Pharma(Cardio Resp) Midterm


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Pharma(Cardio Resp) Midterm

  1. 1. Nsg. Pharmacology midterm
  2. 2. <ul><li>CARDIOVASCULAR SYSTEM- responsible for delivering oxygen & nutrient rich blood to all of the body & removes w aste products for excretion </li></ul><ul><li>HEART- hollow muscular organ loc inside the thoracic cavity bet T 2-T4, inverted triangle, main organ for pumping blood. </li></ul><ul><li>Chambers: </li></ul><ul><ul><li>ATRIUM- 2 upper parts of the heart </li></ul></ul><ul><ul><li>VENTRICLE- 2 lower parts of the heart </li></ul></ul><ul><li>Frank starling’s law-the further heart Ms is stretched, the stronger in returns to its original form </li></ul><ul><li>Cardiac cycle: </li></ul><ul><ul><li>Systole </li></ul></ul><ul><ul><li>diastole </li></ul></ul>
  3. 4. <ul><li>Electrophysiological properties: </li></ul><ul><ul><li>EXCITABILITY </li></ul></ul><ul><ul><li>AUTOMATICITY </li></ul></ul><ul><ul><li>CONTRACTILITY </li></ul></ul><ul><ul><li>REFRACTORINESS </li></ul></ul><ul><ul><li>CONDUCTIVITY </li></ul></ul><ul><li>Receptors: </li></ul><ul><li>ALPHA adrenergic </li></ul><ul><ul><li>ALPHA 1 </li></ul></ul><ul><ul><li>ALPHA 2 </li></ul></ul><ul><li>BETA adrenergic </li></ul><ul><ul><li>BETA 1 </li></ul></ul><ul><ul><li>BETA 2 </li></ul></ul>
  4. 6. <ul><li>Cardiac Valves: </li></ul><ul><ul><li>Atrioventricular Valves </li></ul></ul><ul><ul><li>Semilunar Valves </li></ul></ul><ul><li>CONDUCTION SYSYTEM: </li></ul><ul><li>SA node  AV node  Bundle Of His  Purkinje fibers </li></ul>
  5. 7. <ul><li>ACTION POTENIAL OF CARDIAC MUSCLE </li></ul><ul><li>5 PHASES: </li></ul><ul><ul><li>PHASE 0 : CELL IS STIMULATED, Na gates open Na enters the cells ( + flow of electrons) DEPOLARIZATION </li></ul></ul><ul><ul><li>PHASE 1 : SHORT PERIOD- Na IN THE CELL equals those outside </li></ul></ul><ul><ul><li>PHASE 2 : “PLATEU STAGE” cell membrane are less permeable to Na., Ca slowly enters the cell., K begins to leave the cell (REPOLARIZATION) </li></ul></ul><ul><ul><li>PHASE 3 : Gates are closed & K rapidly moves out of the cells (RAPID REPLARIZATION) </li></ul></ul><ul><ul><li>PHASE 4 : CELLS COME TO REST. Electrolytes go to their respective places </li></ul></ul>
  6. 8. <ul><li>MECHANICAL ACTIVITY- </li></ul><ul><ul><li>SARCOMERE - basic functional unit of the heart muscle </li></ul></ul><ul><ul><li>ACTIN – 2 contractile proteins of sarcomere (thin filaments) </li></ul></ul><ul><ul><li>MYOSIN – protein of sarcomere that is thick & has small projections </li></ul></ul><ul><ul><li>TROPONIN – protein that seperates actin & myosin when the sarcomere is at rest </li></ul></ul><ul><li>* when heart Ms is stimulated, Ca enters the cells ( starts to repolarize) & Ca reacts c troponin & inactivates it. Allowing actin & myosin to react c each other thus, “ SLIDING FILAMENT THEORY” occurs </li></ul>
  7. 9. <ul><li>NORMAL BLOOD FLOw (TO & FROM THE HEART): </li></ul><ul><li>Inf. Vena Cava & Sup. Vena Cava ( UN O2 BLOOD)  R. Atrium </li></ul><ul><li>( TRICUSPID VALVE )  R. Ventricle  ( PULMONIC VALVE )  </li></ul><ul><li>PULMONARY ARTERY  LUNGS ( OXYGENATED BLOOD ) </li></ul><ul><li> PULMONARY VEIN  L. Atrium  ( MITRAL VALVE )  L. </li></ul><ul><li>Ventricle  ( AORTIC VALVE )  ASCENDING AOTA  </li></ul><ul><li>SYTEMIC CIRCULATION  metabolic demands & </li></ul><ul><li>expenditures </li></ul>
  8. 11. <ul><li>Anti lipidemic drugs- drugs that ↓ lipid amount in the blood. </li></ul><ul><li>Cholesterol-base unit for formation of steroids(sex & cortical hormones),basic unit for the formation & maintenance of cell membrane </li></ul><ul><li>(HMG-Co A): hydroxymethylglutaryl-coenzyme A reductase= regulates the early step in the cellular synthesis of cholesterol 2° to ↓ cholesterol amt. </li></ul><ul><ul><li>HDL : high density cholesterol (good cholesterol), transports cholesterol to the liver for excretion </li></ul></ul><ul><ul><li>LDL : low density cholesterol (bad cholesterol), transport to peripheral tissues (CAD associated ) </li></ul></ul>
  9. 12. <ul><li>CAD (coronary artery dse.)- progressive growth of atheromas in the coronary arteries thereby causing thickrning of the blood vessel (↓oxygenated blood in the heart vs. ↑ oxygen demand & expenditure) </li></ul><ul><li>Risk factors: </li></ul><ul><ul><li>Modifiable: </li></ul></ul><ul><ul><ul><li>Cigarette smoking </li></ul></ul></ul><ul><ul><ul><li>Sedentary lifestyle </li></ul></ul></ul><ul><ul><ul><li>High stress level </li></ul></ul></ul><ul><ul><ul><li>Hypertension </li></ul></ul></ul><ul><ul><ul><li>Obesity </li></ul></ul></ul><ul><ul><ul><li>Diabetes </li></ul></ul></ul><ul><ul><ul><li>Gout </li></ul></ul></ul><ul><ul><ul><li>Chlamydia infection </li></ul></ul></ul><ul><ul><li>Non modifiable: </li></ul></ul><ul><ul><ul><li>Genetic predisposition </li></ul></ul></ul><ul><ul><ul><li>Age </li></ul></ul></ul><ul><ul><ul><li>gender </li></ul></ul></ul>
  10. 14. <ul><li>Hyperlipidemia- ↑level of lipids in the blood </li></ul><ul><li>Flow of cholesterol: dietary fats  stomach  Small intestine  gall bladder (releases bile in S. Intestine)  Bile sythesizes fat (micelles)  micelles absorb in the S.intestine (chylomicrons)/ bile recycled to liver  chylomicrons absorbed in lymphatics  heart  syytemic circulations & metabolic purposes </li></ul><ul><li>ANTIHYPERLIPIDEMIC AGENTS: drugs that ↓cholesterol amount </li></ul><ul><ul><li>BILE ACID SEQUESTRANTS </li></ul></ul><ul><ul><li>HMG-Co A REDUCTASE INHIBITOR </li></ul></ul><ul><ul><li>CHOLESTEROL ABSORPTION INHIBITOR </li></ul></ul><ul><ul><li>OTHER ANTILIPIDEMIC AGENTS </li></ul></ul>
  11. 15. <ul><li>BILE ACID SEQUESTRANTS- binds c bile acids ,↓ levels of bile acid (contains cholesterol) re-entering hepatic circulation. </li></ul><ul><ul><li>CHOLESTYRAMINE (QUESTRAN)- powder that must be dilluted </li></ul></ul><ul><ul><li>COLESTIPOL (COLESTID)- powder & tablet </li></ul></ul><ul><ul><li>COLESEVELAM ( WELCHOL)- tablet </li></ul></ul><ul><li>Actions: ↑ the liver use of cholesterol to make more bile acid(thus, ↓ LDL in the periphery) </li></ul><ul><li>Ix: hyperlipiemia, pruritus, biliary obstruction </li></ul><ul><li>Pharmacokinetics: not absorbed systemically, binds c bile acids in the intestine & excreted in fecal form </li></ul><ul><li>CIx^Cautions: allergy, biliary obstruction, abnormal intestinal function^pregnancy & lactation </li></ul>
  12. 16. <ul><li>Adverse effects: headache, anxiety, fatigue, N & V, ↑ bleeding time ( ↓ absorption of Vit. K),↓clottin factor,↓ Vit A & D </li></ul><ul><li>Nsg Intervention: </li></ul><ul><li>Do not administer powder agents in dry form </li></ul><ul><li>Ensure the consistency, viability of tablets(affects absorption) </li></ul><ul><li>Avoid any drug combinations </li></ul><ul><li>Asses GI functioning (frequency of BM) </li></ul><ul><li>Health teaching about drug </li></ul><ul><li>Support & encouragement </li></ul>
