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CHAPTER 42: INTRODUCTION TO THE mitral or bicuspid valve- valve on the left side of the heart; CONDUCTIVITY

CARDIOVASCULAR SYSTEM composed of two leaflets or cusps - where the specialized cells of the heart can conduct an
impulse rapidly through the system so that the muscle cells
* systole of the heart are stimulated at approximately the same time…
Cardiovascular System - the contraction of ventricles
- responsible for delivering oxygen and nutrients to all of * absolute refractory period
the cells of the body and for removing waste products for
excretion * The heart’s series of one- way valves keeps the blood ***** SA node is the dominant influences most of the time,
- consists: 1. heart 2. pump3. interconnected series of tubes flowing on the correct direction, as follows: keeping the resting heart rate at 70 to 80 beats per minute
1. Deoxygenated blood: right atrium, though tricuspid valve
THE HEART to right ventricle, through pulmonary valve to the lungs * Sarcomere- the basic unit of the cardiac muscle
- hollow, muscular organ divided into 4 chambers: atriums ( 2. Oxygenated blood: through the pulmonary veins to - made up of two contractile proteins: actin (thin filament)
“porch” or entryway) and ventricles ( lower part) ventricle, through aortic valve to the aorta and myosin (thick filament) kept apart by the protein
- is the pump that keeps blood flowing through 60,000 miles troponin
of tubes, constituting the cardiovascular system CONDUCTION SYSTEM OF THE HEART
- consist of: * Degree of shortening- determined by the amount of Ca
*auricle- attached to each atrium; collects blood that is 1. SA node- located in top of the right atrium, acts as the present—the more Ca is present, the more bridges will be
pumped into the ventricles by arterial contraction pacemaker of the heart formed…
2. AV nodes- slows the impulse, allowing for the delay
** a partition called a septum separates the right half of the needed for ventricular filling, and sends it from the atria into ARRYTHMIA OR DYSRYHTHMIA
heart from the left. The right receives deoxygenated blood the ventricles by way of the bundle of His - a disruption in cardiac rate or rhythm
from everywhere in the body through the veins ( vessels that 3. Bundle of His- w/c enters the septum and divides into - interfere with the work of the heart and can disrupt cardiac
carry blood toward the heart) and directs that blood into the three bundle branches output, which affects every cell in the body
lungs… 4. Bundle branches- w/c conduct impulses through the - occurs when there is a shift in the pacemaker of the heart
ventricles from the SA node to some other sit, called ectopic focus
*** arteries- where aorta delivers blood into the systemic 5. Purkinje fibers- w/c delivers the impulse the ventricular
circulation cells FIBRILLATION
- vessels that carry blood away from the heart - very serious arrhythmias arise when the combination of
***Sinoatrial (SA) node ectopic foci and altered conduction set off an irregular,
CARDIAC CYCLE uncoordinated twitching of the atrial or ventricular muscle
- … each period of the ventricles followed by a period of AUTOMATICITY
systole= cardiac cycle… - where the cells can generate action potentials or electrical ELECTROCARDIOGRAPHY
impulses without being excited to do so by external stimuli -is a process of recording the patterns of electrical impulses
* myocardium as they move through the heart
- fibers of cardiac muscle 5 phases: - an important diagnostic tool in the care of the cardiac
- form two intertwining networks called atrial and 1. Phase 0- points of stimulation; where: sodium gates open patients
ventricular syncytia along the cell membrane, and sodium rushes into the cell,
resulting in a positive state—an electrical potential called ELECTROCARDIOGRAPHY MACHINE
* Starling’s law of the heart depolarization - detects the patterns of electrical impulse generation and
-occurs when muscle fibers of the heart are stretched by the 2. Phase 1- when Na ions concentrations are equal inside conduction though the heart and translates that information
increase volume of blood that has returned spring back to and outside of the cell to a recorded pattern
normal size; is similar to stretching a rubber band… 3. Phase 2 (plateau stage)- cell membrane becomes less
permeable to Na Ca slowly enters the cell K slowly ELECTROCARDIOGRAM
* Diastole leaves the cell -a measure of electrical activity; provides no information
- the period of cardiac muscle relaxation where the heart 4. Phase 3- rapid repolarization  K rapidly moves out of about the mechanical activity of the heart
from the systemic and pulmonic veins, w/c flow into the the cell
right and left… 5. Phase 4- cell comes to rest as the sodium- potassium The normal ECG pattern is made up of main waves:
pump returns the membrane spontaneous repolarization 1. P wave- formed as impulses originating in the SA node or
