A metabolic disorder that alters the metabolism of glucose, fats, and proteins, causing numerous clinical complications; Predisposes to cardiovascular disease.

Determined by a fasting blood glucose level

of > 106mg/dL & glycosuria

↑ risk

Atherosclerosis: (heart attacks, strokes, plaques)

Retinopathy: loss of vision

Neuropathies: Motor/Sensory changes extremeties

Nephtopathy: Renal dysfunction r/t changes in glomerulus

Cells produce specific hormones that maintain glucose levels.

Alpha cells release glucagon in response to low glucose levels

Beta cells release insulin in reponse to high glucose levels

Delta cells somatostatin (GH inhibitor) in response to very low glucose levels

Produced by pancreatic beta cells

When glucose levels increase around beta cells, insulin is released and reacts to specific receptors to transport glucose into cells.

You eat: Glucose levels ↑ insulin realse: glucose↓

Glucagon in response to low glucose levels

mobilizes glycogen stored in liver

Monitor closely signs for hypo/hyperglycemina

Infants often have insulin diluted in a syringe.

teenagers growth complicates dose (compliance)

Metformin PO antidibetic approved for > 10 yr

Encourage proper diet & exercise program

Teach for warning S/S of hypo/hyperglycemia

Caution against OTC herbal therapies (alter glucose levels)

Insulin therapy best for P&L (times of stress)

Underlying problems can complicate therapy

Supply a weeks worth in fridge for usual dose can be helpful

Dietary deficiencies make it dificult to control diabetes

Monitor kidney & liver function

Remind importance diet & exercise, skin and foot care

More likely to experience organ damage (vision, renal, coronary artery disease, infrctions) r/t diabetes

 Glycosuria: Sugar spilling into urine because blood glucose is too high for reapbsorption/Cystitis common

Fatigue: Needs insulin to facilitate glucose into the cell 

Polydipsia: A need to add fluids to the body

Polyphagia: Cells think they are starving

Ketosis: Body shifts uses fat for energy

Acidosis: Liver cannot clear all acid wastes products

↑BUN (blood urea nitrogen): Muscle/protein breakdown

Lack of insulin

Loss of insulin receptor sensitivity

High blood glucose levels lead to basement membrane thickening & changes receptors

replacement or stimulation of insulin realse is Tx

Test for Diabetes Mellitus

Fasting glucose level of >106mg/dL

Glycosylated hemoglobin levels (HbA1c) test <7%

Diet, Exercise, and Lifestyle changes

may delay onset of diabetes

Insulin dependent

Associated with rapid onset; mostly in younger people; connected with viral distruction of beta cells; requires insulin replacement because beta cells are no longer functioning

Increasing in younger people b/c of obesity rate

Slow progressive onset

Produce insulin but not enough; receptor sites have lost their sensitiviy and the require more insulin to lower glucose; or person does not have enough receptor to support the body size

Diet: To control amount and timing of glucose in body

Weight loss: To decrease receptor sites that need to be stimulated & abd fat that blocks adiponectin release

Exercise: To ↑ movement of glucose in the cells and to ↑ K+ to push glucose into cell

When Diet & Excersize no longer work, Sulfonylureas & other Anitdiabetic drugs are used

Stress elevates blood glucose to cover "fight" or "flight" response.

When caring for pts in times of stress monitor for the need for emergency administration of glucose

(400mg/dL)

Also monitor for a potential hypoglycemic event

Diabetic Pts in times of stress require changes to their insulin dose

Blood glucose lower than 40mg/dL

Occurs in starvation, Tx of hyperglycemia, or PO's that lower blood sugar too low

Headache, drowsiness, coma

weakness, twitching, seizures

Palpitations, ↑BP, rapid shallow breathing

Diaphoresis, cool, clammy

hunger

pt appear drunk

Tx of type 1 diabetes 

Tx of type 2 diabetes that cannot be controlled by diet or other agents

Tx of hyperkalemia (with glucose to shift K+ into cells)

Thx for periods of stress

newly Dx patients being stabalized

Gestational diabetes

Lispro (Humalog)

Aspart (Novolog)

Glulisine (Apidra)

Detemir (Levemir)

Regular Insulin (Humulin R)

NPH Insulin (Humulin N)

Today virtually all insulin is produced by 

Genetically altered bacteria

Replaces indogenous insulin in the body by:

Promoting the storage of body's fuel by facilitating facilitating the transport of metabolites and ions across cell membrane and stimulates the synthesis of glycogen, lipids and proteins by reacting with specific cell receptors. 