  13. 17. <ul><li>HMG CoA REDUCTASE INHIBITORS- blocks the enzyme LDL levels ↓, HDL ↑. Usually referred as “ statins ” </li></ul><ul><ul><li>ATORVASTATIN (LIPITOR)-can be used in children10-17y/o </li></ul></ul><ul><ul><li>FLUVASTATIN (LESCOL)- fungal product </li></ul></ul><ul><ul><li>LOVASTATIN (MEVACOR)- old version, limited s/effects but can lead to RHABDOMYOLYSIS </li></ul></ul><ul><ul><li>PRAVASTATIN (PRAVACHOL)- effective in CAD & MI px </li></ul></ul><ul><ul><li>ROSUVASTATIN (CRESTOR) newest, ↑HDL ,↓LDL but causes RHABDOMYOLYSIS in asians </li></ul></ul><ul><ul><li>SIMVASTATIN (ZOCOR)- also prevents MI, CAD but no severe toxicity </li></ul></ul>
  14. 18. <ul><li>Actions:blocks the formation of cellular cholesterol (LDL) & may or my not ↑ HDL. </li></ul><ul><li>Pharmacokinetics: all absorbed in the GI, & undergo first pass in the liver, excreted by urine or feces. Peak effects in 2-4 wks. </li></ul><ul><li>CIx^Cautions: allergy, liver & renal dse. (Pregnancy cat X), endocrine abnormality </li></ul><ul><li>Adverse effects: flatulence, abdominal pain, N & V, headache, dizziness, insomnia, liver & renal affetation. </li></ul><ul><li>Nsg. Implementation- </li></ul><ul><li>Administer drug in pm / hs ( ↑ bld cholesterol occurs during night – 5am) </li></ul><ul><li>Monitor cholesterol levels </li></ul>
  15. 19. <ul><li>Monitor liver enzyme levels </li></ul><ul><li>Must be in conjunction c exercise & diet </li></ul><ul><li>Suggest lifestyle changes </li></ul><ul><li>Periodic opthalmic exam </li></ul><ul><li>Stop lovastatin, atorvastatin, fluvastatin in any acute serious medical condition (infection, ↓ BP, major surgery, trauma, endocrine d/o) </li></ul><ul><li>Pregnancy & lactating caution / alternatives </li></ul><ul><li>Health teaching abt. Medication </li></ul>
  16. 20. <ul><li>CHOLESTEROL ABSORPTION INHIBITORS- ↓ absorption of cholesterol in the small intestine, ↓ dietary cholesterol delivered in the liver & liver ↑ cholesterol clearance </li></ul><ul><ul><li>EZETIMIBE (ZETIA) </li></ul></ul><ul><li>Ix: hyperlipidemia, adjunct to diet & exercise </li></ul><ul><li>Pharmacokinetics: absorbed properly. Peaks 4-6hrs. </li></ul><ul><li>CIx^Cautions: allergy, pregnant & lactating, liver & kidney dse. </li></ul><ul><li>Adverse effects: diarrhea, abdominal pain, back pain, URTI, muscle aches & pain </li></ul>
  17. 21. <ul><li>Nsg Implementation: </li></ul><ul><ul><li>Monitor cholesterol, triglyceride LDL levls </li></ul></ul><ul><ul><li>Monitor liver function test </li></ul></ul><ul><ul><li>Advise diet & exercise regiment </li></ul></ul><ul><ul><li>Discuss possibilty of lifestyle changes </li></ul></ul><ul><ul><li>Patient teaching </li></ul></ul><ul><li>Other Antilipidemic drugs </li></ul><ul><ul><li>FIBRATES (fibric acid derivatives) </li></ul></ul><ul><ul><li>NIACIN </li></ul></ul>
  18. 22. <ul><li>FIBRATES- stimulate breakdown of lipoproteins from tissue & remove it in plasma, ↓lipoprotein & triglyceride synthesis & secretion </li></ul><ul><ul><li>FENOFIBRATE (TRICOR)- inhibits triglyceride synthesis in the liver, decreases LDL, increases uric acid secretion, may stimulate triglyceride breakdown </li></ul></ul><ul><ul><li>GEMFIBROZIL (LOPID)- inhibits lipid breakdon in periphery, reduces production of triglycerides & LDL, increases HDL . Should not be combined c statins (RHABDOMYOLYSIS) </li></ul></ul><ul><li>NIACIN-VIT. B3, inhibits the release of free fatty acids from adipose tse. ↑ rate of triglyceride removal from plasma & generally ↓LDL, ↑HDL </li></ul><ul><ul><li>NIACIN (NIASPAN / NICOTINIC ACID)- </li></ul></ul>
  19. 23. <ul><li>BLOOD P °- P° exerted by the heart to the arterial walls </li></ul><ul><li>DETERMINANTS: </li></ul><ul><ul><li>HEART RATE </li></ul></ul><ul><ul><li>STROKE VOLUME-amt. of bld pumped out of the left ventricle c each heartbeat </li></ul></ul><ul><ul><li>PERIPHERAL RESISTANCE- resistance of muscular arteries to the bld being pumped through </li></ul></ul><ul><li>VASOGENIC CENTER- loc in the medulla oblongata </li></ul><ul><li>BARORECEPTORS / P° RECEPTORS- can be found in the atria,arteries </li></ul>
  20. 24. <ul><li>RENIN-ANGIOTENSIN SYSTEM- compensatory mechanism by the kidney (hypotension / lack of oxygen in the kidneys occurs) </li></ul><ul><li>Renin  liver (produces angiotensin)  angiotensin I  bloodstream  LUNGS (converts I-II by the use of A.C.E.  Angiotensin II  angiotensin II receptor in the blood vessels  VASOCONSTRICTION </li></ul><ul><li>Angiotension II  angiotensin III  stimulates adrenal cortex (produces aldosterone)m = Water & Na retention. </li></ul><ul><li>HYPERTENSION / HPN / HTN- bld p° is above normal 140/90 mmhg </li></ul><ul><ul><li>Pre hypertension, Stage 1 & 2 </li></ul></ul><ul><li>HYPOTENSION- bld pressure is below normal </li></ul>
  21. 25. <ul><li>HYPERTENSION CONTROL </li></ul><ul><ul><li>STEP 1: lifestyle modifications ( diet, exercise, etc.) </li></ul></ul><ul><ul><li>STEP 2: drugs are added (failed step 1) DIURETICS (dec. serum Na levels), BETA BLOCKERS (dec. HR & strength of contrcation, & vasodilaion), ACE inhibitor (blocks conversion of angiotensinI –II), Ca CHANNEL BLOCKER ( relaxes Ms contraction), or AUTONOMIC BLOCKER </li></ul></ul><ul><ul><li>STEP 3: inadequate response to former step, drug may be changed, combined or increased. </li></ul></ul><ul><ul><li>STEP 4: combination of the 3 former steps. </li></ul></ul>
  22. 26. <ul><li>DIURETICS- drugs that promote urination (excretes Na & K) </li></ul><ul><li>Classifications: </li></ul><ul><ul><li>THIAZIDES & THIAZIDE LIKE DIURETIC / K sparing diuretics = prevents K loss, K is reabsorbed in the proximal renal tubule </li></ul></ul><ul><ul><ul><li>Ex: INDAPAMIDE, METALAZONE, HYDROCHLOROTHIAZIDE,CHLOROTHIAZIDE </li></ul></ul></ul><ul><ul><li>LOOP DIURETICS / K w asting diuretics = does not promote K reabsorption </li></ul></ul><ul><ul><ul><li>Ex: FUROSEMIDE, ETHACRYNIC ACID, BUMETANIDE </li></ul></ul></ul>
  23. 27. <ul><li>SYMPATHETIC BLOCKERS </li></ul><ul><ul><li>BETA BLOCKERS: blocks vasoconstriction, ↓HR cardiac Ms contraction, ↑ bld flow to kidneys (↓ release of renin), these drugs have many side effects, not recommended for all people, often used in monotherapy in step 2 </li></ul></ul><ul><ul><li>Ex: ACEBUTOLOL, ATENOLOL, METOPROLOL,PROPANOLOL </li></ul></ul><ul><ul><li>2. ALPHA & BETA BLOCKERS: useful in combination c other agents. More potent in blocking the SNS response. Px often complain of fatigue , inability to sleep, GI & Gu disturbance </li></ul></ul><ul><ul><li>Ex: CARVEDILOL, LABETALOL, GUABENZ, GUANADREL, GUANETHIDINE </li></ul></ul>
  24. 28. <ul><ul><li>ALPHA ADRENERGIC BLOCKERS: inhibit the postsynaptic receptor sites. alpha1 receptor blocker (dec. SNS tone,= vasodilation), alpha2 receptor blocker (prevents norepinephrine release) </li></ul></ul><ul><ul><li>Ex: PHENOXYBENZAMINE, PHENTOLAMINE </li></ul></ul><ul><ul><li>ALPHA2 AGONIST- stimulate the alpha2 receptors in CNS (inhibits the CV center to lower Sympathetic outflow) </li></ul></ul><ul><ul><li>Ex: CLONIDINE, GUANFACINE, METHYLDOPA </li></ul></ul><ul><ul><li>ALPHA1 BLOCKER: decreases vascular tone, vasodilation. </li></ul></ul><ul><ul><li>Ex: DOXAZOSIN, PRAZOSIN, TERAZOSIN </li></ul></ul>
