Transcript Pharmacology Review II

Pharmacology Review II
Chapters 28 - 38
All Materials in this presentation come from:
Karch, A. (2008). Focus on: nursing pharmacology.
New York, NY: Lippincott Williams & Wilkins.
Sympathetic response
Eyes wide open
Breath hard
Heart pounds
Stress
Causes
Release of
Norepinephrine
Hormones
released
Sympathetic response
Alpha 1
receptors
Beta 1 receptors
Beta 2
receptors
Stress
Causes
Release of
Norepinephrine
(1 heart)
(2 lungs)
Alpha 2
receptors
Sympathetic response
Alpha 1 receptors
Beta
1
Receptors
Stress
Causes
Release of
Norepinephrine
Alpha 2 receptors
Beta
2
Receptors
Sympathetic response
Alpha 1 receptors
Dilate pupils
Close bladder spinchter
Vasoconstrict blood vessels
Beta 1 receptors
Increase heart rate
Breakdown fat for energy
Stress
Response
Alpha 2 receptors
Regulate norepinephrine
Moderate insulin release
Beta 2 receptors
Dilate bronchi
Breakdown glycogen
Relax uterine muscle
Sympathetic response
Alpha 1 receptors
Agonists “ine”
Blockers “zosin”
Stress
Beta 1 receptors
Blockers “olols”
Response
Alpha 2 receptors
Clonidine
Beta 2 receptors
Blockers “olols”
Parasympathetic Response
Acetylcholine
responses
Heart slows
Digestion starts
Bladder works
Eyes constrict
Bronchi constrict
Parasympathetic Response
Muscarinic Receptors
(Smooth muscle)
Pupils, bladder,
GI motility
Heart vessels
Nicotinic Receptors
NMJ
Muscle constractions
Heart Rate medications
• Too Low
• Too fast
Adrenergic Agonists
Adrenergic Blockers
•Epinephrine
•Amiodarone
•Dopmaine
•Bretylate
•Dobutamine
•Carvediol
Adrenergic Agonists - “ine”
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Ephedrine
Dopamine
Dobutamine
Aramine
Norepinephrine
Epinephrine
“ine” it to win it!
The race against time with shock
David Price
Case Study # 1
Adrenergic Agonists
• Your patient, 70 yr old diabetic,
suddenly goes into shock…..
• knowing that diabetes contributes to
nephropathy…
• You quickly tell the rapid response team
because they will want to use what?
Instead of epinephrine for him…….
Dopamine
Dopamine stimulates heart and blood
pressure
and
Increases blood flow to the kidneys to
prevent renal shutdown
Help me!
I need oxygen…
Case Study # 2
Adrenergic Blockers
• Daniel’s grandfather told him to start
taking saw palmetto for BPH.
• Daniel is not old enough to be worried
about BPH, but since he knows grandpa
is hypertensive and has CHF…
• He warns him about…..
Increased adrenergic efffects
Herbs, teas, and alternative medicines
(like saw palmetto) can cause serious
arrhythmias or blood pressure changes
Carvediol (Coreg) is used for
hypertension and CHF
Case Study # 3
Adrenergic Blockers
• Stephanie, a new nurse, forgot to take
Mrs. Jones’ HR before giving her her
morning dose of amiodarone. Now, her
heart rate is very low, 49 bpm…
• Why?
Adrenergic Blockers
• Amiodarone and carvedilol work to slow
the heart rate.
• Mrs. Jones’ may have had bradycardia
and it has become worse.
• Patients in shock, CHF or with asthma
should also avoid these drugs.
Alpha Adrenergic Blockers
• Doxazosin
• Alfuzosin
• Terazosin
• Tamulosin
• Prazosin
(Minipress)
That patient is not
“dozin”
on the floor!
Orthostatic hypotension
Is a side effect of
Prazosin (anti-hypertensive)
Case Study # 4
Adrenergic blockers
Speaking of prostrates and BPH,
• Which adrenergic blocker used to treat
hypertension is also effective in the
treatment of BPH?
Adrenergic Blockers - “zosins”
• Doxazosin (Cadura)1 - 8 mg PO/day
treats hypertension, BPH
• Tamsulosin (Flomax) BPH only
• lfuzosin (Uroxatral) BPH only
Have the PSA
level checked regularly
Beta Blockers
• Treat
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Inderal…
kick in
about now!!!
hypertension
Angina
Migraines
Reinfarction after MI
Syncope
Cardiac arrhythmias
Stage fright
These block the “fight or flight” response….
