-is the formation of papules, nodules anf cysts on the face, neck, shulders, and back resulting from keratin plugs at the base of the pilosebaceous oil glads near the air follicles.

macules-flat with varying colors

papules- raised,palpable, and less than 1cm in diameter

vesicles- raised, filled with fluid and thess than 1 cm in diameter

Plaques- hrd,rough,raides, and flat on top

* frequently used to locate lesions or foreign objects and to provide local anesthesia to the area.

Fluorecein sodium: Dye used to demonstrate defects in corneal epithelium. Corneal scratches turn bright green; foreign bodies are surrounded by a green ring. Loss of conjunctiva shows orange-yellow. Dye appears in nasal secretions if lacrimal duct patent.

Fluorecein & benoxinate: dye and local anesthetic. Used for short corneal and conjuctival procedures, including removal of foregin bodies.

Rose Bengal: preferred dye when superficial conjunctival tissue or corneal pathology or injury suspected.

* used in selected aspects of a comprehensive eye examination and in the removal of foreign bodies from the eye.

Two most common topical anesthetics are proparacaine HCL (Ophthaine,Ophthetic) and tetracaine HCL (Pontocaine)

Corneal anesthesia is achieved within 1 minute and generally lasts 15 minutes.

The blink reflex is temorarily lost; therefore the the corneal epithelium is not kept moist. WISP TEST: will verify blink response is lost , so procedure can begin.

To protect the eye, a patch is usually worn over the eye until the effects of the drug are gone.

Conjunctivitis is the inflammation of the delicate membrane covering the eye ball and lining of the eyelid and local skin and eye irritation are possible side effects of topical ophthalmic aniinfective drugs.

Common occuring ocular conditions:

Conjunctivitis: an eye infection that can be bacterial, viral, or allergic in origin.

Blepharitis: infection of margins of eyelid

Chalazion: infection of meibomian glands of the eyelids that may produce systs, causing blockage of the ducts.

Hordeolum: local infection of eyelash follicles and glads on lid margins.

Keratitis: corneal inflammation

Uveitis: infection of the vascular layer of the eye ( ciliary body, choroid, and iris)

Bacterial- ciprofloxacin (Cipro)

antiinfective

*treat conjunctivitis and eye infection of the membrane coverining eyeball and lining of eyelid

Baterial origin

Treat bacterial conjunctivitis and corneal ulceration

2 gtt q 15 min for 6 hours then 2 gtt every 30 min for the rest of the day

Bacterial- Gentamycin (Garamycin)

antiinfective

Bacterial infections of the external eye

comes in solution or ointment

Tobramycin (Tobrex)

antiinfective

for external ocular infections due to bacteria

solution and ointment preparations

Silver nitrate 1%

antiinfective

(Dey-Drop)

prevent and treat opthalmia neonatorum

* for babys eyes (bacteria tranmission through birth canal)

Triple Antibiotic (neomycin / polymixin B / Bacitracin)

antiinfective

effective against gram - bacteria (combination dosage form effective against many gram- organisms)

ointment - 1 cm applied in conjunctival sac q 3-4h

Fungal- Natamycin (Natacyn)

antiinfective

may cause transient stinging or temporary blurring vision.

solution 5%

Viral- trifluridine (Viroptic)

antiinfective

for treatment of herpetci ophthalmic infections and keratoconjunctivitis caused by HSV-1 and HSV-2

1% solution; 1 gtt every 2h while awake

21 days of treatment

viral- Vidarabine (Vira-A)

antiinfective

for treatment of herpes simplex keratitis and kreatoconjunctivitis

3% ointment

5x a day treatment

Allergic- Cromolyn sodium (crolom), ketotiden (Zaditor), olopatadine (Patanol)

antiinfective

antiinfective

SE: stinging, burning, and headache.

alleviate dryness, during surgery, CNS disorders with excessive blinking

liquid and ointments

lubricants used to alleviate dryness, during surgery, CNS disorders with excessive blinking

Clients sometimes will have a reaction due to the preservatives in the lubricant.

Antiglaucoma

belong to: cholinergic, anticholinesterase miotics, beta-adrenergic blockers, carbonic anhydrase inhibiorts, osmotics, and anticholinergics

glaucoma : an increased intraocular pressure (IOP) resulting from excessive production or diminished outflow of aqueous humor.

Classifications: primary and secondary

Primary: pathologic change within the eye

Secondary: change associated with systemic disease and use of selected drugs.

* note: the angle of the anterior chanmber also determines the type of glaucome

Types: open angle / closed angle

Open angle: diminished outflow of aqueous humor related to degenerative changes in the trabecular meshwork.

Closed angle: triggered by emotions and drugs that dilate pupils.