  25. 29. <ul><li>ANGIOTENSIN CONVERTING ENZYME- blocks the conversion of (RAAS), can be combined c diuretics </li></ul><ul><ul><li>BENAZEPRIL (LOTENSIN)- for HPN only, can cause cough </li></ul></ul><ul><ul><li>CAPTOPRIL ( CAPOTEN)- HPN & CHF, DIBETIC NEPHROPATHY, LVF p MI. can cause cough, GI distress </li></ul></ul><ul><ul><li>ENALAPRIL (VASOTEC)- HPN, CHF, LVF </li></ul></ul><ul><ul><li>LISINOPRIL (ZESTRIL)- HPN, CHF, a day POST MI px. </li></ul></ul><ul><li>Pharmacokinetics: crosses placenta & breastmilk. </li></ul><ul><li>CIx^Cautions: allergy, renal & liver dse. Pregnant & lactating^ CHF, hyponatremic px </li></ul><ul><li>Adverse effects: tachycardia, MI, rash, pruritus, GI irritation, pancyopenia, proteinuria </li></ul>
  26. 30. <ul><li>Nsg. Implementation: </li></ul><ul><li>Encourage px to implement lifestyle changes (diet, exercise, smoking cessation etc.,) </li></ul><ul><li>Complete medical Hx (pregnant / Lactating) </li></ul><ul><li>Getting baseline data (VS) proior to giving the drug </li></ul><ul><li>Provide thorough px teaching about the drug </li></ul><ul><li>Know appropriate actions / interventions to do due to occurrence of side effects </li></ul>
  27. 31. <ul><li>CALCIUM CHANNEL BLOCKER- prevents the movement of calcium into the cardiac & smooth Ms hen the cells are stimulated (inability to contract & loss of smooth Ms tone, vasodilation, dec. peripheral resistance) can be also effective in treatment of angina (dec. cardiac workload) </li></ul><ul><ul><li>AMLODIPINE (NORVASC)- hpn & angina </li></ul></ul><ul><ul><li>DILTIAZEM (DILZEM)- hpn (sustained release) </li></ul></ul><ul><ul><li>FELODIPINE (PLENDIL)- hpn </li></ul></ul><ul><ul><li>VERAPAMIL (CALAN)- hpn , arrythmia (sustained release) </li></ul></ul><ul><li>Pharmacokinetics: gen absorbed in the body. Crosses the placenta </li></ul><ul><li>CIx^Cautions : allergy, pregnant & lactating, renal & hepatic dse. </li></ul>
  28. 32. <ul><li>Adverse effects : dizziness, headache, fatigue, hypotension, bradycardia, edema, heart block, skin flushing </li></ul><ul><li>Nsg. Implementation : </li></ul><ul><li>Complete medical & drug Hx </li></ul><ul><li>Take VS & baseline data full minute </li></ul><ul><li>Thorough assessment prior, during & after drug administration </li></ul><ul><li>Do appropriate protocol during adverse effects & refer accordingly </li></ul>
  29. 33. <ul><li>VASODILATORS - used when other therapies fail. Produces relaxation of vascular smooth Ms. dec. peripheral resistance & BP. Do not block reflex tachycardia. Used in severe hypertension </li></ul><ul><ul><li>HYDRALAZINE (APRESOLINE )-maintains increase blood flow while relaxing smooth Ms. </li></ul></ul><ul><ul><li>NITROPUSIDE (NIPRIDE)- used in the tx of hypertensive crisis </li></ul></ul><ul><li>Pharmacokinetics: rapidly absorbed & widely distributed </li></ul><ul><li>CIx^Cautions: allergy, renal & hepatic dse., pregnant & lactating px., ^ CHF, CAD, cerebral insuficiency, hypotension </li></ul><ul><li>Nsg. Implementation : </li></ul><ul><li>Monitor VS & other baseline data </li></ul><ul><li>Health teaching about the drugs & related factors </li></ul><ul><li>Observe px for adverse reaction to drug </li></ul><ul><li>Manage px (reacted adversely) properly </li></ul>
  30. 34. <ul><li>OTHER ANTI HPN DRUGS- tx of severe HPN </li></ul><ul><ul><li>MECAMYLAMINE ( INVERSINE)- occupies cholinergic receptor sites of autonomic neuron (blocks Ach at Sympathetic & Parasymoathetic ganglion) </li></ul></ul><ul><li>ANTI HYPOTENSIVE DRUGS- usually indicated if px BP is decreased. Use of (SYMPATHOMIMETIC DRUGS) </li></ul><ul><li>SYMPATHOMIMETIC DRUGS- react c sympathetic adrenergic receptors( ↑ BP, blood vol., Cardiac Ms contraction) </li></ul><ul><ul><li>MIDODRINE (Pro-Amatine)- tx for orthostatic hypotension </li></ul></ul><ul><ul><li>Action: activates alpha receptors in arteries & veins to ↑BP (can also be used in px having liver dse) </li></ul></ul><ul><ul><li>Pharmacokinetics: absorbed in GI, </li></ul></ul><ul><ul><li>CIx^Cautions: supine hpn, CAD, ARF, pregnant & lactating px </li></ul></ul><ul><ul><li>Adverse effects: piloerection, rash, vision changes, vertigo, headache, problem in urination. </li></ul></ul>
  31. 35. <ul><li>Nsg. Implementation </li></ul><ul><li>Monitor VS (BP prior to giving meds) </li></ul><ul><li>Comfort measures </li></ul><ul><li>CIx in bedridden px </li></ul><ul><li>OTHER SYMPATHOMIMETIC DRUGS </li></ul><ul><ul><li>DOBUTAMINE </li></ul></ul><ul><ul><li>DOPAMINE </li></ul></ul><ul><ul><li>EPHEDRINE </li></ul></ul><ul><ul><li>EPINEPHRINE </li></ul></ul><ul><ul><li>ISOPROTERENOL </li></ul></ul><ul><ul><li>METARAMINOL </li></ul></ul>
  32. 36. <ul><li>CONGETIVE HEART FAILURE- “dropsy” heart fails to pump blood around the body. </li></ul><ul><li>CAUSES: </li></ul><ul><ul><li>CAD- 95% cause of CHF, insufficiency of blood to meet O 2 demand of the myocardium (Ms becomes hypoxic & ↓ capacity to contract ) </li></ul></ul><ul><ul><li>CARDIOMYOPATHY- viral infection, alcoholism, steroid abuse, collagen d/o </li></ul></ul><ul><ul><li>HPN- leads to enlarged cardiac Ms ( puts cardiac Ms in constant ↑ oxygen demand) </li></ul></ul><ul><ul><li>VALVULAR HEART DSE.- overload of the ventricles due to inadequate closing of the valves (leakages of blood / backflo w) </li></ul></ul>
  33. 37. <ul><li>RIGHT SIDE HEART FAILURE vs. LEFT SIDE HEART FAILURE </li></ul><ul><li>COMPENSATION: </li></ul><ul><li>↓ CO  stimulation of barroreceptors (aortic arch &carotid sinus)  ↑ SNS response (↑ HR, BP, rate & depth of RR, +inotropic effect , blood volume )  RAAS (kidneys)  compensated CHF  overtime prolonged stress to the heart (cardiomegaly)  heart Ms increases due to over work & chambers of the heart dilate (↑ blood volume they have to handle ) will further lead to aggravated CHF. </li></ul>
  34. 38. <ul><li>TREATMENT: </li></ul><ul><ul><li>VASODILATORS (ACE inhibitors & NITRATES)- ↓ work load of the heart </li></ul></ul><ul><ul><li>DIURETICS- ↓ blood volume, venous return & BP </li></ul></ul><ul><ul><li>BETA ADRENERGIC AGONIST- stimulate beta receptors in SNS (↑ Ca flo w in heart cells, myocardial contraction) </li></ul></ul><ul><ul><li>CARDIOTONIC (“INOTROPIC” / “PRESSORS”)- ↑ heart contraction </li></ul></ul><ul><ul><ul><li>4. 1 CARDIAC GLYCOSIDES (lanoxin)- most often used in CHF rapid action onset & can be safely be excreted unchanged in the urine ( antidote=digoxin immune fab) </li></ul></ul></ul><ul><li>Action: ↑ intracellular Ca, allows Ca to enter myocardial cells during depolarization. </li></ul><ul><ul><ul><li>↑ myocardial contraction (inotropic effect) </li></ul></ul></ul><ul><ul><ul><li>↑ CO & renal perfusion( ↑urine output, ↓ blood vol.↓renin release & renin angiotensin system) </li></ul></ul></ul><ul><ul><ul><li>↓ HR (- chronotropic effect) ↓conduction velocity in AV node </li></ul></ul></ul>
  35. 39. <ul><li>CIx^Cautions: allergy, Vtach & Vfib, heart block,SSS, AMI,^ pregnant & lactating px. </li></ul><ul><li>Adverse effects: headache, yello w halo around objects=digitalis toxicity </li></ul><ul><li>Nsg. Implementation : </li></ul><ul><li>Monitor apical pulse 1 full min </li></ul><ul><li>Check dosage & preparation </li></ul><ul><li>Standby emergency equipments & meds (lidocaine, K salts, dilantin, atropine, Ca monitor) </li></ul><ul><li>Avoid combining it c food & antacids </li></ul><ul><li>Monitor px for therapeutic level (0.5-2ng/ml) </li></ul><ul><li>Monitor electrolyte level (K) </li></ul>
