Prairie View A&M University NURS3013 ATI notes (complete 100% updated 2026/2027).

Prairie View A&M University NURS3013 ATI notes (complete 100% updated 2026/2027). FUNDAMENTALS 1. Lab values a. Sodium 135-145 mEq/L b. Potassium 3.5-5.0 mEq/L c. Total Calcium 9.0-10.5 mg/dL d. Magnesium 1.3-2.1 mg/dL e. Phosphorus 3.0 –4.5 mg/dL f. BUN 10-20 mg/dL g. Creatinine 0.6b – 1.2mg/dL M, 0.5 – 1.1 F * h. Glucose 70 -110 mg/dL i. HbA1c 6.5% j. AST 0-35 units/L k. ALT 4-36 units/L l. Albumin m. Total cholesterol 200 mg/dL n. HDL: Male 45 mg/dL, women 55 mg/dL o. LDL 130 mg/dL p. WBC 5,000-10,000/mm3 q. RBC: Male 4.7-6.1, Female 4.2-5.4 r. Hemoglobin: Male 14-18, Female 12-16 s. Hematocrit: Male 42-52%, Female 37-47% t. Platelet 150,000-400,000/mm3 u. pH 7.35-7.45 v. pC02 35 to 45 mm Hg w. HCO3 21-28 mmol/L x. p02 80-100 mmHg y. Normal PT = 11-12.5 sec, Normal INR = 0.7-1.8 (Therapeutic INR 2-3) i. Normal PT = 11-12.5 ii. PT on Coumadin should be 2-3x higher iii. INR of 3.9 means it is 3.9x higher than normal person z. Normal PTT = 30-40 sec (Therapeutic PTT 1.5 – 2 x normal or control values) i. PTT on heparin should be 1.5-2 x higher aa. Digoxin 0.5 to 2.0ng/mL bb. Lithium 0.8 to 1.4 mEq/L cc. Dilantin 10-20 mcg/mL dd. Theophylline 10 to 20 mcg/mL ee. The normal range of Kidney Glomerular Filtration Rate is 100 to 130 mL/min/1.73m2 in men and 90 to 120mL/min/1.73m2 in women below the age of 40. GFR decreases progressively after the age of 40 years. 2. Latex allergies a. Note that clients allergic to bananas, apricots, cherries, grapes, kiwis, passion fruit, avocados, chestnuts, tomatoes, and/or peaches may experience latex allergies as well 13. Order of assessment → Inspection, palpation, percussion, auscultation a. Except with abdomen it is IAPP-inspect, auscultate, percuss and palpate. 4. Cane walking → COAL (Cane, Opposite, Affected, Leg) 5. Crutch walking → Remember the phase “step up” when picturing a person going up stairs with crutches. The good leg goes up first followed by the crutches and the bad leg. The opposite happens going down the stairs….OR “up to heaven…down to hell” 6. 3 point gait → Allows pt to be mobile without bearing weight on affected extremity a. Used when pt is non-weight bearing on a leg 7. Delegation → RNs DO NOT delegate what they can EAT (Evaluate, Assess, Teach) a. A nursing assistant can perform tasks such as taking vital signs, range of motion exercises, bathing, bed making, obtaining urine specimens, enemas and blood glucose monitoring. Nursing assistants cannot interpret results or perform any task beyond the skill level of the certification they received. i. Performing gastrostomy feeding thru an established gastrostomy tube b. The PN is managed under the supervision of the RN. Certain higher level skills can be delegated after competency has been established by the RN (e.g., dressing changes or suctioning). 8. Medical asepsis is “clean technique” and surgical asepsis is sterile technique 9. Isolation Precautions a. b. ***AIRBORNE → “My chicken hez TB” i. Measles, chicken, TB ii. Management → Neg pressure room, private room, mask, n95 for TB c. DROPLET → SPIDERMAn i. Sepsis, scarlet fever, strep, pertussis, pneumonia, parvovirus, influenza, diphtheria, epiglottitis, rubella, mumps, adenovirus ii. Management → private room, mask d. CONTACT → MRS WEE i. MRSA, VRSA, RSV, skin infection (herpes zoster, cutaneous diphtheria, impetigo, pediculosis, scabies, and staphylococcus), wound infections, enteric infection (C diff), eye infections (conjunctivitis) ii. Management → gown, gloves, goggles, private room 10. Venturi mask (4-10L/min) is the most precise O2 delivery. Best for pt w/ chronic lung disease (i.e. COPD) 11. Aerosol mask/Face tent good for pt w/ facial trauma or burns 12. Dysphagia is difficulty swallowing; Dysphasia is difficulty speaking a. Dysphagia → Aspiration precautions; Avoid thin liquids and sticky food and provide oral care prior to eating (helps to enhance taste of food) 13. Home oxygen education → Avoid synthetic or wool fabrics (encourage wearing cotton) a. Educate to apply a water-soluble lubricant to soothe irritation of the mucous membranes 14. Incentive Spirometer use → Instruct pt to keep a tight mouth seal around mouthpiece and to inhale and hold breath for 3-5 secs 15. Restraints → Assess and document pt physical needs, safety and comfort q 15-30 mins a. Renew of prescription → Adults - q4h, 9-17 y/o - q2h, under 9 y/o - q1h b. Staff member must remain continuously w/ pt or view the pt via camera 16. Trendelenburg position (legs in the air) → Used to promote venous circulation 17. Arterial disorder → Place legs in a dependent position) a. If its Arterial you dAngle 18. Venous disorder → Elevate legs a. Make a v with your 2 fingers (the 2 fingers being the legs) to help remember care for pt with arterial vs venous disorder b. If its Venous you eleVate 2PHARMACOLOGY ANTAGONISTS Agonists → Drugs that allow the body’s neurotransmitters, hormones, and other regulators to perform the jobs they are supposed to perform (i.e. Morphine sulfate is an opioid agonist that works on mu receptor) Antagonists → Prevent the body from performing a function that it would normally perform (i.e. Narcan) ● I.e. Narcan ANTIDOTES 1. Muscarinic agonists, cholinesterase inhibitors → Bethanechol, Neostigmine a. Atropine 2. Anticholinergic drugs (Atropine) → Physostigmine 3. Digoxin, digitoxin → Digibind 4. Warfarin (Coumadin) → Vitamin K 5. Heparin → Protamine sulfate 6. Insulin-induced hypoglycemia → Glucagon 7. Acetaminophen (Tylenol) → Acetylcysteine ELECTROLYTE REPLACEMENTS ELECTROLYTE INFORMATION REGARDING SUPPLEMENTS Sodium → 135-145 mEq/L ● Major electrolyte in extracellular fluid Administer isotonic IV therapy of 0.9% normal saline or Ringer’s lactate Hyponatremia → ↑HR, ↓BP, confusion, fatigue, N/V, headache Hypernatremia → ↑HR, muscle twitching/weakness, GI upset Potassium → 3.5-5.0 mEq/L ● Essential for maintaining electrical excitability of muscle, conduction of nerve impulses, and regulation of acid/base balance *Kayexalate for hyperK ● Potassium chloride (K-Dur) ● Oral or IV administration ● NEVER give IV push to avoid fatal hyperkalemia ● Dilute potassium and give no more than 40 mEq/L per IV to prevent irritation of vein ● Administer no faster than 10 mEq/L per IV ● Concurrent use with potassium-sparing diuretics or ACE inhibitors can cause hyperkalemia Hypokalemia → Dysrhythmias, muscle weakness/cramps, constipation/ileus, hypotension, weak pulse Hyperkalemia → dysrhythmias, muscle weakness, numbness/tingling, diarrhea Calcium → 9.0-10.5 mEq/L ● Essential for normal musculoskeletal, neurological, and cardiovascular function ● Calcium citrate (Citracal) ● Calcium carbonate or calcium acetate ● Implement seizure precautions during administration and have emergency equipment on hand 3Hypocalcemia → +Chvostek’s & Trousseau’s signs, muscle spasms, numbness/tingling in lips/fingers, GI upset, ↓BP, ↓HR Hypercalcemia → ↓ DTR, kidney stones, lethargy, constipation Magnesium → 1.3-2.1 mEq/L ● Regulates skeletal muscle contraction and blood coagulation ● Magnesium sulfate ● Magnesium gluconate or magnesium hydroxide ● Monitor BP, pulse and respirations with IV administration ● Decreased/absent deep tendon reflexes indicates toxicity ● Have injectable calcium gluconate on hand to counteract toxicity when giving magnesium sulfate via IV Hypomagnesemia → Hyperactive DTR, tetany, seizures, constipation/ileus Hypermagnesemia → ↓BP, muscle weakness, lethargy, respiratory/cardiac arrest Bicarbonate → 7.35-7.45 ● Maintains blood pH to prevent metabolic acidosis ● Sodium bicarbonate ● Given orally as an antacid or via IV ● Numerous incompatibilities with IV form ANXIETY MEDICATIONS 1. Benzodiazepines - Alprazolam (xanax) → antidote is flumazenil 2. Atypical anxiolytics - Buspirone (BuSpar) → Used for