pharmacology test 4

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pharmacology test 4
2012-04-14 22:16:34
pharmacology test

pharmacology test 4
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  1. Antidysrythmics
    • •Dysrythmia- any disturbance or abnormality in the normal cardiac rhythm
    • •Can be fast, slow, irregularly regular or regularly irregular
    • •Frequent after MI, hypoxia- feels as a skipped beat
    • •Most are very serious and require an anti-dysrhythmic agent
  2. Medications
    • •AGENTS:
    • •CLASS I- membrane- stabilizers (Fast sodium channel blockers)
    • •CLASS II- Beta-blockers
    • •CLASS III- prolong repolarization
    • •CLASS IV- Calcium channel blockers (Verapamil)
  3. Definitions
    • •Membrane Stabilizers- interferes with the sodium channels and stabilizes the hearts excitability
    • •Beta blockers- blocks epi and norepi at the best
    • adrenergic receptor sites (beta 1,2 and 3)
    • •Prolonging repolarization- used for difficult to treat dysrythmias and conversion
    • •Calcium channel blockers- decreases intracellular calcium = reduction of muscle contration
  4. Class I’s
    • •PROCANAMIDE- useful in atrial and ventricular tachy-dysrhythmias
    • •Most effective in suppressing premature Vent contractions and preventing the recurrence of V tach.
    • •Can cause lupus-like syndrome
    • •Can cause n/v/d- anorexia
    • •Can cause fever, leucopenia, maculopapular rash, itching, flushing
    • •NOT used in clients with Lupus, complete heart block, 2nd
    • and 3rd degree heart block
  5. Class I
    • •PROCANAMIDE- useful in atrial and ventricular tachy-dysrhythmias
    • •Most effective in suppressing premature Vent contractions and preventing the recurrence of V tach.
    • •Can cause lupus-like syndrome
    • •Can cause n/v/d- anorexia
    • •Can cause fever, leucopenia, maculopapular rash, itching, flushing
    • •NOT used in clients with Lupus, complete heart block, 2nd
    • and 3rd degree heart block
  6. Quinidine
    • •Can cause loss of hearing, blurred vision, GI upset, tinitus, diarrhea, n/v and vertigo
    • •Can cause thrombocytopenic pupura (TTP)
    • -blood disorder that causes blood clots to form in small blood vessels around the body, and leads to a low platelet count.
    • •Can cause decreased blood flow to the brain and death so TEST DOSES are given!!
    • •Check potassium levels very closely- befroe, during and after…
    • •Increased potassium = increased effects of the medication
    • •And vice versa!
  7. Norpace
    • used primarily for treatment of Vent dysrythmias
    • •Can cause anti-cholinergic side effects
    • •Vent dysrythmias
    • •Not used in clients with poor left vent function
    • •Can cause hypotension and widened QRS intervals on EKG
    • •Incidence of lupus is less than that of Procanamide
  8. Class II
    • Betablockers: selective (1) and nonselective (1&2)
    • •Blocks (or slows) the SNS stimulation to the heart-
    • • REDUCES THE HEART RATE and force contraction
    • •Especially beneficial after an MI because many catecholamines are released at that time and can make the heart hyperirritable
    • •25% reduction rate of cardiac death after an MI if on Class II’s
  9. More on beta blockers
    • •Blocking the beta cells (1, 2 & 3)
    • •Beta adrenergic receptors- part of the SNS (fight or flight)
    • •β1-adrenergic receptors are located mainly in the heart and in the kidneys
    • •β2-adrenergic receptors are located mainly in the lungs, gastrointestinal tract, liver, uterus, vascular smooth muscle, and skeletal muscles
    • •β3-adrenergic receptors are located in fat cells
    • •MOST end in “lol”
    • •There is a little hint to help…
    • •Labetalol
    • •Propanalol
    • •Atenalol
    • •Metoprolol
  10. Propanalol
    • •Used commonly for acute sinus tachy
    • •So it will cause a decrease in heart rate which can = Bradycardia! Assess closely
    • •Can also cause rash and itch
    • •Erratic blood sugars up and down
    • •Chest pain
    • •Joint pain
  11. Tenormin (Atenolol)
    • Blocks beta-1’s on the heart
    • •(Also used for angina and hypertension)
    • •Contraindicated in clients with severe bradycardia, CHF and cardiogenic shock
  12. Breviblock
    • •shorter acting beta-blocker, Blocks beta 1’s
    • •Used for SVT
    • •And used for dysrythmias that originate above the ventricals and are fast
    • •Can be used for tachyarrythmias that occur after an
    • acute MI
    • •Can be used to control hypertension
    • •Not used for bradycardia or in clients with asthma
    • •not used for those with 2nd or 3rd degree heart block or CHF
  13. Lopressor (Metoprolol)
    • •commonly given after an MI to reduce risk of cardiac death
    • •Can be used for treatment of hypertension and angina
    • •LOPRESSOR HCT- contains a hydrochlorathiazide diuretic
    • •To diurese the patient, thus decreasing Bp – so assess what?