By subcut injection only

• The abdomen, 2 inches from the belly button. The abdomen is the best place to inject insulin, fastest 
• The top outer area of the thighs. Insulin usually is absorbed more slowly from this site, unless you exercise soon after injecting insulin into your legs
• The upper outer area of the arms/Rotate sites

Because Insulin is a replacement hormone, there are no contradictions

Caution: Monitor glucose levels closely in P&L 

Used in gestational diabetes

Effectiveness of nursing infant should be monitored

Most common: Hypoglycemia & Ketcidosis

Local reation @ injection site; hypersensitivity

Caution in any drug that ↓ glucose levels Monoamine oxidase inhibitors (MOAIs antideppressants), beta-blockers (block the S/S hypoglycemia), salicylates, & alcohol; herbal Thx

Nursing Implications / Patient Teaching

Insulin Thx

Alway Assess: for drug allergies, P&L, other medications

Focus PX Assess

CNS: A&O, mental, PERRLA/Skin: Coloration, Lesions, Temp/Cardio: BP, PR/Resp: RR, Breath sounds, Pulse Ox

Lab: Urinalysis, blood glucose, HgbA1C

NC/PT:

Diet & Exercise, skin care, injury/infection, Explain reason for insulin, check expiration date of insulin, rotate to mix, rotate injection sites, teach S/S of hypoglycemia (too much insulin, low glucose), At first sign of hypoglycemia drink high sugar (OJ) or keep candy, honey, must not skip meals, if ill do not take usual insulin dose & contact physician, Avoid OTC or Herbal Thx, Carry Med Alert tag, report signs of hyperglycemia (friuty breath, ↑thirst & urination, blurred vision, monitor blood glucose, keep follow-up appointments

Bind to K+ channels on pancreatic beta cells

Increase effect of antidiuretc hormone on renal cells

Only effective in patients who have functional beta cells May lose their effectiveness over time

Classified as First-Generation & Second-Generation

All can cause Hypoglycemia

chlorpropamide (Diabinese)

 tolazamide (Tolinase)

Tolbutamide (Orinase)

"Mide's"

glyburide (DiaBeta, Micronase, Glynase Pre Tab)

glimepiride (Amaryl)

glipizide (Glucotrol)

"ide's"

 First-Generation Sulfonylurea

Class: Hormone, Antidiabetic

Indication: Adjunct to diet & exercise to lower glucose level in type 2 diabetes

Actions: Stimulates realease of insulin from functioning pancratic cells; may improve and ↑ number of insulin receptor sites

Route: PO 1h/3-4h/60h

Adverse: Gi discomfort, anorexia, heartburm, N&V, hypoglycemia

 Second-Generation Sulfonylurea

Class: Hormone, Antidiabetic

Indications: Adjunt to diet & exercise in management of type 2 diabetes; with metformin or insulin for stablization of diabetes

Actions: Stimulates realease of insulin from functioning pancratic cells; may improve and ↑ number of insulin receptor sites

Route: PO 1h/none/24h

Adverse: GI discomfort, anorexia, N&V, hearburn, diarrhea, allergic skin reactions, & hypoglycemia

Theraputic Action/Indications Sulfonylureas

Stimulate insulin release from beta cells

Improve insulin binding and ↑number of receptors

Adjunct to diet/exercise to lower blood glucose in type 2 diabetics

Adjunct to insulin to improve type 2 control of diabetes

Allergy

Diabetes complicated by fever, infection, trauma, major sugery, ketoacidosis, renal/hepatic disease, Pregnancy (use insulin), lactation (risk of hypoglycemia to baby), Type 1 diabetic's beta cells do not function & would not benifit from Thx 

Drugs that acidify the urine may ↓the amount of excretion

Caution used with beta-blockers (mask hypoglycemia),

alcohol & Herbal Thx (alters glucose levels)

Biguanide/Non-Sulfonylureas

metformin (Glucophage)

Indications: Adjunct to diet/exercise for Tx of type 2 diabetics > 10y; ER for > 17y; Adjunct for Tx of polycistic ovary syndrome

Actions: ↑peripheral use of glucose,  ↑ production of insulin, ↓hepatic glucose production, & alter GI absorption of glucose

Route: PO Slow/2-2.5h/10-16h

Adverse: Hypoglycemia, lactic acidosis, GI upset, nausea, anorexia, diarrhea, hearturn, & allergic skin reaction

Contraindications: In allergy to drug/Diabetes complicated by fever, infection, trauma, major sugery, ketoacidosis, renal/hepatic disease, Pregnancy (use insulin), lactation (risk of hypoglycemia to baby), Type 1 diabetic's beta cells do not function & would not benifit from Thx

Interactions: Drugs that acidify the urine may ↓the amount of excretion;Caution used with beta-blockers (mask hypoglycemia) ;alcohol & Herbal Thx (alters glucose levels)

NC/PT in Nonsulfonylureas 

metformin

Assess for contraindications

Baseline Px

CNS: Orientation, reflexes, Mental state (stress, may need to switch to insulin coverage)

Cardio: BP, PR/ Skin: Lesions, infections Resp: Adventitious breath sounds Lab: Monitor glucose levels, liver enzymes

Nutritional consult/excersize regimen

P/T of drug name, dose, schedule, skin assess, daily feet inspecction, hygiene measures, follow-up labs, S/S hypo/hyperglycemia

Class: Glucose-Elevating drug/Diagonostic agent

Indications: Counteracts severe hypoglycemia (<40 mg/dL) in diabetic patients Tx with insulin