  36. 40. <ul><ul><li>4. 2 PHOSPODIESTERASE INHIBITORS- used for px unresponsive to glycoside tx. Short term CHF tx only </li></ul></ul><ul><ul><ul><li>INAMRINONE (INOCOR)- iv prep only </li></ul></ul></ul><ul><ul><ul><li>MILRINONE (PRIMACOR)- </li></ul></ul></ul><ul><li>Action: blocks the enzyme phospodiesterase & ↑myocardial cell adenosine monophospate (↑ Ca levels in the cells=stronger contraction & prolongs the effect of sympathetic stimulation) </li></ul><ul><li>Pharmacokinetics: widely distributed post injection </li></ul><ul><li>CIx^Cautions: allergy, aortic & pulmonic valvular dse. Acute MI, hypovolemia, elderly px, pregnant & lactating px. </li></ul><ul><li>Adverse effects : ventricular arrythmias (Vfib), hypotension, chest pain, N & V, etc., </li></ul><ul><li>Nsg. Implementation: </li></ul><ul><li>Monitor BP & PR (hook px to cardiac monitor) </li></ul><ul><li>Monitor px for adverse effects (arrythmias) </li></ul><ul><li>Accurate I & O </li></ul>
  37. 41. <ul><li>ARRYTHMIA / DYSRYTHMIA- abnormality / disturbance in normal & rate & rhythm of the heart </li></ul><ul><ul><li>Bradycardia </li></ul></ul><ul><ul><li>Tachycardia </li></ul></ul><ul><ul><li>(PAC / PVC, Atrial flutter / Atrial fibrilation, Vtach / Vfib, AV heart blocks 1-3, bundle blocks) </li></ul></ul><ul><li>CAUSES: changes in automaticity & conductivity) </li></ul><ul><li>Electrolyte disturbance alters action potential </li></ul><ul><li>Oxygen deprivation (hypoxia / anoxia) </li></ul><ul><li>Structural damage in the conduction pathways through the heart </li></ul><ul><li>Alteration in bld. Acidity / alkalinity (waste products accumulation) </li></ul>
  38. 42. <ul><li>ANTIARRYTHMIC AGENTS- corrects dysrythmia </li></ul><ul><ul><li>CLASS 1(a,b,c),2 ,3 ,4 & others </li></ul></ul><ul><li>CLASS 1: blocks the Na channels in the cell during action potential ( local anesthetics / membrane stabilizers) </li></ul><ul><ul><li>1a: ↓ & prolongs phase 0 of the action potential </li></ul></ul><ul><ul><ul><li>DISOPYRAMIDE (NORPACE)- tx for ventricular arrythmia (adult & young px) </li></ul></ul></ul><ul><ul><ul><li>MORICIZINE (ETHMOZINE)- ↑ cardiac deaths (proarrytmia) </li></ul></ul></ul><ul><ul><ul><li>PROCAINAMIDE (PROCAINE)-for tx of ventricular arrythmia (po, im, iv prep) </li></ul></ul></ul><ul><ul><li>1b: ↓ & shorten duration of action potential </li></ul></ul><ul><ul><ul><li>LIDOCAINE (XYLOCAINE)- vtach / vfib in MI or cardiac surgery px. </li></ul></ul></ul><ul><ul><li>1c: markedly ↓ phase 0 (extreme slo wing of conduction) </li></ul></ul><ul><ul><ul><li>FLECAINIDE (TAMBOCOR)-tx Vtach & PAT,( ↑mortality) </li></ul></ul></ul>
  39. 43. <ul><li>CLASS 2: beta adrenergic blockers causing depressed phase4 of the action potential( slows cell recovery, conduction & automaticity) </li></ul><ul><ul><li>ACEBUTOLOL (SECTRAL)- anti hpn drug, tx of PVC’s </li></ul></ul><ul><ul><li>ESMOLOL (BREVIBLOC)- short term tx for SVT </li></ul></ul><ul><ul><li>PROPANOLOL (INDERAL)- anti hpn, anti angina, anti migraine headache & anti SVT due to digoxine or cathecolamine overdose </li></ul></ul><ul><li>CLASS 3: blocks K channels & prolongs phase 3 of action potential (delays repolarization & conduction rate) </li></ul><ul><ul><li>AMIODARONE (CORDARONE)- not usually 1 st choice </li></ul></ul><ul><ul><li>SOTALOL (BETAPACE)-tx for maintenance of NSR & can cause any arrythmia (proarrythmia) </li></ul></ul><ul><ul><li>BRETYLIUM-for unresponsive arrythmia to other drugs </li></ul></ul><ul><ul><li>IBUTILIDE (CORVERT)- converts atrial fibrillation to flutter of recent onset (less 90 days) </li></ul></ul>
  40. 44. <ul><li>CLASS 4: blocks Ca channel in the cell membranes(↓depolarization, ↑prolongation of phase 1&2 replarization) </li></ul><ul><ul><li>DILTIAZEM (CARDIZEM)- treats PSVT </li></ul></ul><ul><ul><li>VERAPAMIL ( CALAN)- treats SVT, atrial flutter & fibrillation </li></ul></ul>
  41. 46. <ul><li>ANTIANGINAL DRUGS- helps restore 0xygen supply Vs. demand by 1. dilating tha coronary vessels, 2. decreasing load of the heart. </li></ul><ul><ul><li>NITRATES / NITROGLYCERIN: cause smooth Ms relaxation & Ms tone (fast acting, dilates veins, arteries & capillaries. </li></ul></ul><ul><li>NITRO-BID / NITROSTAT- given SL / TL (spray), IV, patch, transmucosal, PO. Fast acting. </li></ul><ul><ul><li>ISOSORBIDE DI NITRATE (ISORDIL) slow effect but last upto </li></ul></ul><ul><ul><li>ISOSORBIDE MONO NITRATE (IMDUR)4 hrs. taken prior to angina attacks </li></ul></ul><ul><ul><li>AMYL NITRATE (GENERIC)- inhaled & takes effect in 30 secs. </li></ul></ul><ul><li>CIx^Caution: allergy, hypotension, cerebral bleeding, pregnant & lactating px </li></ul><ul><li>Adverse effects: ↓BP, headache, dizziness, tachycardia, N & V ↑ </li></ul>
  42. 47. <ul><li>CORONARY ARTERY DSE- narro wed lumen of the bld vessel ( blood & oxygen are decreased) due to atheromas therby causing atherosclerosis. </li></ul><ul><li>ANGINA PECTORIS- “chest pain” “suffocation of the chest” </li></ul><ul><li>STABLE ANGINA- relieved by rest & NTG no damage to heart cells are noted </li></ul><ul><li>UNSTABLE ANGINA- more pronounced. Heart is having ischemia. Unrelieved by rest & NTG. No complete damge to heart is noted </li></ul><ul><li>PRINZMETAL ANGINA- spasm of blood vessels not narrowing occurs. Pain occurs at rest at the same time of the day (each day) </li></ul><ul><li>MYOCARDIAL INFARCTION- completely occluded coronary vessels leading to injury, ischemia, necrosis </li></ul>
  43. 49. <ul><li>Nsg. Iplementation: </li></ul><ul><li>Give drug in SL route not oral </li></ul><ul><li>Asks the px if the tablet given “fizzles” or “burns” </li></ul><ul><li>Check for the expiry date </li></ul><ul><li>Assess VS one full minute & baseline data </li></ul><ul><li>Instruct the px to maintain sitting / lying position during & after administration to prevent fall </li></ul><ul><li>Health teaching about the drug </li></ul>
  44. 50. <ul><li>BETA BLOCKERS- blocks SNS ( ↓BP, HR, ↑myocardial contractility) </li></ul><ul><ul><li>METOPROLOL (NEOBLOC)- dilates cardiac & renal vessels, decrease cardiac load & potentiates every cardiac beat </li></ul></ul><ul><ul><li>PROPANOLOL (INDERAL)- </li></ul></ul><ul><ul><li>NADOLOL (CORGARD)- </li></ul></ul><ul><li>Pharmacokinetics- metabolized in liver excreted by urine </li></ul><ul><li>CIx^Caution: allergy, bradycardia, heart block, cardiogenic shock^ DM, PVD </li></ul><ul><li>Adverse effects: dizziness, vertigo, CHF, arrythmias, flatulence, impotence, decreased exercise tolerance. </li></ul>
  45. 51. <ul><li>Nsg. Implementation </li></ul><ul><li>Do not abruptly DC these drugs </li></ul><ul><li>Must be given c food for better absorption </li></ul><ul><li>Assess VS prior & after giving the medication </li></ul><ul><li>Health teaching for px </li></ul><ul><li>Prevent falls </li></ul>
