pharm 2

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pharm 2
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  1. The Diuretics

    overall goal for use
    reduction of fluid volume

    benefits of reduced fluid volumes:

    • reduced workload of the heart (blood volume is reduced)
    • increased cardiac output
    • decreased peripheral edema
    • decreased pulmonary congestion
  2. The Diuretics

    What general conditions are diuretics used for ??
    • heart failure
    • cirrhosis/liver disease
    • renal diseaes/failure
    • hypertension (one class of diuretics used as a primary treatment; others are secondary)
    • pulmonary edema

    WHY???

    Because for ALL of these conditons excess fluid is a problem !!
  3. What does too much fluid volume really do ??
    • increased circulating plasma volume
    • increased peripheral vascular resistance
    • increased cardiac workload

    • decreased cardiac output
    • decreased blood flowto kidneys
    • decreased renal output which further results in increased fluid !!

    • 1. fluid "backs up" to pulmonary system and crackles happen !!
    • 2. fluid escapes to tissues i.e., peripheral edema happens !!
  4. hypertension notes

    important to assess or:
    can happen to a pt if bp is not controlled
    • d daily weight
    • i I&O
    • u urine output
    • r response of blood pressure
    • e electrolytes
    • t take pulses


    • i ischemic episodes (TIA)
    • c complications: the 4 C's

    • CAD coronary artery disease
    • CRF chronic renal failure
    • CHF congestive heart failure
    • CVA cerebral vascular accident
  5. Lab tests related to diuretics
    • potassium 3.5-5.0
    • sodium 135-145
    • chloride 96-106
    • calcium 9.0-10.5
    • magnesium 1.3-2.1
    • phosphorus 3.0-4.5

    renal function specific:

    • minumum urine output per hour (adult) 30 ml/hour
    • pediatrics 1-2 mL/kg/hour
    • serum creatinine: 0.5-1.2 (gender related differences)
    • BUN 10-20 mg/dL
  6. Thiazide Diuretics

    purpose
    • work in distal convoluted tubule to:
    • prevent reabsorption of water
    • promote diuresis when renal function is not impaired
  7. Thiazide Diuretics

    prototype

    administration
    hydrochlothiazide (HydroDIURIL)

    administration: oral or I.V.
  8. Thiazide Diuretics

    Watch out !!
    • pregnancy category B
    • use with caution in view of impaired renal function as it just may not work
  9. Thiazide Diuretics

    adverse reactions
    • common: hypotenstion
    • common: electrolyte imbalance
    • common: hyperglycemia (amt of sugar is more concentrated)
    • common: photosensitivity of skin
    • common: GI upset
  10. Thiazide diuretics

    DDI
    • digoxin (cardiac sensitive to potassium balance - hypokalemia)
    • antihypertensives (lowers blood pressure - so double whammy)
    • lithium (narrow theraputic window - dependent on fluid, water, sodium balance)
    • NSAIDs (like ibuprofen, NSAIDs = need more because of diuretics - because NSAIDs blunt affects)
  11. Thiazide Diuretics

    know what shows the drugs are working or not working
    • decreased blood pressure
    • decreased edema
    • increased urine output
  12. "High ceiling" Loop Diuretics

    purpose
    • block reabsorption of sodium and chloride in the ascending loop of Henle to:
    • prevent reabsorption of water
    • cause extensive diuresis
    • because the "loops" increase renal blood flow, they are useful in renally compromised patients
    • you often see the "loops" used for edema in Med-Surg applications
  13. "High ceiling" Loop Diuretics

    extra notes
    • potassium-wasting diuretic
    • diuresis is quite extensive within 5 minutes
    • increased renal blood flow- good if have renal problems
    • increase dose - increase effects
  14. "High ceiling" Loop Diuretics

    prototype

    administration
    furosemide (Lasix)

    Bumetanide (Bumex)

    • oral or I.V.
    • (give slowly by I.V. to avoid ototoxicity)

    • give over 3-5 minutes
    • caution: sulfa drug sensitivity

    if fluid is in 3rd spaced tissues - then lasix will be slower to work
  15. "High Ceiling" Loop Diuretics

    watch out!!
    • pregnancy category C
    • use with caution in view of diabetes (it increases blood sugar)
    • use with caution in view of gout (may result in hyper uricemia)

    • Watch out !!
    • this class of diuretic dumps potassium
  16. "High Ceiling" Loop Diuretics

    adverse reactions
    • common: hypotension
    • common: electrolyte imbalance
    • hypokalemia
    • hyponatremia
    • hypochloremia
    • hypocalcemia
    • hypomagnesemia
    • common: hyperglycemia
    • Ototoxicity (transient deafness =rare)
  17. "High Ceiling" Loop Diuretics