anxiety, panic disorder, OCD, PTSD a. S/E include dizziness, nausea (take w/ meals to decrease), headache b. NO SEDATION. Dependency is not likely so long-term use is ok. Full effect not felt for several weeks ANXIETY AND DEPRESSION MEDICATIONS 1. SSRIs (selective serotonin reuptake inhibitors) - inhibits serotonin reuptake (↑ serotonin) a. Citalopram (Celexa), Sertraline (Zoloft), Fluoxetine (Prozac), Paroxetine (Paxil) i. End in “ine” so think of how it's stressful to have a teen in the house - these meds are used for anxiety and depression b. Pt education → Avoid St. John's wort. Ensure a healthy diet c. S/E include insomnia (paroxetine), nausea, fatigue, sexual dysfunction, wt gain d. Watch for serotonin syndrome!! S/S → agitation, hallucinations, fever, diaphoresis, tremors e. Full effects not felt for up to a month DEPRESSION MEDICATIONS 1. Atypical antidepressants → Bupropion (Wellbutrin), Trazodone a. Used for depression and as an aid to quit smoking (be APPROPRIATE and don’t smoke) b. Common S/E - appetite suppression, wt loss, GI distress, agitation, seizure, headache c. Headache and dry mouth may be severe and pt should notify provider if this occurs d. Avoid use in pt w/ seizure disorders 2. TCAs (Tricyclic Antidepressants) → Amitriptyline (Elavil) a. AMY TRIPPED OVER A TRICYCLE IN THE DESERT (amitriptyline is a tricyclic antidepressant) i. In the desert → main S/E are anticholinergic (everything dries up) 1. Urinary retention, constipation, dry mouth, blur vision, photophobia, tachycardia - MOST SERIOUS IS URINARY RETENTION b. S/E include sedation, sweating, seizures (all start with S) 4c. Indication - depression, neuropathy, fibromyalgia, anxiety, insomnia d. Watch for Anticholinergic effects and orthostatic hypotension 3. MAOIs (Monoamine Oxidase Inhibitors) → Phenelzine (Nardil) - used for depression a. AVOID TYRAMINE FOOD INGESTION - may cause hypertensive crisis i. Aged cheese, cheeseburgers, avocados, bananas, red wine, salami/pepperoni, chocolate 1. Remember “MAOIs are a feen for aged cheese, avocadoes, etc) b. Interact with a bunch of drugs (if it’s a choice, probably correct) c. S/E include agitation/anxiety, orthostatic hypotension, hTN crisis 4. Serotonin-norepinephrine reuptake inhibitors (SNRIs) → Venlafaxine (Effexor), Duloxentine a. Adverse effects include nausea, wt gain, and sexual dysfunction BIPOLAR MEDICATIONS 1. Mood stabilizers - Lithium - indicated for bipolar disorder (KURT COBAIN 1.5) a. S/E include GI upset, fine hand tremors, polyuria, wt gain, kidney toxicity, electrolyte imbalance b. LITHIUM TOXICITY is 1.5 mEq/L and above i. Sx → Coarse tremors, confusion, hypotension, seizures, tinnitus b. Fine hand tremors is expected, coarse hand tremors is sign of toxicity c. Avoid diuretics, anticholinergics, or NSAIDs (hard on kidneys) d. Adequate fluid and sodium intake!!! 5. Antiepileptics - Carbamazepine (Tegretol), Valproic acid (Depakote) a. Used for bipolar disorder AND as an anticonvulsant/AED b. Carbamazepine S/E - blood dyscrasias (anemia, leukopenia, thrombocytopenia -monitor CBC), vision issues (nystagmus, double vision), hypo-osmolarity, rash c. Valproic acid S/E - HEPATOTOXICITY, pancreatitis, thrombocytopenia, GI upset OPIOID AND NICOTINE WITHDRAWAL MEDICATIONS 1. Opioid withdrawal → methadone (used for withdrawal and long-term maintenance 2. Nicotine withdrawal → Bupropion (Wellbutrin) which is also an atypical antidepressant a. Bupropion - remember be appropriate and don’t smoke 3. Nicotine replacements include gum, patch, and nasal spray 4. Varenicline (Chantix) reduces cravings and withdrawal symptoms. Monitor for suicide and depression ANTIPSYCHOTIC MEDICATIONS Schizophrenia has both positive and negative symptoms ● POSITIVE symptoms - weren’t there before dx (agitation, delusions, hallucinations) ● NEGATIVE - taken away from the pt (social withdrawal, lack of emotion, lack of energy, flatten affect) ● Conventional antipsychotics (1st generation) control positive symptoms ● Atypical controls positive and negative symptoms ● IM injections may be administered for non-compliant p was ts. Conventional q 2-4 w, atypical q2wk 1. Conventional (1st generation) - Chlorpromazine (Thorazine), haloperidol (Haldol) a. Indications → Schizophrenia, psychotic disorders b. Extrapyramidal (EPS)→ dystonia, Parkinson’s symp, akathisia, tardive dyskinesia) i. Drooling, tremors, rigidity, unable to stand still, involuntary movement of face/tongue ii. May take anticholinergics to control EPS c. Neuroleptic malignant syndrome (NMS) → Fever, dysrhythmias, muscle rigidity 2. Atypical - Risperidone (Risperdal), clozapine (many end in -done or -pine) 5a. S/E → DM, wt gain, increased cholesterol (all kind of go together), orthostatic hypotension, anticholinergic effects b. Nursing considerations → Initiate fall precautions, monitor CBC and liver function ALCOHOL ABUSE MEDICATIONS Alcohol withdrawal: Starts within 4-12 hrs of last drink, peaks at 24-48hrs 1. Meds during withdrawal a. During withdrawal → Goal is to stable VS (↓BP, HR, RR) and prevent seizures b. Meds to decrease BP, HR, RR - benzos (chlordiazepoxide, diazepam, lorazepam), antihypertensives (clonidine, propranolol) c. Meds to prevent seizures → AED (carbamazepine) 2. Meds to promote abstinence a. Disulfiram (Antabuse) → if pt ingests etoh, they will get many unpleasant S/E including N/V, sweating, palpitations, and hypotension b. Naltrexone (Vivitrol) → suppresses craving for etoh (available in monthly IM injections) c. Acamprosate (Campral) → ↓ abstinence symptoms (anxiety, restlessness) NERVOUS SYSTEM MEDICATIONS 1. Cholinergics → Neostigmine (Prostigmin), Pyridostigmine, Edrophonium zx a. Indicated for myasthenia gravis (works to ↑ Ach at receptor sites by inhibiting cholinesterase) i. Remember that cholinesterase breaks down Ach (acetylcholine) 1. STIG is a race car driver pulling up and stopping cholinesterase, which ↑ Ach b. S/E include excess Ach (remember anticholinergics are dry. Cholinergics are really wet) i. Increased salivation, N/V/D, sweating, bradycardia c. Antidote is atropine d. Administration → 45-60 mins before meals to prevent aspiration 2. Dopamine Agonist - Levodopa/Carbidopa (Sinemet) S/E → N/V, drowsiness, dyskinesias (tics), orthostatic hypotension, darkening of urine and sweat, psychosis a. Eat less protein (high protein meals decrease the effectiveness of med) 3. Anticholinergic agent - Benztropine (Cogentin) → indicated w/ parkinson’s a. MOA is to decrease Ach in CNS → S/E include anticholinergic effects 4. Antiepileptics → Phenytoin (Dilantin) a. S/E - gingival hyperplasia, diplopia, nystagmus, rash, ataxia, hypotension b. Pt educaton → routine blood draws, and Decreases effectiveness of oral contraceptives 5. Antiglaucoma agent (Topical beta blocker) → Timolol a. Indicated for glaucoma (primarily open angle). Works by decreasing IOP 6. Antiglaucoma agent (Carbonic anhydrase inhibitor) → Acetazolamide (Diamox sequels) a. Indicated for glaucoma, HF, altitude sickness b. MOA - causes diuresis and lowers IOP. S/E include flulike symptoms, GI upset, electrolyte imbalance (Na and K) so need to monitor Na and K values 7. Ear drops to treat otitis externa → Ciprofloxacin with Hydrocortisone (Cipro HC) a. Roll container gently prior to admin (or gently shake suspension), keep on side for 5 mins after i. Lightly pack ear w/ cotton 8. Neuromuscular Blocking Agent → Succinylcholine, Pancuronium (both are trouble makers) a. MOA → blocks Ach, causing skeletal muscle paralysis i. Succ is like suck it you're never gonna get to these Ach receptors ii. Pancur helps out and puts a pan over the Ach receptors to block them b. Used as an adjunct to anesthesia in surgery or intubation procedures 6c. S/E include respiratory arrest, apnea, muscle pain after surgery (common) d. Monitor for malignant hyperthermia → sx are fever and muscle