  46. 52. <ul><li>CALCIUM CHANNEL BLOCKER- prevents Ca movement into cardiac & smooth Ms cells upon stimulation. </li></ul><ul><ul><li>AMLODIPINE (NORVASC)-prinzmetal angina, coronary </li></ul></ul><ul><ul><li>DILTIAZEM (DILZEM) vasospasm, chronic angina, </li></ul></ul><ul><ul><li>NICARDIPINE (CARDENE)effort associated angina pectoris </li></ul></ul><ul><ul><li>NIFEDIPINE (CALCIBLOC) hypertension </li></ul></ul><ul><ul><li>VERAPAMIL (ISOPTIN)- arrythmia </li></ul></ul><ul><li>Pharmacokinetics: gen. absorbed, metabolized in liver. Crosses placenta & breast milk </li></ul><ul><li>CIx^Cautions: allergy, pregnant & lactating, liver & kidney dse. </li></ul><ul><li>Adverse effects: hypotension, bradycardia, dizziness, heart block, flush & rush </li></ul>
  47. 53. <ul><li>BLOOD COAGULATION- complex process involving vasoconstriction, platelet clamping, & clotting factor </li></ul><ul><li>CLOTTING FACTOR- produced in the liver & breaks do w n fibrinogen into insoluble fibrin threads. </li></ul><ul><li>INTRINSIC PATH W AY: </li></ul><ul><li>HAGEMAN FACTOR- clotting factor XII (chemical found in the bld.) activated due to exposure of damage bld vessels to collagen </li></ul><ul><li>EFFECTS: </li></ul><ul><li>Clot formation activated </li></ul><ul><li>Clot dissolving process iniated </li></ul><ul><li>Inflammatory response started </li></ul><ul><li>Activation of clotting factor XI (plasma thromboplasmin antecedent / PTA) & activates cascade sereies of coagulant substances “intrinsic pathway”: </li></ul><ul><li>ends in the conversion of prothrombin to thrombin (converts fibrinogen to insoluble fibrin threads)  (thrombus)  plugs the injury & seal the sysytem </li></ul>
  48. 54. <ul><li>EXTRINSIC PATH WAY: clotting outside the vessel. Tissue Thromboplastin released by injured cells. </li></ul><ul><li>PLATELET AGGREGATION- adhesion of platelets in the endothelial lining / site of injury. </li></ul><ul><ul><li>Once they stick, releases ADP & other chemicals to attract other platelets to stick as well. </li></ul></ul><ul><li>CLOT RESOLUTION & ANTICLOTTING- blood plasma contains anti clotting substances: </li></ul><ul><ul><li>ANTITHROMBIN III- prevents thrombin formation </li></ul></ul><ul><ul><li>PLASMIN / FIBRINOLYSIN- blood protein that breaks do w n blood clot </li></ul></ul><ul><li>THROMBOEMBOLIC D/O- common </li></ul><ul><ul><li>CORONARY ARTERY DSE. </li></ul></ul><ul><ul><li>CVA, PVD , AMI, DVT </li></ul></ul><ul><ul><ul><li>HYPOXEMIA, HYPOXIA, NECROSIS DUE TO LO W OXYGEN & BLOOD SUPPLY </li></ul></ul></ul>
  49. 55. <ul><li>HEMORRHAGIC D/O- rare. </li></ul><ul><ul><li>HEMOPHILIAS, BLOOD DYSCRASIAS, DENGUE, OVERDOSE OF ANTICOAGULANT THERAPY </li></ul></ul><ul><li>ANTICOAGULANTS- drugs that interfere c normal coagulation process. </li></ul><ul><li>ANTIPLATELET DRUGS: ↓ formation of platelet plug by ↓ responsiveness of the platelets to stimuli that cause them to stick in the vessel </li></ul><ul><ul><li>ASPIRIN (ASA)- TIA, CVA, & MI </li></ul></ul><ul><ul><li>PLAVIX (CLOPIDOGREL)- MI, CVA, ISCHEMIA </li></ul></ul><ul><ul><li>PLETAAL (CILOSTAZOL)- INTERMITTENT CLAUDICATION </li></ul></ul><ul><li>Pharmacokinetics: higly bound to proteins </li></ul><ul><li>CIx^Cautions: allergy, bleeding d/o, pregnant & lactating px </li></ul><ul><li>Adverse effects: bleeding, bruising, headache, dizziness, weakness, N & V, GI distress, rash </li></ul>
  50. 56. <ul><li>Nsg. Implementation: </li></ul><ul><li>Small frequent feeding (GI disturbance) </li></ul><ul><li>Symptomatic treatment for (aches & pain) </li></ul><ul><li>Precautions against bleeding </li></ul><ul><li>Health teaching about the drug </li></ul><ul><li>ANTICOAGULANT - alters coagulation process clotting cascade, thrombin formation </li></ul><ul><ul><li>WARFARIN (COUMADIN)- DVT, PULMO EMBOLUS A-FIB, MI *3days to effect & lasts 4-5 days (not ideal for acute cases)* </li></ul></ul><ul><ul><li>HEPARIN (GENERIC)- DVT, A-FIB,PULMO EMBOLUS, DIC, ABG, CLOTTING IN IV LINE *does not cross breast milk (ideal-lactating) </li></ul></ul><ul><li>Pharmacokinetics: varies in each drug </li></ul>
  51. 57. <ul><li>CIx^Cautions: allergy, bleeding d/o, liver & kidney dse. ^CHF, </li></ul><ul><li>Adverse effects: bleeding (gums to sever internal hge.), hair loss, N & V, GI upset, diarrhea, bruising, </li></ul><ul><li>Nsg. Implementation: </li></ul><ul><li>Monitor for therapeutic level (Heparin: clotting time & APTT) </li></ul><ul><li>(Coumadin: PT & INR) </li></ul><ul><li>Observe for S / Sx of excessive bleeding </li></ul><ul><li>Keep antidotes available (Heparin: Protamine SO4) (Coumadin: Vit. K / Konakion) </li></ul><ul><li>Safety & comfort measures </li></ul>
  52. 58. <ul><li>LO W MOLECULAR Wt. HEPARIN- blocks factor Xa , IIa & angiogenesis ( process that allows CANCER cells to develop new bld vessels. used pre or post surgery & prolonged bed rest ( ↑ risk of thrombus formation ) & is continued for 7days - 2wks. </li></ul><ul><ul><li>TINZAPARIN (INNOHEP)- DVT, used c coumadin </li></ul></ul><ul><ul><li>DALTEPARIN (FRAGMIN)- DVT, Pulmo Embolus, Unstable Angina </li></ul></ul><ul><ul><li>ENOXAPARIN (CLEXANE)- DVT, Angina, Pulmo Embolus,MI </li></ul></ul><ul><li>CIx^Cautions: bleeding d/o, pregnant & lactating, should be used c standard heparin </li></ul>
  53. 59. <ul><li>THROMBLOLYTICS- destroys formed thrombus by activating natural anticlotting system (conversion of plasminogen to plasmin) </li></ul><ul><ul><li>STREPTOKINASE (STREPTASE)- Coronary Artery Thrombosis , Pulmo embolus, MI, DVT </li></ul></ul><ul><ul><li>UROKINASE ( ABBOKINASE)- Coronary Artery Thrombosis, MI, </li></ul></ul><ul><li>Pharmacokinetics: fast acting , iv preparations only. </li></ul><ul><li>CIx^Cautions: allergy, liver & kidney dse, pregnant & lactating, bleeding d/o </li></ul><ul><li>Adverse effects: bleeding (gums & internal organs), bruising, rash, flushing (allergic reaction), bronchospasm, </li></ul><ul><li>Nsg. Implementation: </li></ul><ul><li>Administer AH prior to giving thrombolytics </li></ul><ul><li>Prepare for blood typing & cross matching (F WB) </li></ul><ul><li>Monitor for bleeding </li></ul>
  54. 60. <ul><li>Nsg. Implementation </li></ul><ul><li>DC heparin if px is having thrombolytics (unless ordered) </li></ul><ul><li>Monitor & assess px for S/Sx of bleeding </li></ul><ul><li>Monitor blood coagulation results </li></ul><ul><li>Bleeding precautions </li></ul><ul><li>Thorough px teaching & evaluate teaching plan </li></ul>
  55. 61. <ul><li>BLEEDING D/O </li></ul><ul><ul><li>HEMOPHILIA – genetic d/o px lacks clotting factor </li></ul></ul><ul><ul><li>LIVER Dse. – affects production of clotting factors & proteins needed to prevent bleeding </li></ul></ul><ul><ul><li>BONE MARRO W d/o – platelet are not formed in sufficient quantity to be effective </li></ul></ul><ul><li>Anti Hemophilic agents: </li></ul><ul><ul><li>ANTIHEMOPHILIC FACTOR (Bioclate, ReFacto) – factor VIII (clotting factor missing in Hemophilia A) </li></ul></ul><ul><ul><li>COAGULATION FACTOR VIIa (NovoSeven) – for Hemophilia A & B </li></ul></ul><ul><ul><li>FACTOR IX COMPLEX (Benefix, Profilnine SD) – contains plasma fractions of many of the clotting factors & ↑ blood levels of factors II, VII, X, used for tx of (hemophilia B (christmas dse. - ↓ factor IX), control bleeding episodes in Hemophilia A & factor VII deficiency. </li></ul></ul>