Actions: Accelerate the breakdown of glycogen to glucose in the liver, ↑glucose levels

Route: IV, IM, or subcut (0.5-1 mg) 1m/15m/9-20min

Adverse: Hypotension, N&V, respiratory distress with hypersensitivity reactions, & hypokalemia with overdose

Used in pregnacy when benifits outweigh the risk

Caution in lactation (hypoglycemia in baby)

Caution in patients with renal/hepatic/cardiovascular disease

↑ anticoagulation effects when combined with anticoagulants (adjust dose)

NC/PT

glucagon

Allergies

baseline Px

CNS: Orientation, reflexes

Cardio: BP, PR, output

Resp: BR, Sounds

Lab: Glucose levels, glucosuria, renal/liver function

Have insulin ready if hyperglycemia results of OD

Monitor nutritional status, weight changes

Which of the following is a clinical manifestation of hyperlglycemia?

1. Edema
2. Lack of thirst
3. Itchy skin
4. Hyperexcitability

Itchy skin

Rationale: Clinical S/S of hyperglycemia are fatigue, lethary, irriation, glycosuria, polyphagia, polydipsia, & itchy skin

True/False

Second-generation sulfonlureas have several advantages over first generation sulfonylureas including the fact that the enteract with mor protein bond drugs?

Which is a promary action of glucose  elevating agents?

1. Accelerate the breakdown of glycogen
2. Increase insulin release
3. Improve binding to insulin receptors
4. Decrease use of incretins

Accelerate the breakdown of glycogen

Rationale: The action of glucose elevating agents is to increase glucose levels by decreasing insulin release and accelerat the breakdow of glycogen in the liver to release glucose

What are the theraputic actions for

metformin (Glucophage)

What are the most common adverse effects of

glyburide (Micronase)

What are the indications of

chlopropamide (Diabinese)

Double check to prevent medication errors

Encourge a healthy lifestyle

Rotate vials to mix

Rotate injection sites 

Monitor glucose levels, especially in times of stress

Monitor & teach for S/S  of hypo/hyperglycemia

Monitor food intake

Monitor for infection/skin hygiene

Teach self medication administration 

HF is a disfunction of that occurs when disorders damage or overwork the cardiac muscle resulting in ineffective pumping of blood through the body. The leading cause of HF is CAD which results in insufficient supply of blood to meet the oxygen demands of the myaocarduim causing the muscles to become hypoxic and no longer function.

Cardiomegly (viral, alcoholism, steroid use, or collagen disorder) alters the muscle and leads to ineffective contration/Hypertension leads to an enlarged heart; forcible contractions increase the demand for oxygen/Valvular heart disease stretches & overloads the ventricles b/c the valves do not close tightly; increasing oxygen need and contraction force

HF patient's present with heart pumping problems & compensatory mechanisms that are trying to balance the problem.

Left Sided HF: Engorgment of pulmonary veins leading to difficulty of breathing (tachypnea, dyspnea, orothpnea); hemoptysis (coughing up blood) & rales' pulmonary edema; decreased peripheral pulses

Right Sided HF: Usually from COPD; Right side of heart must work harder to move blood into the lungs; causing venous system congestion & edema from venous pressure, JVD; liver enlargement, increases blood flow to  kidney causing excessive urination 

Indications: Tx of HF, Afib

Actions: Increases intracellular calcium and allows more calcium to enter the myocardial cell during depolarization causing a positive inotropic effect (↑force of contraction); increased renal perfusion with a diuretic effect and decrease in renin release; a negative chronotropic effect (↓ heart rate); and slowed conduction through the AV node

Thrombocytopenia occurs frequently with inamrinone;

Arrhythmias, hypotension, N&V, pericarditis, pleuritis, fever, chest pain, burning at injection site

Important teaching points for a patient taking

digoxin

Digoxin is used to Tx HF and Afib

Reduces swelling and increases urination

Take digoxin as perscribed and maintain regular check up to monitor drug dose

Do not stop taking, do not catch up on missed doses

Teach to take pulse and record it on a calendar; if <60 call Px and hold dose

Consult provider if rapid weight gain, weakness, skin rash, foot/hand edema, dificulty breathing Vison changes may have yellow halo's 

Avoid OTC/herbal Thx with digoxin

Wear medical tag

Angiotensin-converting enzyme (ACE) inhibitors & nitrates (Vasodilators)

Diuretics 

Beta-andrenergic agonists

Human B-type natriuretic peptides 

They decrease the heart's workload and relieve HF by

affecting the intracelluar calcium levels in the heart muscle, leading to increased contractility, which increases cardiac ouptut, which increases renal blood flow, decreasing renin release (disrupts renin-angiotensin-aldosterone system), and increases urine ouptut, decreasing blood volume

Class: Cardiac Glycoside

Indication: Treatment of acute HF, atrial arrythmias

Action: Increases intracellular clacium during depolarization causing and positive inotropic effect (increased force of contration); Increases renal perfusion with a diuretic effect & decreasing rennin release; a negative chonotropic effect (slower heart rate), and decreases conduction through the AV node