Cholinergic & anticholinesterase miotics

antiglaucoma

for Open-angle gaucoma

lower the IOP, increases blood flow to retina and decreases loss of vision and retinal damage

Direct acting cholinergics- similar to acetylcholine

antiglaucoma

pilocarpine (Isopto Carpine)

Direct acting cholinergics- similar to acetylcholine

antiglaucoma

decreased IOP in glaucoma, induce miosis :

abnormal constriction of the pupil of the eye, caused by drugs or illness

DOSE: 1-2 gtt TID-QID (1%-2% solution)

ointment used at betime : Ocusert q 7 days (disc)

SE: eye pain, blurry vision, headache, N/V/D, increased salivation and sweating

ADVERSE: HTN, SOB, tachycardia, bronchospasm, retinal detachment.

CONTRAINDICATED: asthma, epilepsi, GI/GU obstruction, eye issues.

carbachol (Isopto Carbachol)

Direct acting cholinergics- similar to acetylcholine

antiglaucoma

used if pilocarpine not effective

1-2 gtt QD-QID

Indirect-acting anticholinergics

antiglaucoma

physostigmine salicylate (Isopto Eserine)

Indirect-acting anticholinergics

antiglaucoma

Wide- angle glaucoma

short acting

ointment and solution 3-4 X/day

demecarium bromide (Humorsol)

Indirect-acting anticholinergics

antiglaucoma

Open-angle gaucoma

1-2 gtt BID

Beta-adrenergic blockers (beta-blockers)

antiglaucoma

"-olol"

- for use to decrease IOP in open-angle glaucoma

betaxolol (Betoptic)

Beta-adrenergic blockers (beta-blockers)

antiglaucoma

"-olol"

selective beta blocker. Used to decrease elevated IOP in chronic open-angle glaucoma and ocular hypertension. Contraindicated in clients with asthma caused by increased airway resistance from systemic absorption.

*NOT for asthma patients

* CAUTION with oral beta blockers

1 gtt BID

carteolol (Ocupress)

Beta-adrenergic blockers (beta-blockers)

antiglaucoma

"-olol"

open angle glaucoma

CAUTION with oral beta blockers- may potentiate effect of systemic beta-blockers

1 gtt BID

timolol (Timoptic)

Beta-adrenergic blockers (beta-blockers)

antiglaucoma

"-olol"

- reduces production of aqueous humor.

monitor vital signs

blurred vision decreases with use.

levobunolol (Betagan)

levobetaxolol (Betaxon)

Beta-adrenergic blockers (beta-blockers)

antiglaucoma

"-olol"

Prostaglandin Analoques

antiglaucoma

- as effective as beta blockers with fewer side effects

SE: brown pigmentation in green-brown or yellow-brown irises; permanent

Blurred vision, ocular hyperemia, dry eye, tearing, and light intolerance

latanoprost (Xalatan)

Prostaglandin Analoques

antiglaucoma

to lower IOP; generally well tolerated

1 gtt at bedtime : 0.005% solution

bimatoprost (Lumigan)

Prostaglandin Analoques

antiglaucoma

increases outflow of aqueous humor through trabecular meshwork and uveoscleral routes.

1 gtt at bedtime : 0.03% solution

travoprost (Travatan)

Prostaglandin Analoques

antiglaucoma

increases uveoscleral outflow, and more effective in african american than non-african american

1 gtt at bedtime : 0.004% solution

unoprostone (Rescula)

Prostaglandin Analoques

antiglaucoma

not recommended for children

1gtt : 0.15% solution BID

Carbonic anhydrase inhibitors

antiglaucoma

interfere with production of carbonic acid, which leads to decreased aqueous humor formation and decreased IOP.

open-angle glaucoma

used if other agents not effective

SE: anorexia, lethargy, depression, N/V, hypokalemia, parathesia (base side effect profile)

CAUTION: Do not use if allergy to SULFA or pregnant

teratogenic!

acetazolamide (Diamox)

Carbonic anhydrase inhibitors

antiglaucoma

reduce aqueous humor formation, thus lowering IOP

250-1000 mg/d

brinzolamide (Azopt)

Carbonic anhydrase inhibitors

antiglaucoma

topical treatment of elevated IOP in clients with ocular hypertension or o/a glaucoma

1 gtt TID

timolo/dorzolamide

Carbonic anhydrase inhibitors

antiglaucoma

(0.5% / 2%)

1gtt BID

dorzolamide (Trusopt)

Carbonic anhydrase inhibitors

antiglaucoma

Osmotic

antiglaucoma

used pre and post operatively to decrease vitreous humor volume, reducing IOP for emergency treatment of acute closed-angle glaucome (medical emergency)

SE: headache, N/V/D, disorientation

mannitol (Osmitrol)

Osmotic

antiglaucoma

IV solution 5-20%

1.5-2 g/kg over 30-60 minutes

other osmotics:

isorsorbide (ismotic)

glycerin: decreased volume of introcular fluid to lower ocular tension.

