Pharmacology Review Chapter 29-38

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

StressCauses

Release of Norepinephrine

Heart pounds

Hormones released

Breath hard

Eyes wide open

Sympathetic response

StressCauses

Release of Norepinephrine

Beta 1 receptors

Alpha 2 receptors

Beta 2 receptors

Alpha 1 receptors

(1 heart)(2 lungs)

Sympathetic response

StressCauses

Release of Norepinephrine

Alpha 1 receptors

Beta1

Receptors

Alpha 2 receptors

Beta2

Receptors

Sympathetic response

Stress

Response

Alpha 1 receptorsDilate pupils

Close bladder spinchterVasoconstrict blood vessels

Alpha 2 receptorsRegulate norepinephrineModerate insulin release

Beta 2 receptorsDilate bronchi

Breakdown glycogen Relax uterine muscle

Beta 1 receptorsIncrease heart rate

Breakdown fat for energy

Sympathetic response

Stress

Response

Alpha 1 receptorsAgonists “ine”

Blockers “zosin”

Alpha 2 receptorsClonidine

Beta 2 receptorsBlockers “olols”

Beta 1 receptorsBlockers “olols”

Parasympathetic Response

Acetylcholineresponses

Heart slows

Digestion starts

Bladder works

Eyes constrict

Bronchi constrict

Parasympathetic Response

Muscarinic Receptors

(Smooth muscle)Pupils, bladder,

GI motilityHeart vessels

Nicotinic Receptors

NMJMuscle constractions

Heart Rate medications• Too Low • Too fast

Adrenergic Agonists

•Epinephrine

•Dopmaine

•Dobutamine

Adrenergic Blockers

•Amiodarone

•Bretylate

•Carvediol

Adrenergic Agonists - “ine”

• Ephedrine• Dopamine• Dobutamine• Aramine• Norepinephrine• Epinephrine

David Price

“ine” it to win it!The race against time with shock

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 # 2Adrenergic 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 # 3Adrenergic 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 ofPrazosin (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 – hypertension– Angina– Migraines– Reinfarction after MI– Syncope– Cardiac arrhythmias– Stage fright

These block the “fight or flight” response….

Inderal…kick in

about now!!!

Beta Blockers - “olols”

• 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

*(Material in ATI prep)

Apply cotton ballhere to prevent Systemic effect

Case Study # 5Beta 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 blockersRemember:

Beta 2 receptors dilate the lungs

• Beta blockers inhibit this response

• Bronchospam, COPD, Asthma, diabetes and hypoglycemia are all contraindicted

Kasey’s mom’s lungs

were unable

to dilate with the inflammation

caused by the pollen

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 # 6Cholinergic 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 # 7Indirect 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: • urinary frequency • Incontinence (on ATI practice exam)

Know this!

Case Study # 8Alzheimer’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

• 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 # 9Anticholinergics

• What are the contraindications?

• Think of any condition that could be aggravated by blocking the parasympathetic system…..

Anticholinergics

• Contraindications:• Glaucoma,• Paralytic ileus• Tachycardia• Myasthenia gravis

• Side effects:• Blurred vision• Pupil dilation• Weakness• Insomnia• Dry mouth• Constipation• Urine retention example: Atropine

Dries you out like a desert..

Case Study # 10Vasopressin

Case Study # 11Glucocrticoids

• Laura hurt her knee running the mini-marathon. 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.

Live Vaccines:• Measles• Mumps• Rubella• Polio• Varicella (chicken

pox)

Case Study # 12Glucocorticoids

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:

• 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

• 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

Hypo• Most common• Women over 50• Elderly• Goiter, obesity,

lethargy, coarse skin, thick tongue

Hyper• Graves’ disease• Tachycardia• Palpitations• Intolerance to heat• Flushing• hypertension

Treat withLevothyroxine (Synthroid) 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 # 15Antihypercalcemic 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.

HyperglycemiaBlood sugar > 126 mg/dL

Can contribute to: AtherosclerosisRetinopathyNeropathyNephropathy

Watch for:Fruity breath

FatigueIrritationItchy skin

DehydrationKussmaul’s respirations

Hypoglycemia

• Blood Sugar < 40 mg/dL

Recognize these signs:Headache

Blurred visionTachycardia

Hunger, nauseaDiaphoresis, 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 # 15Antidiabetic 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 # 16Antidiabetic

• Michelle is a high school sophomore with Type I diabetes.

• 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?

Breakfast

Type I Diabetes

• Michelle needs to be checking her blood glucose level 3 -5 times per day.