  56. 62. <ul><li>Cautions^CIx: allergy, pregnant & lactating liver dse c DIC </li></ul><ul><li>Adverse effects: headcahe, flushing , chills, fever, lethargy , N & V, </li></ul><ul><li>Nsg. Implementation: </li></ul><ul><li>Should be administered IV route only </li></ul><ul><li>Monitor px response & clotting factor levels </li></ul><ul><li>Monitor px for S/Sx of thrombosis ( compressive stockings, positiioning, ambulation, exercise ) </li></ul><ul><li>Decrease rate of infusion if allergic reaction occurs </li></ul><ul><li>Arrange bld typing & cross matching in case of serious blood loss. </li></ul><ul><li>Provide px teaching. </li></ul><ul><li>Offer support & encouragement </li></ul>
  57. 63. <ul><li>Systemic Bleeding: result of excessive plasminogen activity & risk of bleeding from clot dissolution </li></ul><ul><li>HEMOSTATIC DRUGS – drugs used to control / treat bleeding </li></ul><ul><ul><li>APROTININ (Trasylol) – IV drug that forms complexes c kinins, plasmins, & other clot dissolving factor to block the activation of plasminogen system. Usu for CABG pxs. </li></ul></ul><ul><ul><li>AMINOCAPRIC ACID (AMICAR) – inhibits plasminogen activating substance & some antiplasmin activity. Oral & IV form usually prevents recurrence of SAH </li></ul></ul><ul><li>Cautions^CIx: allergy, DIC, ^ cardiac conditions, renal & hepatic dysfxn., </li></ul><ul><li>Adverse effects : clotting, hallucinations, dizziness, N & V, diarrhea, fatigue, malaise, etc., </li></ul><ul><li>Nsg. Implementation: </li></ul><ul><li>Monitor px for S/Sx of thrombosis </li></ul><ul><li>Orient px & safety measures if hallucination occurs </li></ul>
  58. 65. <ul><li>RESPIRATORY SYTEM: brings O 2 in the body, allows exchange of gases & expels CO 2 & other end products. </li></ul><ul><li>MAJOR PARTS </li></ul><ul><ul><li>UPPER RESP. TRACT </li></ul></ul><ul><ul><ul><li>- nose c (conchae) – entry & filters inhaled air </li></ul></ul></ul><ul><ul><ul><li>nasal cavity c (epithelial lining) - warms & humidifies air </li></ul></ul></ul><ul><ul><ul><ul><li>contains goblet cells that produce mucus, traps dust & microorganisms, pollen & other foreign substances </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Contains cilia , microscopic hair-like projections of the cell membrane, constanly moving to profell mucus down towards the throat </li></ul></ul></ul></ul><ul><ul><ul><li>Sinuses (pairs) – air filled passages through the skull </li></ul></ul></ul><ul><ul><ul><li>Phaynx – funnel shaped tube extends from nose to larynx </li></ul></ul></ul><ul><ul><ul><ul><ul><li>Has 3 parts (na sopharynx , oropharynx, larygopharynx ) </li></ul></ul></ul></ul></ul><ul><ul><ul><li>Larynx – aka “voice box” lies anterior to esophagus. </li></ul></ul></ul>
  59. 67. <ul><ul><li>LO WER RESP. TRACT </li></ul></ul><ul><ul><ul><li>Trachea – aka “windpipe” from larynx to T7 then divides into </li></ul></ul></ul><ul><ul><ul><li>R & L bronchus – R is shorter, wider more vertically downward than L </li></ul></ul></ul><ul><ul><ul><ul><li>Segmental bronchi & subsegmental bronchi </li></ul></ul></ul></ul><ul><ul><ul><ul><li>- Bronchioles – final path wat to the alveoli </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Terminal bronchioles – last airways of the conduction system (nose – terminal bronchioles = antomic dead space ) </li></ul></ul></ul></ul></ul><ul><li>LUNGS – paired organs in the thoracic cavity capable of oxygenting blood & expelling CO2 apex= T1, base= diaphragm </li></ul><ul><li>ALVEOLI ( RESPIRATORY BRONCHIOLES, ALVEOLAR DUCTS, ALVEOLAR SACS) = RESPIRATORY ZONE = GAS EXCHANGE / VENTILATION </li></ul><ul><li>PERFUSION – alveoli receives UnO 2 blood from the R ventricle </li></ul>
  60. 68. <ul><li>RESPIRATION – act of breathing, controlled by CNS (medulla Oblongata controls inspiratory Ms., diaphragm, Ext. intercostals & abdominal Ms) </li></ul><ul><li>MEDULLA OBLONGATA- </li></ul><ul><ul><li>DORSAL PART – controls inspiration </li></ul></ul><ul><ul><li>VENTRAL PART – usu. dormant unless needs to ↑ ventilation or active exhalation. </li></ul></ul><ul><li>PONS – “ apneustic center ” rate & depth of respiration </li></ul><ul><ul><ul><li>“ pneumotaxic center” – allo ws talking & breathing </li></ul></ul></ul><ul><li>VAGUS NERVE – parasympathetic nerve. Stimulation of diaphragm contraction & inspiration, may also lead to bronchoconstriction. </li></ul><ul><li>CEREBRAL CORTEX – allo ws voluntary control of breathing (holding out breath or altering rate & depth of breathing) </li></ul>
  61. 69. <ul><li>Upper resp. tract conditions- </li></ul><ul><ul><li>Common cold – viral invasion leading to activation of inflammatory response (histamine & prostaglandin) </li></ul></ul><ul><ul><ul><li>Mucus membranes engorged c blood, tissue s w ells, goblet cells produce more mucus </li></ul></ul></ul><ul><ul><ul><li>Sinus pain, nasal congestion, sneeze, runny nose, teary eyes, scratchy throat, headache, can block the eustachian tube & affects hearing or evn otitis media. </li></ul></ul></ul><ul><ul><li>Sinusitis – inflammation reaction that leads to pain ? Or even lead to brain infection </li></ul></ul><ul><ul><li>Pharyngitis & Laryngitis – common bacteria or virus. Cardiac affectation ? </li></ul></ul><ul><li>Lo wer Resp. tract conditions- </li></ul><ul><ul><li>Atelectasis – lung collapse as a result of outside P ° against the alveoli thus, lung expansion does not occur </li></ul></ul><ul><ul><li>Pneumonia – viral / bacterial invasion by aspiration leading to ↓ gas exchange = poor oxygentation ( DOB, fatigue, fever, abnormal breath sounds) </li></ul></ul>
  62. 70. <ul><ul><li>Bronchitis – bacteria, virus or foreign materials infect the inner layer of the brochi that leads to narro wing of the airway due to inflammation (Acute / Chronic) </li></ul></ul><ul><ul><li>Bronchiectasis – chronic dse. Involving bronchi & bronchioles char. by dilation of the bronchial tree, chronic infection & inflammation, normal cells are replaced by fibrous scar tse. </li></ul></ul><ul><li>Obstructive pulmonary dses. </li></ul><ul><ul><li>Asthma – char. by reversible bronchospasm, inflammation, hyperactive airways triggered by allergens, irritants, stress, exercise, emotions. Releasing histamine = bronchospasm / bronchoconstriction in minutes then cytokines in 3-5 hrs = mucus production & edema = obstruction </li></ul></ul><ul><ul><li>COPD – permanent obstruction of airways often related to cigarette smoking. </li></ul></ul>
  63. 71. <ul><ul><li>Emphysema – loss of elastic tissue of the lungs, destroyed alveolar walls, hyperinflated lungs that can lead to collapse c experition. </li></ul></ul><ul><ul><li>Cystic Fibrosis – hereditary dse. Accumulation of copious amts. of very thick secretions in the lungs. Secretions obstruct airway & destroys lung tse. </li></ul></ul>