rigidity i. Tx → admin 100% O2, cooling measures, admin dantrolene (skeletal muscle relaxant) 9. Muscle relaxants → Dantrolene (dantrium) - monitor for hepatotoxicity 10. Baclofen → enhances GABA in CNS (watch for drowsiness) 11. Urinary Tract stimulant → Bethanechol (“Remember that Beth has a bad bladder”) a. Used for non-obstructive urinary retention. Works by stimulating cholinergic receptors in GU tract b. S/E → cholinergic symptoms (flushing, sweating, urinary urgency, bradycardia, hypotension) c. Admin 1 hr before or 2 hr after meals to minimize N/V 12. Urinary Tract Antispasmodic → Oxybutynin (MOA → inhibits Ach in the bladder) a. Indication → Overactive bladder symptoms (frequency, urgency, nocturia) b. S/E → anticholinergic symptoms 13. Insomnia medication → Zolpidem (Ambien). Allow at least 8 hrs of sleep 14. Sedative/Hypnotic → Pentobarbital, Propofol, Midazolam a. Indication → induction and maintenance of anesthesia, conscious sedation, intubation b. Propofol S/E → pain at IV site, high risk of bacterial contamination BRONCHODILATORS Bronchodilators are used to treat the symptoms of asthma that result from inflammation of the bronchial passages, but THEY DO NOT TREAT THE INFLAMMATION. Therefore, most pt with asthma take an inhaled glucocorticoid concurrently to provide the best outcomes → 2 most common classes of bronchodilators are beta2-adrenergic agonists and methylxanthines 1. Beta 2 Adrenergic Agonists → Albuterol (short-acting), Salmeterol (Long-acting) a. Albuterol for ACUTE EPISODES!!! Like an asthma exacerbation b. Salmeterol for long-term control of asthma symptoms c. Albuterol S/E → tachycardia, angina, tremors (instruct pt to report chest pain, change in HR) d. Oral preparations can cause angina pectoris or tachydysrhythmias w/ excessive use e. Take beta 2 adrenergic agonist - wait 5 mins - take glucocorticoid f. Metered-dose inhalers → Wait at least 1 min between inhalations, clean the mouthpiece everyday w/ warm water and soap 2. Methylxanthines → Theophylline (used for long-term control of chronic asthma) a. Theo - think you may see God soon if you take it (S/E include fatal dysrhythmias, seizures) b. Nursing interventions → Monitor serum levels for toxicity (20 mcg/mL) i. Mild toxicity - GI distress and restlessness, mod-severe toxicity - dysrhythmias, seizures c. Increased serum levels w/ caffeine, cimetidine (Tagamet), and ciprofloxacin (Cipro) d. Decreased serum levels w/ Phenobarbital and Phenytoin RESPIRATORY MEDICATIONS: AIRFLOW DISORDERS 1. Inhaled Anticholinergic → Ipratropium a. MOA → Blocks Ach my in no b. receptors in airway, causing bronchodilation, S/E → dry mouth, hoarseness c. Pt education → increase fluids, suck on sugar-free candy 2. Inhaled Glucocorticoids → Beclomethasone a. Indication → asthma (may be used alone or in combo with a beta 2 adrenergic agonist) b. S/E → hoarseness, candidiasis (RINSE MOUTH WITH WATER AFTER ADMIN) 3. Oral Glucocorticoid → Prednisone a. S/E → bone loss, weight gain/fluid retention, hyperglycemia, hypokalemia, infection, muscle weakness, PUD, adrenal gland suppression b. Periods of stress may require additional doses, do not stop suddenly, avoid NSAIDs 74. Leukotriene Modifier → Montelukast, Zafirlukast a. Think lukast reduces effect of leukotrienes, which ↓ airway inflammation and bronchoconstriction b. Indications → asthama and prevention of exercise-induced bronchoconstriction c. Zafirlukast S/E → increase in liver enzymes (be sure to monitor LFTs) d. Pt education → take montelukast in evening or 2hr b4 exercise, avoid taking zafirlukast w/ food RESPIRATORY MEDICATIONS: UPPER RESPIRATORY DISORDERS 1. Antitussives: Opioids → Codeine a. Indications → nonproductive cough (MOA is to decrease cough reflex) b. S/E → sedation, respiratory depression, constipation, GI upset, dependency c. Pt education → change position slowly, avoid etoh, ↑ fiber and fluid 2. Expectorants → Guaifenesin (Mucinex) a. Indications → nonproductive cough associated w/ respiratory infection b. MOA → reduces viscosity of secretions (thins secretions), making cough more productive c. Pt education → increase fluid intake to help liquefy secretions 3. Mucolytics → Acetylcysteine a. Indications → pulmonary disorders w/ thick mucous secretions (i.e. CF) b. Antidote for acetaminophen poisoning (think acetylcysteine is for acetaminophen poisoning) c. MOA → improves flow of secretions in respiratory tract d. S/E → N/V, rash, bronchospasm (use caution w/ asthmatics) e. Medication can smell like rotten eggs (expected finding) 4. Decongestants → Phenylephrine, Pseudoephedrine a. Indications → rhinitis (nasal congestion), MOA → vasoconstriction of resp tract mucosa b. S/E → agitation, nervousness, palpitations c. May cause rebound congestion from prolonged use (educate to limit use to 3 to 5 days) 5. Antihistamines → Diphenhydramine (1st gen), Loratadine (2nd gen) a. Indications → nasal congestion, mild allergic reactions, motion sickness b. Diphenhydramine S/E → sedation, anticholinergic effects 6. Nasal Glucocorticoids → Mometasone, fluticasone, budesonide (many end in -one) a. Indications → rhinitis (nasal congestion) b. S/E → headache, nasal burning, pharyngitis (sore throat) MEDICATIONS AFFECTING URINARY OUTPUT 1. Loop Diuretics → Furosemide (Lasix) a. Indications → pulmonary edema, edema (RT HF, liver or kidney disease), HTN b. MOA → Blocks reabsorption of Na, Cl, and water (furosemide - think furious diuresis) c. S/E → dehydration, electrolyte imbalances (hypokalemia, hyponatremia), hypotension, ototoxicity, hyperglycemia d. Nursing interventions → infuse IV at 20 mg/min, weigh daily, I&O, monitor electrolytes e. Pt education → consume foods high in potassium (potatoes, bananas, dried fruits, nuts) 2. Thiazide Diuretics → Hydrochlorothiazide a. Indications → HTN, edema (RT HF, liver or kidney disease) b. S/E → dehydration, hypokalemia, hyperglycemia c. Nursing interventions → weigh daily, I&O, monitor electrolytes, encourage foods high in K 3. Potassium Sparing Diuretics → Spironolactone a. Indications → HF, HTN; CONTRAINDICATED W/ SEVERE KIDNEY FAILURE b. MOA → blocks aldosterone, promoting excretion of Na and water, but retention of Potassium c. S/E → HYPERKALEMIA, amenorrhea, gynecomastia, impotence d. Pt education → avoid salt substitutes containing potassium 4. Osmotic Diuretics → Mannitol a. Indications → edema, ↑ ICP, ↑ IOP (Man I had a bad headache bc i had ↑ ICP but man it all went away when I took mannitol) 8b. S/E → HF, pulmonary edema, renal failure, dehydration, electrolyte imbalances (Na, K) c. Must use filter needle when drawing from the vial and filter in IV tubing i. Prevents administering microscopic crystals ● Furosemide and Hydrochlorothiazide - monitor for HYPOkalemia ○ Nausea, vomiting, fatigue, leg cramps, and general weakness ● Spironolactone - monitor for HYPERkalemia → Weakness, fatigue, dyspnea, dysrhythmias ● Spironolactone - contraindicated w/ severe kidney disease!!!! ● Loop and thiazide diuretics ok even w/ severe kidney impairment ● ALL DIURETICS monitor wt, I&O, and electrolytes (Sodium, Potassium) MEDICATIONS AFFECTING BLOOD PRESSURE 1. ACE inhibitors → Captopril, lisinopril a. Indications → HTN, HF, MI, diabetic nephropathy b. MOA → blocks ACE enzyme (functions to convert Angiotensin I to AII) which results in vasodilation, sodium and water excretion, and potassium retention c. S/E → Angioedema, Cough, Elevated potassium i. Others include hypotension, rash, dysgeusia (altered taste) ii. Angioedema is treated w/ epinephrine and symptoms will resolve once med is stopped d. Possible first dose orthostatic hypotension - educate pt to monitor BP for at least 2 hr after e. Captopril - educate pt to take at least 1 hr before meals; all other ACEs not affected by food f. Captopril may cause neutropenia (rare, but very serious). Educate on signs of infection