Beta Blockers - “olols”
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Carteolol
Nadolol - Corgrad
Penbutolol - Levator
Pindolol
Propranolol - Inderal
Sotalol - Betapace
Timolol
What’s all that
“lol” crap on
the cell phone.
I got all the “lols”
I need
For my hypertension
Beta Blockers
• Timolol*, also a beta blocker, is used to treat
glaucoma.
• Do not use if patient has bradycardia
Apply cotton ball
here to prevent
Systemic effect
*(Material in ATI prep)
Case Study # 5
Beta Blockers
Kasey’s mom has been taking Nadolol
(Corgard) to control her hypertension and
angina (she’s a nurse and it’s stressful).
The family went on a picnic to enjoy all the
spring flowers in Knoxville….
Now she’s in ER because
she can’t breathe…
what’s going on?
Beta blockers
Remember:
Beta 2 receptors dilate
the lungs
• Beta blockers inhibit
this response
Kasey’s mom’s lungs
were unable
to dilate with the inflammation
caused by the pollen
• Bronchospam, COPD,
Asthma, diabetes and
hypoglycemia are all
contraindicted
Beta 1 blockers
If you work in East Tennessee, get use to :
• Sectral (acebuterol)
• Zebeta (bisoprolol
• Lopressor (metropolol)
• Toprol
• Atenolol
for COPD, hypertension and seasonal rhinitis
Case Study # 6
Cholinergic agents
• Mrs. Brown had a bladder lift surgery
(urethral sling). She has high
expectations but right now she can’t
even pee….
• The doctor prescribes:
Urecholine (bethanechol).
• How will you monitor her progress?
Cholinergics
• Monitor her BP, ECG, urine output and
lung sounds
• These drugs stimulate the
parasympathetic system.
• Side effects include: increased
salivation, diarrhea, GI upset
Case Study # 7
Indirect acting cholinergics
If you have myasthenia gravis
and
become exposed to nerve gas…
Good News !
Why?
Pyridostigmine
• Pyridostigmine acts as an antidote.
• This drug allows Ach to accumulate in
the synaptic cleft to give patients some
control of muscles.
• Nerve gas causes paralysis as ACH
accumulates at the NMJ.
Prostigmin (neostigmine)
Another cholinergic for mysastenia gravis
that increases GI motility
Side effects:
Know this!
• urinary frequency
• Incontinence
(on ATI practice exam)
Case Study # 8
Alzheimer’s Disease
• Many older patients are now taking
Aricept (donepezil) for mild to moderate
Alzheimer’s.
• How would you counsel the caregiver of
a patient starting Aricept?
Aricept (donepezil)
• 5 -10 mg PO at bedtime
• Eat frequent small meals to offset
nausea, vomiting
• Side effects do include insomnia and
fatigue
• Increased risk of GI bleeding with
NSAIDs
Anticholinergics
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•
•
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Inhibit vagal responses in the heart
Relaxes the GI
Inhibits GI secretions
Causes mydriasis, cyclopegia
Treats parkinsonism
“Can’t see, can’t pee, can’t eat!”
Case Study # 9
Anticholinergics
• What are the contraindications?
• Think of any condition that could be
aggravated by blocking the
parasympathetic system…..
Anticholinergics
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Contraindications:
Glaucoma,
Paralytic ileus
Tachycardia
Myasthenia gravis
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Side effects:
Blurred vision
Pupil dilation
Weakness
Insomnia
Dry mouth
Constipation
Urine retention
example: Atropine
Dries you out like a desert..
Case Study # 10
Vasopressin
Case Study # 11
Glucocrticoids
• Laura hurt her knee running the minimarathon. Her doctor prescribed short term
treatment with prednisone and told her to
come back in two weeks to see if she needed
knee surgery….
• Should she go ahead and get her chicken
pox vaccine for nursing school while she’s
there?
Glucocoticoids and vaccines
• No! Laura!
• Glucocorticoids
block the immune
response and cause
a risk of infection to
live virus vaccines.
