Ch 12 What is the pathophysiology behind someone with Parkinsons disease?

Degenerative disorder of CNS caused by death of neurons that produce the brain neurotransmitter dopamine. Goals Restoring dopamine function Blocking effects of acetylcholine Main groups of drugs to treat Parkinsons Dopaminergic agents (increase dopamine levels in brain) Cholinergic blockers AKA anticholinergics Sinemet= combination of Levodopa and Carbidopa Stimulates dopamine Is the drug of choice for parkinsons b/c it can cross the blood-brain barrier. Carbidopa Prevents metabolism of Levodopa making it more available to enter the CNS Drug is used to treat Alzheimers Acetylcholineresterase inhibitors (Cholinergic agents) Works - Acetylcholineresterase is inhibited it is blocked. So acetylcholine increases because the enzyme is not breaking it down. Donepexil hydrochloride (Aricept) Tacrine (Cognex) Patho behind multiple sclerosis An autoimmune disorder of the CNS mylien sheath is destroyed preventing impulses from travelling across to each other Pharmacotherapy Relieve symptoms Attempt to reduce inflammation and prevent attacks on the nervous system Categories Immunomodulators only clinically proven drugs for treating underlying causes slow down the autoimmune destruction of the mylien Myelin Protein builders Stimulates myelin basic protein coating Skeletal muscle relaxants Treat muscle spasms of MS Centrally acting muscle relaxants Cyclobenzaprine (Flexeril), (Baclofen) Direct acting muscle relaxants Dantrolene Sodium (Dantrim)

Pt teaching Take w food/milk 4 equal doses Cause drowsiness Avoid alcohol/ other CNS depressents Report yellow skin/ eyes Seizures Considerations regarding antiseizure meds and pregnancy Pregnancy category D They can cause folic acid deficiency Decrease effectiveness of oral contraceptives Eclampsia: characterized by HTN, HA, and edema Goal Suppress neuronal activity just enough to prevent abnormal or repetitive firing Increase the electrical threshold GABA (Gamma aminobutric acid) It is the primary inhibitory meurotransmitter in the brain What do some antiseizure meds do to GABA Changing (intensifying) the action of GABA Suppresses the ability of neurons to fire causes CNS depression Barbiturates Phenobarbital (Luminal) Low margin of safety High potential for dependency SE- Drowsiness With overdose- resp depression, CNS depression, coma, and death Succinimides ethosuximide (Zarontin) Delay the entry of calcium into neurons by blocking channels Adverse effect- psychosis or extreme mood swings Drug category of choice for status epilepticus Diazepam (valium) Benzodiazapines ( end in pam) Hydantions Carbamezepine (Tegretol) Valproic acid (Depakene, Depakote) Phenytoin (Dilantin) Adverse effects Can cause dysrhythmias Peripheral neuropathy with long term use

Ahranulocytosis, aplastic anemia Connective tissue reactions (gingivial hyperttophy) carefully monitor serum levels

Pain Nonnarcotic med is contraindicated in young kids Aspirin, Tylenol Choice- *Ibuprofen Analgesic Medications used to relieve pain Opioid Natural or synthetic morphine-like substance Non-opiod Anti-inflammatory drug Combination opioid/ nonnarcotic meds Smaller doses of narcotic,less dependcy, less AE Potential uses for opioids Suppress cough reflex Slow GI motility Cause sedation Euphoria or intense relaxation SE/AE for opiods N & V (extremely common) Sedation Itching **Constipation is a severe S/E we usually give stool softeners along with an opioid **Respiratory depression in too high of a dose can make patients stop breathing *Max 8 a day Opioid antagonists These reverse the effects of opioids They block the effects of an opioid/treat overdose ( CNS depression, or respiratory arrest) Naloxone (Narcan) Patients may experience rapid loss of analgesia They will feel their pain return intensely After administration Breathing pattern/vitals Pain level of patient Subcategories of NSAIDS Selective COX-2 inhibitors example: Vioxx, Celebrex (Removed from the market) B/C- cause severe heart problems/heart attacks. GI effects

Ibuprofen and ibuprofen-like example: nonsalicylates These block COX 1 and 2 prostaglandins Drugs of choice for mild to moderate pain. ** Have anti-inflammatory, analgesic, and anti-pyretic properties SE/AE for NSAIDS Most are safe and produce adverse effects at high doses GI: N& V Diarrhea **Gastric irritation and bleeing **CV: increased risk of heart attrack and stroke Tylenol -Has anti-pyretic and analgesic effects -**Does not have any anti-inflammatory activity Max dose- 4,00 mg or 4 grams *live toxic and can cause hepatotoxicity Reversal agent for Tylenol overdose Acetylcysteine (Mucomyst) What is the MOA for anti-migraine meds for acute attacks? Constrict certain vessels within the brain in order to stop the migraine Sumatriptan (Imitrex) Ergotamine (Ergostat) *Pregnancy Category X Respiratory Antihistamine Prevent the histamine from attaching top the receptor site. They are taken orally and reduce the symptoms of sneezing, rhinorrhea, and watery eyes. Cetirizine (zyrtec) Diphenhydramine HCL (Benadryl) Loratadine (Claritin) Fexofenadine (Allegra) S/S Drowsiness, Dry mouth, Impaired memory/coordination