    DDI
    • digoxin
    • antihypertensives
    • lithium
    • NSAIDs
  18. "High Ceiling" Loop Diuretics

    know what shows the drug is working or not working
    • decreased peripheral edema or pulmonary congestion
    • weight loss
    • decreased blood pressure
    • increased urine output
  19. Potassium Sparing

    purpose
    • block the action of aldosterone
    • +keeps potassium and gets rid of sodium and water
  20. Potassium Sparing

    prototype

    administration
    spironolactone (aldactone)

    • oral only
  21. Potassium Sparing

    extra note
    if can not keep potassium levels up - may be on Lasix and alittle bit of aldactone to keep potassium
  22. Potassium Sparing

    watch out
    • this class of diuretics keeps potassium
    • Do not administer if K+ is >5.0 mEq/L
  23. Potassium Sparing

    adverse reactions
    • common: hyperkalemia
    • common: endocrine effects (gynecomastia/impotence/irregualar menstural cycles)

    triamterene may turn urine blue
  24. Potassium Sparing

    DDI
    • Ace inhibitors (may increase K+ levels)
    • concurrent use of potassium supplements (may increase K+ levels)
    • lithium (because of fluid balance problem)

    also: other drugs that increase potassium = like Ace inhibitors
  25. Potassium Sparing

    know what shows the drugs are working or not working
    • decreased blood pressure (if used as antihypertensive)
    • decreased edema
    • potassium levels WNL
    • (watch for hyperkalemia on cardiogram= T wave will peak)
  26. Potassium Sparing

    know what to teach
    • diet=) avoid potassium
    • do not eat bananas, strawberry, avocado
  27. Osmotic Diuretics

    purpose
    increase blood osmolality to create diuresis

    attracts fluids from other compartments (third-spaced, cerebral, intraocular)
  28. Osmotic Diuretics

    prototype
    mannitol (Osmitrol) - I.V. bolus in an ampule

    Isosorbide (Ismotic)-used for glaucoma
  29. Osmotic Diuretics

    administration
    • I.V. - most effective given as bolus
    • note: manitol requires use of filter needle to draw up or filter in IV tubing
    • note: Isosorbie & glycerin have oral formulations

    used for cerebral edema
  30. Osmotic Diuretics

    watch out
    extreme caution needed when administering to cardiac patients (mannitol may increase edema and cardiac workload)

    do not use in patient with total renal failure
  31. Osmotic Diuretics

    adverse reactions
    • headache
    • nausea
    • vomiting
    • dizziness
    • rash
    • blurred vision
    • thrombophlebitis
    • fluid/electrolye disorders
    • dehydration
    • thirst
    • urticaris
    • hypotenstion
  32. Osmotic Diuretics

    DDI

    from Epocrates.com
    • lithium
    • MAOIs
    • organic nitrates
  33. Osmotic Diuretics

    know what shows the drugs are working or not working
    • decreased intracranial pressure
    • decreased intraocular pressure
    • normal renal function
  34. Osmotic Diuretics

    know what to monitor
    • cerebral edema=)
    • mental status changes
    • coma ??
    • intracranial pressure decreased
  35. A client is to take furosemide daily. Teaching instructions should include:
    good sources of potassium include avocados and strawberries
  36. A client taking which of the following would be at risk for ototoxicity ??

    spironolactone
    furosemide
    hydrochlorthiazide
    mannitol
    furosemide
  37. A client is to receive mannitol,IV push bolus. Which of the following would be of concern if noted after the mannitol is administered ??
    distended neck veins
  38. Anti-anemia: Iron

    purpose
    provide iron needed for RBC formation and oxygen transport
  39. Anti-anemia: Iron

    prototype
    • Ferrous sulfate (Feosol)
    • Iron Dextran (NFeD)
  40. Anti-anemia: Iron

    administration
    ORAL (except for INFeD which is given IM/IV)

    • Watch out !!
    • Giving with antacids/milk/"cyclines" decreases effect
  41. Anti-anemia: Iron

    adverse effects
    • GI upset but taking with food can decrease effectiveness
    • take with orange juice 1 hr before or 2 hrs after