g. Interactions i. Other BP meds - ↑ hypotension effect ii. Potassium supplements or potassium sparing diuretics - ↑ risk of hyperkalemia iii. Lithium - ↑ serum lithium levels (may lead to lithium toxicity) iv. NSAIDs - can ↓ therapeutic effects of ACE inhibitors 2. Angiotensin II Receptor Blockers → Losartan, Valsartan a. Indications → HTN, HF, MI, diabetic nephropathy (same as ACEs) b. MOA → Blocks action of angiotensin II, resulting in vasodilation c. S/E → angioedema, GI upset, hypotension 3. Aldosterone antagonists → Spironolactone, Eplerenone 4. Calcium Channel Blockers - Nifedipine, Amlodipine, Nicardipine, Felodipine, Verapamil, Diltiazem a. Indications → HTN, angina b. MOA → blocks calcium channels in blood vessels and heart, leading to vasodilation and ↓ HR c. S/E → ↓ HR, ↓ BP, dysrhythmias, constipation, peripheral edema d. NO GRAPEFRUIT JUICE!!! REVIEW OF ALPHA AND BETA RECEPTORS WHEN ACTIVATED (AGONISTS) Alpha 1 = vasoconstriction (↑BP), Alpha 2 = vasodilation (↓ HR, BP) Beta 1 = Tachycardia (helps to stimulate the heart), Beta 2 = Bronchodilation. Remember 1 heart 2 lungs 5. Centrally Acting Alpha 2 Agonists → Clonidine (Catapres) a. Indication → HTN b. MOA → ↓ sympathetic outflow to heart and blood vessels (↓ HR, BP, CO) c. S/E → drowsiness, dry mouth (educate pt to suck on hard candy and increase fluids) 6. Beta Adrenergic Blockers a. Cardioselective: Beta 1 (affects only the heart) → Metoprolol, Atenolol, Esmolol i. Metoprolol S/E → erectile dysfunction b. Non-selective: Beta 1 and Beta 2 (affecting both heart and lung) → Propranolol, Nadolol i. S/E → bronchoconstriction (AVOID USE W/ ASTHMATICS) c. Alpha and Beta blockers → Carvedilol, Labetalol 97. Medications (Vasodilators) for Hypertensive Crisis → Nitroprusside (Nitropress) a. MOA → Direct vasodilation of arteries and veins, rapidly decreasing BP (preload & afterload) b. S/E → Cyanide poisoning, thiocyanate toxicity CARDIAC GLYCOSIDES AND HEART FAILURE MEDICATIONS 1. Cardiac Glycosides → Digoxin a. Indications → HF, treatment of aFIB (dysrhythmias) i. “Mom digya get a prescription for your HF? Yeah i got digoxin” b. MOA → Positive inotropic effect (increased force and efficiency of heart contractions) and negative chronotropic effect (decreased HR) c. S/E → Dysrhythmias, bradycardia d. Digoxin toxicity sx: GI upset (N/V), fatigue/weakness, vision changes (normal level = 0.5-2.0) i. Hypokalemia → increases risk of dig toxicity ii. Antidote is Digibind e. ALWAYS GET PULSE FOR FULL MINUTE PRIOR TO ADMIN (treat bradycardia w/ Atropine) 2. Adrenergic Agonists a. Epinephrine (Adrenaline) → used w/ cardiac arrest, asthma i. Causes bronchodilation, vasoconstriction (↑BP), and ↑HR and CO ii. Watch out for chest pain (epi ↑ cardiac workload and O2 demand, which can cause angina) b. Dopamine (Inotropin) → used w/ shock and HF i. Improves renal blood flow (at low/moderate doses), ↑ HR/CO c. Dobutamine → used w/ HF (↑CO - less effect on HR or BP) ANTIDYSRHYTHMIC MEDICATIONS 1. Class I → Procainamide, Lidocaine a. Indications → SVT, V Tach, aFlutter, aFIB b. S/E → hypotension, lupus, leukopenia, thrombocytopenia, arrhythmias 2. Class II → Propranolol a. Indications → aFib, Aflutter, paroxysmal SVT, HTN, angina b. S/E → hypotension, bradycardia, fatigue, weakness, bronchospasm (Avoid use w/ asthmatics) i. Watch for coughing at night 3. Class III → Amiodarone a. Indications → aFib, vFib, vTach b. Many serious S/E → hypotension, bradycardia, pulmonary toxicity, visual disturbances, GI upset, liver toxicity, thyroid dysfunction c. Monitor LFTs, and thyroid function d. Monitor for pulmonary toxicity (sx → dyspnea, cough, and CP). If observed - notify HCP e. Monitor for visual disturbances (photophobia, blurred vision - may lead to blindness) 4. Class IV → Verapamil, diltiazem a. Indications → aFib, aFlutter, SVT, HTN, angina b. S/E → hypotension, bradycardia, GI upset ANTILIPEMIC AGENTS (All work to lower cholesterol) 1. Statins → Atorvastatin, simvastatin a. MOA → decrease LDL, increase HDL (also used to prevent MIs) b. S/E → hepatotoxicity, muscle pain, GI upset, rhabdomyolysis c. Admin w/ evening meal (cholesterol is synthesized at night) d. Monitor LFT and CK, educate pt to avoid alcohol use 2. Cholesterol Absorption Inhibitors → Ezetimibe (Zetia) 10a. MOA → inhibits absorption of cholesterol in the small intestine (cholesterol zips thru, not absorb) b. S/E → hepatotoxicity, muscle pain (cholesterol lowering agents - always consider the liver) c. Monitor LFTs and CK level 3. Bile Acid Sequestrant → Colesevelam a. MOA → binds bile acids in intestine, causing increased excretion of cholesterol. Lowers LDL b. S/E → constipation c. Pt education → increase fiber and fluids, take w/ food and a full glass of water d. Interferes w/ absorption of fat soluble vitamins (A, D, E, K) and oral contraceptives 4. Niacin a. MOA → decreases lipoprotein and triglyceride synthesis (in large doses). Lowers LDL&triglycerides b. S/E → flushing of face, GI distress, hepatotoxicity, hyperglycemia c. Nursing interventions → monitor LFTs, monitor blood glucose 5. Fibrates → Gemfibrozil a. MOA → decreases triglyceride production and transport, increases HDL b. S/E → GI upset, gallstones, hepatotoxicity, muscle pain c. Nursing interventions → admin 30 mins before breakfast and dinner d. Monitor LFT and CK levels VASODILATORS DRUG CLASSIFICATION/NAME IMPORTANT INFORMATION Alpha Adrenergic Blockers ● Prazosin ● Doxazosin ● Dilate veins and arteries ● Potential for 1st dose orthostatic hypotension ● Concurrent use of prazosin & NSAIDs or clonidine can interfere w/ reduction of bP Centrally Acting Alpha 2 Agonists ● Clonidine ● Guanfac ine HCl (Tenex) ● Methyldopa (Aldomet) ● Vasodilation is result of CNS involvement ● CNS involvement can cause sedation or drowsiness that should diminish with time ● Concurrent use of clonidine and prazosin, MAOIs or tricyclic antidepressants can interfere with reduction of BP ● Concurrent use with other CNS depressants can increase CNS depression ACE inhibitors ● Capto pril (Capoten) ● Enala pril (Vasotec) ● Fosino pril (Monopril) ● Lisino pril (Prinivil) ● Rami pril (Altace) ● Produce vasodilation by blocking production of angiotensin II ● Should be stopped if client experiences cough, rash, altered taste, angioedema, or signs of infections ● Can cause hyperkalemia so must monitor serum potassium levels ● Concurrent use with potassium supplements or potassium-sparing diuretics can cause hyperkalemia ● Concurrent use with lithium can lead to lithium toxicity Angiotensin II Receptor Blockers ● Lo sartan (Cozaar) ● Val sartan (Diovan) ● Produce vasodilation by blocking the action of angiotensin II ● Can cause angioedema ● Fetal injury can result if used by pregnant women during 2nd and 3rd trimester Calcium Channel Blockers ● Nife dipine (Adalat, Procardia) ● Vasodilation is result of blocking of calcium channels in blood vessels 11● Amlo dipine (Norvasc) ● Felo dipine (Plendil) ● Nicar dipine (Cardene) ● Verapamil (Calan) ● Diltiazem (Cardizem) ● Risk of reflex tachycardia, peripheral edema, and acute toxicity with nifedipine ● Risk of orthostatic hypotension, peripheral edema, constipation, bradycardia, dysrhythmias, and acute toxicity with verapamil and diltiazem ● Drinking grapefruit juice can lead to toxicity ● Concurrent use of digoxin with verapamil can lead to digoxin toxicity Meds for HTN crisis ● Sodium nitroprusside ● Labetalol (Trandate) ● Diazoxide (Hyperstat) ● Fenoldopam (Corlopam) ● Trimethaphan (Arfonad) ● Provide direct vasodilation of veins and arteries & rapid reduction of BP ● Cyanide poisoning can occur and lead to cardiac arrest ● Thiocyanate poisoning can lead to altered mental status and psychotic behavior ● Nitroprusside may be slightly brown, however solutions that are dark blue, red, or green should be discarded ● Continuous BP & ECG monitoring