Decongestants Oxymetazoline (Afrin) Phenylephrine (neo-synephrine) Pseudoephedrine (Sudafed) Selective alpha adrenergic stimulants that cause vasoconstriction to the nasal mucosa *watch for increased b/p because of vasoconstriction MOA (method of action) for decongestants Decreased blood flow Decreased inflammation Less mucus production Easier breathing *Decongestants only relieve these symptoms temporarily SE- - Mild nasal irritation with nasal sprays Rebound congestion caused by overuse Elevation of B/P Bronchospasms Bronchioles constrict allowing less air in so the patient is gasping for breath Teaching points Timed w/ inhalation so reach lungs -Allow 1 minute between each puff to allow med to be absorbed in lungs TAKE BRONCHODILATOR FIRST! If using more than 1 med. Rinse mouth out after use so medicine is not sitting on tongue. Not absorbed into GI tract. Expectorant vs. Antitussive Expectorant Guaifenesin (Robitussin, Mucinex) Thins the mucus and allows it to be coughed up easier Reduces viscosity of bronchial secretions Antitussives- control cough Opioids Dextromethrophan- OCT Benzonatate (Tessalon): has an anesthetic like effect on the stretch receptors in the lungs, does not act on the cough center. *These meds cannot be chewed or the throat will go numb Expectorant different from a mucolytic Mucolytics act directly on a mucus molecule Expectorant directly loosen thick viscous bronchial secretions, easier to cough up

3 categories of bronchodilators Beta-adrenergic agents- (sympathomimetics) Albuterol (Proventil *drug category of choice for acute bronchoconstriction selective to beta 2 receptors in the lung, inhaled they cause rapid bronchodilation S/E-Tolerance can develop (pt. should consult MD) Tremors, palpitations, tachycardia, anxiety, HA (headache), N & V, dizziness Xanthines Theophylline(Theo-dur) End in- Phylline NC- Is chemically related to caffeine , reduce caffeine intake Have a narrow margin of safety Interacts with a large # of drugs S/S of Xanthine toxicity N&V CNS stimulation (confusion, blurred vision) Cardiac arrhythmias in large doses Anticholinergics Ipratropium (Atrovent) Tiotropium (Spiriva) Combivent (Albuterol and Atrovent) It blocks the parasympathetic nervous system few systemic effects B/C their inhaled Work best in combination with other bronchodialtors S/E Tachycardia Urinary retention Dry mouth

3 anti-infammatory categories Preventative or prophylactic treatment Glucocorticoids ( or corticosteroids) Beclomethasone (Beclovent) Given via inhalation to decrease SE / Orally more S/E Long periods could cause: Adrenal gland suppression Peptic ulcers Hyperglycemia Weight gain

Antileukotriene agents Montelukast (Singular) All oral Modify actions of leukotrienes, in inflammatory process in asthmatic patients. Decrease inflammation. S/E-HA, Cough, Nasal congestion, GI upset

Mast cell stabilizers Cromolyn (Intal) Nedocromil (Tildade) Inhibits the release of histamine maximum effects take several weeks

Lipid disorders HDL( Good Cholesterol) LDL(Bad Cholestrol) HDL: > 60 LDL: <100 Total cholesterol: <200 Lower LDL levels Raise HDL levels Statins(HMG-CoA reductase inhibitors)- HMG-CoA is the enzyme that the statins block Avorvastatin (Lipitor) Simvastatin (Zocor) Rosuvastatin (Crestor) **All end is statin** *1st drugs of choice Nursing considerations Monitor liver enzymes (Liver function and levels) Report signs of muscle weakness and tenderness Give at night b/c that when Biosynthesis is higher Decrease Q10 levels in the body Rhabdomyolysis- muscle tissues becomes extremely inflamed, breakdown of muscle. Decrease Q10 levels in the body

Bile-acid sequestrants Cholestyramine (questran) Colestieol (Colestid) Bind to bile acids and increase the excretion of cholesterol in feces Nursing considerations Not absorbed into circulation may prevent absorption of other med/vitamins(digoxin/Coumadin) Take 1-2 hr B4 other meds or 4hr after SE are GI related (constipation, nausea, bloating) Nicotinic acid (B-complex vitamin) High dose need to achieve antilipidemic effect (2-3 grams a day) One OTC version has no effect on lipids (nicotinamide) Nursing considerations SE-hot flashes and flushing Taking one aspirin 30 min b4 , reduce the incidence of flushing and hot flashes. Fibric acid agents Fenofibrate (Tricor) Gemfibrozil (Lopid) Reduces triglyceride and VLDL levels Elevates good cholesterol (HDL) Has little effect on LDL levels * the MOA is not completely understood** Cholesterol absorption inhibitors Act on the cells in the small intestine to inhibit cholesterol absorption. Reduces bad cholesterol Raises good cholesterol Ezetimibe (zetia) Omega 3 fatty acids (fish oil) (Lovaza) Reduce the synthesis of triglycerides liver by up to 20% SE- are rare- aftertaste, belching, chills, gas/bloating Combo Therapy(Adverse effects are fewer and patient adherence is greater) One less pill to take for pts May increase compliance Available in multiple dose combinations Treat to things w/ 1 pill Vytorin is a combo of ezetamibe (Zetia) and simvastatin (Zocor) (Zocor=Statin/Zeta= Cholesterol absorption inhibitors) Caduet is a combo of atorvastatin (Lipitor) and amlodipine (Norvasc) ( Lipitor=Stantin/Norvasc=CCB- anti-HTN)