Adverse Effects: Arrhythmias, yellow vision, headache, weakness, GI upset, electolyte imbalances from dig toxicity

Contraindications: Ventricle tachycardia or fibrillation, Heart block sick sinus syndrome, idiopathic hypertrophic subarotic stenosis (IHSS), acute MI, electrolyte imbalances

Route/dose: PO, IM, IV

More susceptible to toxic effects and more likely to have underlying conditions that can interfere with their metabolism and excretion;

Renal impairment can cause digoxin to accumulate in body-> dose needs to be decrease monitor toxicity closely

In times of stress or difficulty, another should take pulse and monitor adverse effects

Digoxin Immune Fab:

• Range: 0.5-2 ng/mL (1.2-2 nmol/L) 
• Toxic level: more than 2 ng/mL

Apical pulse for 60 sec, hold if heart rate is less than 60/bpm

double check dose

Drug-Drug: Verapamil, amiodarone, quinidine, quinine, erythromycin, tetracycline, or cyclosporine (decrease digoxin dose)

Herbal: Ginseng, hawthorm, and licorice

Monitor K+ levels when taking potassium losing diuretics

Phosphodiesterase Inhibitor

Milrinone (Primacor)

Class: Inotropic 

Indication: Short-term Tx of HF in patients who have not responded to digitalis, diuretics, or vasodilators

Actions: Blocks enzyme phosphodiesterase, leads to increase in cAMP, increases calcium levels in cell, causing stronger contraction and prolonged response to sympathetic stimulation; directly relaxes vascular smooth muscle

Adverse effects: Ventricle arrythmias, hypotension & chest pain; N&V, thrombocytopenia, pericarditis, pleuritis, fever, chest pain, burning at injection site.

Route: IV only

Contraindications: Severe aortic or pulmonic valvular disease, MI, fluid volume deficit, & ventricular arrhythmias; Cautioned use in elderly & P&L

Interactions: Furosemide (lasix) (a loop diuretic)

NC/PT: Monitor serum electrolytes, CBC, and renal/hepatic function tests, weight for fluid retention, capillary refill for perfusion. Protect drug form light, BP & PR, I&O, platelet count to monitor thrombocytopenia, crash cart on standy

True or False:

The primary Tx for congesitve HF is to make the heart beat harder and faster

False:

Primary Tx involves increasing muscle contractility, bringing system back into balance.

Think slow and effective

Improve blood delivery to heart muscle by dilating blood vessels and increasing blood supply. Improve blood delivery to the heart muscle by decreasing the work of the heart, which decreased the demand for oxygen.

Preventing myocardial cell death 

Fatty tumors in the intima of the vessel

Attract platelets and immune factors causing swelling, larger deposits, and decrease the sizes of the vessel

Nitrates

Beta-Adrenergic blockers

Calcium channel blocker

Nitrates

Nitroglycerin

Indication: Tx of acute angina, prophylaxis of angina, IV Tx of angina unresponsive to beta-blockers or organic nitrates, perioperative hypertension, HF associated with MI

Action: Relaxes vascular smooth muscle with a resultant decrease in venous return and decrease in arterial blood pressure, reducing the left ventricular workload and decreasing myocardial oxygen consumption

Route: IV, Sublingual, Translingual Spray, Transmucosal tab, PO (SR tab), Topical ointment, Transdermal

Adverse effects: Hypotension, headache, vomiting, sweating, angina, & syncope

Contraindications: Severe anemia, head trauma, P&L, Cautioned in renal/hepatic dysfunction, hypotension, hypovolemia

Interact:  Ergot derivatives (headache meds), heparin, erectile dysfunction medication

NC: Monitor BP-HR, signs of hypotension, Administer when laying down

Make sure there are no lesions that can interfere with absorption of drug

Sip water to moisten mucous membranes

Place tab under tounge until it dissolves, alternate left/right side, may burn

Check expiration date

Keep in original container away from heat and light

May be repeated in 5min x 3, if pain persists go to ER, to rule out MI

Check for oral lesions that could interfere with absorption

Place tab between gums and cheek pocket until dissolved

Don't swallow tab, rotate sites

Remove old transdermal and wash area to prevent severe hypotension

Label tubes with large letters & keep away from kids

Wear gloves

Make sure to spray under tounge

Keep track of sprays

Beta-Andrenergic Blocker

Metoprolol (Toprol) 

Class: Class: Antianginal; antihyertensives

Indication:Tx stable angina pectoris and hypertension, prevents reinfarctions in MI patients; Tx stable CHF

Actions: Blocks beta-andrenergic receptors in the heart & kidneys, decreases the influence of the SNS of these tissues; decreases cardiac ouput and the release of renin

Route: PO, IV

Adverse Effects: Related to blockage of SNS; Dizziness, vertigo, HF, arrhythmias, gastric pain, diarrhea, vomiting, impotence, bronchospasms,dyspnea,decreased exercise tolerance