when administering these drugs Organic Nitrates ● Nitr oglycerine (Nitrol, Nitrostat) ● Isosorbide di nitr ate (Imdur) ● Dilates veins and prevents spasms of coronary arteries ● Headache is common so client should use with acetaminophen or aspirin ● Tolerance can occur with prolonged use ● Concurrent use with sildenafil (Viagra) can lead to life-threatening hypotension ● Use with alcohol can cause increased hypotension ● Sublingual tablets, translingual spray, or transmucosal preparations should be used at the first sign of angina MEDICATIONS AFFECTING COAGULATION ALL OF THESE MEDICATIONS CREATE A RISK FOR BLEEDING; What to monitor for → coffee ground emesis, black/tarry stools, petechiae, bruising, bleeding gums, tachycardia, hypotension, hematomas, abdominal pain, nose bleeds 1. Parenteral Anticoagulants → Heparin, Enoxaparin (Lovenox; LMWH), Fondaparinux a. Indications → CVA, PE, DVT (conditions requiring fast anticoagulation), prophylaxis post-op b. MOA → Prevents new clots from forming, DOES NOT BREAK UP EXISTING CLOTS c. Complications → Bleeding, heparin-induced thrombocytopenia (HIT), hypersensitivity d. HIT (heparin-induced thrombocytopenia) evidenced by low platelet count and increased development of thrombi i. STOP HEPARIN IF PLATELET COUNT IS LESS THAN 100,000 e. Hemorrhage 2/2 heparin overdose → stop heparin, administer protamine and avoid ASA f. Monitor pTT and keep value 1.5-2x the baseline (normal pTT = 30-40s) i. Therapeutic heparin pTT is normally 60-80s g. Protamine is an antidote. Admin for heparin or enoxaparin overdose h. Contraindications → low platelet count and active bleeding (bleeding disorders, ulcers) i. ASA, NSAIDs and other anticoagulants → increase risk for bleeding j. Must be given via sq or IV (meds cannot be absorbed by the intestinal tract) k. Avoid corticosteroid use (salicylates, NSAIDs), green leafy veggies, and foods high in vitK 2. Oral Anticoagulants → Warfarin (Coumadin) 12a. Indications → treatment of thrombus formation in pt w/ aFIB or prosthetic heart valves; prevention of MI, TIA, PE, DVT; treatment of venous thrombosis b. MOA → Antagonizes vitamin K (prevents formation of several clotting factors) c. S/E → bleeding, GI upset, hepatitis d. Vitamin K is the antidote; if this does not work → admin FFP or whole blood i. Educate pt to maintain consistent intake of vit K (dark green leafy veggies, lettuce, spinach, cabbage, broccoli, brussel sprouts, mayo, canola oil, soybean oil) e. Contraindications → PREGNANCY, thrombocytopenia, uncontrollable bleeding, vitamin K deficiencies, liver disorders, alcohol use disorder f. Full therapeutic effect not achieved for 3-5 days (may need to continue heparin infusion) g. Pt education → avoid sitting for prolonged time, constricting clothing; encourage elevating and moving legs when sitting h. Avoid use of acetaminophen, glucocorticoids, ASA i. Normal PT = 11-12.5s (warfarin pt should be 1.5-2x control) j. Normal INR = 0.7-1.8 (INR is most accurate) i. INR 2-3 → acute MI, aFIB, PE, venous thrombosis, tissue heart valves ii. INR 3-4.5 → mechanical heart valve or recurrent systemic embolism k. If PT or INR exceed therapeutic range → hold dose and notify provider 3. Factor xa inhibitor → Rivaroxaban (Xarelto); think “rivar” makes blood flow like a river a. Indication → prevention of DVT, PE, stroke in pts w/ aFIB b. S/E → elevated liver enzymes (monitor LFTs), bleeding (monitor Hgb and Hct) 4. Antiplatelets → Aspirin, Abciximab, Clopidogrel (Plavix) a. Indications → prevention of MI, CVA b. MOA → inhibit platelet aggregation c. S/E → GI upset (take with food), bleeding, tinnitus (aspirin) d. Key points → DO NOT GIVE ASA TO CHILDREN W/ FEVER (risk of Reye's syndrome) e. Corticosteroids ↑ ASA effects; ASA ↓ beta blockers effects on BP 5. Thrombolytic Medications → Reteplase, Alteplase (tPA); many end in -ase a. Indications → MI, CVA, PE, and occluded central IVs i. All meds treat acute MI; Only Alteplase treats PE, CVA, occluded central IVs ii. If unable to flush PICC line bc clot - can let thrombolytic dwell in there, then flush b. MOA → Dissolves clots that have already formed i. For PE → Medication should be taken within 3 hr of onset of symptoms 1. USED FOR ISCHEMIC STROKE, and pulmonary embolism (PE) c. Contraindicated → Hx: hemorrhagic stroke, internal bleeding, severe HTN, recent trauma/surgery i. Avoid use if pt underwent major surgical procedure in past 3 weeks d. Nursing considerations → Limit venipunctures and IM injections (risk of bleeding) GROWTH FACTORS 1. Erythropoietic Growth Factors → Epoetin alfa: Erythropoietin a. Indications → Anemia (RT CKD, HIV/AIDS, chemotherapy) b. MOA → Act on the bone marrow to increase production of RBCs c. S/E → HTN (2/2 elevated Hct levels), ↑ risk of DVT, CVA, MI (esp of Hgb 11 or higher) d. Nursing considerations → Do not agitate vial i. Monitor for headache (may be RT HTN) ii. Monitor Hgb and Hct 2x per week, ensure sufficient iron levels 2. Leukopoietic Growth Factors → Filgrastim a. Indications → Neutropenia b. MOA → Act on the bone marrow to increase production of neutrophils i. ↑ neutrophils = ↓ risk of infection in neutropenic pts (RT chemotherapy) c. S/E → Bone pain, leukocytosis (high WBC levels), splenomegaly d. Key points → Do not agitate vial, monitor CBC 2x per week 3. Thrombopoietic Growth Factors → Oprelvekin a. Indications → Thrombocytopenia 13b. MOA → increase production of platelets (decreases thrombocytopenia and need for platelet transfusion in pt receiving chemo) c. S/E → Fluid retention, cardiac dysrhythmias (tachycardia, aFib, aflutter), eye effects d. Contraindicated → cancer of bone marrow PEPTIC ULCER DISEASE MEDICATIONS Peptic Ulcer Disease (PUD) → Characterized by an erosion of the mucosal layer of the stomach or duodenum ● Leading cause is H. Pylori infection; Other causes include chronic use of NSAIDs (ASA, ibuprofen) ● Pt w/ H. Pylori → Antibiotics used to eradicate the disease process; All other meds prescribed are used to promote healing of the GI tract 1. Antibiotics → Amoxicillin, Bismuth, Clarithromycin, Metronidazole, Tetracycline, Tinidazole a. Treatment will consist of 2 or 3 axb for at least 14 days → Increase effectiveness and minimize development of medication resistance b. Used for eradication of H. Pylori bacteria 2. Histamine2-Receptor Antagonists → Ranitidine, Cimetidine, Famotidine, Nizatidine (end in -dine) **End in -dine, so think that when you take these you will feel better when you DINE a. Indications → duodenal and gastric ulcers, GERD, Zollinger-Ellison syndrome b. MOA → Blocks H2 receptors in stomach (reduces gastric acid secretion, and lowers the concentration of hydrogen ions in the stomach) c. ↑ risk of bacterial colonization of stomach and respiratory tract due to ↓ in gastric acidity i. Acid in the stomach helps to kill bacteria ii. Use caution in pts who are at high risk for PNA (i.e. COPD pt) d. Pt education → do not overeat, avoid foods that promote gastric acid secretion (i.e. caffeine), reduce stress, get adequate rest, avoid smoking, avoid ASA and NSAIDs e. Monitor for GI bleeding f. Cimetidine → Monitor for lethargy, depression, confusion g. Ranitidine → Monitor for constipation, diarrhea, nausea h. Famotidine → Monitor for drowsiness, dizziness, constipation 3. Proton Pump Inhibitors (PPIs) → Omeprazole, Pantoprazole, Lansoprazole (many end in -azole) a. Indications → Duodenal and gastric ulcers, GERD, Zollinger-Ellison syndrome b. MOA → Inhibits an enzyme needed for gastric acid secretion (reduces gastric acid secretion) i. Decreases stomach acid by inhibiting those gastric proton pumps that make the acid 1. THEY STOP THE ACID AT THE PUMP (“zole” is the nice guy that shuts off the pump) c. S/E → GI upset, increased risk of osteoporosis w/ long-term use 4. Mucosal Protectant → Sucralfate a. Indications → Acute duodenal ulcers b. MOA → Reacts