Hypertension Drug classes to treat HTN Diuretics(Drugs of choice for treating HTN) Chlorothiazide (Diuril) Furosemide (Lasix) Spironolactone (Aldactone) SE Dehydration: thirst, dry mouth, fall in b/p, dizziness, and lethargy Electrolyte imbalance: hypokalemia (this can cause serious abnormalities in cardiac rhythm) Nursing considerations Daily wt. Low sodium diet, I/O, monitor for Electrolyte imbalance

Calcium channel blockers They block the calcium channels connected to the electrical charge of the heart Verapamil (Calan) Nifedipine (Procardia) Amlodipine (Norvasc) Diltiazem (Cardizem) Some end in- ipine SE-* Related to vasodilation* Hypotension/ syncope HA Facial flushing Dizziness, edema Bradycardia Nursing interventions/teaching Daily wt. to assess for edema Teach pt to rise slowly d/c gradually Fast acting forms can cause significant reflex tachycardia Interactions Grapefruit juice: can cause greater absorption of nifedipie Alocohol: Increases the vasodilating effects- severe drop in b/p Nicotine: vasoconstriction- countering the effect

Renin-angiotensin pathway modifiers Drugs that modify RAAS decrease b/p and increase volume/ slow kidney failure Two Typs 1)Angiotensin converting enzyme inhibitors (AKA ACE inhibitors) -Inhibitors block angiotensin II from forming 2)Angiotensin receptor blockers (AKA ARBs) Block the effect of angiotensin II after it is formed Angiotensin converting enzyme inhibitors(ACE) Block formation of angiotensin II so the kidney will not reabsorb sodium which will increase b/p .*Good for kidney failure patients Lisinopril (Zestril) Captopril (Capoten) Enalapril (Vasotec) All end in- pril SE HA, Dizziness Cough**- dry and present only ACE Hypotension- Primarily orthostatic AE: Hyperkalemia, birth defects, angioedema NC- Can have a rapid fall in b/p with the first dose Good choice for diabetics who have HTN, slows the progression of kidney failure Angioedema generally seen after 1st dose. Hypersensitivity reaction swelling of the face or mouth, horsiness, severe dyspnea Angiotensin Receptor Blockers (ARBs) Block the action of angiotensin II after it is formed. Irbesartan (Avapro) Losartan(Cozaar) end in- Sartan SE Facial flushing Dizziness Headache * Orthostatic hypotension AE Hyperkalemia (renal impairment or diabetes or on a potassium supplement) Birth Defects (second and third trimester) Adrenergic blockers(can be selective or non selective) Block the effects of the sympathetic NS leading to vasodilation HR to slow, b/p to decline, and the bronchi to dilate Alpha1-receptors in Arterioles Beta1- receptors in the heart Nonselective blockade of both beta1 and beta2 receptors

Centrally acting- alpha2-adrenergic receptors in the brainstem Alph1 (end in SIN) Prazosin (Minipress) Terazosin (Hytrin) Doxazosin (Cardura) SE- Orthostatic hypotension(Tolerance usually develops) Dizziness, Headache, Nausea Bradycardia Dry mouth Centrally acting alpha2 agonists Clonidine (Catapres) *Also Catapres TTS (transdermal patch) Methyldopa (Aldomet)- converted to a false neurotransmitter in brainstem, causing a shortage of real neurotransmitter and inhibition of the SNS SE Dry mouth Drowsiness(sedation reason infrequently prescribed) Altered urine color- on exposure to air Depression Rash *With transdermal patch Beta Blockers (all end in lol) Decrease heart rate, contractility, and BP Atenolol (Tenormin) Metoprolol (Lopressor, Toprol) Propranolol (Inderal) adverse effects Bradycardia Hypotension Heart failure Bronchospasm *Wheezing Direct acting vasodilators(Used for severe hypertension or hypertensive crisis) Vasodilators work directly relax smooth muscles of arteries Hydralazine (Apresoline)- oral Nitroprusside (Nipride)- IV SE- Too many Severe hypotension Reflex tachycardia- blood pressure decreases, the heart beats faster in an attempt to raise it. NC- Monitor BP carefully

