

antidepressant (tricyclic antidepressants, SSRIs) for neuropathic pain

antiseizure (gabapentin [neurotonin], valproic acid [depakene], phenytoin [dilantin], carbamazepine [tegretol] for neuropathic pain

corticosteroids antiinflammatory; dexamethasone [decadron], prednisone [deltasone]

local anesthetics: Mexiletine [mexitil] antidysrhythmic for neuropathic pain; lidocaine [Xylocaine]

muscle relaxants: benzodiazepines for muscle spasms and anxiety; diazepam [Valium], lorazepam [Ativan], oxazepam [Serax]

289

meds to treat migraines

Ergot preparations
Ergotamine tartate (Ergostat)
Dihydroergotasmine mesylate (Migranal)
**Sumatriptan (Imitrex)
Antiseizure drugs
Beta-adrenergic blockers
Calcium channel blockers
Tricyclic antidepressants

290

meds to treat tension headaches

Analgesics – ASA, acetaminophen, or ibufrophen
Muscle relaxants- amitriptyline (Elavil)
Anti-depressants with counseling

291

When giving pre-op sedatives/hypnotics to elderly patients

monitor closely for confusion or excitement and initiate measures to prevent injury or fall

292


First IV agents will be given, act within seconds

Then once patient is unconscious, inhaled agents will be given to maintain anesthesia

Inhaled agents are gases (nitrous oxide) or volitile liquids--- prevent flow of sodium into neurons
Exact mechanism not known, likely that GABA receptors are activated
Not same mechanism of action as local anesthetics

293

agents administered to achieve balanced anesthesia

neuromuscular blockers
short-acting benzodiazepines
opioids
general anesthetics

294

IV meds first

promote relaxation, diminish pain, and promote sleep

295

Inhaled agents administered once IV agent has caused loss of consciousness

maintain anesthetized state

296

Malignant hyperthermia

triggered by all inhalation anesthetics except Nitrous oxide
characterized by muscle rigidity and profound elevation of temperature (109F)
risk is greatest when inhalation anesthesia is combined with succinylcholine, a neuromuscular blocker that can also trigger the reaction

297

Preanesthesia Agents
Benzodiazepines

Diazepam Valium
Midazolam Versed
Reduce anxiety, sedation, amnesia, “conscious sedation”

298

Preanesthesia Agents
Antihistamines

hydroxyzine [Vistaril]
sedation

299

Preanesthesia Agents
Opiod Analgesics

Morphine [Morphine]
Meperidine [Demerol]
Fentanyl [Sublimaze]
remifentanil [ultiva]
Sedation to reduce tension, anxiety, and to provide analgesia

300

Preanesthesia Agents
Phenothiazines

promethazine [phenergan]
Sedation, antihistaminic, antiemetic,decreased motor activity

301

Preanesthesia Agents
Anticholinergics

Atropine
glycopyrollate [robinul]
Inhibits secretions, bradycardia, vomiting, and laryngospasms


302

Preanesthesia Agents
GI Drugs

Ondansetron [Zofran]
Cimetidine [Tagamet]
metoclopramide [reglan]

Antiemetic
Decrease gastric acidity
Decrease stomach contents

303

Non anesthetic drugs nursing considerations

Physical assessment should include:
VS, reflexes, muscle tone and response, pupil size and reactivity, ECG, lung sounds, bowel sounds, affect and LOC

Monitor for:
HTN, tachycardia, prolonged apnea, bronchospasm, respiratory depression, paralysis, and hypersensitivity

If history is positive for hepatic or renal dysfunction, neuromuscular disease, fractures, myasthenia gravis, malignant hypertermia, glaucoma, or penetrating eye injury, the use of succinylcholine is contraindicated.

304

Propofol (Diprivan)

IV sedative-hypnotic used for induction and maintenance of anesthesia
Used to sedate patients undergoing mechanical ventilation or noninvasive procedures (endoscopy, radiation therapy, MRI)
Single injection onset 60 seconds and lasts 3-5 minutes; can be given low-dose continuous infusion
Adverse effects: respiratory depression, hypotension
Contains soybean oil, glycerin and egg lecithin (check for allergy); these are a great growth medium for bacteria- open and discard within 6 hours

305

Ketamine (Ketalar)

Causes sedation, immobility, analgesia and amnesia; responsiveness to pain is lost
Assessment-produces analgesia, amnesia and immobility, but not muscular relaxation
Increases secretions of the salivary and bronchial glands
During recovery, hallucinations, disturbing dreams and delirium may occur
Useful for young children* undergoing minor surgical and diagnostic procedures

306

anesthetics are usually combined with

EPI to decreaed systemic absorption and prolong the duration of action of the anesthetic and to promote local hemostasis.

caution used on end tissues (may cause tissue ischemia or necrosis) assess gag reflex if used in oral cavity

Use of vasoconstrictors, usually epinephrine, decreases local blood flow and delays systemic absorption and prolongs anesthesia and reduces risk of toxicity. If anesthesia absorption is slower, a lower dose can be used.

307

Local Anesthetics

Sodium Channel Blockers
Classifications:
Esters
Cocaine
procaine (Novocain)
Benzocaine (Solarcaine)
Amides
lidocaine

308

If area has localized infection or abscess, tissue environment will be acidic and effectiveness of agent will be decreased----

will add sodium hydroxide to neutralize environment

309

Amides

produce fewer side effects and usually have a longer duration of action

310

lidocaine (Xylocaine)

most commonly used amide for short surgical procedures

311

Ester-type anesthetics

(Cocaine, Novocain, Benzocaine) are metabolized in the blood by esterase enzymes.

312

Amide-type anesthetics (lidocaine)

are metabolized by enzymes in the liver.