Anticholinergic mydriatics & cycloplegics

antiglaucoma

mydriatics: dilate muscles of accommodation

Cycloplegics: paralyze muscles of accomodation

SE: headache, brow pain, allergy, worsening narrow-angle glaucome (mydriatics), tachycardia, photophobia, dry mouth, conjunctivitis, edema (cycloplegics)

Atropine toxicity- dry mouth, blurred vision, photophobia, tachycardia, confusion

TREAT TOXICITY with phyostigmine

atropine sulfate (Atropsilol)

Anticholinergic mydriatics & cycloplegics

antiglaucoma

most potent cycloplegic. For refraction, iritis, and uveitis

1-2 gtt up to QID

tropicamide (Mydriacyl)

Anticholinergic mydriatics & cycloplegics

antiglaucoma

epinethrine (Epinal)

Anticholinergic mydriatics & cycloplegics

antiglaucoma

age-related

is the leading cause of vision loss in those 65 and older.

The macula is that part of the eye responsible for sharp central vision; damage to the macula blurs central vision in the affected eye.

2 forms: wet / dry

WET: which progresses rapidly is associated with growth of abnormal blood vessels behind the retina that shift the macula from its normal position.

DRY: slowly destroys vision over a period of years is a gradual destruction of light-sensitve cells in the macula that leads to a blurred or blind spote in the center of vision in one or both eyes.

* options for treatment include laser treatment, photodynamic therapy, and medications.

pegaptanib (Macugen)

ranibizumab (Lucentis)

Macular Degeneration

pegaptanib (Macugen): eye injectable

ranibizumab (Lucentis): eye injectable every month

Antibaterials : external or internal otic infections

EAR (OTICS)

external- tetracycline (Acromycin)

or

chloramphenical (Chloromycetin)- infection of ear canal ex. swimmers ear

1:4 peroxide

Antihistamine & Decongestants

EAR (OTICS)

reduce middle ear and nasal congestion in acute otis media

ex.

Dimetapp

Dimetane

Triaminic

Irrigation

EAR (OTICS)

irrigation of the ear may also be ordered. Irrigation is best accomplished when there is direct visualization of the tympanic membrane. must be done gently to avoid damage to the eardrum

common solutions:

burows

hydrogen peroxide 3%

hypertonic sodium chloride solution 3%

acetic acid (vinegar) solution

Contraindications include: perforation of eardrum and hypersensitivity

earwax, producted by glands in the outer half of the ear canal, usually moves to the external os by itself and is washed away. However, ceruminolytics are sometime deeded to loosen and remove impacted cerumen from the ear canal. Irrigation with hydrogen peroxide solution can flush cerument deposits out of the ear canal. For chronic impactation or or two drops of olive oil or mineral oil soften the wax or prescription meds:

cerumenex- soften ear wax OTC

debrox

ear-dry

Non-pharmacologic

acne vulgaris

gentle cleansing QID

well-balanced diet

decrease stress

Topical Agents

Acne Vulgaris

benzoyl peroxide (Clearasil) BID

salicylic acid  BID

tretinoin (Retin-A) derivative of vitamin A

adapalene (Differin)- antiinflammatory & eliminates blackheads.

SE (Differin)- photosensitivity

tetracycline,clindamycin,erythromycin- gel for moderate acne.

Systemic Agents - oral antibiotics

Acne Vulgaris

tetracycline and erythromycin: tetracycline inhibits bacterial protein synthesis. used to treat acne with lower maintenance dose over a period of months.

severe acne: isotreintoin (Accutane): WARNING VERY TERATOGENIC , IPLEDGE

Isotretinoin (Accutane) is a derivative of vitamin A, is used for severe cystic acne, can be administered orally or topically. It decreased sebum formation and secretion, and it hav antiinfammatory and antikeratinizing (keratolytic) effect.

Adverse reaction: nosebleeds, pruritus, and inflammation of the eyes and lips. AVOID WITH PREGNANCY.

Psoriasis

is a chronic skin disorder that affects 1-2% population

onset apearts at 30 yrs of age

* is characterized by erythematous papules and plaques covered by silvery scales. It appears on the scalp, elbows, palms of the hands, knees. and soles of the feet.

With psoriasis, epidermal cell growth and epidermal turnover is accelerated to approximately 5X the normal expected epidermal growth!

Topical/ systemic preparations

Topical / Systemic preps for Psoriasis

Keratolytics (salicylic acid / sulfer)

* psoratic scales may be loosened with keratolytics (salicylic acid/ sulfer)

Topical glucocoritcoids are sometimes used for mild psoriasis.

other topical preps for psoriasis include anthralin (Anthra-Derm, Lasan) and coal tar (Estar, PsoriGel)

Topical / Systemic preps for Psoriasis

* Coal tar- are available in shampoos, lotions, and creams. They have an unpleasant odor and can cause burning and stinging.

* calcipotriene (Dovonex)- mild to moderate psoriasis, a sythetic form of vitamin D3 derivative useful for suppressing cell proliferation. This drug can cause local irritation, but the serious adverse effects are hypercalciuria and hypercalcemia (icreased urin and serum calcium levels)

Photochemical therapy for Psoriasis

PUVA

efalizumab (Raptiva)

etanercept (Enbrel)

infliximab (Remicade)

adalimumab (Humira)

these biological agents are expensive, have fewer side effects with comparable efficacy to other systemic treatments.