* tricuspid- valve on the right side of the heart; composed begins again pacemaker pass through the atrial tissue
of 3 leaflets or cusps 2. P wave- precedes the contraction of the atria
3. Ta wave- appear around the QRS complex
Critical points of the ECG are as follows : - also referred as arterial system - occur if the blood pressure falls, either from the loss of
1. P-R interval: reflects the delay of conduction at the AV - where the vessels can either constrict or dilate, increasing blood flowing from high- pressure to low pressure areas
node or decreasing resistance, based on the needs of the body - if severe, it can progress to shock and even death as cells
2. Q-T interval: reflects the critical timing of repolarization are cut off from their oxygen supply
of the ventricles * capillary system
3. S-T segment: reflects the important information about the - where blood from tiny arterioles flows * Hypertension
repolarization of the ventricles - connects the arterial and venous system - excessive high blood pressure
- can damage the fragile lining of blood vessel
TYPES OF ARRHYTHMIAS * capillary fluid shift - cause disruption of blood flow to the tissues
1. Sinus arrhythmias - shifting of fluid in the capillaries - caused by neurostimulation of the blood vessels that cause
- has a slower- than- to normal heart rate (usually less than - carefully regulated between hydrostatic (fluid pressure) them to constrict and to raise pressure
60 beats/ min) w/ Normal- appearing ECG pattern forces in the arterial end of the capillary and oncotic
2. Supraventricular Arrhythmias pressure ( the pulling pressure of the large, vascular * Vasomotor Tone
- arrhythmias that originate above the ventricles but not in proteins) - work to dilate the vessels if more blood flow is needed in
the SA node an area
- feature an abnormally shaped P wave *Capacitance system
- includes the following: - also referred as venous system *Cardiovascular center
a. Premature atrial contractions (PAC’s)- reflect an ectopic - where the veins has the capacity to hold large quantities of - the coordination of these impulses through the medulla
focus in the atria that is generating an impulse out of the fluid
normal rhythm RENIN – ANGIOTENSIN SYSTEM
b. Paroxysmal atrial tachycardia (PAT)- runs of rapid heart * sinuses of Valsalva -determinant of Blood pressure
originating in the atria - where the myocardium receives its blood through 2 main - activated when the blood flow to the kidneys is decreased
c. Atrial flutter- characterized b sawtooth- shaped P waves coronary arteries that branch off the base of the aorta -…cells in the kidney release an enzyme called rennin
reflecting a single ectopic focus that is generating a regular, - Angiotensin I travels to lungs  Angiotensin- converting
fast atrial depolarization *coronary arteries enzyme (ACE)  reacts  Angiotensin II =
d. Atrial fibrillation- w/ irregular P waves representing many - these arteries encircle the heart in pattern resembling a Vasoconstriction
ectopic foci firing in an uncoordinated manner through the crown (read: p. 635)
atria
3. Ventricular Arrhythmias *pulse pressure CONGESTIVE HEART FAILURE
- impulses that originate below the AV node originate from - the pressure that fills the coronary arteries - if the heart fails to do its job of effectively pumping
ectopic foci that do not use the normal conduction pathways - it is systolic minus diastolic blood pressure readings through the system, blood backs up and system becomes
congested
ATRIOVENTRICULAR BLOCK * end- artery circulation - results: hydrostatic pressure on the venous end of the
- also called heart block - a pattern of circulation capillaries
- reflects a slowing or lack of conduction at the AV node
-occur because of structural damage, hypoxia, or injury to The main forces hat determine the heart’s use of oxygen or
the heart muscle oxygen consumption are as follows:
- First degree of heart block= P-R interval beyond the 1. Heart rate: the more the heart has to pump, the more
normal 0.16 to 0.20 seconds oxygen it will require to do that
2. Preload ( amount of blood that is brought back to the
CARDIOVASCULAR SYSTEM heart to be pumped around): the more blood that is returned
to the heart, the harder it will have to work to pump the
CIRCULATION blood around. The volume of blood that is determinant of
- follows two courses: preload
1. Heart lung or pulmonary circulation: the right side of the 3. Afterload ( resistance against which the heart has to beat):
heart sends blood to the lungs, where carbon dioxide and The higher the resistance in the system, the harder the heart
some waste products are removed from the blood and will have to contract to force open the valves and pump the
oxygen is picked up by the red blood cells blood along. The blood pressure is measure of afterload
2. Systemic circulation: the left side of the heart sends
oxygenated blood out to all of the cells in the body SYTEMIC ARTERIAL PRESSURE

