Acetazolamide

Prototype

Acetazolamide

Actions

Acetazolamide

Classification

Osmotic Diuretic

Prototype

Osmotic Diuretic

Indications

IV agents for cerebral edema, toxic substances

PO agents for glaucoma

Osmotic Diuretic

Side Effects

• GI sx
• dry mouth
• HA
• polyuria
• weakness

mannitol may cause dizziness

Osmotic Diuretic

Contraindications

renal or cardiac dysfunction

intracranial bleeding

Osmotic Diuretic

Nursing implications

crysalization in solution is common - need to warm

IV line filter and filter needles

use indwelling catheter and measure hourly (therapy based on accurate I&O)

Loop diuretics

Prototype:

Loop diuretics

Action

Inhibit reabsorption of sodium and chloride in ascending loop of Henle

Similar to thiazides but more intense

• greater peak increase in urine output
• faster acting
• increasea CA excretion
• less effect o lipids
• parental use
• can use with low GFR

furosemide (Lasix)

SE

ototoxicity

Rosenthal said don't know all SEs but focused on ototoxicity. May be temporary

• Osmotic
• Loop
• Thiazide
• Potassium Sparing

• Increase the amount of Na and chloride excreted by the kidneys
• Decrease circulating volume
• Lower Na seems to decrease sensitivity of vessels to sympathetic stimulation

• Plasma
• Extracellular Fluid

• Block reabsorption of Na into tissue
• It is excreted through urine
• Decreases Na in body and decreases volume (water follows salt rule)

• K
• Na is so prevalent in dietary intake that K is the electrolyte of greatest fluctuation

• Na
• K
• Ca
• Glucose
• Uric Acid

• Proximal
• Loop
• Distal

• Hypovolemia
• Acid-base Dysfunction
• Electrolyte Abnormalities

• Spironolactone

• Glaucoma
• Altitude Sickness
• Management of Seizure Disorders
• Produces Alkaline Urine (helps excrete weak acids)

• IV agents for cerebral edema, toxic substances
• PO agents for glaucoma

• Renal/cardiac Dysfunction
• Intracranial Bleeding

• Inside tubules
• Intensify normal osmotic shifts

Potent Osmotic

• stayes in tubules
• large size, pulls water and solutes into tubule fluid
• kidneys resorb less Na, Cl and water but not significant shifts in electrolytes

• Stay inside tubules
• Large size pulls water and solutes into tubular fluid (chemically inert)
• Kidneys reabsorb less Na, Cl, and water in an effort to equalize concentration, but not significant shifts of electrolytes

• Crystallization in solution is common (need to warm)
• IV line filter and filter needles
• Use an indwelling catheter with a urometer to measure hourly urine output

• IC Bleeding
• Kidney Impairment

• Inhibit reabsorption of Na and chloride in the ascending loop of Henle
• Similar to thiazides but more intense

Loops are/have

• Greater peak increase in urine output
• Faster acting
• Increase Ca excretion
• Less effect on lipids
• Parenteral use
• Can use with low GFR (kidney failure)

• Digoxin, Lithium (increase risk of ototoxicity)
• NSAIDs (antagonize diuretic effects)

• Hypovolemia
• Hypotension
• Electrolye Imbalances

• Postural Hypotension
• Dietary counseling re: foods rich in K
• More likely to need K supplements
• Avoid Sun
• Alert to Hearing Loss
• May need higher dose if placed on NSAID

• Fairly well absorbed
• Peak 1-2 hour (IV effect within minutes)

• Significant Edema (CHF, cirrhosis, renal disease)
• HTN

• Postural Hypotension
• Blurred Vision
• HA
• GI Distress
• Anorexia
• Confusion
• Ototoxicity
• Photosensitivity

• HCTZ (Thiazide)
• Loop Diuretics

• Inhibits Na and Cl reabsorption in early distal tubule
• May increase serum levels of Ca, glucose, and uric acid
• Reduces plasma and ECF
• Has direction action on peripheral vessels to decrease peripheral resistance

• Cholesterol
• TG Levels

• Essential HTN
• Chronic Edema (CHF, cirrhosis, renal failure)
• Treatment of HYPOcalcemia (decreases Ca excretion)