Heart Failure Digoxin (Lanoxin) -Cardiac (digitalis) glycosides (Oral or IV) Increase the force of myocardial contraction (increase cardiac output) Slow electrical activity in the heart, which decreases HR. SE- too many Signs of Toxicity(Serum dig level above 2 ng/ml is considered toxic) Hypokalemia will increase the potential for digoxin toxicity! GI- Loss of appetite, vomiting and diarrhea CNS stimulation- HA, drowsiness, confusion, blurred vision, halos in visual fields Cardiovascular- Severe bradycardia and abnormal rhythms can occur and be fatal Digoxin immune fab (Ovine, Digibind) FOR TOXIC LEVEL IV stops it from reaching the tissues Rapid onset- less than 1 minute NC- Any time there is a low therapeutic indexcheck serum levels. *Check apical HR for 1 full minute prior to administering- not given routinely if HR <60 bpm Margin of safety is very narrow Pts need close monitoring- Pt is usually hospitalized for several days to adjust the dose and monitor blood levels. ACE inhibitors Decrease the workload on the heart and let it work more efficiently Lisinopril (Prinivil, Zestril) Captopril (Capoten) Ramipril (Altace) Quinapril (Accupril) End in pril SE- Cough, headache, dizziness, orthostatic hypotension, rash, increased potassium Diuretics(Rarely used alone- usually in combination) Reduce fluid overload and lower b/p SE- electrolyte imbalance Can cause severe cardiac problems! Furosemide (Lasix) Spironolactone (Aldactone) End in - ide or one

Beta-adrenergic blockers(in combination) Slow the HR and reduce BP to decrease workload on the heart Exhibit a negative inotropic Carvedilol (Coreg) Metoprolol (Toprol XL) NC- Must carefully monitor because these drugs have the ability to worsen the HF Vasodilators( pt that cant tolerate ACE) Decreasing cardiac workload Hydralazine (Apresoline) arterioles (dilates) Isosorbide dinitrate (Isordil) veins (dilates) BiDil- combination of the two, working synergistically SE- Reflex tachycardia Orthostatic hypotension Minor role due to adverse effects Dysrhythmias They are abnormalities of electrical conduction in the heart Symptoms Dizziness SOB Weakness Fainting Palpitations Adenosine (Adenocard) Given IV as a rapid bolus to terminate serious atrial tachycardia It slows conduction through the AV node and decreases automaticity. Only used for paroxysmal supraventricular tachycardia. NC Pt must be on ECG monitor. Can be considered a chemical defibrillation CCBs and dysrhythmias Slows conduction velocity and prolongs the refractory period. Diltiazem (Cardizem) Verapamil (Calan) SE- beta blockers too the risk for these is much greater SCBs and dysrhythmias (Largest group) Blocking sodium channel will slow the spread of the impulse through the myocardium. Quinidine (Quinadine) Lidocaine (xylocaine) *label should read lidocaine for dysrhythmias *Early symptoms of lidocaine toxicity include excitement, confusion, and irritability

Beta-adrenergic blockers Block beta receptors in heart- slows HR Propranolol (Inderal) Metoprolol (Lopressor) SE- Bradycardia Hypotension Bronchospams NC- Of particular concern in pts with asthma and COPD Potassium channel blockers Stabilize dysrhythmias Prolongs the action potential by increasing the refractory period (resting stage) Amiodaron (Cordarone) Sotalol (betapace) SE Hypotension, Bradycardia Coagulation disoders Vitamin K is very important in coagulation. We get vitamin K from our diet Narrow margin of safety / monitor blood levels closely Ability to correct dysrhythmias but also can worsen or create new ones Thromboembolic disorders Angina CVA Deep vein thrombosis Indwelling devices MI Post op hemorrhage Anticoagulants (Prolong bleeding time by interfering with platelet aggregation) Started IV or SQ b/c thromboembolic disease can be life threatening. May take several weeks to reach its max effect( Coumadin 1 week) Heparin- Immediate anticoagulant activity IV onset immediate subQ onset may take up to an hour Protamine sulfate will reverse heparin Lab value- -aPTT (thromboplastin time) Normal is 30-45 seconds

Low molecular weight heparins (LMWHs) More predictable responses than heparin Longer half-life once daily dosing Fewer lab tests required Drug of choice for many clotting disorders Enoxaparin (Lovenox) Dalteparin (Fragmin)

Warfarin (Coumadin) Several days to reach maximum effect Oral anticoagulant take up to 10 days to diminish Use with feverfew, garlic, ginger may increase bleeding Vitamin K will reverse Coumadin Lab- PT (prothrombin time) Normal is 12-15 seconds SE Observe for signs of bleeding Monitor labs Flu-like symptoms (Dizziness, chills, weakness, pale skin) Low blood pressure Palpitations, fatigue, feeling faint Patient teaching Avoid vita K Use soft tooth brushes, and electric razors Do not use herbal supplements such as feverfew, garlic, or ginger with anticoags bc they could increase bleeding. Antiplatelet They work in the arteries to prolong bleeding time by interfering with platelet aggregation Aspirin (ASA) Ticlopidine (Ticlid) (ADP blockers). Clopidogrel (Plavix) (ADP blockers Aspirin considerations (81mg) A single dose of ASA can have an anticoagulant effect for a week Do not use in kids under 6 Should not take with other anticoags unless ordered SE- GI discomfort, bleeding