Contraindications: Bradycardia, heart block, cardiogenic shock, Asthma or COPD, P&L; Cautioned in diabetes, peripheral vascular disease (PVD), thyrotoxicosis

Interactions: Clonidine (hypertension & ADHD drug)

NC/PT:Titrate over 2 weeks; continuously monitor in IV therapy; Monitor BP, pulse, rhythm, and cardiac output regularly, supportive comfort measures temp control, small meals, monitor for CV effects, HF, bock, dizziness and confusion, hypoglycemia, and respiratory distress

Calcuim Channel Blockers

diltiazem (Cardizem)

Class:Antianginal, antihypertensive, calcium channel blocker

Indications: Tx of Prinzmetal angina, effort-associated angina, & Chronic stable angina; also used to Tx essential hypertension & paroxysmal Supraventricular tachycardia

Actions:Inhibits the movement of calcium ions across the membranes of the myocardial and arterial muscle cells, altering the action potential and blocking muscle cell contraction

Route:PO, IV

Adverse effects:Hyptension, Cardiac arrhythmias, GI uspet, skin reactions, Headache

Contraindications: Hypersensitivity; Heart block/Sick sinus syndrome; Renal/hepatic dysfunction; HF

Interations: Vary with each drug

NC/PT:Monitor Pulse, BP, HR & rhythm, ECG, RR & breath sounds; Monitor renal & hepatic labs; Monitor skin color & integrity; Monitor close while establishing dose, or titrating; Swallow ER/SR tabs (do not cut, crush, chew); avoid grapefruit juice’ report irregular heart beat or swelling.

Proper aministration, storage, effectiveness instructions for those who take this drug

Patients should determine what activities or situations tend to bring on the anginal attack and avoid them

Maintanance of regular checkups and lifestyle changes to decrease the risk CAD and improve antianginal therapy

Blood flow changes potential in fetus and nursing

More likely to experience arrhythmias, hypotension, and heart disease

Caution should be taken when considering mobility & balance

More likely to have renal/hepatic impairment which could interfere with metabolism and excretion of drug; start with lower doses 

Drugs are added and removed from regimen

Teach proper administration, storage, and timing of use

The patient asks the nurse to explain the type of angina he is experiencing: The pain is due to the imbalance of myocardial supply and demand. What type does he have

1. Unstable
2. Prinzmetal's
3. Stable
4. Ischemic

Metabolized in liver, excreted in urine

IV: 1-2min/3-5min
Sublingual tab: 1-3min/30-60min

Translingual spray: 2min/30-60min

Transmucosal tab: 1-2min/3-5min

Oral (SR tab): 20-45min/8-12h

Topical oint: 30-60min/4-8h

Transdermal: 30-60min/24hr







 

Absorbed in GI tract and metabolize in liver

PO: 15min/90min/15-19h

IV: Immediate/60-90min/15-19h

Antiplatelet Agents

Aspirin

Class: Antiplatele, analgesic, antipyretic, salicylate

Indications: Reduce risk of recurrent TIAs or strokes, reduce death or nonfatal MI, anti-inflammatory, analgesic, and antipyretic effects

Actions: Inhibit platelet adhesion & aggregation by blocking receptor sites on the platelet membrane

Route: PO

Adverse effects: Acute aspirin toxicity with hyperpnea (possibly leading to fever, coma, cardio collapse), anaphylactic reaction, bleeding, headaches, dizzeness, tinnitus, and weakness, GI distress

Contraindications: Allergy, bleeding disorders, recent surgery, closed head injuries, platelet levels should be monitored for thrombocytopenia, & P&L

Interactions: Combined with other blood clotting drugs

NC/PT: Small frequent meals for GI upset, safety measures that prevent bleeding, monitor platelet count, mark chart for patient recieving this drug

Anticoagulant Agents

heparin 

Indications:Prev/Tx of venous thrombosis & emboli; Dx & tx of disseminated intravascular coagulaltion; Prev clots in blood samples

Actions: Inhibits thrombus clot production by blocking prothrombin-> thrombin & fribrinogen -> fibrin

Route: IV, subcut

Adverse effects: Alopecia, bruising, chills & fever, osteoporosis, renal function suppression

Contraindications: Hemmorrahgic disorders, recent trama, spinal puncture, GI ulcers, TB, catheters, miscarriage

Interactions: ↑ bleeding when combined with anticoagulants, salicylates, penicillins, or cephalosporins; ↓ coagulation when combined with nitroglycerin

NC/PT: Assess for Allergies & disorders that ↑ bleeding tendencies, lactaion, renal/hepatic disease, HF, thyrotoxicosis, senility, diarrheas & fever, CBC, WBCT, APTT, Clotting studies, renal/hepatic function, blood occult, ECG, S/S of bleeding, safety from precautions, avoid IMs, have antidotes near by (protamine sulfate), follow up tests, Med Alert tag

Thrombolytic Agents

Urokinase (Activase)

Tx: Acute MI; Pulmonary emboli; ischemic stroke

Indications:  Lysis of pulmonary emboli or pulmonary emboli with unstable hemodynamics in adults