Note: most modify the inflammatory process and inhibit the activation of memory effector T lymphocytes...WEEKLY MONITOR CBC AND T-CELL COUNTS IS REQUIRED! WATCH FOR SIGNS OF INFECTION; DO NOT GIVE MEDICATION.

The common wart is hard, horny nodule that may appear anywhere on the body, particularly on the hands and feet.

Warts may be benign lesions, or they may be precursors to cancerous lesions. especially those in the genital region.

Drugs that treat: salicylic acid, podophyllum resin, and cantharidin.

Salicyclic acid

Verruca Vulgaris (Warts)

Liquid nitrogen

Verruca Vulgaris (Warts)

Electrodesication

Verruca Vulgaris (Warts)

cautery / laser

note: wart can also be removed by surgical excision

Podophyllum Resin

Verruca Vulgaris (Warts)

cantharidin (Cantherone)

Verruca Vulgaris (Warts)

INH: isoniazid

hydrazaline

anticonvulsants

antidysrhythmics (Pronestyl) : can cause lupuslike symptoms

also called exogenous dermatitis is caused by chemical or plant irritation. A skin rash with itching, swelling, blistering, oozing, or scaling at the affected skin sites characterizes this disorder.

Note: perfumes, dyes, clothing, cosmetic, poison ivy, poison oak and sumac

OTC

Contact Dermatitis

Prescription

Contact Dermatitis

topical steroids: Cordran, Decadron, Aristocort

Oral Steroids: Medrol Dosepak

Note: prolonged use of topical glucocorticoids can cause thinning of the skin with atrophy of the epidermis and dermis and purpura from small-vessel eruptions;therefore, prolonged use is discouraged

when the hair shaft is lost and the hair follicle cannot regenerate, male-pattern baldness, or alopecia, occurs.

Treatments:

minoxidil (Rogaine): topical, MEN only

finasteride (Propecia): tablet for BPH, works better in younger men.

* BURN: mafenide (Sulfamylon) is an aniinfective for 2nd and 3rd degree burns

dose: apply thin layer BID

SE: rash, burning/stinging, uriticaria, edema

Adverse: bone marrow suppression, fatal hemolytic anemia

silver sulfadiazine (Silvadene)

Pituitary gland

(hypophysis)

secretes: growth hormone (GH), thyroid-stimulating hormone (TSH), adrenocorticotropic hormone (ACTH), follicle-stimulating hormone (FSH), and luteinizing hormone (LH)

Posterior (neuohypophysis)

Anterior (andenohypophysis)

Anterior pituitary gland secretes TSH in respnse to thyroid-releasing hormone (TRH) from the hypothalamus. TSH, or thyrotropic hormone, stimulates the release of thyroxine (T4) and triiodothyronine (T3) from the thyroid gland. Hypersecretion of TSH can cause hyperthyroidism and thyroid enlargement, and hyposecretion can cause hypothyroidism. Serum TSH levels should be checked to determine whether there is a TSH deficit or excess. TSH and T4 levels are frequently measured to differentiate pituitary from thyroid dysfunction.

decreased T4 level / normal or elevated TSH leval can indicate a thyroid disorder.

Growth Hormone

Anterior lobe of Pituitary (adenohypophysis)

no specific target, affects bone and tissues

given SQ or IM; inactivated by gastric secretions

Given before bone epophyses fused

long-term use increases glucose level, causing diabetes.

Note: if needed started by age 5 to 13/15

also, needed when child falls off of pediadric growth curve.

Growth Hormone Deficiency

Anterior lobe of Pituitary (adenohypophysis)

Deficiency in children: NOT given if obese; severe respiratory issues or have Prader-Willi syndrome (is an uncommon genetic disorder. It causes poor muscle tone, low levels of sex hormones and a constant feeling of hunger).

somatrem (Protropin)- 100 mcg/kg X3 weeks SQ/IM

somatotropin (Humatrope)- 60 mcg/kg X3 weeks SQ/IM

are two growth hormones used to treat growth failure in children because of pituitary GH deficiency

Growth Hormone Excess

Anterior lobe of Pituitary

GH hypersecretion 2nd to pituitary tumor

* radiation to destroy tumor or bromocriptine (Parlodel) to inhibt release of GH.

*octreotide (Sandostatin)- supress GH release

-giantism (during childhood)

-acromegaly (in adulthood): physical changes of overgrowth (hands, hump on forehead)

TSH

Thyroid stimulating hormone

is secreted in response to thyroid-releasing hormone (TRH) from hypothalamus.

TSH- stimulates thyroid to release thyroxine (T4) and triiodothyronine (T3)

* hypothyroid- reduced TSH secretion or gland disorder

*hyperthyroid- excess TSH secretion

thyrotropin (Thyrogen)- for diagnosing hypothyroidisn and treat thyrois cancer SQ/IM

prednisone (Deltasone, Orasone)

glucocorticoid (adrenal cortex)

decreases inflammatory occurrence; as an immunosuppressant; to treat dermatologic disorders

mode: suppression of inflammation and adrenal function

Dose: 5-60 mg/day; may taper dose to avoid severe adrenal insufficiency

SE: N/D, increased appetitie, headache, weight gain, depression, mood changes, euphoria, hyperglycemia, abnormal fat deposits

Adverse: HTN, tachycardia, osteoporosis, muscle wasting, IOP, thin skin with purpurs, growth retardation, GI hemorrhage, thrombophlebitis.