w/ stomach acid to form a thick paste that adheres to ulcers i. Protects the ulcer from further injury from acid and pepsin c. S/E → Constipation d. Med administration → QID (1 hr before meals, and at bedtime) i. May break or dissolve the medication in water, but do not crush or chew tablet 5. Antacids → Aluminum hydroxide, Magnesium hydroxide, Calcium carbonate, Sodium Bicarbonate a. Indications → PUD, GERD (promotes healing and relief of pain) b. MOA → Neutralizes stomach acid c. Aluminum hydroxide and Calcium carbonate→ May cause constipation d. Magnesium hydroxide → May cause diarrhea e. Med administration → Take at least 1 hr before or after any other meds i. Take 1 hr and 3 hrs after meals, and at bedtime (this may cause non-compliance w/ med) 1. Encourage compliance by reinforcement of positive effect of this med ii. Instruct to chew the tablet thoroughly and then drink at least 8 oz water or milk f. Never take an antacid with any other medications 6. Prostaglandin E analog → Misoprostol 14a. Uses → Prevention of gastric ulcers in pt taking NSAIDs on long-term basis i. Also induces labor by ripening the cervix b. MOA → Prevention of gastric ulcers c. S/E → Diarrhea, dysmenorrhea/spotting d. Prior to administration → Perform pregnancy test (med will result in miscarriage) GASTROINTESTINAL DISORDERS 1. Antiemetics → Ondansetron (Zofran), Diphenhydramine, Meclozine, Metoclopramide (Reglan) a. Ondansetron MOA → Blocks serotonin receptors in CTZ i. Key points → Administer prior to chemotherapy (Vs. after pt already nauseous) b. Nursing consideration → remember most antiemetics can cause sedation so watch out for additive effect if given w/ narcotic analgesics and protect your pt from injury c. Metoclopramide → Monitor for extra-pyramidal S/E 2. Laxatives a. Psyllium → Bulk forming laxative (softens stool and increases bulk) b. Docusate sodium → surfactant laxative (softens stool by increasing water content) c. Bisacodyl → Stimulant laxative (stimulates peristalsis) d. Magnesium hydroxide → Osmotic laxative (draws water into intestine, promotes peristalsis) i. Monitor for Mg toxicity and dehydration e. Contraindicated → Bowel obstructions (need to R/O as cause of constipation) f. Lactulose → Laxative used for hepatic encephalopathy i. Indications → Hepatic encephalopathy (used to decrease ammonia levels and improve mental status) ii. MOA → Lowers pH in colon (promotes ammonia excretion) iii. Monitor for electrolyte imbalances and hyperglycemia 3. Antidiarrheal → Loperamide (Imodium), Diphenoxylate plus atropine a. MOA → Stimulate opioid receptors in intestines, causing a decrease in motility and increased absorption of Na and water b. S/E → Drowsiness, constipation c. Diphenoxylate plus atropine → at high doses, can cause opioid and anticholinergic effects 4. Prokinetic Agents → Metoclopramide (Reglan) a. Indications → N/V, gastroparesis, GERD b. MOA → Accelerates gastric emptying (Blocks dopamine and serotonin receptors in CTZ) i. Gets food and other stuff out of your stomach fast, so that way you can’t throw it up c. S/E → Drowsiness, extrapyramidal symptoms (rigidity, tremors, twitching, TD, restlessness) 5. IBS Medications a. IBS w/ diarrhea → Alosetron (Lotronex) b. IBS w/ constipation → Lubiprostone (Amitiza) 6. 5-Aminosalicylates → Sulfasalazine a. Indications → IBS, Crohn’s disease, Ulcerative colitis b. MOA → Inhibits prostaglandin synthesis (decreases colon inflammation) c. S/E → Blood dyscrasias (Anemia, agranulocytosis), GI upset, rash, headache VITAMINS, MINERALS, AND SUPPLEMENTS 1. Iron Supplements → Ferrous sulfate (PO route), Iron dextran (IV/IM route) a. PO S/E → GI upset/constipation, black stool, teeth staining b. IV and IM S/E → Staining at IV site, hypotension, flushing c. Key points → Vitamin C increases absorption i. Take on an empty stomach (such as 1 hr before meals) ii. Keep out of reach of children - there is risk for fatal toxicity in children 2. Vitamin B12/Cyanocobalamin a. Indications → Tx vitamin B12 deficiency, megaloblastic (macrocytic) anemia RT vitB12 deficiency 15i. Vit B12 deficiency can result in megaloblastic (macrocytic) anemia ii. Vit B12 deficiency affects all blood cells produced in the bone marrow b. Megaloblastic anemia is either caused by a lack of folic acid or a lack of B12 i. If lack of B12 → most likely intrinsic factor where pt unable to absorb B12 ii. B12 is necessary to convent folic acid to from its inactive form to its active form 1. Pt must have parenteral or intranasal B12 admin for rest of life in order to prevent folic acid deficiency 3. Folic Acid a. Uses → Treatment of megaloblastic anemia, prevention of neural tube defects, treatment of malabsorption syndrome, supplement for alcohol use disorder b. Before admin of folic acid - check vitamin B12 levels i. Avoid folic acid administration if pt has B12 deficiency 4. Potassium Supplements a. Uses → Prolonged vomiting or diarrhea, K loss from diuretic use 5. Magnesium Sulfate - Antidote is Calcium gluconate HERBAL SUPPLEMENTS 1. Echinacea a. Helps to stimulate the immune system → Used to treat the common cold b. Chronic use → can ↓ positive effects of meds for TB, HIV, or cancer 2. Garlic, ginger root and ginkgo biloba → high risk for bleeding 3. Ginger Root → Used for morning/motion sickness and nausea; May also ↓ pain and stiffness from RA a. Suppresses platelet aggregation 4. Ginkgo Biloba → used to increase recall ability and mental processes (think Dementia and AD) a. May interact w/ meds that lower seizure threshold i. Antihistamines, antidepressants, and antipsychotics b. May interfere w/ coagulation 5. Ginseng → Used to improve appetite. Can ↓ effectiveness of Timolol; Does not affect bleeding 6. Valerian (kinda sounds like Valium) a. Uses → ↑GABA to prevent insomnia (promotes sleep w/ ↑ effect over time -risk 4 dependence) b. May cause drowsiness and depression c. Use caution in pt w/ mental health disorders d. Contraindicated → Pregnancy or breastfeeding 7. Black Cohosh→ Acts as an estrogen substitute (might be used during menopause) a. ↑ effects of antihypertensives meds and may ↑ effect of estrogen meds b. ↑ hypoglycemia in pt taking insulin or other diabetes meds 8. St. John’s Wort → Used for mild depression 9. Saw Palmetto → Helps with prostate a. May result in false low prostate-specific antigen levels MEDICATIONS AFFECTING THE REPRODUCTIVE TRACT Key points when using Estrogen/Progesterone for birth control ● If used properly → prevent ovulation, thicken cervical mucus, alter endometrial lining to reduce chance of fertilization 1. Estrogens → Conjugated equine estrogen, Estradiol, Estradiol hemihydrate a. Uses → Contraception, treatment of hypogonadism and prostate cancer (prevents spread) i. Relief of moderate to severe postmenopausal symptoms (i.e. hot flashes, mood changes), prevention of postmenopausal osteoporosis 16b. S/E → Endometrial and ovarian cancers, potential risk for estrogen-dependent breast cancer, embolic events (DVT, CVA, MI, PE) i. HTN, weight gain, edema c. Contraindications → Current smokers, HTN, pt or family hx of heart disease, atypical undiagnosed vaginal bleeding, breast or estrogen-dependent cancer, hx of embolic events d. Interactions → May reduce effectiveness of warfarin 2. Progesterones → Medroxyprogesterone (Provera), Norethindrone, Megestrol acetate a. Uses → Contraception (alone or in combination w/ estrogen), counter adverse effects of estrogen in menopausal hormone therapy i. Treat dysfunctional uterine bleeding due to hormonal imbalances, amenorrhea, endometriosis, advanced cancer of the endometrium, breast, and kidney b. Complications → Breast cancer, thrombotic events, edema, jaundice, migraines c. Contraindicated → Hx of embolic events, CVD, breast or genital cx; High risk for embolic events d. Pt education → Delay conception for 3 mos after D/C meds 3. Androgens → Testosterone (Androderm-50), Methyltestosterone a. Indications → Hypogonadism in males, delayed puberty in boys, anemia not responsive to traditional therapy, postmenopausal breast cancer, muscle wasting in men w/ AIDS b. S/E → Acne, hypercholesterolemia, liver dysfunction, polycythemia (↑Hgb and Hct), premature epiphyseal closure, edema, ↑ in growth of prostate cancer i. Women → Deeping of voice, baldness, hirsutism (hair growth on face) c. Contraindicated → Prostate or breast cancer; Severe cardiac, renal, or liver disease d. Pt education → There is high risk for abuse; Reduce cholesterol intake, daily wt 4. 