• Hyponatremia
• Hypovolemia
• Polyuria
• Oliguria in the renal compromised patient
• Hypokalemia (up to 1/2 of long-term users have sx at soe point)
• Increased risk of digitalis toxicity

• Renal Disease
• Gout
• Diabetes
• Hyperlipidemia
• Pregnant Women

• Drugs that affect the same electrolytes or minerals
• Digoxin (K shifting impacts this)

• Supplment K in diet
• Monitor BP, lipid levels
• Drug may make patients feel tired (drink more non-sugar, non-caffeine fluids)

• Dried Fruits
• OJ
• Banana
• Limited use of salt substitutes (KCl)

• Spironolactone

• Compliance
• Diet
• Hypovolemia
• Hypokalemia
• Controlling K Levels

• An obvious increase in urine may last only a few weeks, but the drug is still needed. Patients may stop or self-increase the dose.
• Voiding at inopportune times (tailor schedule to lifestyle...don't take late in the day

Diuretics

Issues with Diet

• Low or controlled salt intake
• MUST take in adequate water

Diuretics

Issues with Hypovolemia

• Dizziness
• Confusion
• Insatiable Thirst
• Salt Craving

Diuretics

Issues with Hypokalemia

• Thirst
• Muscle Weakness
• Lethargy
• Depression
• Muscle Cramping
• Vomiting

Diuretics

Issues with controlling K levels

• Oral agents (KLc in liquids, powders, effervescent tablets-bad taste, potassium-sparing diuretics)
• IV K supplement

• Falls
• BP
• Electrolytes (K)
• Signs of Hypovolemia

• Block action of aldosterone in the distal tubule, promotes Na and water excretion
• Low potency, similar to thiazides
• Allows K to remain in system

• Prevention/treatment of Hypokalemia
• HTN and Edema, especially in liver failure and adrenal disease issues
• Use in combo with HCTZ to counteract K loss

• Drugs that decrease K excretion (ACE inhibitors, salt substitues, K supplements)
• Sironolactone increases t 1/2 of digoxin
• Decreases effects of anticoags (does needs to be adjusted)

• Hypovolemia
• Hpotension

• Chronic Angina
• HTN
• Treat Cardiac Dysrhythmias
• Prevent a 2nd MI
• Treat Vascular HA
• Tremors
• Anxiety

• Decrease HR, conduction, contractility, and CO
• Inhibits renin release by kidneys
• Reduces myocardial demand for O2
• Decreases peripheral vascular resistance which lowers BP

• Non-selective
• Decreases cardiac contractility (negative inotropic effect), which drops arterial pressure and inhibits renin release
• Especially useful in HTN with tachycardia/angina
• More selective beta blockers can help avoid most significant SE

• Atenolol
• Metoprolol

• Negative Chronotrope (rate)
• Negative Inotrope (contraction)
• Negative Dromotrope (conduction)
• Lower CO
• Lower CO = Lower BP
• Bradycardia
• Fatigue
• Impotence

• Don't alter the drug regimen
• No OTC decongestants and cough/cold meds with pseudoephedrine/phenylprine
• How to avoid orthostatic hypotension
• Weight/diet management
• Check pulse: if less than 45, don't give
• Monitor for signs of depression
• Should be on one post MI

• Rebound HTN
• Tachycardia
• Massive sympathetic "rescue" causes rapid HR and high BP

• Hyperkalemia
• Dry Cough
• Angiodema (excess bradykinine floating around)
• HA
• GI sx
• Loss of Taste
• Weakness
• Dizziness
• Hypotension
• Rash
• Fever
• Joint Pain

• Full effects not seen for several weeks
• Taste impairment disappears in 2-3 weeks
• Cough not indicative of lung disease
• Do not use in renal artery stenosis
• Do not use K supplements or substances containing large amounts of K (salt substitutes, low sodium milk)
• Do not use with pregnancy (no blood to fetus)