Thrombolytics (Clot busters- dissolve existing clots) **Narrow margin of safety between dissolving normal and abnormal clots Used for MI, pulmonary embolism, CVA, DVT, arterial thrombosis, coronary thrombosis, to clear thrombi in blocked IV caths *All end in ASE Alteplase recombinant (Activase) Reteplase recombinant (Retavase) Streptokinase (Streptase)- this was the first thrombolytic How is stable angina treated? With fats acting organic nitrates. How is unstable angina treated? With oral organic nitrates, beta-adrenergic blockers, or CCBs What is the MOA for the nitrates? Relax both arterial and venous smooth muscle to reduce the workload on the heart Nitroglycerin (Nitrostat) Short acting sublingually to quickly stop an acute angina attack in progress Isosorbide Dinitrate (Isordil) Long acting Orally or through a patch. (Preventative) SE Hypotension Reflex tachycardia Flushing of the skin Tolerance, sometimes HA *MOST COMMON NC Inform pt of med deterioration; every 3 months nitroglycerin prescriptions should be refilled and a dark colored glass container should be used for storage Why are pts. Instructed to have a Patch free time each day? Usually done at night, to delay the onset of tolerance

Antibacterials Pathogenicity- ability of an organism to cause disease in humans Virulence-The measure of an organisms disease producing potential.

Factors lead to the development of acquired resistance Overuse of antibiotics Misuse of antibiotics Patients often D/C antibiotic when they begin feeling better Allows some microorganisms to survive, thus promoting resistant strains Broad-effective against a wide variety of bacteria Narrow-effective against only one microorganism or a restricted group of Super infection. A/E of antibody therapy Secondary infections caused by anti-infective therapy Penicillin (Bacteriostatic or Bactericidal) Penicillin G (pfizerpen) Amoxicillin (amoxil) Ampicillin (Principen) END in- cillin *Chemical structure of PCN that is responsible for its antibacterial activity Penicillinase - Enzyme Secreted by Some Bacteria( aka beta-lactamase) Splits beta-lactam ring of penicillin Antibiotic classifications contain a beta lactam ring Penicillin, Cephalosporin What is the purpose of a beta lactamase inhibitor Protect the penicillin molecule from destruction Only available in fixed-dose combinations with penicillins Augmentin (amoxicillin + clavulanate) Timentin (ticarcillin+clavulanate) SE of PCNs Allergy most common Rash Fever Anaphylaxis GI distress Oral/vaginal Candidiasis No Acidic fruit juices *Some may reduce effectiveness of oral contraceptives Cephalosporins - contraindicated in a patient who has had a previous anaphylactic reaction to a PCN Start w/ cef ie Cefaclor (Ceclor)

Tetracyclines Very broad spectrum- high risk for supper infection Doxycycline (Vibramycin) Tetracycline (Achromycin) End in- cycline Nursing considerations Should not take with milk May cause photosensitivity do not give to kids under 9 (May cause yellow-brown teeth discoloration in children) preg classD Out dated med may become Nephrotoxic Macrolide Erythromycin (E-Mycin) Azithromycin (Zithromax) All end in-thromycin Zithromax or a Z-pack * Safe alternative to penicillin Use for infections that are resistant to penicillins Has longer half- life, so a 5 day dose will be used in sted of 10 day, thought to increase pt. adherence Mild GI upset, diarrhea, abd pain High risk for super infections (b/c Broad spectrum) Aminoglycosides Narrow spectrum drugs Used for serious aerobic gram-negative infections Ototoxicity- increased w/other drugs, ask md b4 using *frequent hearing tests while taking drug so you D/C at first symptoms Nephrotoxicity elevated BUN end in - mycin Gentamicin (Garamycin) Tobramycin (Tobramycin) Fluoroquinolones Ciprofloxacin (Cipro)- Exposure to anthrax Levofloxacin (Levaquin) End in- floxacin NC- Use in children monitored carefully because of potential effects of cartilage development Do not take with multivitamins or mineral supplements because they interact to reduce absorption of antibiotic up to 90%

Sulfonamides Trimethoprim-sulfamethoxazole (Bactrim, Septra) Start with- sulfa Treat- UTI SE Formation of crystals in urine Allergic reactions N, V Serious blood abnormalities (uncommon) NC- Not for use in kidney fail pt. no potassium supplements Monitor I&O, color constancy of urin Vancomycin Red mans syndrome-flushing, hypotension, rash on upper body Happens when vancomycin is infused quickly Instill slowly Ototoxicity Nephrotoxicity- check BUN/cretine TB Isoniazid (INH) S/E- Numbness of hands and feet (peripheral neuropathy) Rash Fever Liver toxicity (rare) *Liver enzymes usually performed monthly Antifungals, Antivirals, Antiparasitics Superficial infections Scalp, skin, nails, mucous membranes (oral cavity, vagina) Treated with topical agents Nystatin (Mycostatin) Butenafine (Lotrimin) Miconazole (Monistat) Tolnaftate (Tinactin) NC-Minor skin irritation Should not be applied to open sores b/c more may be absorbed Avoid tight undergarments if vaginal area and Occlusive dressings promote yeast Teach pt importance of infection control- hand washing, gloves when applying med, changes socks daily if on feet, dont share personal items.