Adrenocorticotropic Hormone

ACTH

Anterior Pituitary

Secretion of ACTH occurs in response to corticotropin-releasing factor (CRF) from the hypothalamus. ACTH from the anterior pituitary stimulates the release of glucocorticoids (cortisol), mineral corticoids (aldosterone), and androgen from the adrenal cortex.

* Usually ACTH and cortisol secretions follow a diurnal rhythum in which the ACTH and cortisol secretion is higher in the early morning and then decreases through the day. 

Note: stresses such as surgery, sepsis, and trauma override the diurnal rhythm, causing an increase in secretions of ACTH and cortisol.

*can gain weight in abdomen-not necessarily due to eating.

corticotropin (Acthar)

ACTH drug

adrenocorticol disorder, anti-inflammatory agent, acute MS

is used to diagnose adrenal gland disorders, to treat adrenal gland insufficiency, and as an anit-inflammatory drug in the treatment of allergic response.

DOSE: 10-25 units in 500 ml D5W every 8 hours (dx testing)

80-120 units/day SQ/IM for 2-3 weeks (Acute MS)

SE: n/v, mood swings, increased appetite, water/sodium retention, hypokalemia, hypocalcemia

Adverse: osteoporosis, muscle atrophy, decreased wound healing, cataracts, glaucoma, edema, pancreatitis, ulcer.

Drug-Drug: ulcrs with aspirin, decreases effects of insulin/antidiabetics

CAUTION: phychiatric disorders, hepatic disease, PUD (peptic ulcer disease), MG,CHF, fungal infection, increase glucose (hyperglycemia)

Posterior Lobe of Pituitary

Hormones: ADH / Oxytocin

ADH (antidiuretic hormone) : promotes water reabsorption from kidneys to maintain fluid balance. When there is a deciciency of ADH, large amounts of water are excreted by the kidneys. This condition, diabetes insipidus (DI), can lead to severe fluid volume deficit and electrolyte imbalances. Head injury and brain tumors resulting in trauma to the hypothalamus and pituitary gland can also cause DI.

vasopressin (Pitressin): SQ/IM 5-10 units BID to QID

desmopressin (DDAVP): intranasal 0.1-0.4 ml/d

DDAVP good for kids that wet the bed- supresses formation of urin.

Nursing measures: monitor weight, I&O, and labs

Thyroid Gland

secrete thyroxine (T4) and triiodothyronine (T3)

The functions of T4 and T3 are to regulate protein synthesis and enzyme activity and to stimulate mitochondrial oxidation. Approx. 20% of circulating T3 is secreted from the thyroid gland, and 80% of T3 comes from the degadation of about 40% of T4 which occurs in the periphery.

*T3 and T4 are carried in the blood by thyroxine-binding globulin (TBG) and albumin, which protect the hormones from being degraded. T3 is more potent than T4 and only unbound T3 and T4 are active and produce a hormonal response. controlled by feedback mechanisms

primary thyroid gland disorder

decreased T4 and TSH

S/S: cold, weight gain, memory impairment, lethargy, constipation, slow pulse, abnormal menses, slow speech, deep voice, edema of eyelids and face

Secondary: lack of TSH secretion

levothyroxine (levothroid, synthroid)- drug of choice

increases T3 and T4

Dose: 25-50 mcg/d; maintenance 50-200

SE: N/V/D, tremors, cramps, insomnia, headache, weight loss.

Adverse: tachycardia, hypertension, angina, cardiac dysrhythmias

Drug-Drug: decrease effect of diabetic agents, digitalis; increase warfarin

Phenytoin (Dilantin) increases T3 levels

Digoxin & Lithium increase action of thyroid drugs

Thioureas drug of choice for hyperthyroidism (block thyroid hormone action). Treat thyrotoxic crisis and to prepare for sub-total thyroidectomy, and can cause goiter formation if use prolonged.

methimalole (Tapazole)- potent, long half-life

150-60 mg/day (1 week for effect)

SE: rash, headache, GI distress

propylthioracil (PTU)- inhibits conversion of T4 to T3

treat hyperthyroidism & Graves

SE: 300-450 mg/day

Iodine

Hyperthyroidism

lugol's solution: suppresses thyroid function in subtotal thyroidectomy for Graves disease.

reduce size and vascularity of thyroid gland

avoid foods high in iodine (seafood, iodized salt)

3-5 gtts TID (dilute, through straw, after meals)

maximum effect 10-15 days

radioactive iodine (131)- destroys thyroid cells

treat thyroid cancer and hyperthyroidism

SE: radiation sickness, bone marrow depression

Throid replacement

NURSING MEASURES

*take thyroid med before breakfast (no other meds/OTC's)

*MedicAlert ID (must stay on meds, can cause re-bound and death!)