Actions: Activates plasminogen to plasmin, which in turn breaks fibrin threads in a clot to dissolve a formed clot

Route: IV

Adverse effects: Bleeding, cardiac arrhythmias, hypotension, angioneurotic edema, Hypersensitivity-rash, flushing, bronchospasm, and anaphylactic reaction

Contraindications: Any condition that could be worsened by dissolution of clots (sugery, internal bleeding, cerebrovascular accident (CVA) within the last 2 months, OB delivery); known clotting disorders, uncontrolled hypertension, liver disease, P&L (risk for bleeding, baby)

Interactions: Anticoagulants & Antiplatelets

NC/PT:  Monitor for therapeutic effectiveness: Measurable signs of clinical response may not occur for 6–8 h after therapy is started  Note: Anticoagulant therapy with heparin is reinstituted at end of urokinase therapy and when thrombin time has decreased to less than twice normal control value (usually within 3–4 h).Be aware that severe spontaneous bleeding, including fatality from cerebral hemorrhage, has occurred during urokinase treatment. Risk is estimated to be twice that associated with heparin therapy. See streptokinase for additional nursing implications.

Patient & Family Education

Report any of the following to physician immediately: evidence or suspicion of bleeding, fever, chills, itching, difficulty breathing, back or chest pain. Do not breast feed while taking this drug.

Conditions that predispose a person to the formation of clots & emboli (CAD); involves the formation of thrombi result in decreased blood flow or total occulsion of a blood vessel; Emboli break off and travel to smaller vessels;  S&S hypoxia, anoxia, or necrosis of area; Tx with antiplatelet, anticoagulant, & thrombolytic drugs

Disorder of excess bleeding; hemophilia, liver disease, bone marrow disorders; treated with drugs that promote coagulation and clotting factors;

Antihemophilic & hemostatic agents

What is the advantage of a low-molecular-weight-heparin medication?

1. Indicated for patients who are on an exercise regimen
2. Initiates angiogenesis
3. Blocks factors IXa & Iaa
4. Cause fewer systemic adverse effects

Antihemophilic Agents

Antihmophilic factor (Bicolate, others)

Indication: Tx of classic hemophilia to provide temporary replacement of clotting factors to correct or Prevent blooding episodes or to allow surgery

Action:Replace clotting factors that are either genetically missing or low in a particular type of hemophilia

Route: IV

Adverse effects:Allergic reaction, stinging at IV site, headache, rash, chills, nausea, hepatitis, AIDS (risks assoc. with blood products).

Contraindications: Allergy to mouse proteins, Factor IX when liver disease is present, lactation

Interactions: 

NC/PT: Monitor factor VIII regularly, pulse, reduce rate of infusion in significant tachycardia, fever, chills or tingling; Mark chart & wear medical alet tag, Monitor clotting studies & hepatic fuction test, for thrombosis; administer by IV only

Hemostatic Agents

Aminocaproic Acid

Indications: Prev/Tx excess bleeding in hyperfibrinolytic states; prevent reocurring subarachnoid hemorhage, manage megakaryocitic thrombocytopenia, decrease need for platelet administration, to abort and Tx hereditary angioneurotic edema

Actions: Inhibits plasminogen activtor substances and had antiplasmin activity that inhibits fibrinolysis and prevents the breakdown of clots

Routes: PO, IV

Adverse effects: Hallucinations, dizziness, tinnitus, headache, weakness, hypotension, nausea, cramps, diarrhea, fertility problems, malaise, elevated serum creatine phosphokinase (CPK normal values: 10 - 120 mcg/L) 

Contraindications: Acute DIC (dissemented intravascular coagulation); renal/hepatic dysfunction

Interactions: Estrogen, hormonal contraceptives

NC/PT: Patient on therapy may need up to 10 tablets first hr and constant dosing; Orient & support patient with CNS effects, Monitor for S/S of clotting, renal/heptic  function test, urinalysis and clotting tests

Excreted largely in urine

PO: Rapid/  2h / Unknown

IV: Immediate/ minutes / 2-3h

Processed as normal clotting factors would

IV: Immediate / Unknown / Unkown

Current belief: H. pylori infection cause chronic ulcers; Tx with combination of antibiotics and omeprazole (Prilosec)

Patients that have experienced: Strokes, salivary gland diorders, surgery of head neck, that may not be able to produced saliva

Patients with common duct problems, pancreatic disease, or cystic fibrosis may not be able to produce pancreatic enzymes

Famotidine is the only H2 antagonist approved for children

Lansoprazole approved proton pump inhibitor for peds

Antacids for children c/o upset stomach

CAUTION: Prevent electrolyte imbalances or nutritional interference

Caution: Overuse of any drug used to decrease GI secretions could lead to Electrolyte imbalances or interference or action of other medication absorbtion; See physician if discomfort continues

Antacids: Spaced 1-2h b/4 taking other medication/increased risk of colitis & GI infections/ Backup contraceptive use for misoprostol due to miscarriage, F&E in neonate