Amphotericin B Opportunistic fungal disease in AIDS clients Prolonged therapy with corticosteroids Extensive burns Receiving anticancer drugs Recent organ transplants Nephrotoxic to some degree in most pts Kidney function tests monitored closely Digoxin toxicity if used with digoxin azole drugs. Fluconazole (Diflucan) Itraconazole (Sporonox) Ketoconazole (Nizoral)- take w/ water juice/coffey/tea to increase absorption Safer/ PO What does HAART therapy stand for High active antiretroviral therapy Aggressive therapy Goal is to reduce the plasma level of HIV to lowest level possible Advantages to starting pharmacotherapy in the latent phase of HIV PRO-Delays the on set of acute symptoms/ development of AIDS CON- Cost a lot of money, side effects of meds, Proments restance to drug an when no longer effective when turns in to AIDS. Zidovudine (Retrovir, AZT) AE Severe toxicity to blood cells can result Anemia/leukopenia Numbness/tingling of hands and feet Fatigue/generalized weakness Goal- Reduce the plasma level of HIV to lowest level possible ***Drug reduces RBC and WBC count. Valacyclovir (Valtrex) herpes, cold sores, chicken pox an shingles Dont cure, lessen symptoms What are some antivirals used for influenza? Neuroamidase inhibitors Oseltamivir (Tamiflu) Amantadine (Symmetrel) Zanamivir (Relenza) What is unique about metronidazole (Flagyl)? Has antiprotozoal and antibacterial activity What are some usages? Amebiasis in the intestines and trichomoniasis in the vagina

What are some SE/AE? Anorexia, N, D Dizziness, HA Dryness of mouth/metallic taste What is an important teaching component? Do Not drink Alcohol Chemotherapy Why is it difficult to kill cancer cells without major toxicity to normal cells? Physiology of cancer cells same as normal cells Drugs can seriously affect both What is the benefit to using combinations of multiple chemo agents? Different classes affect different stages of the cancers life cycle- increasing percentage of cell kill Allows lower dosages of each agent Reducing toxicity Slowing development of resistance Why do we dose chemotherapy in rounds? Gives normal cells a chance to recover Cancer cells may also be more sensitive during the time of the next treatment What are nursing considerations related to nausea and vomiting in the chemo patient? Treated with antiemetic drugs before treatment begins Risk for imbalanced nutrition, less than body requires due to N,V,D and anorexia Pt consumes small meals, drink plenty cold liquids, and avoid strong smelling/spicy foods Methotrexate (Mexate)- disrupts metabolic pathways Choriocarcinoma, Bone cancer, Head/Neck cancer, Breast Carcinoma, Lung Carcinoma aslo; non-neoplastic disorders-psoriasis, Rheumatoid arthritis, Lupus, Severe psoriasis, What types of cancers do we use hormone/hormone blockers for? Breast cancer- testosterone; Prostate caner- female sex hormone Tamoxifen- Hormone antagonists less toxic Fewer AE Can cause SAE long use a high doses Palliation use What is epoetin alfa (Epogen, Procrit)?(Interferon alfa 2 (RoferoneA, Intron A) Not kill CA cells directly, Stimulate the bodys immune system to fight the CA Given to Limit or counteract the toxicity of antineoplastics Stimulates RBC production to limit anemia

Drug Classes Alkylating agents ( Cyclophosphamide (Cytoxan) ) Act by chemically binding to nucleic acids (DNA) and inhibiting cell division Kill or slow down replication of tumor cells Antimetabolites (Methotrexate (Mexate) ) This disrupts metabolic pathways Kill cancer cells or slow growth Antitumor antibiotics (Doxorubicin (Adriamycin) ) Cytotoxicity Obtained from bacteria and have the ability to kill CA cells Interact with DNA in a manner similar to alkylating agents Plant alkaloids/natural products (Vincristine (Oncovin) Ability to arrest cell division- sometimes called mitotic inhibitors Dose limiting effect neurotoxicity Numbness and tingling in the limbs, muscular weakness, loss of neural reflexes, and pain. Hormones and hormone blockers (Tamoxifen (Nolvadex) Slow the growth of hormone-dependent tumors Biologic response modifiers (Interferon alfa 2 (RoferoneA, Intron A) Stimulate the bodys immune system Given to minimize toxic effects of other antineoplastics Miscellaneous drugs (Epoetin alfa (Epogen, Procrit) Stimulates RBC production to limit anemia Given to limit or counteract the toxicity of antineoplastics Endocrine Diabetes What does insulin do? Insulin affects carbohydrate, lipid, and protein metabolism Without insulin glucose cant enter the cells to be used for fuel What does glucagon do? It blocks insulin Type 1 LACK of insulin secretion, Genetic Treated - combination of diet, exercise, and insulin 3 Ps Polyuria Polyphagia Polydipsia