    • •Selective- beta 1’s
    • •Metoprolol is used for a number of conditions including: hypertension, angina, acute myocardial infarction, supraventricular tachycardia, ventricular tachycardia, congestive heart failure and prevention of migraine headaches
    • •Causes hypotension, dizziness, blurred vision, etc.. Safety will be an issue at first
  14. Inderal
    • •is nonspecific (beta 1 and 2- works on receptors in the heart and lungs!)
    • •Reduces heart rate
    • •Reduces myocardial contractility
    • •Oldest of this class of drug- many uses
    • •Used for hypertension, angina
    • •Used for VTach, supervent dysrhythmias, pheocromocytoma*
    • •Used post MI, and for migraines
  15. What is pheocromocytoma?
    • •Adrenal gland tissue tumor
    • •Results in the release of too much epinephrine and norepinephrine- controling heart rate, metabolism, and blood pressure
    • •Common in early middle-adulthood
    • •Rarely cancerous
    • •Tremors, hypertension, tachy, weight loss, irritability and palpitations occur
  16. Betapace
    • •Used for the treatment of DOCUMENTED life-threatening
    • vent dysrythmias such as sustained V tach!
    • •Can cause new dysrhythmias
    • •Not used for bronchial asthma clients, sinus brady or cardiogenic shock
  17. Class III
    • •Most commonly used to treat dysrhythmias that are difficult
    • to treat
    • •Used for the conversion of A-fib and flutter to a NSR
    • •Still somewhat investigational
  18. Amiodarone (pacerone)
    • •used for life-threatening vtack or V-fib that is resistant to other drugs (Drug of last resort!)
    • •Used also for the treatment of sustained V-tack
    • •Recently studied- shown to effect atrial dysrhythmias that are resistant
    • •Has a lot of unwanted s/e-
    • •Containes IODINE in it’s structure (watch for allergies) therefore can cause hyper or hypo- thyroidism
    • •Doses exceeding 400mg/D are more likely to see unwanted s/e’s
    • •MOST common s/e- corneal microdeposits- causes halo’s, dry eyes and photophobia
    • •Occurs in almost all adults on the med for 6 months or more
    • •Is lipophilic- loves to migrate to adipose tissue
    • •MOST serious s/e = PULMONARY TOXICITY- dyspnea and cough causing damage to the alveoli- can result in pulmonary fibrosis!
    • •May also provoke new dysrhythmias
    • •Has a long half-life- approaching DAYS!
    • •May take several months after DC of the drug for s/e to discontinue
  19. Bretylium
    • •adrenergic blocking (slows release of norepi)
    • •Slows conduction of ventricular portion of muscle
    • •Only available IV
    • •Used to treat life-threatening V-tach or fib
    • •Used primarily in a code situation
    • •Causes postural hypotension in 50% of patients
    • •Can cause N/V
    • •Given slow IV to reduce s/e
  20. Covert
    • •Indicated for ATRIAL dysrhythmias (A-fib and flutter)
    • •ONLY drug therapy available for rapid conversion into NSR fro a-fib/flutter
    • •Other way?- Electrocardioversion
    • •Only IV and weight based
    • •Other classes of antidysrhythmics should not be given if Corvert is being used, if so… give 4 hours apart
  21. Class IV
    • •Used as anti-dysrhythmics and for the treatment of hypertension and angina
    • •(Calcium channel blockers)
    • •Slows or blocks the calcium channels of the cell into the myocardium
  22. Cardizem and Verapamil
    • •CARDIZEM- Not used for MI, pulmonary congestion, severe hypotension, cardiogenic shock, sick-sinus syndrome, or 2nd/3rd degree heart block
    • •VAREPAMIL (Calan)- Used to prevent and convert recurrent PSVT( paroxysmal SVT) and to control vent response in a-fib or flutter
    • •Same contraindications as Cardizem
    • •Precipitates with Nafcillin and Sodium Bicarb
    • •Nitrates*- these are often taken WITH CCB’s
    • •Be careful with the elderly- increased side effects- weakness and dizziness (safety)
    • •Nicotene can decrease effectiveness
    • •ETOH increases hypotensive episodes
    • •Do not stop abruptly- can have a rebound effect!