• Completely blocks the angiotensin I converting enzyme
• Prevents production of angiotensin II, w hich is a powerful vasoconstrictor
• Decreases vascular tone
• Absence of aldosterone release leads to excretion of fluid
• Renal protective in diabetes
• Improve squeeze of heart (stops remodeling)

• Essential HTN with normal renal function
• Often used with a thiazide or loop diuretic (counteracts K retention of ACE)
• HF: used with digoxin and diuretics
• Diabets: for renal protection even without HTN

• Decreases sympathetic outflow from brain to periphery
• Generalized decrease in sympathetic tone (A2 receptors)
• Lowers CO, HR, peripheral resistance

• Same as general ones, plus high risk for rebound HTN if durg abruptly withdrawn
• Central-acting sympatholytic is counter-intuitive since it's an A2 agonist

• Severe Hypotension
• Can affect A1 receptors and lead to severe hypertensive crisis

• Central-acting Sympatholytic (Clonidine)
• Peripheral-acting Alpha Adrenergic Blocker (doxazosin)

• Weakness
• GI sx
• Stuffy Nose
• Edema of the Lower Extremities
• HA
• Syncope
• SOB
• Orthostatic Hypotension

• First Dose Hypotensive Reaction (instruct to avoid rapid postural
• Effects may not be achieved for 4-6 weeks
• May relax bladder sphincter too much

• Weight Loss
• Na Restrictions
• Exercise
• Meds if the Above doesn't Work

• Falls
• BP
• Electrolytes - K
• Signs of Hypovolemia

• If you feel better, do not stop taking medication
• If diuretic effect lessens over time, do not increase meds

• Positive Inotrope (Increases force of contraction)
• Negative Chronotrope (decreases HR)
• Negative Dromotrope (decreases conduction velocity)
• Potent (use small doses)

• Oral, IM, or IV (formulation greatly affects absorption)
• t 1/2 is 36 hours
• Narrow therapeutic range: 0.5-0.8 ng/mL

• Incr cardiac contractility
• Decr electrical conduction rate
• Indirectly decr HR and inceases Na and water excretion

• HF
• Atrial fibrillation or other supraventricular dysrhythmia when ventricular rate is too rapid

• 0.5 stat, then 0.25 q6h x 2
• Then standard dose 6 hours later and qd

• Cardiac: bradycardia, AV block, other rhythm disturbances
• GI: n/v, anorexia
• Vision: green/yellow tint to white objects, halos around lights (usually not until toxic)

• Periodic Drug Levels
• Electrolyte Levels (K alterations)
• Assessment of HR prior to Administration

• Early: n/v, vision changes
• Late: dysrhythmias due to progressive heart block (may be fast, as if need more medication)

• Hold doses
• Immune Fab (Digibind) binds with molecule and then is excreted by the kidneys. As more tissue molecules are released into the bloodstream, more binding takes place
• Hasten elimination by binding (charcoal, cholestryramine)

• Drugs that reduce absorption or decrease function (antacids, laxatives, cholesterol-lowering agents, ACE/ARB)
• Drugs that depress cardiac function (beta blockers, calcium channel blockers)
• Hypokalemia

• Hypokalemia
• Even therapeutic levels of Digoxin might be too high if K levels are low
• Most common offender is diuretic use

• Cardiac Function (watch HR, dysrhythmias)
• Electrolyte Imbalances (hypokalemia and hypomagnesemia increase risk of toxicity and hyperkalemia and hypercalcemia may produce dysrhythmias)
• Renal Insufficiency Patients (decreases excretion, which may cause toxicity)
• Female Patients
• Monitor Effecgt of other Drugs containing Na or K, use of diuretics

• Drug Therapy
• Angioplasty/stent or Bypass

• Beta Adrenergic Blockers
• Calcium Channel Blockers
• Organic Nitrate Vasodilators

• Relieve pain
• Bring balance to MVO2 supply and demand
• Decrease the severity and frequency of anginal episodes
• Prevention of future MI

• Vasodilates vessels in the periphery therby decr workload of heart
• Dilates coronary arteries, improving blood flow
• Does NOT dilate plaque-covered, damaged vessels
• Comes in metered tablets, sprays, ointments

