Coagulation Cascade

Prothrombin

Thrombin

Fibrinogen

Fibrin

Fibrinolysis

Thrombus

Embolus

Antiplatelet

Thrombolytic 

Hemostatic 

Hemophilia

Deep Vein Thrombosis (DVT)

Heparin

• TC: Anticoagulant
• PC: Indirect thrombin inhibitor
• Acts by prolonging coagulation time, thereby preventing excessive clotting within blood vessels. 
• Side effects may include bleeding, HIT, severe or life threatening thrombosis. Black box warning that epidural or spinal hematomas may occur when heparin is used in patients receiving spinal anesthesia. 
• Pregnancy category C
• Contraindicated in patiens with active internal bleeding, bleeding disorders, severe hypertension, recent rauma, intracranial hemorrhage, or bacterial endocarditis. Protamine sulfate may be used to reverse overdose. 

Warfarin (coumidin)

• TC: anticoagulant
• PC: Vitamin K antagonist
• Acts by inhibiting the action of vitamin which inhibits synthesis of clotting factors II, VII, IX, and X. Used for prevention of stroke, MI, DVT, and pulmonary embolism. 
• Side effects may include abnormal bleeding. Black box warning that this drug can cause major or fatal bleeding and INR monitoring is required constantly. 
• Pregnancy category X.
• Contraindicated in patients with recent trauma, active internal bleeding, bleeding disorders, intracranial hemorrhage, severe hypertension, bacterial endocarditis, or severe hepatic or renal impairment.

Enoxaparin (lovenox)

• TC: low molecular weight heparin
• PC: anticoagulant, does not change aPTT
• Potentiates antithrombin III, inactivates clotting factor X. Used for prevention of post –op DVT
• Injection site bruising

Dabigatran (Pradaxa)

• TC: thrombin inhibitor
• PC: anticoagulant
• Direct thrombin inhibitor. Used to reduce risk of stroke, embolism in atrial fibrillation
• side effects include dyspepsia
• No blood work required

Clopidogrel (Plavix)

• TC: antiplatelet drug
• PC: ADP receptor blocker
• Acts by inhibiting platelet aggregation, directly inhibiting ADP binding to its receptor which prolongs bleeding time. Used for the prevention of thromboembolic events in patients with a recent history of MI, stroke, or peripheral artery disease
• Side effects may include flu-like syndrome, headache, dizziness, bruising, and rash or pruritus. Black box warning that those patients with poor metabolism will exhibit less therapeutic effect. 
• Pregnancy category B.
• Contraindicated in patients with active bleeding. Overdose treated with platelet transfusion. 

Alteplase (Activase)

• TC: drug for dissolving clots
• PC: thrombolytic 
• Acts by converting plasminogen to plasmin, which then dissolves fibrin clots. Used for the treatment of stroke due to thrombus. 
• Side effects may include general bleeding, and possible, but rare, intracranial bleeding. 
• Pregnancy category C. 
• Contraindicated in patients with active internal bleeding, history of stoke or head injury in the past 3 months, recent trauma or surgery, severe uncontrolled hypertension, intracranial neoplasm, or arteriovenous malformation. No specific treatment for overdose. 

Aminocaproic acid (Amicar)

• TC: clot stabilizer
• PC: hemostatic/antifibrinolytic
• Acts by inactivating plasminogen, the precursor of the enzyme plasmin that digests the fibrin clot. Used in situations where there is excessive bleeding and clots are being dissolved prematurely. 
• Side effects may include hypotension and bradycardia. 
• Pregnancy category C.
• Contraindicated in patients with disseminated intravascular clotting or severe renal impairment. 

activated partial thromboplastin time (aPTT)

• Normal: 25-35 seconds
• Drug: heparin
• Desired Level with Drug Therapy: Levels should be 1.5-2.5 times the control

prothrombin time (PT)

• Normal: 11-13.5 seconds
• Drug: coumidin
• Desired Level with Drug Therapy: Up to 2.5 times the control

International normalized ratio (INR)

• Normal: 1.3-2.0
• Drug: coumidin
• Desired Level with Drug Therapy: 2.3 times normal

Define hematopoiesis and explain why these drugs are administered to patients following

      chemotherapy or organ transplant.

This is the process of blood cell formation. Blood cells are formed primarily in red bone marrow and require B vitamins, vitamin C, copper, iron, and other nutrients. In patients receiving chemotherapy the red bone marrow is hindered in its ability to produce blood cells because the antineoplastic drugs used in chemo are extremely harmful to bone marrow. In those with organ transplant blood counts may be low so certain drugs may be given to buffer the blood levels. 

Epoetin alfa (erythropoietin) (Epogen) 

• TC: erythropoiesis-stimulating drug
• PC: erythropoietin 
• Acts by stimulating erythropoiesis. Used to treat chronic renal failure, patients undergoing chemo, given to patients prior to surgery or blood transfusion, and to treat anemia in patients infected with HIV.  
• Side effects may include headache, fever, nausea, diarrhea, and edema. Black box warning for serious cardiovascular and thromboembolic events. 
• Pregnancy category C.
• Contraindicated in patients with uncontrolled hypertension and known hypersensitivity to mammalian cell products, and myeloid malignancies. Overdose treated with phlebotomy. 