Frequently prescribed more than 1 GI reflux disease drug and are more likely to develop adverse effects (sedation, confusion, dizziness, urinary retention, and cardio). Safety measures for mobility & balance

Absorption of nutrients interference (↓ B12 absorption with H2 blockers and proton pump inhibitors leads to pernicious anemia)

Renal/hepatic impairment can interfere with metabolism & excretion)

Start out with lower dose

OTC drugs increase the chance of toxicity

Proton Pump inhibitors Omeprazole (prilosec) may be the best choice for older adults in treating GERD

"tidine"

Cimetidine (tagament)

famotidine (Pepcid)

ranitidine (Zantac)

H2 Antagonists

Cimetidine (tagament)

Indication: Short-term treatment of active duodenal ulcers and benign gastric ulcers. Maintenance therapy for duodenal ulcers after healing of active ulcer(s). Management of gastroesophageal reflux disease (GERD). Treatment of heartburn, acid indigestion, and sour stomach (OTC use). Management of gastric hypersecretory states (Zollin- ger-Ellison syndrome).

Antacid

Sodium Bicarbonate

Indication: Relief of upset stomach from hyperacidity; prophylaxis for GI bleeding & stress ulcers; adjunct to severe diarrhea; tx metabolic acidosis; tx of certain drug intoxications to minimize uric acid crystallization

Action: Neutralizes/reduces gastric acidity; increases pH; inhibits acitvity of pepsin

Route: PO, IV

Adverse effects: Gastric rupture, systemic alkalosis (headache, nausea, irritability, weakness, tetany, confusion), hypokalemia (shifts K+), gastric rebound

Contraindications: Allergy, electrolyte imbalances, GI obstruction, renal dysfunction, P&L

Interactions: Drugs that are absorbed in the acidic environment

NC/PT: Allergies, renal dysfuntion, electrolyte disturbances, bowel sounds for motility, hydration status, serum electrolytes/renal tests, administer 1-2h apart from other drug, S/S of acid-base imbalance, nutritional intake, monitor OTCs

 How do Proton Pump Inhibitors work?

Important P/T for drug

ranitidine (Zantac)

Crosses placenta/enters breast milk, and has a slow metabolism in the liver

Adverse affect are dizziness, headache, diarrhea. Avoid taking OTCs, space apart from your antacid if prescibed, follow up appointments for any underlying problems, 

 Proton Pump Inhibitors 

Omeprazole (prilosec)

Indications: Short term Tx of active duodenal ulcers, GERD, erosive esophagitis, and benign ulcers

Action: Inhibits specific secretory receptors to prevent final step of acid production, decreasing the level of acid in the stomach

Route: PO

Adverse Effects: CNS: dizziness, headache, asthenia, insomnia, GI Diarrhea, tongue atrophy, abd. pain, Upper respiratory tract symptoms, alopecia, pruritis, rash, backpain

Contraindications:Allergy P&A

Interactions: Warfarin

NC/PT: Changes in bowel elimination, administer b/f meals, do not open, chew, or crush caps, provide saftey for CNS affects, follow up if not better 4-8 wks, small meals may help GI upset

Prostoglandin

Misoprostol (Cytotec)

Indication: Prevent NSAID or aspirin induced ulcers in patients at risk for complications of ulcers, as an abortifacient with mifepristone

Action: Inhibits gastric secretion and increases bicarbonate and mucous productions, protecting the lining of the stomach; increases stimulatory effects in the uterus

Route: PO

Adverse Effects: GI: N&V, flatulence, abd. pain, GU: Excessing bleeding spotting, hypermenorrhea, dysmenorrheal, miscarriage

Contraindications: Pregnancy & lactation, renal imparment

NC/PT: Childbearing women should have a serum preganacy test 2 wks b/4 thx, use of barrier contraceptives, monitor renal/ hepatic function tests, provide both written and oral information about risk with pregnancy, evaluate nutrition, take with meals and at bedtime, 

Therapeutic action of sucralfate (carafate)

GI Protectant

Digestive enzymes

Pancrelipase (creon, pancrease)

Indications: Replacement Thx in patients with dificient exocrine pancreatic secretions

Actions: Replaces pancreatic enzymes to aid in digestions and absorption of fats, proteins, carbohydrates

Adverse Effects: Nausea, abd. cramps, diarrhea, hyperuricosuria

Route: PO

Contraindications: Allergy, Caution in HF, hypertension, renal failure (increased cardio load) P&L

NC/PT: Monitor mucous membranes, cardiopulmonary assessments, administer with meals and snacks so enzyme is available when needed, monitor electrolyte and pancreatic levels, assess nutritional status

GI Stimulant

metoclopramide (Reglan)

Increase GI secretions & motility

Indications: Relief of diabetic gastroparesis, short-tern reflux disorder, postop induced N&V, facilitates small bowel intubation, gastric emptying, barium transit

Actions: Stimulates movement of upper GI tract without stimulating gastric, pancreatic, or biliary secretions, sensitizes tissues to acetylcholine