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Live Vaccines:
Measles
Mumps
Rubella
Polio
Varicella (chicken
pox)
Case Study # 12
Glucocorticoids
Pat goes from doctor to doctor. She has
no idea how long she’s been taking
prednisone for back pain. She’s had
hydrocortisone injections in both knees.
Now, Pat is taking prednisolone for her
asthma…besides gaining a ton of
weight…
what else is going on?
Glucocorticoids
Prolonged use causes risk of:
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Adrenal insufficiency (ACTH depleting)
Diabetes (glucose elevating)
Fluid retention (weight gaining)
Protein breakdown (muscle shrinking)
Immunosuppression (germs getting)
Osteoporesis (bone shrinking)
Case Study # 13
• What does Katy Perry (Pink) have in
common with the thyroid?
• Hint: “Your hot, then your cold,
up then your down!”
The thyroid regulates????
Thryoid function
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Thyroid hormones affect:
Heat production
Body temperature
Oxygen consumption
Cardiac output
Blood volume
Metabolism
Hey, don’t forget us!
The parafollicular cells
Reduce clacium resoprtion
Thyroid function
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Hypo
Most common
Women over 50
Elderly
Goiter, obesity,
lethargy, coarse
skin, thick tongue
Treat with
Levothyroxine (Synthroid)
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Hyper
Graves’ disease
Tachycardia
Palpitations
Intolerance to heat
Flushing
hypertension
Treat with PTU
(propylthiouracil)
Case Study # 14
• Joan has typical Graves’ disease symptoms:
puffy eyes, increased body temp., tachycardia
and hypertension.
• You tell her that PTU treatment will help her
attention span and focus* but she needs to
know……
(*this info from ATI material, not textbook)
Graves’ disease
• PTU causes an increased risk for
bleeding with oral anticoagulants
• Monitor serum levels of digoxin,
metoprolol, and propranolol as patient
heart rate returns to normal (euthyroid
state).
Case Study # 15
Antihypercalcemic agents
• Christine’s mom has been taking Fosamax
(Alendronate) for several weeks. She says, “I
know I need it for my bones, but it upsets my
stomach awful…”
• Christine finds out her mom has been taking
it with breakfast and then lays back down for
awhile…should she stop taking it?
Fosamax (alendronate)
Christine tells her mom:
For maximum effect with Fosamax,
Take it 30 minutes before breakfast and
remain upright at least 30 minutes.
Christine is going to order the newspaper
for her mom to read before breakfast.
Hyperglycemia
Blood sugar > 126 mg/dL
Can contribute to:
Atherosclerosis
Retinopathy
Neropathy
Nephropathy
Watch for:
Fruity breath
Fatigue
Irritation
Itchy skin
Dehydration
Kussmaul’s respirations
Hypoglycemia
• Blood Sugar < 40 mg/dL
Recognize these signs:
Headache
Blurred vision
Tachycardia
Hunger, nausea
Diaphoresis, cool clammy skin
Patient may appear drunk !
Case Study # 16
Antidiabetic agents
• Brittany’s aunt is diabetic. The doctor
has warned her to monitor her sugar
carefully. Her HBA1c was 9%.
• She has been stopping by Krispee
Kreme again. How can Brittany tell?
HbA1c
• Glycosylated hemoglobin levels
provides 3-month average of glucose
levels. No fasting is required.
• 6% indicates a pre-diabetic level
• Should be < 7%
Case Study # 15
Antidiabetic agents
• The nurse gave Mr. Greene 1 mg
glipizide before breakfast as usual. The
trays at the nursing home were delayed
because the chef was late to work. Mr.
Greene is shaky and in a cold sweat.
• What should be done?
Antidiabetics
• Give Mr. Greene 4 oz. of orange juice or
some form of 10-15 g of carbohydrate
• Then check his blood glucose level and vital
signs
• Patients on beta blockers may also have
hypoglycemic and hyperglycemic episodes
but warning signs are blocked
Case Study # 16
Antidiabetic
• Michelle is a high school sophomore
with Type I diabetes.
Breakfast
• She has had several recent
hypoglycemic episodes.
• You, the school nurse, meet with
Michelle to ask her how often she is
checking her blood glucose level…
• How often should she check it?
Type I Diabetes
• Michelle needs to be checking her blood
glucose level 3 -5 times per day.