5-Alpha Reductase Inhibitors (BPH Medications) → Finasteride, Dutasteride “That guy has a FINE RIDE, but he does have BPH” a. Indications → Male pattern baldness, BPH (Benign prostatic hyperplasia = big prostate) b. MOA → Inhibits 5-alpha-reductase (prevents conversion of testosterone) i. Reduces prostate size and increases hair growth c. S/E → decrease libido, gynecomastia (enlarged breast in men) d. Key points → Pregnant women should not handle medication e. Pt education → Therapeutic effect may take 6 mos or longer, do not donate blood unless med has been D/C for at least 1 month 5. Alpha1-Adrenergic Antagonists (BPH Medications) → Tamsulosin (Flomax), Silodosin, Alfuzosin a. Indications → BPH; Off-label use for women to tx urinary hesitancy or retention b. MOA → Relaxes smooth muscles of the prostate (↑ urinary flow) c. S/E → Hypotension, dizziness, headache, issues w/ ejaculation d. Contraindications → Liver failure (Alfuzosin, Silodosin), renal failure (Silodosin) e. Pt education → Take at same time every day, monitor BP, change position slowly 6. Erectile Dysfunction Agents → Sildenafil (Viagra), Tadalafil, Vardenafil (End in -fil) “Fil is the guy that helps the nitric oxide ‘fil’ the penis” a. MOA → Enhances effect of nitric oxide released during sexual stimulation, resulting in increased blood flow to the corpus cavernosum (helps lead to getting and keeping an erection) b. S/E → Priapism (prolonged erection), MI, sudden death, headache, flushing, back pain i. Sildenafil → Temporary vision changes including “blue vision” ii. Levitra → Muscle aches c. Not all men can spend time w ‘fil’ → Men w heart problems, uncontrolled BP probs, hx of stroke, or health problem that can cause priapism d. Key points → Do not take with other nitrates (i.e. NTG), use caution w/ CVD MEDICATIONS AFFECTING LABOR AND DELIVERY 1. Uterine stimulants → Oxytocin (Pitocin), Dinoprostone, Methylergonovine a. Indications → Induction (or enhancement) of labor, postpartum hemorrhage, placenta delivery b. MOA → ↑ Strength, frequency, and length of uterine contractions c. S/E → Uterine rupture, uterine tachysystole, placental abruption, painful contractions 17d. Methylergonovine → Monitor for HTN crisis (contraindicated w/ HTN, asthma, preeclampsia) i. Use only after delivery, and not during labor e. Nursing interventions → Monitor BP, RR, and HR q 30-60 mins and w/ every dosage change i. Monitor contractions - 1st stage of labor q 15 mins; 2nd stage q 5 mins ii. Monitor for uterine tachysystole (5 contractions in 10 mins, occurring within 1 min of each other, or a series of single contractions lasting greater than 2 mins) iii. If uterus has been overstimulated → Can use magnesium to cause relaxation 2. Tocolytic Medications → Terbutaline, Nifedipine, Indomethacin, Magnesium Sulfate, Hydroxyprogesterone caproate a. Indications → Preterm labor (Delays but does not prevent labor); COPD, asthma b. MOA → Activates beta 2 adrenergic receptors (causes relaxation of uterus and bronchodilation) c. S/E → Tachycardia, angina, restlessness, tremor d. Contraindicated → Gestation of 34 wks or greater, cervical dilation 6 cm e. Magnesium Sulfate toxicity → Loss of DTRs, UO 25-30mL/hr, RR 12, pulmonary edema, severe hypotension, chest pain 3. Glucocorticoid medications → Betamethasone, Dexamethasone a. Uses → Reduce neonatal respiratory distress syndrome b. MOA → Releases enzymes that produce/release lung surfactant to stimulate fetal lung maturity c. Medication administration → deep IM using ventrogluteal or vastus lateralis muscle i. Betamethasone IM for 2 doses 24 hr apart, Dexamethasone IM for 4 doses 12 hr apart ii. Gestation between 24-34 wks CONNECTIVE TISSUE DISORDERS MEDICATIONS Medication that end in -mab or -nib are typically immunosuppressants used for cancer/autoimmune disorders ● Priority is risk for infection (RT suppression of immune system) DMARDs slow the joint degeneration and progression of RA Glucocorticoids and NSAIDs provide symptom relief from inflammation and pain 1. Disease-Modifying antirheumatic drugs (DMARDs) → Methotrexate, Cyclosporine, Hydroxychloroquine a. Indications → RA, psoriasis i. Methotrexate uses → Cancers ii. Cyclosporine uses → UC, prevention of Graft Vs. Host disease in transplant pts 1. Also used w/ Multiple Sclerosis patients b. Methotrexate MOA → Inhibits folic acid metabolism (prevents cell reproduction) c. S/E → Infections, hepatotoxicity, GI upset i. Methotrexate S/E → Bone marrow suppression (make sure to monitor CBC) ii. Cyclosporine S/E → Hirsutism, nephrotoxicity (monitor renal function) d. Nursing interventions → Notify provider ASAP of any S/S of infection, monitor LFTs e. Hydroxychloroquine pt education → Eye exam q6mos (med can cause retinal damage) 2. Antigout Medications a. Colchicine → Used to decrease inflammation and pain in an acute gout attack 18i. S/E → GI upset, thrombocytopenia b. Probenecid → Inhibits uric acid resorption (Treats hyperuricemia RT chronic gout) i. GI upset → GI upset, renal calculi (kidney stones) c. Allopurinol → Inhibits uric acid production (Treats hyperuricemia RT chronic gout) i. S/E → GI upset, rash, hepatotoxicity, nephrotoxicity ii. This is the only medical preventative treatment for gout iii. Potential serious interactions include use of saliscylates, loop diuretics, phenylbutazamines, alcohol and warfarin iv. Foods to avoid with gout → Anchovies, sardine in oil, yeast, organ meat (liver, kidneys, sweetbreads), legumes (dried beans and peas), gravies, mushrooms, spinach, asparagus, cauliflower d. NSAIDs and Prednisone → Used as 1st line defense to treat pain and inflammation of gout attack 3. Medications for Systemic Lupus erythematosus (SLE) → Belimumab 4. Medications for fibromyalgia → Duloxetine, Milnacipran, Pregabalin BONE DISORDER MEDICATIONS 1. Calcium supplements → Calcium citrate a. Ensure pt has sufficient vitamin D b. Monitor for hypercalcemia → Tachycardia, elevated BP, muscle weakness, hypotonia, constipation, N/V, abdominal pain, lethargy, confusion Raloxifene, Alendronate and Calcitonin patient education ● Monitor bone density (should have bone density scan q 12-18 mos), encourage adequate calcium and vitamin D intake, weight-bearing exercises, (i.e. walking 30-40 mins/day) 2. Selective estrogen receptor modulator → Raloxifene (“Locks Calcium into the bone”) a. Uses → Postmenopausal osteoporosis, reduces risk of breast cancer b. MOA → Binds to estrogen receptors, ↓ bone resorption (helps keep Calcium in the bone) i. Slows bone loss and preserves bone mineral density c. S/E → increased risk of embolic events, hot flashes, leg cramps d. Contraindicated → Hx of venous thrombosis 3. Bisphosphonates → Alendronate, Ibandronate, Risedronate “After you take your Alendronate, you should go out and fly your drone” a. Uses → Prophylaxis and tx of postmenopausal osteoporosis, Paget’s disease b. MOA → Prevents bone resorption c. S/E → Esophagitis, GI upset, muscle pain, visual disturbances d. Esophagitis is the highest priority!!! It can cause ulcers in esophagus i. Medication administration → Take on an empty stomach w/ 240 mL of water, in the AM 1. Sit upright or ambulate for 30 mins after taking 2. Ibandronate → Remain upright &not ingest food or other meds