Filgrastim (Neupogen)

• TC: drug for increasing neutrophil production 
• PC: colony stimulating factor
• Acts by increasing neutrophil production in the bone marrow and enhances the phagocytic and cytotoxic functions of existing neutrophils. Used to treat patients with neutropenia and immunosuppression in patients with AIDS.
• Side effects may include fatigue, rash, epistaxis, decreased platelet counts, neutropenic fever, nausea, and vomiting, and bone pain. 
• Pregnancy category C. 
• Contraindicated in patients with hypersensitivity to E. coli proteins. No treatment for overdose.

Pernicious Anemia

Cyanocobalamin (nascobal) 

• TC: drug for anemia
• PC: vitamin supplement
• Purified form of vitamin B12 used to restore vitamin deficiencies. 
• Side effects may include hypokalemia, rashes, itching, or other signs of allergy. Anaphylaxis is possible, but rare. 
• Pregnancy category A (C when used parenterally).
• Contraindicated in patients with sensitivity to cobalt and folic acid deficiency anemia, severe pulmonary disease, and heart disease.  

Ferrous sulfate (Feosol)

• TC: antianemic drug
• PC: iron supplement
• Iron supplement containing 20-30% elemental iron. Used in patients with iron deficiency. 
• Side effects may include GI upset. Black box warning that iron containing products are a leading cause of fatal poisoning in children.
•  Pregnancy category A
• Contraindicated in patients with hemolytic anemia, hemochromatosis, peptic ulcer, regional enteritis, or ulcerative colitis. Should not be taken with antacids. Overdose is treated with deferoxamine. 

Antigen

Antibodies

Vaccines

Immunization

Booster

Titer

Toxoids

Active immunity

Passive immunity

·         Hairy cell leukemia, AIDS-related kaposi’s sarcoma, non-Hodgkins lymphoma, malignant melanoma, and chronic hepatitis virus B or C infections.

Explain the need for immunosuppressant medications following organ and tissue transplants.

·         Immunosuppressant drugs are needed after organ and tissue transplants because the new tissue can be marked as foreign by the body and rejected. Suppressing the immune system reaction helps to prevent tissue rejection. 

Hepatitis B Vaccine

• TC: vaccine
• PC: vaccine
• Acts by providing active immunity to individual who are at risk for exposure to Hep-B. 
• Side effects may include mild to moderate fever and chills, fatigue, dizziness, fever, and headache. 
• Pregnancy category C.
• Contraindicated in patients with hypersensitivity to yeast, severe hypersensitivity to the first dose, fever or active infections, or those with compromised cardiopulmonary status. Overdoses have not been recorded. 

Interferon alfa-2b

• TC: immunostimulant
• PC: interferon, biologic response modifier
• Acts by stimulating the immune system to help combat infections. Used to treat cancers and viral infections. 
• Side effects may include fever, chills, dizziness, and fatigue, headache, nausea, vomiting, diarrhea, and anorexia. Depression and suicidal thoughts have been reported. Black box warning, this drug may cause fatal or life-threatening neuropsychiatric, autoimmune, ischemic, or infections disorders. 
• Contraindicated in patients with hypersensitivity to IFN’s, autoimmune hepatitis, and hepatic decompensation. Neonates and infants should not receive this drug because it contains benzyl alcohol.

Cyclosporine (Sandimmune)

• TC: immunosuppressant
• PC: calcineurin inhibitor 
• Acts by inhibiting the immune system. Used to prevent transplant rejection.
• Side effects may include reduced urine output, hypertension and tremor, headache, gingival hyperplasia, and elevated hepatic enzymes.
• Contraindicated in those with a hypersensitivity to the drug. Constant blood monitoring is required. No treatment for overdose. 

 Explain the pathophysiology of inflammation and fever.

 Inflammation is the body defense mechanism that occurs in response to different stimuli. The central purpose of inflammation is to contain the injury or destroy the microorganism. 

Inflammation

Histamine

Mast cells

Prednisone

• TC: anti-inflammatory drug
• PC: corticosteroid
• Acts by being metabolized into the body to help reduce inflammation. Used to treat acute bronchospasm, hodgkins disease, acute leukemia, and lymphomas.
• Side effects for short term use are rare. Long term use can cause cushings syndrome and gastric ulcers. 
• Pregnancy category C.
• Contraindicated in patients with active viral, bacterial, fungal, or protozoan infections. No specific treatment for overdose. 

  What drug is indicated for treatment of fever?

        Antipyretic (specifically acetaminophen) 

  Explain how bacteria are described and classified.

        Bacteria are classified according to their gram stain, cellular shape, and ability to use oxygen. 