Type 2 Insensitive or resistant to insulin Treat - controlled through lifestyle changes and oral hypoglycemic agents Common in overweight clients and those having low HDL-cholesterol and high triglyceride levels Syndrome X Type 1& 2 untreated Microvascular destruction of capillaries in the eyes, kidneys and peripheral tissues. Macrovascular atherosclerosis of middle to large arteries such as those in the brain. Heart disease Kidney disease Stroke Blindness Lack of circulation in extremities Nerve degeneration is common Lipids are used for energy resulting in acidosis and possible coma Why is human insulin better than beef or pork? Fewer allergies Better absorbed Less resistance Preparation and administration Clear b4 cloudy Short b4 long Give subQ *Only regular insulin may go IV Roll, do not shake vial Rotate sites to prevent tissue atrophy or hypertrophy Never PO- GI secretions destroy the insulin. **Increased needs: infections, fever, stress **Decreased needs: exercise Once opened rm temp x1 month, refrigerated x3 months Remove from refrigerator 30 minutes prior to injection Rapid acting insulin Lispro (Humalog) Aspart (Novolog) Must be given within 5 minutes of a meal!! *Clear Short acting Regular, (Humulin R) *Clear

Given subQ or IV Generally given 30 minutes before a meal Intermediate Protamine containing: NPH, Humulin N Zinc containing: Lente, Humulin L *Cloudy Protamine and zinc are added to prolong the duration of insulin action Long Humulin U (Ultralente) Lantus Onset 1 hour, no peak Duration 24 hours *do not mix *1x/day usually at bedtime What is the #1 AE of insulin Hypoglycemia * Blood sugar of less than 70 mg/dl Tachycardia Confusion Sweating Drowsiness Convulsions, coma, and death Hyperglycemia(3Ps) Underdose of insulin or hypoglycemic agent Fasting blood glucose greater than 126 mg/dl Polyuria Polyphagia Polydipsia Glucosuria Weight loss/gain Fatigue Mechanisms of action for the oral hypoglycemic Increase insulin receptor cells sensitivity, which increases insulin binding SE/AE Hypoglycemia GI upset Nausea, Vomiting, Loss of appetite Photosensitivity High potential for drug interaction

Alpha-glucosidase Inhibitors (enzyme inhibition) Delayed glucose absorption Acarbose (Precose) Miglitol (Glyset) Biguanides (Increases insulin sensitivity) very hard on the kidneys Decreases glucose production in the liver/ small intestines Metformin HCL (Glucophage) Meglitinides (Stimulating release of insulin from the beta cells of the pancreas) Increase our bodys use of glucose Nateglinide (Starlix) Repaglinide (Prandin) SE-hypoglycemia Sulfonylureas Stimulate the release of insulin from beta cells Decrease glucose production/ metabolism of the insulin by the liver Acetohexamide (Dimelor) Tolbutamide (Orinase) 2nd gen Glimepiride (Amaryl) Glyburide (DiaBeta) Glipizide (Glucotrol) End in - ide Thiazolidinediones (TZD) Increasing sensitivity of muscle and fat tissue to insulin More glucose enters cells in the presence of insulin Pioglitazone (Actos) Rosiglitazone (Avandia) *4-6weeks for notable effect and several months for full therapeutic effect Thyroid Regulates basal metabolic rate S&S of hyperthyroidism Graves disease Increased body metabolism Tachycardia Weight loss High body temperature Anxiety Drug used to treat hyperthyroidism. Propylthiouracil (Propacil, PTU) *Does not destroy any T3 or T4 already produced. Just blocks synthesis.

SE- Hypothyroidism Slowed body metabolism Slurred speech Bradycardia Weight gain Low body temperature Intolerance to cold

S&S of hypothyroidism Myxedema Slowed body metabolism Slurred speech Bradycardia Weight gain Low body temperature Intolerance to cold Drug used to treat hypothyroidism. Levothyroxine (Synthroid) Drug of choice Relatively inexpensive * High potency NI Give on an empty stomach, one-half to one hour before breakfast. Avoid infant soy formula, cotton seed meal, walnuts, and high-fiber foods while taking 4 hours before or after -iron products, calcium supplements, or antacids. Show pt how take there pulse On med for life SE- Resemble s/s of Hyperthyroidism- (May occur 1-3 weeks after change in therapy) Increased body metabolism Tachycardia(Rapid, bounding pulse even sleeping) Weight loss High body temperature Anxiety Menstrual irregularities/ osteoporosis in women Avoid lemon balm Monitor Serum levels of circulating T3 and T4 hormones To check for toxic levels an effectiveness of drug NI- Do not stop abruptly Foods containing iodine may be restricted Take with meals Pregnancy category D may cause hypothyroidism in the fetus