• Oral: time-released with heavy first pass effect (not good for emergent needs)
• Oral mucous membranes: quick (minutes)
• Ointment: slow release, 30-60 minutes, messy
• Transdermal patches: sustained release, longer-term effects

• Reflex tachycardia
• Anytime BP falls, sympathetic activity occurs

• SL tablet, wait 5 minutes
• If pain persists, repeat with 2nd and 3rd doses
• After 2nd dose, call 911

• IV nitro binds with PVC, so must use special tubing and glass bottle
• Glass bottles need vented spike on the tubing
• Must run through pump
• Closing monitoring of BP
• High falls risk

• Ointment (measured length, apply to hairless surface, cover with plastic)
• Transdermal patch (don't soak in water, rotate placement, 12 hours on, 12 hours off)
• WEAR GLOVES

• HA (lessens over first 2 weeks)
• Hypotension (can trigger reflex tachycardia)

• All antihypertensives
• All sympathomimetics
• Nicotine
• Sildenafil

• Dose-dependent hypotension and reflex tachycardia

• Airtight, light-resistant containers (brown glass bottles or aluminum sprays)
• Bottles expire 6 months after opening
• HA is normal (if none, it's not working)
• Expect orthostatic hypotension
• Handle patches and ointments with gloves
• Try to avoid angina triggers
• Temp sensitive
• Spray meters are more expensive, but last longer than bottles (since bottles expire)

• Propranolol
• Atenolol

Vasospasm

(Prinzmetal)

• Works on workload of heart by vasodilating peripheral vessels
• Dilates coronary arteries

• Glycosides
• ACE Inhibitors

• Abnormal Automaticity
• Abnormal Conduction
• Block of Impulse Conduction
• Re-entry Phenomenon

• Supraventricular
• Ventricular

• Sinus Tachycardia
• Atrial Flutter
• Atrial Fibrilation
• Premaure Atrial Contractions (PACs)

• Premature Ventricular Contractions (PVCs)
• Ventricular Tachycardia
• Ventricular Fibrillation

• Worsen
• Create a new one

• Ventricular Dysrhythmias
• Post-MI Dysrhythmias
• HTN
• Hyperanxiety (stage fright)
• Hyperthyroid (helps with racing heart)

• Anticholinergic effect
• Blocks vagal stimulation and increases HR
• Increases conduction through the AV node

• Sequesters or binds withthe bile so it cannot be reabsorbed
• Body responds by making more cholesterol and bile than before

• Works solely in the GI tract (is not absorbed)
• Comes in powder or bar form
• Mix with juice or semi-solid as it tastes bad

• Hyperlipidemia
• Elevated LDLs
• Adjunctive therapy in dig overdose, affects absorption and reabsorption of dig

• Constipation (even fecal impaction especially in the elderly)
• Flatulance
• N/v
• Abdominal Pain
• Impaired absorbance of fat soluble vitamins

• Affects absorption of most other drugs
• Need to watch administration times

• Most effective drug to lower LDL
• Inhibits critical enzyme in formation of cholesterol (HMG-CoA), thus decreasing total cholesterol, LDL, and triglycerides, while also increasing HDL

• HA
• GI Disturbances
• Myalgia (can progress to muscle damage)
• Drug-induced Liver Dysfunction

• Liver Disease Patients
• Chronic Alcoholics
• Patients with Unaccountable Muscle Aches/Pains

• Active Hemorrhage
• Recent Hemorrhagic Stroke
• Recent Surgery
• Hemophilia
• Pregnancy
• Recent Abortion/Miscarriage

• Injectable (rapid-acting, temporary)
• Oral (long-term therapy)

• Fibrin Deposits
• Extension of a Thrombus
• Thromboembolic Complications

• Prophylactic anticoagulation
• Low dose for high risk patients undergoing procedures with a high degree of blood loss
• Full dose anticoagulation for DIC, embolism, or thrombus management

• Bleeding and hemorrhage (GI, GU, mucosal)
• Allergic reactions (animal products)
• Heparin-induced thrombocytopenia (HIT)

• Bleeding precautions
• Frequent blood draws
• Do not aspirate for SC injections (>2 cm from umbilicus or surgical site)
• Does not dissolve clots, only prevents them