Pathogenicity

Virulence

Invasiveness

Culture

Culture

Gram positive/negative

Sensitivity

Bacteriostatic

Bactericidal

Healthcare acquired infections (HAIs)

Community-acquired infections

Drug resistance

Methicillin-resistant staph aureus (MRSA)

Serum Sickness

Cross hypersensitivity

Suprainfection

Pseudomembranous Colitis

 List nursing interventions to prevent the spread of infection. 

        Use standard precautions. ALWAYS wash hands. 

Penicillin G sodium/Potassium

• TC: antibacterial 
• PC: Cell wall inhibitor; natural penicillin
• Used to fight streptococci, pneumococci, staphylococci, gonorrhea, and syphilis. 
• Side effects may include diarrhea, nausea, vomiting, pain at the injection site. Anaphylaxis is a possible serious side effect. 
• Pregnancy category B. 
• Contraindicated in patients with a hypersensitivity to the drug. Use with caution in patients with severe renal disease. 

Cefotaxime (Claforan)

• TC: antibacterial
• PC: cell wall inhibitor: first generation cephalosporin 
• Used against bacterial infections that are caused by susceptible gram positive organisms. Used to treat infections of the respiratory tract, urinary tract, skin structures, biliary tract, bones, septicemia, and endocarditis.
• Side effects may include rash, diarrhea, supra-infections, pain and phlebitis at the injection site. Allergic reactions are possible but rare. 
• Pregnancy category B. 
• Contraindicated in patients with a hypersensitivity to the drug. Use with caution in patients with severe renal disease. 

Tetracycline (Sumycin)

• TC: antibacterial
• PC: tetracycline; protein synthesis inhibitor
• Used against a broad range of gram-positive and gram-negative organisms. Very effective against Chlamydia, Rickettsiae, Mycoplasma, and H. pylori. 
• Side effects may include nausea, vomiting, epigastric burning, discoloration, photosensitivity, and diarrhea. Tendency to affect vaginal, oral, and intestinal flora and cause supra-infections. 
• Pregnancy category D.  
• Contraindicated in patients with hypersensitivity to the drug. Drug should not be used during the second half of pregnancy, in children younger than 8, and in patients with severe renal impairment. 

  Define tuberculosis and list signs and symptoms.

·       Tuberculosis is caused by the bacterium M. tuberculosis which invades the lungs. The bodies immune system can suppress the infection but the mycobacteria becomes dormant and lives protected in tubercles. These may remain dormant during a person’s entire life. Signs and symptoms include cough, fever, chest pain, difficulty breathing, greenish or yellow sputum. 

  Explain how the pharmacotherapy of tuberculosis differs from that of other infections. 

Isoniazid (INH)

• TC: anti-tuberculosis drug
• PC: mycolic acid inhibitor 
• Acts by inhibiting the synthesis of mycolic acids, which are essential components of mycobacterial cell walls. First line treatment drug against tuberculosis. 
• Side effects may include numbness of the feet and hands, rash, and fever. Neurotoxicity is a concern during therapy. Patient may exhibit paresthesia of the fee and hands, convulsions, optic neuritis, dizziness, coma, memory loss, and various psychoses. 
• Pregnancy category C. 
• Black box warning that hepatotoxicity may sometimes develop and may prove fatal if untreated. Monitor for jaundice, fatigue,  elevated hepatic enzymes, or loss of appetite to ensure hepatotoxicity does not develop.
• Contraindicated in patients with hypersensitivity to the drug and in patients with severe hepatic impairment. Overdose may be fatal, treated symptomatically. 

  Compare and contrast the pharmacotherapy of superficial and systemic fungal infections. 

·         Systemic infections are treated with Amphotericin B and newer Azole drugs.

·         Superficial infections are rarely medical emergencies. These infections may occur in any patient. These types of infections are treated mainly with drugs applied topically.  

Amphotericin B (Fungizone)

• TC: antifungal (systemic type)
• PC: polyene
• Acts by binding to ergosterol in fungal cell membranes, causing them to become permeable or leaky. Used to treat most of fungi pathogenic to humans which can cause systemic infections. 
• Side effects may include fever, chills, vomiting, headache, phlebitis during IV therapy, possible nephrotoxicity, electrolyte imbalances, cardiac arrest, hypotension, dysrhythmias, hearing loss, vertigo, unsteady gait, and tinnitus. 
• Pregnancy category B.
• Contraindicated in patients with hypersensitivity to the drug. Caution should be used in those with renal failure. Overdose may result in cardiac arrest, no specific treatment for overdose. 

Nystatin (Mycostatin)

• TC: superficial antifungal
• PC: polyene
• Acts by binding to sterols in the fungal cell membrane, causing leakage of intracellular contents as the membrane becomes weakened. 
• Side effects may include minor skin irritation, diarrhea, nausea, and vomiting. 
• Pregnancy category C (oral preperations) or A (topical preparations) 
• Contraindicated in patients with a hypersensitivity to the drug. No specific treatment for overdose.