*S/s hyperthyroidism

*2-4 weeks for improvement

*avoid foods that inhibit thyroid secretion- stawberries, peaches, pears, cabbage, turnips, spinach, kale, brussel sprouts, cauliflower, radished, peas

Antithyroid

NURSING MEASURES

* take meds with meals

*do not stop abruptly; thyroid crisis

S/S hypothyroid

1-3 weeks for improvement

monitor pulse for increase or decrease

SE: rash, hives, alopecia, loss of hair pigment, bruising, weakness

* report fever or sore throat (agranulocytosis); monitor CBC

secrete parathyroid hormone (PTH), which regulates calcium levels in the blood. A decrease in serum calcium stimulates the release of PTH. Calcitonin decreases serum calcium levels by promoting renal excretion of calcium.

PTH hormone agents treat hypoparathyroidism

synthetic calcitonin treats hyperparathyroidism

to treat hypoparathyroidism and manage hypocalcemia in chronic renal failure.

*promotes calcium absorption for GI tract, increasing serum calcium level.

*monitor calcium levels weekly

DOSE: 0.25 mcg/d, has long onset, peak and duration

SE: anorexia, N/V/D, cramps, headache, lethargy, dizzinness, photophobia

Adverse: hypercalciuria, hyperphosphatemia, hematuria

Caution: malabsorption, CVD, renal calculi, elevated vitamin D

Drug-Drug: increase cardiac dysrhythmia with digoxin, verapamil

Drug-lab: increase serum calcium with thiazide diuretics.

for bone disease and hypocalcemia associated with chronic renal disease and dialysis.

300-350 mcg/wk, then 50-100 mcg/day

for treating paget disease; for hypercalcemia caused by antineoplastic therapy, and hyperparathyroidism

0.5 mg/d SQ ; maint: 0.25 mg/day

Adrenal Glands

medulla/cortex

medulla secretes:catecholamines epinephrine and norepinephrine and is linked with the SNS.

Cortex secretes: cortiosteroids (glucocorticoids and mineralocorticoids.

primary glucocorticoid is cortisol

primary mineralocorticoid is aldosterone.

Glucocorticoids

Adrenal Cortex

Glucocorticoids are influenced by ACTH, which is realeased from the anterior pituitary gland. They affect carbohydrate, protein, and fat metabolism and muscle and blood cell activity.

Cortisol, the main glucocorticoid, has antiinflammatory, antiallergic, and sntistress effects. Indications of glucocorticoid therapy include  head trauma with cerebral edema, surgery, infections, emotional upsets, and anxiety.

Cortisol

secreted by the adrenal cortex

sodium and water retention with potassium excretion. Decrease-adrenal insufficiency = Addison's ; increase-adrenal hypersecretion= Cushing's

anti-inflammatory, antiallergic, antistress

tread head trauma with cerebral edema

autoimmune (MS, MG, RA), ulcerative colitis

allergic (asthma, contact dermatitis, anaphylaxis

prevent organ transplant rejection

vasular inflammation (polyarteritis nodosa)

given oral, deep IM, IV, topical, aerosol

Different potencies

decrease effectiveness of warfarin with steroids

decrease effectiveness of steroid with barbiturates, phenytoin, rifampin

WATCH HERBALS!!! CASCARA, SENNA, CELERY SEED, JUNIPER, GINSENG, ECHINACEA, AND LICORICE

cortisone acetate (Cortate)

hydrocortisone (Cortef, hydrocortone)

Intermediate-acting

glucocorticoids

methylprednisolone (Medrol, Solu-medrol, Depo-medrol)-IV,SQ

prednisolone (Hydeltrasol)- parenteral into joints/soft tissue.

prednisone triamcinolone (Aristocort, Kenacort, Kenalog, Amacort)- topical

Long-acting

glucocorticoids

beclomethasone (Vancenase AQ, Beconase AQ)-inhalation

betamethasone (Celestone)- oral, IV, IM; very potent

dexamethasone (Decadron)- IV push/IV, IM, PO; shock, asthma attack. Decreased effect with oral antidiabetics and anticoagulants. Hypokalemia with anti-pseuso. PCN antibiotics and thiazides.

ketaconozole (Nizoral): is effective in treating clients with Cushing syndrome and is useful as an adjunct to surgery or radiation. Avoid high doses do to cardiac rhythm issues.

aminoglutethimide (Cytadren)- is frequently prescribed for temorary treatment of cushing syndrome, especially clients with adrenal adenoma or carcinoma, ectopic ACTH producing tumors, or adrenal hyperplasia

baseline vital signs, including weight and height

monitor lab: K+, glucose

avoid herbals, thiazides

Medic-Alert

Diet high in potassium

Do not stop drug abruptly; taper dose

avoid persons with URI due to immune suppression

take with food to avoid GI issues

Mineralcorticoids (corticosteroid)

primary aldosterone

another type of corticosteroid secrete aldosterone. Aldosterone is controlled by the rinin-angiotensis system, not by ACTH. Maintain fluid balance by promoting the reabsorption of sodium from the renal tubules, excrete potassium, water retention (edema)