    • give between meals - hard to avoid calcium in diet
    • will bind with calcium/tetrocycline decrease effect
  42. Anti-anemia: Vitamin B12

    purpose
    convert folic acid from inactive to active form (all cells need folic acid for DNA production)
  43. Anti-anemia: Vitamin B12

    prototype

    administration
    Cyanocobalamin (Crysamine)

    oral, nasal, SQ/IM
  44. Anti-anemia: Vitamin B12

    watch out
    sensitivity to cobalt - radiation from cancer
  45. Anti-anemia: Vitamin B12

    adverse reactions
    • uncommon
    • hypokalemia can occur as a result of increased RBC production, rash/itching; anaphylaxis possible but rare
  46. Anti-anemia: Folic Acid

    purpose
    provide necessary ingredient for DNA production and erythropoiesis (RBC, WBC, platelets)
  47. Anti-anemia: Folic Acid

    prototype
    folic acid (folacin, folvite)
  48. Anti-anemia: Folic Acid

    administration
    oral

    note: absorbed better in pill form as opposed to in food
  49. Anti-anemia: Folic Acid

    watch out
    • DDI: sulfas and methotrexate decrease folate levels
    • (may be put on folic acid supplement)
  50. Anti-anemia: Folic Acid

    adverse reactions
    flushing, allergic response if given IV
  51. Why do we worry about hyperkalemia ??

    Key facts about hyperkalemia
    • most dangerous of the electrolyte disorders
    • commonly accompanies metabolic acidosis
    • several common underlying mechanisms can result in too much K+
    • best clinical indicators:
    • serum potassium levels
    • electrocardiogram tracings

    • serum potassium levels exceeding 7 mEg/L:
    • possible serious cardiac arrhythmias/heart block leading to cardiac arrest

    good thing we have Kayexalate to treat it!!
  52. Kayexalate

    purpose
    to promote potassium excretion
  53. Kayexalate

    prototype
    sodium polystyrene sulfonate (Kayexalate)
  54. Kayexalate

    administration
    oral or rectal

    in pill form - comes in huge pill - can they swallow it ??
  55. Kayexalate

    watch out
    use with caution in patients who cannot tolerate shifts in sodium and pts who receive digoxin or K+ sparing diuretics
  56. Kayexalate

    adverse reactions
    common: electrolyte imbalance: you can send the K+ too low

    sodium excess possible
  57. Kayexalate

    DDI
    • calcium or magnesium antacids or laxatives may reduce drug effect (oral form)
    • patients on digoxin and potassium-sparing diuretics require frequent K+ monitoring
  58. Potassium Supplements

    purpose
    to treat hypokalemia (K+ level <3.5 mEq/L)
  59. Potassium Supplements

    prototype
    potassium chloride (K-Dur)
  60. Potassium Supplements

    administration
    • oral (powder to mix in water common)
    • In at least 4 ounces liquid, do not crush ER tabs

    • IV: rapid IV infusion can result in fatal hyperkalemia
    • no more tha 40 mEq per liter IV solution
    • no more than 10 mEq/hour rate
    • really tears up veins - watch for phlebitis
  61. Potassium Supplements

    watch out
    • do not use with K+ sparing diuretics
    • do not use when there is severe renal disase or hypoaldosteronism
  62. Potassium Supplements

    adverse reactions
    • common: GI distress - oral
    • GI ulceration - oral
    • hyperkalemia - IV
  63. Potassium Supplements

    DDI
    • spironolactone (and other potassium sparers)
    • ACE inhibitors due to risk for hyperkalemia
  64. Magnesium levels

    hyper
    depressed deep tendon reflex

    treatment: calcium gluconate

    • give this because we have caused this
    • we have caused this in treating something else
  65. Magnesium Supplements

    purpose
    replacement or prevention of hypomagnesemia
  66. Magnesium Supplements

    prototype
    magnesium sulfate
  67. Magnesium Supplements

    administration
    • oral - used to prevent low magnesium
    • IV - used when magnesium levels are already low and in OB applications (to treat preterm labor)
  68. Magnesium Supplements

    watch out
    • pregnancy risk B
    • caution used in view of renal/cardiac disease (a "no no" if AV block is present)
    • cautious use in view of rectal bleeding, nausea/vomiting, abdominal pain
  69. Magnesium Supplements

    adverse reactions
    common: hypermagnesemia: monitor for deep tendon reflexes
  70. Magnesium Supplements

    DDI
    decreased absorption of tetracyclines
  71. Sodium Bicarbonate

    purpose
    an alkalinizer to correct metabolic acidosis (acidosis = <7.35)
  72. Sodium Bicarbonate

    prototype
    sodium bicarbonate (aka "bicarb")
  73. Sodium Bicarbonate

    administration
    • oral - as an antacid
    • IV - generally bolus but can be added to solution for continuous infusion (rare)