for 1 hr after med 4. Calcitonin → Calcitonin-salmon a. Uses → Treats (but does not prevent) postmenopausal osteoporosis, treat hypercalcemia b. Most commonly give by nasal spray i. S/E includes nasal dryness/irritation. Educate pt to rotate nostrils daily c. Nursing intervention → Monitor for Chvostek’s or Trousseau’s sign (indicates hypocalcemia) NONOPIOID ANALGESICS MEDICATIONS 1. Nonsteroidal anti-inflammatory drugs (NSAIDs) → Aspirin, Ibuprofen, Naproxen, Indomethacin, Celecoxib, Ketorolac a. Uses → Mild to moderate pain, fever, inflammation b. S/E → GI discomfort, GI bleeding, renal toxicity, rash 19c. ASA S/E → Tinnitus, Reye syndrome, and Salicylism i. Reye syndrome → Avoid ASA in children/adolescents w/ viral illness ii. Salicylism sx → tinnitus, sweating, headache, dizziness, respiratory alkalosis d. ASA toxicity → Treated w/ activated charcoal, gastric lavage e. Contraindicated → PUD, bleeding disorders (i.e. hemophilia and vit K deficiency) f. Ketorolac → Contraindicated w/ advanced renal disease; Do not use longer than 5 days g. Pt education → Avoid alcohol 2. Acetaminophen (Tylenol) a. Indications → Mild to moderate pain, fever b. S/E → Hepatotoxicity in high doses (INTAKE SHOULD NOT EXCEED 4g/DAY) i. Pts who consume more than 3 alcoholic drinks per day - limit to 2g/day c. Acetaminophen toxicity (OD) → Antidote is acetylcysteine i. Administer via an duodenal tube to prevent emesis and subsequent aspiration d. Interactions → Acetaminophen slows metabolism of warfarin (risk for bleeding) OPIOID AGONISTS AND ANTAGONISTS MEDICATIONS 1. Opioid agonists → Morphine, Fentanyl, Meperidine, Methadone, Codeine a. Monitor for hypotension, respiratory depression, sedation, constipation, urinary retention 2. Agonist-Antagonist opioids → Butorphanol, Nalbuphine, Buprenorphine, Pentazocine a. Lower potential for abuse, less respiratory depression, less analgesic effect b. Buprenorphine can be used to treat opioid dependence 3. Opioid antagonist → Naloxone (Narcan) a. Watch for HTN, tachycardia, agitation, GI upset ADJUVANT MEDICATIONS FOR PAIN 1. Tricyclic antidepressants → Amitriptyline, Imipramine 2. Anticonvulsants → Carbamazepine, gabapentin MISCELLANEOUS PAIN MEDICATIONS 1. Migraine medications a. Ergot alkaloids → Ergotamine, Dihydroergotamine b. Triptans → Sumatriptan, Almotriptan, Frovatriptan c. Indications → Vascular headaches (migraine and cluster headaches) i. Used as abortive therapy to stop a migraine after it begins or after prodromal manifestations start d. MOA → Vasoconstriction of intracranial arteries e. Ergotamine S/E → GI upset, muscle pain, numbness/tingling, HTN f. Sumatriptan S/E → Warm/tingling sensation, dizziness, angina, injection site discomfort g. Pt education → Lay down in a dark, quiet place to help with symptoms i. Avoid alcohol and tyramine-rich foods (aged cheese, wine) - Can trigger migraines 2. Local anesthetics → Lidocaine a. Topical route → Used to decrease pain in conditions involving the skin and mucous membranes, IV insertion b. Parenteral route → Used to ↓pain in minor surgical procedures, epidurals, diagnostic procedures i. Minor procedures such as IV insertion, injection (pediatric), wart removal c. MOA → Blocks conduction of pain impulses in a circumscribed area d. Parenteral S/E → Hypotension, bradycardia, prolonged labor, spinal headache, allergic reaction e. Nursing considerations → EMLA cream, apply 1 hr before procedure and cover w/ occlusive dressing; Avoid wrapping or heating the area i. Prior to the procedure → Remove the dressing and clean the skin w/ aseptic solution 20INSULINS “We’ll climb to the peak… Starting FAST and ending SLOW” ONSET PEAK DURATION FASTEST Rapid-Acting: Lispro (Humalog) 15 mins 30 min-1 hr 3-4 hrs FAST Short-Acting: Regular (Humulin R) 30min-1hr 2-3 hrs 5-7 hrs SLOW Intermediate-Acting: NPH (Humulin N) 1-2 hrs 4-12 hrs 18-24 hrs SLOWEST Long-Acting: Insulin Glargine (Lantus) 1 hr NONE 24 hrs Tricks to remember insulins ● Rapid-Acting: Lispro (HumaLOG) → Log has 3 letters; Onset begins in 30 mins, duration is 3 hrs ● Short-Acting: Regular (HumuLIN R) → LIN is just a regular person ○ Regular has 7 letters and the duration is up at 7 hrs ● Intermediate-Acting: NPH (Humulin N) → Neal Patrick Harris is of intermediate height ○ He is a hard working actor. If you call him, he will come onset in 1-2 hrs and stay for 18-24hrs Insulin Key Points ● Increase dosage during illnesses ● Insulin suspensions - gently rotate vial b4 admin ● Hypoglycemia = BG 70 ● Hypoglycemia in fully conscious pt → Administer 15 g glucose (i.e. 4 oz OJ, 8oz milk) ● Hypoglycemia NOT fully conscious pt → Administer IM glucagon Mixing short-acting and long-acting insulins ● Draw short-acting insulin in syringe first, then longer-acting insulin ● Do not mix long-acting insulins (insulin glargine) w/ other insulins NPH and premixed insulins - should appear cloudy Regular and insulin glargine - should appear clear **DRAW UP THE CLEAR BEFORE THE CLOUDY Remember Nancy Regan, RN ● Inject air into NPH, inject air into regular ● Draw up regular, draw up NPH 21ORAL ANTIDIABETIC MEDICATIONS Therapeutic Uses: Control blood glucose levels in T2DM; Used in conjunction w/ diet and exercise changes ● T1DM will always need insulin; T2DM may be managed with only oral antidiabetics Monitor for hypoglycemia!!!! ● Abrupt onset → Tachycardia, palpitations, diaphoresis, shakiness (SNS symptoms) ● Gradual onset → Headache, tremors, weakness (PNS symptoms) 1. Sulfonylureas → Glipizide, Chlorpropamide, Tolzamide, Glyburide, Glimepiride a. S/E → Photosensitivity, GI upset b. Pt education → Avoid alcohol, wear sunscreen 2. Meglitinides → Repaglinide (“woman in the pageant can’t go on stage bc she has angina”) a. S/E → Angina b. Administration → TID, eat within 30 mins of dose 3. Biguanides → Metformin a. MOA → ↓ glucose production in the liver, and ↑ glucose uptake b. S/E → Metallic taste i. GI upset (anorexia, nausea, diarrhea); Usually subsides w/ use; May cause wt loss of 3-4 kg ii. Vitamin B12 and folic acid deficiency; May need B12 supplement iii. Lactic acidosis; Sx - hyperventilation, myalgia, sluggishness, somnolence c. Pt education → Avoid alcohol, take medication w/ food d. Concurrent use of iodine-containing contrast media can result in acute kidney failure i. If taking metformin → D/C 24-48 hr prior to procedure; Can resume 48 hr after test 4. Thiazolidinediones → Pioglitazone a. MOA → ↓ insulin resistance, ↑ insulin glucose uptake, ↓ glucose production b. S/E → Fluid retention, ↑LDL, hepatotoxicity c. Contraindicated → HF d. Administration → Take 1x day, with or without food e. Pt education → Monitor for signs of hepatotoxicity, wt daily 5. Alpha glucosidase inhibitors → Acarbose a. MOA → Inhibits glucose absorption in the GI tract b. S/E → Anemia, hepatotoxicity i. GI upset (abdominal distention/cramping, hyperactive BS, diarrhea, excessive gas) c. Contraindicated → GI disorders (inflammatory disease, ulceration, or obstruction) d. Administration → TID, w/ first bite of food 6. Hyperglycemic Agents → Glucagon a. Indications → Severe hypoglycemia when pt is unable to take PO glucose b. MOA → Stimulates breakdown of glycogen into glucose in the liver c. S/E → GI upset d. Administration → SQ, IM, or IV route; Provide food as soon as pt can safely swallow ENDOCRINE DISORDERS MEDICATIONS HYPERthyroidism sx → Anxiety, tachycardia, palpitations, altered appetite, abdominal cramping, heat intolerance, fever, diaphoresis, weight loss, menstrual irregularities Hypothyroidism sx → Depression, bradycardia, weight gain, anorexia, cold intolerance, dry skin, menorrhagia 1. Thyroid hormone → Levothyroxine (Synthroid) (“synthetic form of thyroid hormone”) a. Indications → Hypothyroidism b. MOA → Acts as a synthetic form of T4 or T4 c. S/E → Hyperthyroidism (if dose is too high) 22d. Nursing considerations → Monitor