Route: PO, IV, IM

AE: N&V, diarrhea, Intestinal spasms, cramping, declining BP, Parkinson-like syndrome

Contraindications: Allergy, GI obstruction, P&L 

Interaction: Digoxin, chycloporine, alcohol

NC/PT: Assess for allergy, abdomen, GI obstruction, bleeding perforation, Cardio BP-PR, administer 15 min b/4 meals and at bedtime, Monitor diabetic patients for glucose absorbtion alterations (insulin adjusments), avoid alcohol & CNS depressants

Antidiarrheal

Lopermide (Imodium)

Block stimulation of GI tract for relief of diarrhea

Ind: Relief of acute & chronic diarrhea assoc. with IBS, reduction of volume discharge from ileostomies

Actions: Inhibits peristalsis, slowing motility and movement of water & electrolytes

Route: PO

Adv: Constipation, Abd. distension, dry mouth, toxic megacolon

Contra: Allergy: Caution: P&L, GI obstruction, diarrhea from poisons

Interact: Depends on drug used

NC/PT: Administer & monitor after each loose stool

Travelers Diarrhea

Rifaximin 

acts locally in GI tract to destoy bacteria (E.coli)

If traveling prophilaxis of Bactrim & Septra

bismuth (Pepto) Tx

True/False

Pepto-Bismol can be involved in salicylate toxicity

True

Pepto-bismol caots the lining of the GI tract and soothes irritation stimulating local reflexes to cause excessive GI activity & diarrhea

Why should laxatives be taken on a short-term basis

1. To prevent a fluid deficit
2. To prevent cathartic dependence
3. To prevent relief of ABD distention
4. to obtain relief of intestinal cramping

Speed up or improve movement of intestinal contents for constipation

Increase tone of GI tract and stimulate motility

Decrease movement time to increase time for absorbtion of water and nutrients

When straining is undesirable (post-op, MI, OB)

Short-term relief of constipation

Dx procedures

Removal of ingested poisons

Adjunct thx to flush helminths

Chemical Stimulants P:Caster Oil

Bulk Stimulants P: Magnesium citrate

Lubricants: Mineral oil

Laxitives should not be used routinely, proper diet, fluids, and exercise should be tried first

Glycerin suppository is the best choice

children with encopresis can take senna or mineral oil

Loperamide for children >2

Monitor F&E 

Caution on dependency

Proper diet, fluids, and exercise

More likely to develop adverse effects when using GI drugs

Sedation, Confusion, Dizziness, F&E imbalances, & Cardio events

Renal/Hepatic dysfunction could interfere with metabolism & absorbtion

Monitored for toxic effects with OTCs

Psyllium is known to have the least advers effects for (drink plenty of water so fluid is not pulled from esophagus)

Proper diet, fluids, exercise, 

Chemical Stimulant Laxatives

Castor Oil ( Neoloid)

Ind: To evacuate bowel for Dx proceedures, remove ingested poisons, flush helminths

Action: Stimulates nerve plexus in intestinal wall, stimulation of reflexes to increase movement

Route: PO

AE: Diarrhea, Abd cramps, perianal irritation, dizziness, cathartic independence, F&E imbalances

Contra. Ind: Heart block, CAD, Should not be used in pregnancy

Inter: Must be separated by 30m of other meds, 

NC/PT: Blocks Vitamin A,D,K & E absorption,

Bulk Stimulant Laxatives

Magnesium Citrate 

Ind: Short-term relief of constipation, to prevent straining,  evacuate bowels for Dx, remove poisons, flush helminths

Action: Increases motility of GI tract by increasing fluid in contents, which enlarges bulk and stretches stimulators

Route: PO

AE: Diarrhea, Abd. cramps, bloating, perianal irritation, dizziness

Contra:Acute abd disorders (appendicitis,diverticulitis,ulcrative colitis), heart block, CAD, Caution P&L (labor induction), seizures

Inter: Space this and other meds by 30m

Lubricant Laxative

Mineral Oil

Ind: Short-term relief of constipation, to prevent straining, remove poisons, flush helminths

Action: Forms slippery coat on contents of intestinal tract, keeps water in bolus preventing impaction

Route: PO

AE: Diarrhea, abd cramps, perianal irritation, bloating, interference of Vitamins A,D,K & E

Contra: Acute abd disorders (appendicitis,diverticulitis,ulcrative colitis), heart block, CAD, Caution P&L (labor induction)

Assess for allergy, impaction or obstruction, abd pain & N&V (do not administer), distention, bowel sounds, pregnacy, base px, cardio stats, elimination patterns, nutritional intake, activity level, Serum electrolytes, 

Administer laxative as a temporary measure with a full glass of water, do not chew tabs, do not continue thx if diarrhea persists, bathroom facilities available

Encouage high fiber, fluid exercise, and caution about cathartic dependence

Charicterized abdominal distress, bouts of diarrhea or constipation, bloating, nausea, flatulence, headache, fatigue, dipression, and anxiety. Stress related

Tx: Lubiprostone