* resistance system * Hypotension


CHAPTER 43: DRUGS AFFECTING BLOOD - block the effects of the SNS - well absorbed, widely distributed
PRESSURE - useful in blocking many of the - metabolized in liver, excreted in urine
compensatory effects of the SNS and feces
- altering the body’s regulatory mechanisms - cross the placenta and associated with
- alter the normal reflexes that control BP serious fetal abnormalities
β-blockers block vasoconstriction; ↓ HR; ↓
- does not cure the disease but is aimed at
muscle cardiac contraction; ↑
maintaining the BP within normal limits to Contraindications
blood flow to kidneys; used in
prevent the damage that hypertension can - allergy
monotherapy in Step 2
cause - impaired renal function
α- and β- blocking of all receptors in SNS;
blockers patients complain of fatigue, - pregnancy and lactation
Stepped-Care Approach to Treating
loss of libido, inability to sleep,
Hypertension Caution
GI and GU disturbances
- by the Seventh Joint National Committee - CHF
α-adrenergic inhibit postsynaptic α1-
on Prevention, Detection, Evaluation, and - salt/volume depletion
blockers adrenergic receptors, ↓
Treatment of Hypertension, from the
sympathetic tone in the
National Institute of Health Adverse Effects
vasculature and causing
vasodilation; diagnose and - effects of vasodilation and alterations in
Step 1: Lifestyle Modifications blood flow
manage episodes of
o weight reduction o reflex tachycardia, chest pain,
pheochromocytoma
o reduction of sodium intake angina, CHF, cardiac arrhythmias
α1-blockers block postsynaptic α1-receptor
o moderation of alcohol intake o GI irritation, ulcers, constipation,
sites, ↓ vasculature and
o smoking cessation liver injury
causing vasodilation; do not
o increased physical activity block presynaptic α2-receptor o renal insufficiency, renal failure,
sites proteinuria
Step 2: Inadequate Response α2-agonists stimulate α2-receptors in the o rash, alopecia, dermatitis,
o continue lifestyle modifications CNS and inhibit the CV centers, photosensitivity
o initial drug selection ↓BP; many adverse CNS, GI - unrelenting cough
1. diuretic or β-blocker effects, cardiac dysrhythmias - associated with fetal pancytopenia and
2. ACE inhibitor, calcium channel MI
blocker, α-blocker, α- and β- Angiotensin-Converting Enzyme (ACE)
blocker Drug-Drug Interactions
Inhibitors
- allopurinol = risk of hypersensitivity
Step 3: Inadequate Response - block the conversion of angiotensin I to reactions ↑
o increase drug dose, or angiotension II in the lungs
o substitute another drug, or - as monotherapy or combined with Food-Food Interactions
o add a second drug from another diuretics - food = absorption of oral ACE inhibitors ↓
class
Prototype: captopril (Capoten) Nursing Considerations
Step 4: Inadequate Response - for hypertension, congestive heart failure - encourage patient to implement lifestyle
o add a second or third agent or (CHF), diabetic neuropathy, left changes
diuretic if not already prescribed ventricular dysfunction after MI - administer on empty stomach, 1 or 2
- associated with fatal pancytopenia, hours before meals
Diuretics cough, GI distress - monitor fluid volume
- ↑ the excretion of sodium and water from
the kidney Therapeutic Actions and Indications Angiotensin II Receptor Blockers (ARBs)
- first agents tried in mild hypertension - ↓ BP and aldosterone release - selectively bind the angiotensin II
- ↑ urination and disturb electrolyte and - indicated for treatment of hypertension, receptors in blood vessels to prevent
acid-base balances alone or with other drugs vasoconstriction
- prevents the release of aldosterone in the
Sympathetic Nervous System Blockers Pharmacokinetics adrenal cortex
Calcium Channel Blockers - treatment of hypertensive crisis and
Prototype: losartan (Cozaar) - prevent the movement of calcium into maintain controlled hypertension during
- used alone or as part of combination the cardiac and smooth muscle cells surgery
therapy - when the cells are stimulated - toxic levels cause cyanide toxicity
- treatment of diabetic neuropathy with an - leading to loss of smooth muscle tone,
elevated serum creatinine an d vasodilation, ↓ peripheral resistance Therapeutic Actions and Indications
proteinuria - ↓ BP - act directly on vascular smooth muscle to
- very effective for treatment of angina cause muscle relaxation, leading to
Therapeutic Actions and Indications vasodialtion and drop in BP
- selectively bind with angiotensin II Prototype: diltiazem (Cardizem, Tiamate)
receptor sites in vascular smooth muscle - sustained-release preparation Pharmacokinetics