    • note: IV use is generally restricted to situations where there is proven deficit on ABGs to confirm acidosis
    • note: when given IV, remember - it doesn't mix with anything (i.e., numerous incompatabilities)
  74. Sodium Bicarbonate

    watch out
    • hypertenstion
    • heart failure
    • kidney disease
  75. Sodium Bicarbonate

    adverse reactions
    • sodium overload
    • renal calculi
    • metabolic alkalosis
  76. Sodium Bicarbonate

    DDI
    • corticosteroids (can result in decrease K+, increase Na+)
    • increases effect of pseudophedine and quinidine
    • decreases effect of lithium, salicylates (aspirin), and benzos
  77. Calcium Supplements

    purpose
    • to treat or prevent hypocalemia
    • preventive use is directed toward "at risk" populations (adolescents, women who are postmenopausal, pregnant, breast feeding)
  78. Calcium Supplements

    prototype
    calcium citrate
  79. Calcium Supplements

    administration
    • oral - common
    • take at a different time than glucocorticoids, tetracyclines, thyroid hormone

    IV - somewhat rare, incompatibilities exist
  80. Calcium Supplements

    watch out
    use with caution in view of decreased GI function, renal disease, dehydration
  81. Calcium Supplements

    adverse reactions
    hypercalcemia - somewhat rare, generally only a problem with IV administration
  82. Calcium Supplements

    DDI
    Many possible !! (but it is still pretty darn safe)

    • glucocorticoids - decrease absorption of Ca+
    • tetracyclines - decrease absorption of drug
    • thyroid hormones - decrease absorption of drug
    • thiazide diuretics - increased absorption of Ca+
    • digoxin combined with parenteral Ca+ = severe bradycardia
  83. With any calcium enhancer....
    • encourage clients to consume adequate amounts of dietary calcium
    • What are calcium foods you would recommend??
    • encourge client to perform weight-bearing excercises daily
    • What kind of exercise would you recommend??
  84. SERMs:
    selective estrogen receptor modulators

    purpose
    prevention and treatment of postmenopausal osteoporosis; also as a protection against breast cancer
  85. SERMs

    prototype

    administration
    raloxifene

    oral
  86. SERMs

    watch out
    history of blood clots, cancer, stroke, elevated triglycerides, liver disease
  87. SERMs

    adverse reactions
    • deep vein thrombosis
    • pulmonary embolism
    • stroke
    • common: hot flashes (1 in 10 patients report)
    • leg cramps (1 in 14 patients report)
  88. SERMs

    DDI
    • cholestyramine
    • warfarin
    • systemic estrogens
  89. Biphosphonates

    purpose
    inhibit bone resorption by decreasing number and action of osteoclasts
  90. Biphosphonates

    prototype
    alendronate sodium (Fosamax)
  91. Biphosphonates

    administration
    • oral: tablets or liquid
    • tabs: may be daily or once a week
    • liquid: once a week
  92. Biphosphonates

    watch out
    existing esophageal disorders (GERD) should not use
  93. Biphosphonates

    adverse reactions
    esophagitis

    also a risk for hyperparathyroidism at high doses (monitor PTH levels)
  94. Biphosphonates

    DDI
    • calcium supplements
    • antacids
    • orange juice
    • caffeine will decrease absorption so take 30 minutes before or after these products

    use with salicylates = increased GI distress
  95. Calcitonin-Salmon

    purpose
    inhibits activity of osteoclasts to decrease bone absorption
  96. Calcitonin-Salmon

    prototype
    calcitonin-salmon (fortical, miacalcin)
  97. Calcitonin-Salmon

    administration:
    • intranasal (most common)
    • SQ
    • IM

    • Note: keep nasal spray container in upright position
    • must alternate nasals - bloody and runny nose
  98. Calcitonin-Salmon

    watch out
    • pregnancy category C
    • cautious use in kidney patients
  99. Calcitonin-Salmon

    adverse reactions
    • rhinitis and epistaxis (with nasal spray)
    • skin rash
    • injection site redness/irritation (injectable form)
    • nausea
    • allergic response
  100. Calcitonin-Salmon

    DDI
    decrease in serum lithium levels
  101. Which of the following should a client be monitored for when receiving magnesium sulfate?

    depressed deep tendon reflexes
  102. A client with hyperkalemia has been prescribed Kayexalate rectally. Which of the following is an appropriate nursing intervention related to this route of administration??

    irrigate the colon after the Kayexalate solution has been expelled
  103. Which of the following is used for treatment of hypermagnesemia?

    calcium gluconate
  104. Which precaution is necessary when administering potassium chloride IV?
    select all that apply

    infusion pump
    rate of no more than 10 mEq/hour
  105. Which of the following clients should not take raloxifene (Evista)? select all that apply
    • 55-year-old who had a DVT one year ago
    • 38-year-old who is pregnant

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