*SEVERE decrease in aldosterone leads to hypotension and vascular collapse, as seen in Addison disease. Mineralocorticoid deficiency usually occurs with glucocorticoid deficiency, frequently calld corticosteroid deficiency.

fludrocortisones (Florinef)

mineralocorticoid

is an oral mineralocorticoid that can be given with a glucocorticoid. It can cause a negative nitrogen balance; therefore a high-protein diet is usually indicated

potassium excretion occurs with use of mineralocorticoids and glucocorticoids, the serum K+ level should be monitored due to hypokalemia

0.1-0.2 mg/day

a chronic disease resulting from deficient glucose metabolism, is caused by insufficient insulin secretion from the beta cells. This results in high blood sugar (hyperglycemia).

Diabetes mellitus is characterized by the three p's: polyuria (increased urin output), polydipsia (increased thirst), and polyphagia (increased hunger).

Diabetes mellitus is a disorder of the pancreas, whereas diabetes insipidus in a disorder of the posterior pituitary gland.

Type 1: insulin-dependent diabetes mellitus = 10-12%

Type 2: non-insulin-dependent diabetes mellitus= 85-90%

secondary diabetes( medications, hormonal changes)= 2-3%

Gestational diabetes mellitus= <1%

* certain drugs increase blood sugar and can cause hyperglycemia in prediabetic persons such as: glucocorticoids, thiazide diuretics, and epinephrine.

is released from the beta cells of the islets of Langerhans in response to an increase in blood glucose.

secretion= 0.2-0.5 units/kg/day; increased calorie intake causes increase insulin secretion (0.2-1 unit/kg/day)

Higher range of secretion may also be due to obesity, stress, and tissue insulin resistance.

*Promotes uptake of glucose (oral better than IV), converted to glucogen and stored in liver and muscle.

*Normal serum glucose 70-110; >180 glycosuria occurs.

Polyuria with elevated glucose levels.

Beef/Pork insulin (pork less allergenic)...human insulin (DNA technology)

*Human insulin absorbed faster, shorter duration than beef and pork.

*100 units/ml (U100) or 500 units/ml (U500), 10-ml vial, insulin syringe 100 units per ml. ROLL, DO NOT SHAKE VIALS.

* SQ or IV. IV only regular, never oral (destroyed by gastric secretions)

*heat and massage increase absorption;cooling decreases absorption.

*45-90 degree SQ

*Greater absorption in abdomen and deltoid; thigh and buttock lesser absorption.

*Rotate injection sites to avoid lipodystrophy (more common in women and children)

*lipohypertrophy- raised lump/knot (more common in males)

*illness/stress increase demands for insulin; do not hold for illness!

SE: confusion, agitation, headache, tremors, hunger, weakness, lethargy, uticaria, redness, irritation at site of injection

ADVERSE: tachycardia, hypoglycemic reaction, rebound hyperglycemia(Somogyi effect), lipodystrophy, anaphylaxis, shock

DRUG-DRUG: hypoglycemia with aspirin, warfarin, alcohol, oral hypoglycemic, beta-blockers, TCA, MAOI, tetracycline

hyperglycemia with thiazides, steroids, oral contraceptives thyroid drugs, smoking

Clear

Administer no more than 5 minutes before mealtime

onset: 5-15 min.

peak: 30-60 min.

duration: 3-4 hours

Need intermediate type also to control glucose

lispro (Humalog)

insulin aspart (Novolog)

exubera (inhaled) taken off of market

Clear

Given 30 minutes before meals

onset:  30-60 min.

Peak: 2-4 hours

Duration: 6-8 hours

Humulin R- given SQ or IV

Cloudy

Potamine- prolongs action

Zinc- slows onset of action and prolongs action

Onset: 1-2 hours

Peak: 6-12 hours

Duration: 18-24 hours

Given in am

NPH (protamine)

Lente (Zinc)

Humulin N (protamine)

Humulin L (Zinc)

No peak

insulin glarnine (Lantus)- given at bedtime

onset: 1 hour

Peak: none

Duration: 24 hours

insulin detmir (Levemir)

peaks: 6-8 hours

Duration 12-24 hours

pre-filled pen

* do not need to refigerate;insulin pens for 10 days (hospital)

Humulin 70/30 :70% NPH & 30% regular

Novolin 70/30

Humulin 50/50

Humalog 75/25

unopened vial is refrigerated

opened vials 4 weeks at room temp., 12 weeks refrigerator

less irritating to tissues injected at room temp.