and in the adrenal gland to block - treatment of hypertension - rapidly absorbed and widely distributed
vasoconstriction and aldosterone release - metabolized in the liver and excreted in
- treatment of hypertension and for CHF in Therapeutic Actions and Indications urine
patients who are intolerant to ACE - inhibit the movement of calcium ions - cross the placenta and enter breast milk
inhibitors across the membranes of myocardial and
arterial muscle cells Contraindications
Pharmacokinetics - allergy
- well absorbed, metabolized in liver Pharmacokinetics - pregnancy and lactation
- excreted in urine and feces - well absorbed, metabolized in liver, - cerebral insufficiency
- crosses the placenta, associated with excreted in urine
serious fetal abnormalities and death - cross the placenta, enters breast milk Cautions
- peripheral vascular disease, CAD, CHF,
Contraindications Contraindicaitons tachycardia
- allergy - allergy
- pregnancy and lactation - heart block or sick sinus syndrome Adverse Effects
- renal or hepatic dysfunction - related to changes in BP
Cautions - pregnancy or lactation - cyanide toxicity may occur with
- hepatic or renal dysfunction nitroprusside
- hypovolemia Adverse Effects o dyspnea o imperceptible
- CNS effects o headache pulse
Adverse Effects o vomiting o absent reflexes
- headache, dizziness, syncope, weakness - GI effects o dizziness o dilated pupils
- hypotension, GI complaints - CV effects o ataxia o pink color
- symptoms of upper respiratory tract - skin flushing, rash distant heart
o loss of o
infections and cough consciousne sounds
Drug-Drun Interactions
- rash, dry skin, alopecia
- cyclosporine = ↑ serum levels and
ss o shallow breathing
toxicity of cyclosporine
Drug-Drug Interactions Nursing Considerations
- phenobarbital = risk of ↓ serum levels - monitor BP and fluid volume
Vasodilators
and loss of effectiveness ↑ - produce relaxation of the vascular
Other Hypertensive Agents
smooth muscle, ↓ peripheral resistance
Nursing Considerations and reducing BP
- encourage patient to implement lifestyle only drug: mecamylamine (Inversine)
- do not block reflex tachycardia
changes - ganglionic blocker that occupies
- reserved for use in severe hypertension
- administer without regard to meals; give cholinergic receptor sites of autonomic
and hypertensive emergencies
with food neurons, blocking the effects of
- suggest use of barrier contraceptives acetylcholine at both sympathetic and
Prototype: nitroprusside (Nitropress)
parasympathetic ganglia
- monitor fluid volume - used intravenously
- can cause
o severe hypotension, CHF
o CNS symptoms of dizziness, syncope, o hypertension, bradycardia calcium flow into the myocardial cells and
weakness, vision changes o dizziness, vision changes, vertigo,
parasympathetic blocking symptoms
causing increased contraction, positive
o headache
of dry mouth, glossitis, nausea, o problems with urination inotropic effect
vomiting, constipation, urinary
retention Drug-Drug Interactions 4. CARDIOTONIC DRUGS
o impotence - risk of ↑ effects and toxicity of cardiac
glycosides, beta-blockers, alpha-
- drugs that affect the intracellular calcium
adrenergic agents, corticosteroids if levels in the heart muscle, leading to increased
taken with midodrine contractility
ANTIHYPOTENSIVE AGENTS - increase in contraction strength leads to
Nursing Considerations
- severe hypotension leads to shock - monitor BP
increased cardiac output, which causes
- sympathomimetic drug: first choice drug for - do not administer to bedridden patients increased renal blood flow decreases rennin
treating shock - monitor HR regularly release
- monitor patients with visual problems -increases urine output
Sympathetic Adrenergic Agonists - encourage patients to void before taking -decreased blood flow
- effects of a sympathetic stress response: drug
↑ BP
- relieve CHF
o CHAPTER 44: CARDIOTONIC - has two types:
o ↑ blood volume
o ↑ strength of cardiac muscle AGENTS
contraction A. CARDIC GYCOSIDES
Congestive heart failure (CHF) - used for hundred of years
only drug: midodrine (ProAmatine)
- treat orthostatic hypotension
-condition where the heart fails to effectively - derived form foxglove or digitalis plant
pump blood around the body Drugs:
Therapeutic Actions and Indications - called “dropsy’ or compensation 1. Digoxin (Lanoxin, Lanoxicaps)
- activates alpha-receptors in arteries and
veins to ↑ in vascular tone and BP -treatment of acute congestive heart failure,
- indicated for the symptomatic treatment atrial arrhythmias
of orthostatic hypotension TREATMENTS OF CHF:
Pharmacokinetics
- rapidly absorbed in GI tract
1. VASODILATORS
- metabolized in liver and excreted in urine - used to treat CHF because they can decrease * THERAPEUTIC ACTIONS