  64. 72. <ul><li>RESPIRATORY DRUGS – works to keep the airways open & gases moving efficiently. </li></ul><ul><li>ANTITUSSIVES – drugs that supresses the cough reflex </li></ul><ul><ul><li>BENZONATATE – local anesthetic on resp. passages blocks the stretch receptors that stimulate the cough reflex </li></ul></ul><ul><ul><li>CODEINE – * </li></ul></ul><ul><ul><li>DEXTROMETORPHAN – * </li></ul></ul><ul><ul><li>HYDROCODONE – * </li></ul></ul><ul><li>Ix: common (non productive cough) </li></ul><ul><li>Actions: *acts directly on medullary cough cough center of the brain to depress the cough reflex </li></ul><ul><li>CIx^Cautions: post op px (thoracic & abdominal), ^ asthma & emphysema, hypertension, Hx of addiction, driving px. </li></ul>
  65. 73. <ul><li>Adverse effects: drying effect on the mucous membranes, increase viscosity of resp. secretions. dro wsiness & sedation, nausea, constipation, dry mouth. </li></ul><ul><li>Nsg. Implementation: </li></ul><ul><li>Evaluate & assess cough if c (fever, rash, or excessive secretions) </li></ul><ul><li>Ensure that drug is not taken morethan prescribed </li></ul><ul><li>Provide other measures to relieve cough (humidity, cool temperatures, fluids, </li></ul><ul><li>Health teaching about drug & foods to be taken (vit c & natural fruit juices) </li></ul>
  66. 74. <ul><li>Decongestants – usu. Adrenergics / sympathomimetics causing local vasoconstriction,↓ bld. flo w to irritated & dilated capillaries in nasal & sinus cavities ↑ </li></ul><ul><ul><li>EPHEDRINE – </li></ul></ul><ul><ul><li>OXYMETAZOLINE – </li></ul></ul><ul><ul><li>PHENYLEPHRINE – </li></ul></ul><ul><ul><li>TETRAHYDROZOLINE – </li></ul></ul><ul><li>Action: cause vasocontriction = ↓ edema, inflammation of nasal membranes mostly applied topically (sprays),fast acting </li></ul><ul><li>Ix: common cold, sinusitis, allergic rhinitis </li></ul><ul><li>CIx^Cautions: lesion / erosion in the mucous that could lead to systemic absorption, glaucoma, hypertension. </li></ul>
  67. 75. <ul><li>Adverse effects: local stinging, burning sensation. If used for >5days can lead to rebound congestion </li></ul><ul><li>Nsg. Implementation: </li></ul><ul><li>Proper administration of meds & positioning (parkinsons position, proetts position) </li></ul><ul><li>Safety measures (dizziness, sedation) </li></ul><ul><li>Drug – drug interaction (OTC drug) </li></ul><ul><li>Oral Decongestants – po drugs for Mx/Tx of nasal congestion rel. to common cold, pain reliever & decongestant in otitis media </li></ul><ul><ul><li>DECOLGEN – </li></ul></ul><ul><ul><li>DECOFED – </li></ul></ul><ul><ul><li>DORCOL – </li></ul></ul>
  68. 76. <ul><li>Action: shrinks the nasal mucous membranes by stimulating the alpha adrenergic receptors in nasal cavity = dec. in size & drainage of sinuses = improve airflo w. </li></ul><ul><li>CIx^Cautions: glaucoma, hypertension. </li></ul><ul><li>Adverse effects: rebound congestion, anxiety, restless, tremors, hypertension, arrythmias, sweating, pallor. </li></ul><ul><li>Nsg. Implementation: </li></ul><ul><li>Drug – drug interaction </li></ul><ul><li>Safety measures if (CNS effects occurs) </li></ul><ul><li>Monitor PR, BP etc. </li></ul><ul><li>Shld not be used longer than 7days </li></ul><ul><li>Patient education </li></ul>
  69. 77. <ul><li>Topical Nasal Steroids decongestants – used for thx of allergic rhinitis. </li></ul><ul><li>Action: topical anti inflammatory = blocks inflammatory reaction. </li></ul><ul><li>Ix: allergic rhinitis </li></ul><ul><li>CIx^Cautions: acute Infections, avoid exposure to airborne infection (chickenpox, measles) </li></ul><ul><li>Adverse effects: local burning, stinging, irritation, dryness of mucosa, headache. </li></ul><ul><li>Nsg. Implementation </li></ul><ul><li>Clear nasal passages prior to drug administration </li></ul><ul><li>Position px properly (parkinsons & proetts) </li></ul><ul><li>Monitor px for devt of acute infection </li></ul><ul><li>Thorough teaching for px </li></ul>
  70. 78. <ul><li>ANTIHISTAMINES – relieves respiratory symptoms & treat allergies </li></ul><ul><ul><li>BENADRYL- PHENERGAN – </li></ul></ul><ul><ul><li>CLARITINE MECLIZINE </li></ul></ul><ul><ul><li>CELESTAMINE – </li></ul></ul><ul><li>Action: blocks histamine 1 & its effect = relief for itchy eyes s welling, congestion 7 drippy nose. Also has some anticholinergic effects. </li></ul><ul><li>Ix: seasonal perrinnial allergic rhinitis allergic conjunctivitis, uncomplicated urticaria, angioedema, amelioration of allergic reactions during BT, anaphylactic reactions. </li></ul><ul><li>CIx^Cautions: pregnancy, lactation ^ renal, hepatic, CV px c arrythmia (prolonged QT interval) </li></ul><ul><li>Adverse effects: dro wsiness, sedation. Anticholinergic effect: dryness of the mouth, GI upset, Nausea, dysuria, itching, dry skin. </li></ul>
  71. 79. <ul><li>Nsg. Implementation: </li></ul><ul><li>Administer drug on empty stomach ( 1hr ac, 2hr pc) </li></ul><ul><li>Encourage having( sugarless) candies / lozenges to dec. dry mouth effect. </li></ul><ul><li>Increase fluid intake unless CIx </li></ul><ul><li>Provide skin care regiment (prevent dry skin S/Sx) </li></ul><ul><li>Avoid intake of alcohol (sedation prec.) </li></ul>
  72. 80. <ul><li>EXPECTORANTS – liquefy secretions in the resp. tract, reduces viscosity, easy to cough it out. </li></ul><ul><ul><li>GUAIFENESINE – </li></ul></ul><ul><ul><li>GLYCERYL GUACUOLATE – </li></ul></ul><ul><li>Action: enhances the output of resp. tract fluids = dec. adhesiveness = easier movements of less viscous secretions. </li></ul><ul><li>Ix : dry non productive cough, excessive mucus in the resp. tract, common cold, acute bronchoitis, influenza </li></ul><ul><li>Adverse effects: N & V, headache, rash, </li></ul><ul><li>Nsg. Implementation: </li></ul><ul><li>Caution px ( drug shld. Not be used > 7days </li></ul><ul><li>Advise small frequent feeding if px is taking this drug </li></ul><ul><li>Avoid driving or other tasks that needs coordination </li></ul><ul><li>Do not overdose </li></ul>
  73. 81. <ul><li>MUCOLYTICS - breaks do wn mucus in order cough out thick tenacious secretions. (inhalation / nebulization, p.o., i.v.) </li></ul><ul><ul><li>ACETYLCYSTEINE – can also be antidote (acetaminophen poisoning) </li></ul></ul><ul><ul><li>MUCOMYST – </li></ul></ul><ul><li>Ix: COPD, cystic fibrosis, PTB, atelectasis due to thick mucus production. </li></ul><ul><li>Adverse effects: N & V, stomatitis, urticaria, bronchospasm, rhinorrhea. </li></ul><ul><li>Nsg. Implementation: </li></ul><ul><li>Avoid combining c other drug & dilute c sterile water in neb kit </li></ul><ul><li>If acetylcysteine is used, wipe off residue in px face (risk for skin breakdown) </li></ul><ul><li>Most mucolytics drugs used in nebs are photo sensitive & must be kept in refrigerator. </li></ul>
  74. 82. <ul><li>BRONCHODILATORS /ANTI ASTHMATICS – facilitates respiration & oxygenation by dilating air ways. </li></ul><ul><ul><li>ZEMAIRA – Tx for alpha protease deficiency (hereditary) = sev. emphysema </li></ul></ul><ul><li>Ix: bronchial asthma, bronchospasm c COPD </li></ul><ul><li>XANTHINES – inhibits release of slow reacting substance of anaphylaxis (SRSA) & Histamine </li></ul><ul><ul><li>CAFFEINE / CAFFEDRINE – </li></ul></ul><ul><ul><li>AMINOPHYLLINE / THEOPYLLINE – </li></ul></ul><ul><li>Ix: relief & prevention of Bronchial Asthma, bronchospasm c COPD. </li></ul><ul><li>Adverse effect: Therapeutic level = 10-20ug/ml > normal level = GI upset, Nausea, irritability, tachycardia, seizures, brain damage, death. </li></ul>