DO NOT FREEZE

do not place in heat / direct sunlight

prefilled syringes in refrigerator and used in 1-2 weeks (at home)

Blood glucose checked before meals and at bedtime

insulin dose given according to glucose level

rapid or short-acting insulin used for sliding scale coverage

* more insulin administered than what is needed

S/S: nervous, trembling, cold/clammy skin, headache, lack of coordination, foggy thinking, combative, incoherent

blood sugar < 60

TX: IV or oral glucose

Hyperglycemia on awakening

headache, night sweats, nightmares

increase insulin at dedtime

hypoglycemia at 2-4 am

reduce bedtime insulin

Fatty acids (ketones) beins used for energy due to sugar not being utilized

S/S: thirst, polyuria, fruity breath, rapid, thready pulse, dry mucous membranes, Kussmaul respirations (deep, rapid, labored)

blood sugar >250

looks like fountain pen, more expensive

disposable, insulin-filled sringe

disposable needle

151-300 units in pen

Novolog flex-Pen

Lantus SoloStar

Humalog-Pen

Apidra OptiClik

Levemir FlexPen

Portable: external; needle SQ in abdomen, upper thigh, upper arm.

continuous SQ insulin infusion (CSII)

battery operated

REGULAR INSULIN ONLY

basal insulin (usually 3 per day) with boluses for meals

programmed by patient

can be disconnected to bathe, swim; not more thatn 1-2 hours

even glucose levels with less hypoglycemia and long-term complications

delivered without needle

sting, burning

not for children or elderly

expensive

surgically implanted in abdomen (intraperitoneal or IV)

delivers basal insulin and bolus doses with meals

conrolled glucose leves, less hypolycemia

Oral Antidiabetic Agents

1st generation

Type II Diabetes only!

First Generation Sulfonylureas: stimulate beta cells in pancreas to secrete more insulin

related to sulfa compounds

contraindicated in pregnancy,lactation,DKA, infection/stress

NO ETOH....severe hypoglycemia

warfarin,ASA,MAO, some NSAID increase action

Phynytoin, Warfarin,steroids, INH, decrease action

Short-acting: tolbutamide (Orinase) 510-300 mg/day in 2-3 doses

Intermediate-acting : acetohexamide (Dymelor) 251 mg/day before breakfast

              tolazamide  (Tolinase): 100-251 mg/day

Long-Acting: chlorpropamide (Diabinese) 100-510 mg/day; fluid retention.

Oral Antidiabetic Agents

2nd generation

Type II Diabetes only!

Second Generation Sulfonylureas: Increase tissue response to insulin

Decrease glucose production by liver

Greater hypoglycemic potential than 1st generation, usually with elderly patients

longer duration, fewer side effects

do not use with liver/renal issues

less protein-binding issues (warfarin, ASA)

No ETOH

drug-drug same as 1st generation

glimeperide (Amaryl)- directly stimulate beta cells, improves post-prandial levels, used with insulin in type II ; SE: abdominal cramping, diarrhea

glipizide (Glucotrol, Glucotrol XL):  directly stimulates beta cells

glyburide (Micronase, DiaBeta): 1.25-5 mg/day, up to 20 mg/day

glyburide micronized (Glynase): 1.5-3 mg in am; max 12 mg

Biguanides: metformin (Glucophage)- decreases liver production of glucose from stored glycogen; blunts post-prandial hyperglycemia; blunts increase in serum glucose following a meal; decreases absorption from small intestine; increases insulin receptor sensitivity; does not produce hyper- or hypoglycemia; do not use with renal insufficiency; hold drug 48 hours before and after IV contrast dye due to lactic acidosis o ARF.

Dose: 510 mg QD up to 2510 mg/day

SE: bloating, cramping,diarrhea, headache, metallic taste

Adverse: malabsorption of B12 and folic acid, lactic acidosis

Drug-drug: MULTIPLE!!

acarbose (Precose): inhibits enzyme in the small intestine responsible for the release of glucose from complex carbs in the diet; cannot absorb carbs and are passed through to large intestine; not significantly absorbe, no systemic effects; used in conjuction with diet; does not cause hypoglycemia; may combine with sulfonylurea

Dose: 25 mg with meals

miglitol(Glyset): is absorbed from GI tract ; does not cause hypoglycemia unless taken with insulin or sulfonylurea

Dose: 25-100 mg with meals

SE: GI

* decrease insulin resistance and improves glucose control

pioglitazone (Actos): may be combined with insulin or sulfonylureas

Dose: 15-45 mg/day

SE: hepatotoxic, monitor LFT's

rosiglitazone (Avandia): may be combined with metfromin (Avandamet)

Dose: 4-8 mg QD

SE: hepatotoxic, monitor LFT's Q 3 mo.

* stimulate beta cells to release insulin

short-acting

do not use with liver dysfunction

repaglinide (Prandin): 0.5-4 mg AC BID-QID

may use with metformin

nateglinide (Starlix): 60-120 mg AC TID

may use with metformin

increase incretin hormones and insulin secretion and reduce glucagon secretion

reduces fasting and postprandial glucose levels

sitagliptin (Januvia): 100 mg QD

improves beta-cell response

slows GI emptying

suppresses appetite

Type II only

SE: N/V, jittery, headache, diarrhea

Dose: 5-10 mcg SQ BID 30 min before meal

 pramlintide (symlin) never give in arm

Glucagon: SQ,IM,IV

*treat insulin-induced hypoglycemia, onset 5-20 minutes

diazoxide (Proglycem): related to thiazides

* treat hypoglycemia due to islet cell cancer or hyperplasia