Pharmacology Review III

Chp. 39 - 59

Renal failure

• Acute– Decreased oxygen to kidneys, R-A-A fails– Oliguria <400 ml/day– Wastes accumulate, electrolyte imbalance– Anemia (no erythropoetin produced)– Creatinine, BUN increase– Measure GFR (glomerular filtration rate)

• Chronic– Diabetes most common cause– Polycystic kidney disease– Aspirin, NSAIDs, cocaine toxicity

Case StudyDrugs treating Anemias

• Carl comes into your clinic three times a week for epoetin alfa…

• He mentions some chest pain.

• What type of assessments will you perform on him?

My Hct is improved,But…..

Epoetin alfa, Procrit

• Epoetin alfa will increase the number of RBC (it’s suppose to!)

• Hypertension, Edema and chest pain

• Weakness, dizziness, and seizures are also possible

Increased RBCs = Increased Vascular Presure

Diuretics

• Commonly used for hypertension

• Treat edema related to:– CHF– Acute Pulmonary

Edema– Liver disease– Renal disease

• Contraindications– Lupus– Diabetes– Liver disease– Gout

Case StudyDiuretics

• Granny Starbucks is taking Lasix to treat CHF.

• She loves coffee, but it makes her pee.

• Now, granny won’t drink more than a few sips of anything, because she doesn’t want to become incontinent.

• What’s your advice?

Granny and Lasix

• Explain to granny:– Take Lasix in the morning, so she won’t

have nocturia– Continue to drink fluids to prevent “fluid

rebound”, more edema (because of R-A-A)Worse things can happen,

Granny!Pulmonary EdemaIs life threateningWhen fluid backs up into the lungs.

Granny and Lasix

• The rapid loss of fluid can cause

Hypotension and dizziness

So Granny is also at risk for falls……

Diuretics

• Diuretics increase sodium excretion, as well as water excretion from kidneys…

• Loss of fluid volume can cause: – electrolyte imbalance– Hypotension– Hypoglycemia– metabolic alkalosis

Monitor Potassium levels

Case StudyDiuretics

A bipolar patient on 100 mg PO/day of hydrochlorothiazide complains of weakness, muscle cramps, and pain in his big toe…

What type of tests need to be done?

Hydrochlorothiazide

• Check Potassium level for hypokalemia

• Check Uric acid levels for gout

• Check lithium levels for toxicity if patient taking lithium for bipolar disorder

Digoxin levels and Antidiabetic drugs levelsMay also be affected

Case StudyFuosemide

• Granny Starbucks calls back to talk to the nurse….

• Now, she has bloody gums when she brushes her teeth.

• Did you ask granny if she was also on coumadin?

Furosemide and Anti-coagulants

• Increased risk of bleeding

• Take a moment and warn granny to avoid aspirin and ginko biloba with coumadin as well. These also increase anticoagulation.

Case StudyPotassium -sparing diuretics

• Granny Strabucks’ doctor changes her order to 100 mg/day Aldactone.

• Granny’s daughter calls to say that granny is suddenly very confused since her lunch of spinach salad.

• Is it a sudden case of Alzheimers’ or since she quit taking ginkgo biloba?

Hyperkalemia

• Alzheimers’ is a gradual loss of cognitive ability

• Most common side effect of potassium sparing diuretics is hyperkalemia

• Lethargy, confusion, muscle cramps, ataxia (inability to control muscles)

• Granny needs to go to ER because of a risk for cardiac arrhythmias as well

Case StudyOsmotic Diuretics

• A young man comes into ER having had a motorcycle crash. He receives mannitol 2 g/kg IV to relieve intracranial pressure.

• He is admitted and the CNA tells you the patient is urinating so much the catheter bag has been emptied twice this shift. What will you say?

Osmotic Diuretics

• Inform the CNA that diuresis is expected.

• Monitor the patient’s electrolytes closelySodium (Na+) 135-145 mEq/L

Potassium (K+) 3.5-5.0 mEq13/LCalcium (Ca++) 4.5-5.5 mg/dlBicarbonate (HCO3-) 22-26 mEq/LChloride (CL-) 95-105 mEq/L)Magnesium (Mg++) 1.5-2.5 mEq/L

Phosphate (Po4-- ) 2.8-4.5 mg/dl

Loop of Henle

• Thiazides work at the distal tubule

• Carbonic anhydrase inhibitors work at the proximal end of tubule - increase acid

• Loop diuretics block the chloride pump where 30% of sodium is usually reabsorbed

• Osmotic diuretics do not lose sodium

Case StudyLoop Diuretics

• How much fluid can be lost per day?

• 20 lbs.

• It may take several hours to relieve acute plumonary edema.

Case StudyUrinary Tract Analgesic

• The poor patient from the motorcycle crash is out of ICU, but is complaining of extreme pain from that catheter.

• The doctor prescribed: Pyridium 200 mg PO tid• The same CNA tells you the patient has

blood in his urine. What do you say?

Pyridium

• Tell the CNA reddish, orange urine is a side effect of pyridium

• Monitor for GI upset, headache and rash

• Use pyridium for only 2 days

Have you thanked your

Nursing AssistantToday?

Case Study Bladder Protectant

What do coumadin

And

Pentosan polysufate sodium (Elmiron)

For interstitial cystitis

have in common?