Adrenal What hormones come from the adrenal cortex? Glucocorticoids Mineralocorticoids (Maintain fluid and electrolyte balance) fludrocortisone (Florinef) aldosterone What 3 properties do glucocorticoids have? Anti-inflammatory, Anti-allergic, Immunosuppressant effects Predinisone (Deltasone) Hydrocortisone (Solu-cortef) Methylprednisolone (Solu-Medrol) Dexamethasone (Decadron) Betamethasone (Celestone) All end in- sone Cushings Syndrome *long term use Adrenal atrophy Osteoporosis Increased risk of infections Delayed wound healing Peptic ulcer Accumulation of fat around shoulders and neck Mood and personality changes Hyperglycemia Nursing considerations D/C gradually Always use at the smallest dose possible for the shortest time possible Take in .a.m. Diabetes insipidus Vasopressin (Pitressin) Desmopressin used for enuresis (bed wetting) - nasal spray *Therapeutic response Decreased urinary output Reproductive Combination- estrogen and progestin Mimi- progestin alone Contraindicates the use of a combo pill History of stroke, MI, other vascular disease Clotting disorders (ie- Factor V Leiden) Smokers over 35

Report Blurred vision,Severe headaches, dizziness Leg /Chest pain Shortness of breath, Acute abdominal pain Combo Alesse (monophasic) Ortho-Tri-Cyclen (triphasic) Why is progesterone administered with estrogen in the combo pills? Prevent uterine cancer Mini pill. Micronor Why would someone be prescribed a mini pill Breastfeeding mothers Estrogen will dry up milk supply Those at high risk for thromboembolic disorders What risks are involved with using HRT? Estrogen (Premarin)- menopausal Coronary artery disease Stroke Venous thromboembolism Breast cancer Vision changes What are some recommendations for use of HRT? Should be given short term at lowest doses possible Avoid caffeine, smoking Take w/food to avoid Gi upset At bed time to decrease AE Daily wt (Weight gain, edema) Medroxyprogesterone (Provera)- dysfunctional uterine bleeding What contraindicates the use of Viagra? Nitrates (isosorbide dinitrate, nitroglycerin), Protease inhibitors (ritonavir, amprenavir), Rifampin (decreases effectives) 2 categories of meds used to treat BPH? Alpha1-adrenergic blockers-: blood vessels will be blocked Doxazocin (Cardura) * check bp- postural hypotension Terazocin (Hytrin) Tamsulosin (Flomax) - no effect on blood pressure Finasteride( Proscar)- shrinks enlarged prostate Nursing considerations for use of Proscar? Category X drug, Women who are pregnant or may become pregnant should avoid the semen of men taking the drug

Skeletal Osteoporosis Calcitriol Nasal spray or SQ injection SERM medication. Raloxifene (Evista) Side effects: hot flashes, migraine HA, flu-like symptoms, breast pain, vaginal bleeding *Not recommened due to cardiovascular, cancer Risk- Postmenopausal, High alcohol or caffeine Anorexia nervosa Tobacco use Physical inactivity Testosterone deficiency, particularly in elderly men Lack of adequate vitamin D or calcium in the diet Drugs that lower calcium levels in the blood Hypoparathyroid disease (removal of parathyroid glands or renal failure), digestive related malabsorption disorders /vitamin D deficiencies S/S of hypocalcemia Muscle twitching Tremor Cramping Peripheral neuropathy Confusion Altered mental status Seizures Bisphosphonate Etidronate (Didronel) Alendronate (Fosamax) Risedronate (Actonel) Ibandronate (Boniva) Generic names end in dronate Nursing considerations Patient must sit upright for 30 min following administration Taken on an empty stomach Side effects: nausea, vomiting, abdominal pain, and esophageal irritation

Gout Bulid up or uric acid by kidney in joints * No aspirin therapy Allopurinol (Zyloprim, Aloprim) Not effective in treating acute attacks of gouty arthritis Adverse effects GI disturbances- N, V, D Can be hepatotoxic Colchicine-prevent or to relieve acute attacks of gout SE- GI disturbance- N, V, D Kill topical parasites Permethrin (Nix) *rinsed from the body within 10 minutes after being applied What are some nursing considerations regarding use of Accutane? Most severe cases- therapy is 15-20 wks Isotretinoin (Accutane) Pregnancy category X iPLEDGE system *Monitor liver enzymes and triglyceride levels (b4) When are osmotic diuretics utilized? Name one. Used when a quick loss of intraocular pressure is required Eye surgery Acute closed-angle glaucoma Mannitol (Osmitrol) AE- HA, dizziness, fluid and electrolyte imbalances. Prostaglandins Cause hyperpigmentation of the eye given before pt goes to sleep Describe proper technique for administration of an eye drop. ** Always check which eye gets med 1st Having the pt look up. Administer prescribed # of drops into enter of sac without touching dropper. Press the lacrimal duct with cotton or tissue 1-2 min to prevent systemic absorption. Client should keep eye closed 1-2 min after to increase absorption separate administration by at least 5 minutes