the workload of the overworked cardiac 1.increase intracellular calcium and allow
Contraindications muscle more calcium to enter myocardial cells during
- supine hypertension, CAD,
depolarization, causing following effects:
pheochromocytoma
- acute renal disease
2. DIURETICS a. Increased force of myocardial contraction
- urinary retention - use to decrease blood volume, which b. Increased cardiac output and renal perfusion
decreases venous return and blood pressure c. Slowed heart rate
Cautions - end result: decrease in afterload and preload
- pregnancy and lactation
d. decreased conduction velocity through the
- visual problems and a decrease in the heart’s workload artrioventricular node
- renal or hepatic impairment
3. BETA- ADRENERGIC AGONISTS **PHARMACOKINETICS
Adverse Effects
- stimulate the beta receptors in the 1. absorbed widely
- related to stimulation of alpha-receptors
o piloerection, chills, rash sympathetic nervous system, increasing 2. excreted unchanged in urine
3. caution w/ presence of renal impairements 4. increased cellular calcium causes
4. not given during pregnancy IMPLEMENTATION contraction and prolongs effects of
5. enters breast milk 1. Consult with the prescriber about the end sympathetic stimulation
for a loading dose when beginning therapy 5. indicated for shortterm CHF that has not
*** CONTRAINDICATION 2. Monitor apical pulse for 1 full minute responded to digoxin or diuretics
1. presence of allergy before administration of drugs
2. tachycardia or fibrillation 3. Monitor pulse for any change in quality or **PHARMACOKINETICS
3. heart block or sick sinus syndrome rhythm 1. widely distributed after injection
4. idiopathic hypertrophic subaortic stenosis 4. check for dosage and preparation carefully 2. metabolized in the liver
(IHSS) 5. Check pediatric dosage with extreme extra 3. excreted in the urine
5. acute MI care
6. renal insufficiency 6. follow dilution instructions ***CONTRAINDICATIONS
7. electrolyte abnormalities 7.administer IV doses very slowly at least 5 1. has allergy
minutes 2. w/ severe aortic or pulmonic valvular
****CAUTION 8. Avoid IM administration disease
1. pregnant or lactating women 9. Arrange the patient to be weighed 3. fluid volume deficit
2. **pediatric and geriatric patients 10. Avoid administering oral drug with food or
antacids
*****ADVERSE EFFECTS 11. Monitor patient digoxin level ( 0.5 to 3 ****CAUTIONS
1. headache, weakness, drowsiness and vision ng/mL) 1. Elderly
changes 2. pregnant or lactating women
2. GI upset and anorexia B. PHOSPHODIESTERASE INHIBITORS
3. risk of arrhythmia development - belong to a second class of drugs that act as ***** ADVERSE EFFECTS
cardiotonic (intropic) agents 1. ventricular arrhythmias, hypotension and
*****DRUG-DRUG INTERACTION Drugs: chest pain
1. taken with veramil, aminodarone, quinidine, 1. Inamripone (Inocor) 2. GI effects: nausea, vomiting, anorexia,
quinine, erythromycin, tetracycline or - treatment of adults with congestive heart abdominal pain
cyclosporine = increased therapeutic effects failure not responsive to digoxin, diuretics or 3. Thrombocytopenia
vasodilators 4. hypersensitivity reactions: vasculitis,
NURSING CONSIDERATION 2. Milrinone (Pimacor) pericarditis, pleurititis, and ascites
- shorterm management of CHF in adults
DIAGNOSIS receiving digoxin and diuretics *******DRUG-DRUG INTERACTION
1. Risk for deficient fluid volume related to 1. avoid Fluosemide ( Diuretics)
diuresis *THERAPEUTIC ACTIONS
2. Ineffective Tissue perfusion related in 1. block the enzyme phosphodiesterase NURSING CONSIDERATIONS
cardiac output 2. leads to an increase in myocardial cell
3. Impaired Gas exchanged related to changes cyclic adenosine monophosphate (cAMP) DIAGNOSIS
in Cadiac Output 3. increases calcium levels in the cells 1. decreased cardiac output related to
4. Deficient Knowledge regarding drug arrhythmias or hypotension
therapy
2. risk for injury related to CNS or
Cardiovascular effects
ANTIARRHYTHMIC DRUGS
3. Innefective tissue perfusion related to
hypotension or arrythmias - affect the action potential of the cardiac
4. Deficient knowledge regarding drug cells, altering their automaticity,
therapy conductivity, or both
- proarrhythmic: can also produce new
arrhythmias
IMPLEMENTATION - used in emergency situations when the
1. Protect drug form light hemodynamics arising from the
2. monitor input and output patient’s arrhythmia are severe and
3. monitor platelet count fatal
- may block reflex arrhythmias and help
4. monitor injection sites
keep the CV system in balance, or they
may precipitate new, deadly
arrhythmias