  23. Process: Assessment
    • •Not used in: Hypersensitivity
    • •CHF- can worsen effects of CHF
    • •Complete heart block*
    • •Hypotension
    • •MG
    • •Urinary retention
    • •Hepatic/renal insufficiency
  24. Drugs that interact with these meds:
    • •NMBA’s
    • •Anticholinergic’s- causes increased anti-cholinergic effects
    • •Anticoags- with quinidine
    • •Dig. and quinidine- increases serum dig levels
    • •Cimetadine/Nefedipine
    • •Anticonvulsants
  25. Implementation
    • •Initial EKG and VS- and monitor closely during
    • •IV on a pump
    • •If on Propanalol (Inderal)- report SOB or skin rash
    • •VARAPAMIL (Calan) and beta blockers cannot be given together IV
    • •Look for all other side effects as mentioned
    • •Any increased cough, SOB, weight gain- report..
    • •ALSO: Lets talk about IV Lidocaine commonly used for
    • ventricular dysrythmias
    • •It increase the electricalimpulses and weak impulses are weeded out
    • •SO it slows the heart rate overall
    • •Assess tinitus, blurred vision, HA/dizziness, seizures, hallucinations…
    • •Adenosine-
    • •Given for cardioversion
    • •Causes several seconds of asyystole when cardioverting tach to NSR
    • •Causes anxiety!
    • •Educate and be supportive
  26. Anti-anginal medications
    • •The ACHING of the heart muscle due to insufficient oxygen in the blood
    • •Why?
    • •Often idiopathic…
  27. Types of angina
    • •Chronic Stable Angina- caused by atherosclerosis
    • •Can be triggered by exertion or stress (cold, fear,emotions)
    • •Smoking, drugs, etoh, caffeine, coffee can exacerbate it
    • •Intense pain that subsides in about 15 minutes
    • •Unstable Angina (USA)- early stage of progressive CAD
    • •May end in MI in sunsequent years
    • •Pain increases in severity with each attack and attacks become more frequent
    • •Can happen at rest when condition progresses
    • •Vasospastic Angina- spasms of the smooth muscle layers that surround the atherosclerotic coronary arteries
    • •Happens at rest usually
    • •Seems to follow a regular pattern- occurring around the same time of day
    • •Know the difference between the 3 types!
  28. The drugs:
    • NITRATES/NITRITES-most effective drug for CAD
    • - Act on vascular smooth muscle- relaxes arterial and venous circulation
    • BETA-BLOCKERS- as discussed earlier (review)
    • CALCIUM CHANNEL BLOCKERS -also discussed earlier- (review)
  29. 1- Nitrates/Nitrites
    • •NITROGLYCERIN: (Rapid acting)
    • •Not used for those with ICP, inadequate cerebral perfusion, pericarditis, pericardial tamponade (fluid accumulation in the heart causing increased pressure), severe hypotension, and severe anemia
    • •Orally- metabolized in the liver- a lot is removed from circulation (LARGE first-pass effect) therefore…
    • •Usually given SL or Buccal so bypasses the first pass effect! Can be administered transdermally
    • •Also given IV- for acute MI,CHF, and Pulmonary edema
    • •Can be given topically- bypasses first pass effect- allows for slow delivery of the drug
    • •Dilates all blood vessels, but mainly effect those in the venous circulation
    • •Slight arterial dilation in low doses
    • •Transdermal patches- usually OFF for 8 hours at night, new patch in the AM (review)
  30. 1-Nitrates/Nitrites
    • •HA
    • is most common- can be very severe
    • •Tachycardia
    • •Postural Hypotension- assess laying, sitting and standing and educate safety!
    • •ETOH, phenothiazines, CCB’s- cause increased anti-hypertensive effects- again safety is an issue
    • •½ life = 1-4 minutes- readily absorbed!