  75. 83. <ul><li>Nsg. Implementation: </li></ul><ul><li>Administer oral drug c food or milk </li></ul><ul><li>Monitor px response to drug </li></ul><ul><li>Provide rest & quiet environment </li></ul><ul><li>Monitor px & lab exam for toxic level </li></ul><ul><li>SYMPATHOMIMETICS – dilates bronchi c ↑ rate & depth of respiration (BETA 2 SELECTIVE ADRENERGIC AGONIST) </li></ul><ul><ul><li>ALBUTEROL / PROVENTIL – long acting neb & po > 2 y/o px </li></ul></ul><ul><ul><li>BITOLTEROL / TORNALATE – long acting neb. >12 y/o </li></ul></ul><ul><ul><li>EPHEDRINE – for old & young px </li></ul></ul><ul><ul><li>EPINEPHRINE / EPIPEN – drug of choice in adult & children for acute bronchospasm due to anaphylaxis, CIx in CVD px. </li></ul></ul><ul><li>CIx^Cautions: CVD, vascular dse., DM, hyperthyroidism, pregnant & Lactating px. </li></ul>
  76. 84. <ul><li>Adverse effects: Sympathetic effects: HPN, arrythmia </li></ul><ul><li>Nsg. Implementation: </li></ul><ul><li>Reassure that the chosen drug may have varied effect in px </li></ul><ul><li>Advise minimal use only </li></ul><ul><li>Teach px to use these drugs 30-60 mins prior to exercise (prevent exercise induced asthma) </li></ul><ul><li>Safety measures if CNS effects arises </li></ul><ul><li>Anticholinergic bronchodilators – for px that cant tolerate (symphatomimetics) might respond to these: </li></ul><ul><ul><li>IPRATROPIUM / ATROVENT – not as effective compared to </li></ul></ul><ul><ul><li>TIOTROPIUM / SPIRIVA - symphatomimietics. maintenance for COPD </li></ul></ul><ul><li>Pharmacokinetics: effects 15-30 mins.peaks1-2hrs </li></ul><ul><li>CIx^Cautions: allergy,for atropine like S/Sx </li></ul>
  77. 85. <ul><li>Adverse effects: anxiety, nervousness, dizziness, headache, nausea, GI distress, palpitations. </li></ul><ul><li>Nsg. Implementation: </li></ul><ul><li>Ensure adequate hydration </li></ul><ul><li>Encourage the px to void prior to each dose </li></ul><ul><li>Provide small frequent meals, sugarless lozenges </li></ul><ul><li>Advice px not to drive post drug intake </li></ul><ul><li>INHALED STEROIDS – very effective Tx for bronchospasm. </li></ul><ul><ul><li>BUDESONIDE / SIMBICORT </li></ul></ul><ul><ul><li>FLUNISOLIDE / AEROBID </li></ul></ul><ul><ul><li>TRIAMCINOLONE / AZMACORT </li></ul></ul><ul><li>Action: ↓ inflammatory resp. in the air way = a. dec. swelling, b. promote beta drenergic receptor activity_promote smooth Ms relaxation & inhibit bronchoconstriction </li></ul>
  78. 86. <ul><li>Pharmacokinetics: well absorbed in Resp. Tract. Crosses placenta & enters breastmilk. </li></ul><ul><li>CIx^Cautions: not for emrgency use (acute asthma attack & status asthmaticus), pregnant & lactating px, ^ active infection of resp. system. </li></ul><ul><li>Adverse effects: Irritability, headache, rebound congestion, epistaxis, local infection </li></ul><ul><li>Nsg. Implementation: </li></ul><ul><li>Do not give drug to acute asthma & status asthma attacks </li></ul><ul><li>Taper systemic steroids carefully during transfer to inhaled steroids (adrenal insufficiency c sudden withdrawal) </li></ul><ul><li>Have px use decongestants prior using inhaled steroids </li></ul><ul><li>Have px rinse mouth post drug inhalation (prevent Gi effects) </li></ul><ul><li>Monitor px for S/Sx respiratoty infection </li></ul><ul><li>Thorough health teaching </li></ul>
  79. 87. <ul><li>LEUKOTRIENE RECEPTOR ANTAGONIST – newer class of drugs. Dev. to specifically act at the site of the problem assoc. c asthma but not for acute asthmatic attacks </li></ul><ul><ul><li>ZAFIRLUKAST / ACCOLATE - prophylaxis & chronic Tx of </li></ul></ul><ul><ul><li>MONTELUKAST / SINGULAIR – bronchial asthma </li></ul></ul><ul><ul><li>ZILUETON / ZYFLO - > 12 y/o px </li></ul></ul><ul><li>Action: blocks production of Leukotrienes D4, E4 (components of SRSA) </li></ul><ul><li>Pharmacokinetics: rapidly absorbed from GI tract, crosses the placenta & breastmilk </li></ul><ul><li>CIx^Cautions: allergy, renal & hepatic dse. Pregnant & lactating px </li></ul><ul><li>Adverse effect: headcahe, dizziness, nausea, generalized pain, fever & infection. </li></ul>
  80. 88. <ul><li>Nsg. Implementation: </li></ul><ul><li>Administer drug on EMPTY stomach </li></ul><ul><li>Not to be used in Tx of acute asthma attacks </li></ul><ul><li>Should be take continuously & do not miss dose </li></ul><ul><li>Urge px to avoid OTC that contains ASPIRIN </li></ul><ul><li>LUNG SURFACTANTS – Surfactant ( naturally occurring compounds or lipoproteins contains lipid & apoproteins that ↓ surface tension c/in the alveoli = ↑ expansion of alveoli for gas exchange </li></ul><ul><ul><li>BERACANT / SURVANTA – rescue Tx for infants c RDS; </li></ul></ul><ul><ul><li>CALFACTANT / INFASURF - prophylactic Tx for px c high risk </li></ul></ul><ul><ul><li>COLFOSCERIL / EXOSURF - in dev. RDS px . </li></ul></ul><ul><ul><li>PORACTANT / CUROSURF - rescue Tx for infants c RDS; </li></ul></ul>
  81. 89. <ul><li>Pharmacokinetics: acts immediately into trachea. Metabolized in the lungs </li></ul><ul><li>CIx^Cautions: pregnancy & lactating. Usually used as emergency drugs. </li></ul><ul><li>Adverse effcets: PDA, interventricular Hge., pneumothorax, hyprbilirubinemia, sepsis due to reaction to lipoprotein or the invasive procedures the px under went. </li></ul><ul><li>Nsg. Implementation: </li></ul><ul><li>Provide life support during administration </li></ul><ul><li>Ensure proper placement of ET tube (bilat. Chest movement, lungs sounds) </li></ul><ul><li>Suction infant immediately prior to giving drug but do not suction 2 hrs post administration </li></ul><ul><li>Continue other supportive measures </li></ul><ul><li>Support & encourage parents of the child. </li></ul>
  82. 90. <ul><li>MAST CELL STABILIZERS – Anti asthma & Anti allergy </li></ul><ul><ul><li>CROMOLYN / INTAL – Tx of Chronic Bronchial Asthma, exercise induced asthma & allergic rhinitis. CIx: acute attack, younger than 2 y/o px </li></ul></ul><ul><ul><li>NEDOCROMIL / TILADE / ALOCRIL – Mx of mild-mod bronchial asthma. CIx: px less than 12 y/o </li></ul></ul><ul><li>Action: Cromolyn: limits release of Histamine by the mast cell in response to inflammation & irritation. Usu. Inhaled from a capsule & takes effect 7days. </li></ul><ul><ul><ul><ul><li>Nedocromil: inhibits activity of inflammatory mediators (eosinophils, neutrophils, macrophages, mast cells) = blocking the effect of histamine. </li></ul></ul></ul></ul><ul><li>Pharmacokinetics: cromolyn=active in lungs & excreted during exhalation. Nedocromil=excreted unchanged in the urine </li></ul><ul><li>CIx^Caution: allergy, Pregnant & lactating px. </li></ul>
  83. 91. <ul><li>Adverse effects: headache, dizziness, nausea, sore throat, dysuria, nasal congestion. </li></ul>