Pentosan polysufate sodium

Both have anti-coagulant action

And

involve increased risk of bleeding

Especially with NSAIDs

Upper Respiratory System

• Nose

• Mouth pharynx

• Larynx

• Trachea

• Bronchial tree

Move that mucous

Goblet cells - trap dust,pollen,bacteria

Respiration

The medulla increases the rate and depth of respiration based on input from chemoreceptors sensitive to what?

Respiration

Carbon dioxide levels

And acid levels regulate our breathing, not oxygen levels

Inflammation from

pneumonia causing

viruses or bacteria

decrease the gas exchange

Cough Medicines

HydrocodoneActs on

Medullaary cough center

Benzonatate(Tessalon)

BlocksEffectiveness of coughreceptors

Atitussives(Suppress cough)

Mucolytics(Mucomyst)

Break up mucous

Expectorants(Guaifensin)

Mucinex

For relief of dry,non-productivecough

Antitussives

• True or False:

• Antitussives can be used as long as the patient has a productive cough

Antitussives

• Cough suppression can cause

accumulation of secretions

• Traditional antitussives like hydrocodone are potentially addictive (narcotics)

False-Patient should seek

medical evaluation after 1 week.

Case StudyMucolytics

• Rachel is going to perform postural drainage on a patient with thick mucous secretions and atelectasis in the left lung.

• She knows it will help to administer a bronchodilator or nebulizer treatment

30-60 mins. Before the procedure…

She chooses a mucolytic----

Pulmozyme

• Rachel uses dornase alfa (Pulmozyme)

• Because it will break up the mucous

Pulmozyme is also used for:

-cystic fibrosis

-tracheotomiesElmo

With a trach

Nasal Spray

• Causes vasoconstriction to shrink swollen membranes, opens clogged nasal passages

Blow nose firstCover one nostrilTilt head back

Do not squeeze forcefully,Might send drug into

sinuses

Nasal Sprays

Rebound Congestion (rhinitis medicamentosa)

All May cause localized burning, stinging

Afrin, Allerest, Pretz-D

Beclovent, Pulmicort, Decadron, Azmcort, AeroBid

Topical Nasal

Decongestants

Topical Nasal

Steroid

Decongestants

• Asthma

• Emphysema

• COPD

Respiratory Distress

Syndrome

PumonaryObstructiveDiseases

Obstruction Of

Alveoli

Case StudyOral Decongestants

• Now that you’re a nurse, your friends all want free medical advice…like your neighbor who’s little girl has a stuffy nose and an earache.

What can you recommendfor relief of the pain andcongestion of otitis media?

Oral Decongestants

• Pseudoephedrine (Sudafed, Decofed)

Adult 60 mg PO q4-6 hr

Pediatric:• 2-5 yrs 15 mg PO q4h-6h• 6-12 yrs 30 mg PO q4h-6h

Monitor blood pressure, pulse and auscultations for cardiac stimulation

Case StudyDecongestants

• Available OTC, safe for everyone right?

• Which of the following patients should NOT use Sudafed?– 55 yr old women with hypothyroid– 35 yr old with diabetes type I– 75 yr old with BPH– 66 yr old who jogs daily but has hypertension

Pseudoephedrine

• None of these patients should take it!

• Also any patient with glaucoma,or coronary disease

Used for nasal congestionfrom common cold,

allergic rhinitisAnd cookin’ up meth

And you thought OTC medicines were safe……..

Antihistamines like Allegra, Benadryl and Claritin can cause

heart arrhythmias, GI upset, drowsiness

and

cross the placenta in pregnancy

Case StudyTheophylline

• Steffan, a smoker, who has had asthma for years takes:

Theo-Dur 400 mg/day PO.• He was recently laid off and has been home

chain smoking because of the stress.He comes to ER, can’t breathe and

his heart is actin’ crazy. • His wife states, “he has been so irritable, you all

can just deal with him, I’m going home!”• What will you explain to her?

Nicotine and Theophylline

• Steffan has increased the level of nicotine in his system

• Nicotine breaks down theophylline

• He no longer has the therapeutic level of theophylline to manage his asthma

• Irritability is an expected side effect

He may have a dangerousheart arrhythmia

Bronchodilators

• Adults• (Prophylactic)

– Albuterol– Tormalate– Foradil– Isoetharine– Xopenex

• Children < 12 yr– Albuterol– Alupent– Isuprel– Serevent

• Acute only– Ephedrine

How to get the most out of your asthma meds….

• Use the least possible amount

• Use 30-60 mins. before exercise

• Provide small, frequent meals

• Know warning signs

• Monitor pulse, BP,

and GI upset

Yeah! I used My

Inhaler30 mins. ago

Lung Surfactants

• Survanta (beractant)

• Insafur (calfactant

• Curosurf (poractant)

For babies weighing less than 1350gAt risk for RDS

Effects of hypotension,pneumothorax,

Patent ductus arteriosus, Increased bilirubin

And sepsis

Mast Cell Stabilizers

• Intal (cromolyn)

• Tilade (nedocromil)

Blocks histamine from mast cells esp.

For exercise-induced asthma - ok for kids > 2 years

Blocks eosinophils, neutrophils, macrophages AND mast cells

Use with corticosteroids, only for those over 12 years old

Cromolyn

• Cannot be used during an acute asthma attack

• Asthmatic children taking this drug should not be in a smoke-filled environment

Come on in!

Can’t, I’m on Cromolyn!