    • •S/S of postural hypotension?- flushing, dizziness, sweating, syncope
    • •Patients with acute MI? safety still being investigated, but…
    • •A recent MI? transdermal patch is showing good performance
    • •If nitrates taken with ETOH- severe hypotension
    • •Same with beta blockers, narcotics, antihypertensives, and vasodilators
    • •Tobacco reduces effects
    • •Nitroglycerin increases VMA (vanillylmandelic acid) levels (end stage metabolite of epi and norepi)
  31. SL Nitroglycerin
    • •SL- under the tongue
    • •Used for CP- ASAP
    • •Educate to keep on their person at all times
    • •CP? Lay down- take a dose…
    • •If no relief in 3-5 minutes- redose (#2)
    • •If no relief in 3 minutes- redose (#3)
    • •Call 911!! (if at home)
    • •Isosorbide Dinitrate (Isordil)- Long acting
    • •Metabolized in the liver
    • •Used for acute angina and for the prophylaxis of…
    • •Only PO
    • •Iso Mononitrate- (Imdur, Ismo, Monoket)- Long acting
    • •Provides a more steady, therapeutic response
    • •Ismo and Monoket given 2X daily with 7 hours in between doses so as not to build a nitrate tolerance*
    • •All available PO
  33. 2- Beta-blockers (again)
    • •Beta-blockers- slows the heart rate and decreases contractility
    • •1st line drug for stable angina and “effort induced angina”*
    • •Decreases O2 demand, therefore increases O2 availability to the myocardium
    • •Slows the contractility- decreasing energy needs
    • •Fatigue and lethargy are common s/e’s r/t decreased Bp
    • •PS- BB’s can increase Blood glucose in the DM pt.
  34. 2- Beta-blockers (again) Side effects
    • •Hypotension- due to vasodilation- assess pulses can
    • decrease peripheral blood flow!
    • •Can also cause vasoconstriction- NOT recommended for COPD or asthma clients
    • •Can cause bradycardia
    • •Dizziness, fatigue, lethargy
    • •Can cause impotence, wheezing, dyspnea
    • •NOT USED if on anticholinergics, or on cimetadine, or on diuretics or phenothiazines
  35. Tenormin and Lopressor
    • ATENALOL (Tenormin)- often used after an MI to decrease death rate
    • •Available IV and PO
    • •IV = Good immediately after an MI because blood flow to GI tract is poor and most are intubated
    • •LOPRESSOR (Metoprolol)- Used to treat angina and used after MI
    • •Available IV and PO
  36. CCB’s
    • •Decreases myocardial O2 demand by causing peripheral arterial vasodilation, reduces myocardial contractility
    • (decreases pain) decreases Bp
    • •High risk for causing peripheral edema
    • •Safe with few contraindications
    • •Usually a first line agent in the treatment of angina
    • •CARDIZEM, TIAZAC- effective oral
    • treatment of angina
    • •Available IV also
    • •NIFEDIPINE (Adalat/Procardia)
    • •Once we had to puncture the liquid filled capsule and squeeze under the tongue!
    • •Now they have decided that this increases the mortality rate
    • •Only available IV*
    • •VERAPAMIL (Calan)- We discussed that already!
  37. CCB Side effects
    • •Hypotension
    • •Brady
    • •heart failure
    • •Constipation, nausea
    • •Rash
    • •Peripheral edema
    • •Wheezing
  38. CCB’s should not be used with:
    • •Digoxin- can increase dig levels
    • •H2 blockers- increases CCB level
    • •Beta blockers- additive effects
    • •Theophyline
    • •Lithium
    • •ETOH
    • •Trycyclic antidepressants
    • •Tobacco
  39. Any peripheral vasodilator medications
    • •Can be used for occlusive arterial disease (limited success)
    • •Relaxes smooth muscle of peripheral arterial vessels increasing circulation to the extremities
    • •What will you see?- swelling to the lower legs and feet and often ulcerations below the knees
    • •Can be used to treat Raynaud’s disease (vasospasms and thrombophlebitis)
    • •Viagra is also a vasodilator
    • •Vasodilators cause hypotension, dizziness, post. Hypotension, HA, dysrythmias, sweating, tingling, but disappear after a few weeks of txt.
    • * Some will contain “tartrazine”- can cause an allergic reaction with s/s like bronchial asthma
    • •If allergic to ASA? Increased risk of allergy to tartrazine
  40. Process for all of these meds:
    • •O Assess and list all other drugs
    • •Allergies?
    • •Medical and surgical Hx
    • •Caution with head injuries and pregnant/lactating women
    • •VS, EKG, RESP status
    • •Not used with liver/kidney disease if possible
  41. Implementations
    • •IV Nitro in a glass bottle only*
    • •NO filters
    • •Nitro- new Rx. Every 3 months- loses strength
    • •Keep in a brown bottle- sunlight and light can decrease the effects of medication
    • •No cotton in the bottle- decreases effectiveness
    • •Take on an empty stomach po
    • •Causes a throbbing headache- it is a potent medication!