Class I Antiarrhythmics

- block the sodium channels in the cell


membrane during an action potential
- local anesthetics or membrane-
CHAPTER 45 stabilizing agents
ANTIARRHYTHMIC AGENTS - preferable in situations such as
tachycardia
CORONARY ARTERY DISEASE (CAD)
Class IA Drugs
- progressive growth of atheromatous - depress Phase 0 of the action potential
plaques, or atheromas in the coronary and prolong the duration of the action
arteries potential
→ plaques begin as fatty streaks in
the endothelium
o disopyramide (Norpace)
→ they injure the endothelial lining o moricizine (Ethmozine)
→ development of foam cells (by o procainamide (Pronestyl)
inflammatory process) o quinidine (Quinaglute)
→ platelets, fibrin, other fats, and
remnants collect on the injured
Class IB Drugs
vessel lining
- depress Phase 0 somewhat and actually
→ cause atheroma to grow
shorten the duration of the action
→ blood vessel narrows and limits
potential
blood flow
- injury to the vessel also causes o lidocaine (Xylocaine)
scarring and thickening of cell wall o mexiletine (Mexitil)

 the softer, more lipid atheromas appear Class IC Drugs


to be more likely to rupture than stable, - markedly depress Phase 0, with a
harder cores resultant extreme slowing of conduction
o flecainide (Tambocor) - cimetidine = ↑ serum levels and - absorbed from GI tract, hepatic
toxicity metabolism, excreted in urine
o propafenone (Rythmol)
- oral anticoagulants = ↑ risk for - used only when the benefit to the
bleeding mother outweighs the risk to the fetus
Therapeutic Actions and Indications
- binding to Na channels, depressing Drug-Food Interactions Contraindications
Phase 0 of action potential, changing - foods that alkalize urine (citrus juices,
the duration of action potential - sinus bradycardia (rate less than 45
vegetables, antacids, milk products) = beats/min) and AV block
- have a local anesthetic effect ↑ quinidine levels and toxicity
- treatment of potentially life-threatening - cardiogenic shock, CHF, asthma,
- grapefruit juice = ↑ serum levels and respiratory depression
ventricular arrhythmias toxic effects - pregnancy and lactation
Pharmacokinetics Nursing Considerations
- widely distributed after injection of after Cautions
- monitor cardiac rhythm - diabetes and thyroid dysfunction
rapid absorption through the GI tract - maintain life support equipment on
- undergo hepatic metabolism - renal and hepatic dysfunction
standby
- excreted in urine - give parenteral forms only if the oral
- cross the placenta and enter breast Adverse Effects
form is not feasible - related to the effects of blocking beta
milk
- titrate the dose to the smallest amount receptors in the SNS
Contraindicaitons needed o CNS effects
- allergy o CV effects
- bradycardia or heart block Class II Antiarrhythmics o respiratory effects
- CHF, hypotension, shock o GI effects
- beta-adrenergic blockers that block
- electrolyte disturbances
beta receptors, causing a depression of
- loss of libido, ↓ exercise tolerance,
alterations in blood glucose levels
Cautions Phase 4 of the action potential
- renal or hepatic dysfunction - slow the recovery of cells, leading to
Drug-Drug Interactions
- pregnancy slowing of conduction and ↓
- verapamil = ↑ risk of adverse effects
automaticity
- insulin = ↑ hypoglycemia
Adverse Effects
- associated with their membrane- Nursing Considerations (same as Class I
stabilizing effects and effects on action Prototype: propanolol (Inderal)
Antiarrhythmics)
potentials - used as an antihypertensive,
o CNS effects antianginal, antimigraine headache
Class III Antiarrhythmics
o GI effects drug and as an antiarrhythmic to treat
o CV effects supraventricular tachycardias caused
by digoxin or catecholamines - block K channels, prolonging Phase 3 of
- respiratory depression and respiratory
the action potential, which prolongs
arrest
Therapeutic Actions and Indications repolarization and slows the rate and
- rash, hypersensitivity reactions, loss of
- competitively block beta-receptor sites conduction of the heart
hair, bone marrow depression
in the heart and kidneys
- stabilize excitable cardiac tissue and ↓ Prototype: sotalol (Betapace, Betapace AF)
Drug-Drug Interactions
- indicated for the treatment of
- digoxin, beta-blockers = ↑ risk for BP
documented life-threatening
arrhythmias - indicated for the treatment of
arrhythmias and maintenance of normal
- digoxin = ↑ digoxin levels and digoxin supraventricular tachycardias or PVCs
sinus rhythm
toxicity - proarrhythmic
Pharmacokinetics
Therapeutic Actions and Indications - treat paroxysmal supraventricular - atracurium, gallamine, metocurine,
- block K channels and slow the outward tachycardia pancuronium, rocuronium,
movement of K during Phase 3 of the tubocurarine, vecuronium = ↑
action potential Therapeutic Actions and Indications respiratory depression
- indicated for - block the movement of Ca ions across - calcium products or rifampin = ↓
o life-threatening ventricular the cell membrane, depressing the effects
arrhythmias generation of action potentials, - given IV within 48 hours if IV beta-
o conversion of recent-onset atrial delaying Phases 1 and 2 or adrenergic drugs = risk of severe
fibrillation or atrial flutter to normal repolarization, and slowing conduction cardiac effects
sinus rhythm through the AV node. - diltiazem + cyclosporine = ↑ serum
o maintenance of sinus rhythm after - treatment of supraventricular levels and toxicity
conversion of atrial arrhythmias tachycardia and to control the
ventricular response to rapid atrial rates Nursing Considerations (same as Class I
Pharmacokinetics Antiarrhythmics)
- well absorbed and widely distributed Pharmacokinetics
- metabolized in the liver - well absorbed Other Drugs Used to Treat Arrhythmias
- excreted in the urine - metabolized in liver and excreted in the
- used only when the benefit to the urine adenosine (Adenocard)
mother outweighs the risk to the fetus - used only when the benefit to the - convert supraventricular tachycardia to