• Sliding scale of regulating drip
• Loading dose followed by frequent aPTT labs
• Based on aPTT, the units could incr or decr

• If aPTT too prolonged, can bleed to death
• Stop administering and give antidote

• Prevention of DVT post-op (hip, abd, knee)
• Treatment of established DVT
• Unstable angina

• Local Erythema
• Pain
• Hematoma at Injection Site

• No need to check aPTT
• Patient can be taught self-injection

• No
• No protein binding

• Electric Razors
• Brushing Teeth
• Small Bump = Big Trouble
• Pain in Joint can be Bleed
• Longer than normal for hemostasis for injections and venipunctures

• Group I (fast sodium channel blockers)
• Group II (beta blockers)
• Group III (potassium channel blockers)
• Group IV (calcium channel blockers)

• Long-term prophylaxis and treatment of venous and arterial thrombosis or pulmonary embolism,
• Adjunctive tx for prevention of MI or TIA recurrence

• Individualized
• Maintenance doses range from 2-10 mg daily

• Bleeding
• Decr dietary Vitamin K intensifies effect
• Incr Vitamin K decr effect

• Out-patient drug, so patient is self-medicating
• Most drug interactions increase anticoag effects

• Incr bleeding
• Can usually control by omitting 1 or 2 doses, but don't stop abruptly

• Phytonadione
• AquaMephyton

• Heparin has an immediate effect
• Heparin is given IV at the same time Warfarin is started orally
• Since Heparin inhibits thrombin and Warfarin inhibits synthesis of Vitamin K-dependent clotting factors, they are not substitutes for each other.

• Blocks enzyme necessary to create the stickiness of the vessel walls, so it inhibits platelet aggregation
• Permanently alters the platelet

• 325 mg
• Double
• 7 days

• Prophylaxis of MI in patients with angina or hx of MI
• Prophylaxis of recurrent TIAs/CVA

• Pulmonary or Systemic Emboli/Thrombi
• Acute MI
• Unblock Central IV Lines

• ASA
• NSAIDs
• Anticoags

• Prolongs action potential
• Increases refractory period in all cardiac tissues
• Decr automaticity
• Prolonged AV conduction
• Blocks Na, K, and Ca channels

• Pulmonary Fibrosis
• Thyrotoxicosis
• Dizziness
• Bitter Taste
• Tremors
• Blue-gray Skin Color

• Lifestyle Modification (depends on risk)
• Reduce Lipid-elevating Drugs (thiazides, estrogens)
• Antihyperlipidemics

• Heparin
• LMW Heparin (enoxaparin)

• Aspirin
• GPIIB/IIIA & Ticagrelor

When do you move to step 2?

(Asthma)

• Low-dose steroid inhaler daily
• SABA inhaler for acute symptom control

• Intermediate-dose ICS or low dose ICS
• LABA, SABA inhaler for acute symptom control

• Step 1 (Mild)
• Step 2 (Mild Persistent)
• Step 3 (Moderate)
• Step 4 (Moderate)
• Step 5
• Step 6

• Medium-dose ICS
• LABA, SABA inhaler for acute symptom control

• High-dose ICS
• LABA inhaler for acute symptom control

• Metered-dose Inhalers (MDI)
• Dry Powder Inhalers (DPI)
• Nebulizers (through a mask)

• Hyperglycemia in DM (B2 receptors in liver > glycogen > glucose)
• Tremors
• Nervousness
• Possible cardiac dysrhythmias

• Incr risk of asthma-related death if not used properly
• Oral can cause cardiac symptoms (angina, dysrhythmias)

• Mast Cells
• Many in Respiratory Tree

• H1
• H2

• Vasodilation of venules/arterioles
• Incr capillary permeability (leaky vessels) secondary to capillary contraction
• Bronchoconstriction
• Itching/pain

• Suppressionof inflammation
• Decr secretion of inflammatory mediators
• Decr infiltration of inflammatory cells
• Decr edema of airway mucosa

• Use spacer
• Gargle/rinse afterwards
• Best if used with B2 agonist