    • •Can take an analgesic for HA
    • •Only stable for 96 hours
    • •ALWAYS on a pump
    • •Covered in aluminum foil or in a dark bottle and dark tubing
    • •Not mixed IV with any other drugs
    • •IV nitro- ICU monitoring
    • •Report if blurred vision or dry mouth
    • •Elderly- increased risk of hypotension
    • •Watch for nitrate abuse- can cause sexual stimulation
    • •Angina without relief- call 911
    • •Taper these meds!
    • •Take Bp before giving meds, check lytes
    • •Decrease caffeine containing foods/drinks, cardiac diet and decrease sodium
  42. Hypertension
    • •Blood vessels decrease in elasticity secondary for hypertension
    • •The heart has to work much harder
    • •This causes stress on the heart muscle and vessels, veins and arteries
    • •Hypertension needs to be identified and treated early in the game!
  43. Bp review: slide 64
    • •Blood Pressure:
    • •NORMAL = <130S <85 D
    • •Stage 1 = 140-159 90-99
    • •Stage 2 = 160-179 100-109
    • •Stage 3 =180-209 110-119
    • •Stage 4 = > or = to 210 > or = to 120
    • •Diastolic below 90 to decrease damage risks to kidneys, heart and brain!
  44. Antihypertensives 1. Adrenergics What is an adrenergic?
    • •Adrenergic receptors are the target of catacholamines like epi and norepi
    • •There are receptor subtypes- Alph 1&2,Beta 1&2
    • •They inhibit or block stimulation of epi/norepi
    • •Decreases BP and heart rate
    • •Can cause postural and post-exercise hypotension
    • •Can be used to treat Migraines
    • •Can be used for severe dysmennhorea and menopausal
    • flushing
  45. Side effects & Interactions
    • •Dry mouth
    • •Constipation
    • •drowsiness, constipation
    • •HA
    • •Nausea
    • Rash
    • •Ortho hypotension
    • •CNS depressants- ETOH, barbituarates, opioids
    • •Epi and beta-blockers can increase effect, decreasing BP too much!
  46. Alpha 1 -adrenergic blockers
    • •Newest adrenergic blockers
    • •Best safety profiles
    • •Block alpha 1 receptors in the arteries
    • •Only available po
  47. Minipress
    • •Dilates arterial and venous blood vessels
    • •This decreases blood pressure
    • •Can also relieve urinary symptoms with BPH
    • •Can be used with cardiac glycocides and diuretics fro
    • CHF
    • •Can cause severe orthohypotension, but most will
    • develop a tolerance after the first dose
    • •Other meds: Cardura, flomax and hytrin
  48. Regitine
    • •Used for the treatment of estravasated epi, norepi and dopamine infusion sites
    • •Also used to diagnose pheocromocytoma
    • •How?
    • - If pheocromocytoma is suspected: pt has HTN and an IV dose of Regitine is given- this will cause a decrease in Bp and diagnosis can be made
  49. Alpha 2- adreneric receptor stimulators
    • •Not typically a first line antihypertensive
    • •HIGH incidence of severe orthostatic hypotension, fatigue and dizziness
    • •This class will be used if all other classes fail
  50. The drugs
    • Clonidine- (Catapres) – decreases Bp and can also be used for opioid withdrawal
    • •Clonidine- po, (topical and epidural)*- used for severe pain in cancer patients
    • •Do not stop abruptly- causes “rebound hypertension” Methyldopa- antihypertensive drug of choice for pregnant
    • pt. Why? Beta blockers decrease the SNS stimulation in the heart and decrease heart rate and Bp more so than this drug- so think fetus effects
  51. ACE Inhibitors
    • •ACE- Angiotensin-Converting Enzymes
    • •They mediate extracellular volume and arterial vasoconstriction component of the Bp regulating system
    • •They prevent Na+ and H2O reabsorption
    • •So this in turn causes diuresis
    • •They are the largest group of antihypertensives
    • •Safefirst line agent to treat CHF and hypertension
    • •So with the prevention of sodium and H2o reabsorption- there is a decrease in the blood volume and return to the heart which decrease the Bp.
    • •Hyperkalemia is a risk though!
    • •Monitor k+ levels, and educate about
    • K+ in the diet!