mother outweighs the risk to the fetus sinus rhythm
Cautions - drug of choice for terminating
- shock, hypotension, respiratory Contrindications supraventricular tachycardia
depression, prolonged QTc interval - allergy o very short duration of action (15
- renal or hepatic disease - sick sinus syndrome or heart block sec), picked up by circulating RBCs,
- lactation and cleared through the lvier
Adverse Effects - CHF or hypotension o associated with very few adverse
- related to the changes they cause in effects
action potentials Caution
o nausea, vomiting, GI distress - idiopathic hypertrophic subaortic digoxin (Lanoxin, Lanoxicaps)
o weakness and dizziness stenosis (IHSS) - slows Ca from leaving cell, prolonging
o hypotension, CHF, arrhythmias - impaired renal or liver function the action potential and slowing
- fever toxicity, ocular abnormalities, conduction and HR
serious cardiac arrhythmias - treatment for atrial arrhythmias
- positively inotropic, leading to ↑ cardiac
Drug-Drug Interactions Adverse Effects
output
- digoxin or quinidne = serious toxic - related to their vasodilation of blood
effects cells throughout the body
Nursing Considerations (same as Class I
o CNS effects
Antiarrhythmics)
Class IV Antiarrhythmias o GI effects
- hypotension, CHF, shock, arrhythmias,
- block Ca channels in the cell edema
membrane, leading to depression of
depolarization and a prolongation of Drug-Drug Interactions
Phases 1 and 2 of repolarization, - beta-blockers = ↑ risk of cardiac
slowing automaticity and conduction depression
- digoxin = additive AV slowing
Prototype: diltiazem (Cardizem) - dogixin, carbamazepine, prazosin,
- administered IV quinidine = ↑ serum levels and toxicity
3. w/ head trauma or cerebral hemorrhage - decrease the cardiac workload
4. during pregnancy and lactation
CHAPTER 46: ANTIANGINAL AGENTS Caution
1. patients with hepatic or renal disease Prototype: metoprolol (Toprol, Toprol XL)
ANTIANGINAL DRUGS 2. w/ hypotension, hypovolemia, and conditions
that limit cardiac output - treatment of stable angina pectoris and
- are used to help restore the supply- and- demand hypertension; prevention of reinfarction in MI
ratio in oxygen delivery to the myocardium when Adverse Effects patients, and treatment of stable, symptomatic CHF
rest is not enough 1. CNS effects: headache, dizziness, weakness
- these drugs can work to improve blood delivery 2. GI effects: nausea, vomiting, incontinence Therapeutic Actions and Indications
to the heart muscle in 2 ways: 3. cardiovascular problems: hypotension, reflex 1. completely block- adrenergic receptors in the
1. by dilating blood vessels ( e.i. increasing the tachycardia, syncope, angina heart and juxtaglomerular apparatus, decreasing
supply of oxygen) 4. skin related effects: flushing, pallor, increased the influence of the sympathetic nervous system on
2. by decreasing the work of the heart (i.e. perspiration these tissues and thereby decreasing the
decreasing the demand of oxygen) 5. dermatitis and local hypersensitivity reactions excitability of the heart, decreasing cardiac output,
decreasing cardiac oxygen compensation and
I. Nitrates Dug- drug interaction lowering blood pressure
- are drugs that act directly on smooth muscle to
• ergot derivatives= risk of hypertension
cause relaxation and to depress muscle tone Pharmacokinetics
and decreased anti- anginal effects
- decreases: preload, afterload, myocardial 1. absorbed from the GI tract and undergo hepatic
contractility , oxygen demand • heparin = decreased effects
metabolic
Nursing Considerations: 2. found to increase bioavailability of propranolol,
Prototype: Nitrogylcerin (Nitro-Bid, Nitrostat) but this effect has not been found with other beta-
- treatment of acute angina attack; prevention of 1. Give SQ preparations in the tongue or in buccal
pouch, and encourage the patient not to swallow adrenergic blocking agents
anginal attacks 3. excreted in the urine
2. ask the patient if the tablet “ fizzles” or burns
3. Give sustained- release forms with water and 4. has teratogenic effects
Therapeutic Actions and Indications
- direct relaxation of smooth muscle with a caution the patient not patient not to chew or crush
them Contraindications:
resultant decrease in venous return and decrease in 1. w/ bradycardia, heart block, cardiogenic shock,
arterial pressure, effects that reduce cardiac 4. Rotate the sites of topical forms
5. Make sure that transligual spray is used to under asthma, or COPD
workload and decrease myocardial oxygen 2. pregnancy and lactation
consumption the tongue and not inhaled
6. Break an amyl nitrate capsule and wave it under
the nose of the angina patient Caution:
Pharmacokinetics 1. with diabetes, peripheral vascular disease or
1. rapidly absorbed 7. Taper the dosage gradually
thyrotoxicosis
2. metabolized in liver
3. excreted in urine II. Beta- Blockers
- used to block the stimulatory effects of the Adverse Effects
4. cross placenta 1. CNS effects: dizziness, fatigue, emotional
5. enter breast milk sympathetic nervous system
- block beta- adrenergic receptors and depression and sleep disturbances
vasoconstriction 2. GI problems: gastric pain, nausea, vomiting ,
Contraindications: colitis and diarrhea
1. presence of allergy - prevent the increase in heart rate and increased
intensity of myocardial contractility that occur with 3. Cardiovascular effects: congestive heart failure,
2. w/ severe anemia reduced cardiac output, and arrhythmias
sympathetic stimulation such as exertion or stress
4. Respiratory symptoms: bronchospasm, dyspnea, 2. GI effects: nausea and hepatic injury
and cough 3. Cardiovascular effects: hypotension,
bradycardia, peripheral edema, and heart block
Drug- Drug interaction 4. Skin effects: flushing and rash
1. beta blockers= paradoxical hypertension
2. w/ clonidine= withdrawal Drug-Drug interactions
1. toxicity of cyclosporines if taken w/ diltiazem
NURSING CONSIDERATIONS ( same with beta 2. increased risk of heart block and digoxin toxicity
blockers : Chapter 31) if combined with verapamil