  52. Side effects
    • •Fatigue, HA, mood changes, dizziness
    • •Dry non-productive cough* that reverses if med stopped
    • •Loss of taste
    • •Anemia
    • •Proteinuria
    • •Rash and itching
    • •Hyperkalemia
    • •Not used in renal disease- can cause acute failure
  53. OD and toxicity management (ACEI’s)
    • •s/s = Severe hypotension
    • •Give IVF’s to expand the volume and blood volume
    • •HD may be required for OD of captopril and lisinopril
    • •Do not give with ASA, NSAIDS, K+ sparing diuretics or K+ supplements
    • •No lithium b/c it increases lithium levels
  54. Captopril (Capoten)
    • •Used commonly after an MI to reduce risk of heart failure
    • •Has the shortest half-life of all ACEI’s
    • •Good for patients in fragile state
    • •Only available PO
  55. Lisinopril (Zestril, Prinivil)
    • •NOT used in pregnancy
    • •Lisinopril is used alone or in combination for hypertension
    • •Lisinopril is also used to improve survival after a heart attack.
    • •Used to treat CHF
    • •Low Na+ and low K+ diet suggested
  56. Vasotec
    • •Oral an IV preps
    • •To be converted into an “active metabolite”- must have proper liver function
    • •Improves survival rates of those post MI
  57. Angiotensin II Receptor Blockers
    • •What
    • is Angiotensin II?

    • -A natural substance
    • in the body that narrows blood vessels thus increasing Bp

    • -So if there is an increase in the narrowing effort- Bp increases more so
    • -The blockers relax the blood vessels to decrease Bp by decreasing the narrowing effect
    • •These are fairly well tolerated and do not cause the cough!
    • •Improves survival rates s/p MI
    • •Used to treat CHF
    • •Can be used cautiously with DM, and renal dysfunction in those that have shown a tolerance for the medication without
    • side effects**
    • •Can cause birth defects- not a great idea with pregnancy
  58. Side effects
    • •URI symptoms
    • •Nasal congestion
    • •Dizziness
    • •Dyspnea
    • •Diarrhea, heart burn
    • •Back pain
    • •HA and fatigue
    • •OD/Toxicity- expand circulatory volume and support systems
    • •Hyperkalemia
  59. Interactions
    • •Lithium- increases levels
    • •Cimetadine, Rifampin, and Phenobarbitol reduce the effectiveness of Cozaar
    • •Diflucan decreases the conversion of Cozaar into its active form
    • •Report any side effects to physician
  60. The drugs:
    • •Cozaar/Hyzaar (Cozaar with HCT)- used for txt. Of hypertension and CHF
    • •May have slightler lower mortality rates than seen with ACE inhibitors in CHF
    • •No breast feeding- crosses into the milk
    • •Diovan (Diovan HCT (with diuretic)
    • •Can be used along with other anytihypertensives
  61. Other good info about antihypertensives:
    • •Many as you see- come with a diuretic in on preparation
    • •These decrease extracellular fluid volumes so there is a decrease in preload which decreases the effort of the heart
    • •Those that vasodilate- relax the smooth muscle of the heart and long-term constriction will cause major damage to
    • heart, brain and kidneys!
    • •Ever heard of Minoxidil or Rogaine?
    • •PO- this decreases Bp
    • •Topically it is used for hair growth, but can it cause hypotension? YES
    • •Educate!
  62. Nursing Process:
    • •Assess liver and kidney function
    • •Assess stress
    • •Any PVD?
    • •Any history or suspect of pheocromocytoma?
    • •Use all cautiously with kiddos and elderly- they are more sensitive and the diuretics can cause an increased lyte imbalance
    • •Watch K+
    • •Can take some meds with OJ unless contraindicated
    • •Eat K+ rich foods unless contraindicated
    • •Avoid increased Na+ intake
    • •Garlic can be taken to decrease Bp, but not with coumadin, NSAIDS, anti-platelets or ASA!
  63. Implementation and education
    • •Baseline vs and weight and then along the way
    • •QD weights
    • •I/O
    • •Baseline EKG, telemetry
    • •Wacth for syncope
    • •Swelling in the feet, ankles, eyes
    • •Assess CP and palpitations
    • •Loose weight, avoid stress, exersice safely
    • •Leg cramps? May be hypokalemia
    • •Be wary of the OTC’s
    • •Change positions slowly
    • •No smoking or ETOH
    • •Stay hydrated
    • •Oral formulas with meals to decrease GI upset
    • •Watch sodium intake