III. CALCIUM CHANNEL BLOCKERS NURSING CONSIDERATIONS


-prevent the movement of calcium into the cardiac 1.monitor patient’s blood pressure, cardiac rhythm,
and smooth muscle cells when the cells are cardiac output while the drug is titrated or dosage
stimulated, interfering with their ability to contract is being changed
2. Monitor blood pressure very carefully if the
Prototype: diltiazem ( Cardizem, Cardizem SR) patient is also taking nitrates
3. Periodically monitor blood pressure and cardiac
- treament of prinzmetal’s angina, effort- rhythm while the patient is using these drugs
associated angina, chronic stable angina; used to
treat essential hypertension, paroxysmal
supraventricular tachycardia

Therapeutic Actions and Indications


• inhibit the movement of calcium ions across
the membranes of myocardial and arterial
muscle cells, altering the action potential and
blocking muscle cell contraction

Pharmacokinetics
1. well absorbed
2. metabolized in the live
3. excreted in urine
4. cross placenta and enter milk
5. fetal toxicity reported

Contraindications
1. presence of allergy
2. with heart block or sick sinus syndrome
3. with renal or hepatic dysfunction
4. during pregnancy and lactation

Adverse Effects
1. CNS effects: dizziness, light- headedness,
headache, fatigue
→ liver must use cholesterol to make more bile
acids Therapeutic Actions
→ ↓ serum levels of cholesterol and LDLs → block the formation of cellular cholesterol
→ ↓ serum cholesterol and LDLs, slight ↑ or no
Indications change in HDLs
CHAPTER 47 - reduce serum cholesterol in patients with
LIPID-LOWERING AGENTS primary hypercholesterolemia as an adjunct Indications
to diet and exercise - adjuncts with diet and exercise for the
CORONARY ARTERY DISEASE (CAD) - cholestyramine: treat pruritus associated with treatment of ↑ cholesterol and LDL levels
partial biliary obstruction - slow the progression of CAD
- progressive growth of atheromatous - prevent first MI
plaques, or atheromas in the coronary Pharmacokinetics
arteries
→ plaques begin as fatty streaks in the
- form an insoluble complex Pharmacokinetics
- excreted in feces - absorbed from GI tract
endothelium
→ they injure the endothelial lining - not absorbed systematically - first-pass metabolism in liver
→ development of foam cells (by - excreted through feces and urine
inflammatory process) Contraindications - pregnancy category X
→ platelets, fibrin, other fats, and remnants - allergy
collect on the injured vessel lining - complete biliary obstruction Contraindications
→ cause atheroma to grow - abnormal intestinal function - allergy
→ blood vessel narrows and limits blood - pregnancy or lactation - active liver disease or history of alcoholic liver
flow disease
- injury to the vessel also causes scarring and Adverse Effects - pregnancy or lactation
thickening of cell wall - direct GI irritation
- ↑ bleeding times Caution
- vitamin A and D deficiencies - impaired endocrine function
 the softer, more lipid atheromas appear to be
more likely to rupture than stable, harder - muscle aches and pains
Adverse Effects
cores - GI system
Drug-Drug Interactions
- ↓ or delay the absorption of thiazide diuretics, - CNS effects
digoxin, warfarin, thyroid hormones, - ↑ concentration of liver enzymes
ANTIHYPERLIPIDEMIC AGENTS corticostreriods: - rhabdomyolysis with acute renal failure

- often used in combination Nursing Considerations Drug-Drug Interactions


- should be part of an overall health care - do not administer powdered agents in dry - erythromycin, cyclosporine, gemfibrozil,
regimen that includes exercise, dietary form (mix with juices, soups, etc.) niacin, antifungal drugs = ↑ risk for
restrictions, and lifestyle changes to ↓ risk of - ensure tablets are not cut, chewed, or rhabdomyolysis
CAD crushed - digoxin, warfarin = ↑ serum levels and
- give drug before meals resultant toxicity
Bile Acid Sequestrants - administer oral medicatiosn 1 hour before or - oral contraceptives = ↑ estrogen levels
5 to 6 hours after the bile acid sequestrant - grapefruit juice = ↑ serum levels and risk of
Prototype: cholestyramine (Questran) - arrange for bowel program toxicity
- powder mixed with liquids and taken up to 6
times a day HMG-CoA REDUCTASE INHIBITORS (“statins”) Nursing Considerations
Therapeutic Actions - administer drug at bedtime
→ bind with bile acids in the intestine to form a Prototype: atorvastatin (Lipitor) - monitor serum cholesterol and LDL levels,
complex that is excreted in the feces - associated with severe liver complications including liver function, before and during
therapy
- arrange for ophthalmic medications - fibrate = ↑ risk of cholethiasis
- ensure patient has attempted a cholesterol- - ezetimibe = ↑ warfarin levels
lowering diet and exercise program for at
least 3 to 6 months before therapy Nursing Considerations
- encourage patient to make lifestyle changes - monitor serum cholesterol, triglyceride, LDL
levels, liver function test before and during
Cholesterol Absorption Inhibitors therapy
- ensure patient has attempted a cholesterol-
Prototype: ezetimibe (Zetia) lowering diet and exercise program for
several months before therapy
Therapeutic Actions - encourage patient to make lifestyle changes
→ works in the brush border of the small
intestine to ↓ absorption of dietary cholesterol Other Drugs Used to Affect Lipid Levels
→ drop in serum cholesterol levels
fibrates
Indications → stimulate the breakdown of lipoproteins from
- lower cholesterol level the tissues and their removal from the plasma
- treatment for homozygous familial → ↓ in lipoprotein and triglyceride synthesis and
hypercholesterolemia secretion
- reduce elevated sitosterol and campesterol
levels - absorbed from GI tract
- metabolized in liver
Pharmacokinetics - excreted in urine
- absorbed well
- metabolized in the liver and small intestine vitamin B3
- excretion is through feces an urine → inhibits release of free fatty acids from
adipose tissue
Contraindications → ↑ rate of triglyceride removal from plasma
- allergy → ↓LDL and triglyceride level, ↑ HDL levels
- pregnancy, lactation, severe liver disease (if → also ↓ levels of apoproteins needed to form
in combination with statin) chylomicrons

Cautions - associated with intense cutaneous flushing,


- pregnancy or lactation nausea, abdominal pain, development of gout
- elderly patients or with liver disease - given at bedtime
- administer 4 to 6 hours after the bile acid
Adverse Effects sequestrant
- mild abdominal pain and diarrhea
- headache, dizziness, fatigue, upper Combination Therapy
respiratory tract infection (URI), back pain, - if the patient shows no response to strict
muscle aches and pains dietary modifications, exercise, and lifestyle
changes, and the use of lipid-lowering agent,
Drug-Drug Interations combination of therapy may be initiated to
achieve desirable serum LDL and cholesterol
- cholestyramine, fenofibrate, gemfibrozil, levels
antacids = ↑ risk of elevated serum levels of
ezetimibe
- cyclosporine = ↑ risk of toxicity
Drug- Drug interactions
ANTICOAGULANTS • risk of excessive bleeding increases if any of these drug is
combined with another drug that affects blood clotting
- are drugs that interfere with the normal coagulation process
- affect the process at any step to slow or prevent clot formation Nursing considerations
1. provide small and frequent meals
I. ANTIPLATELET DRUGS 2. provide comfort measures and analgesia for headache
3. suggest safety measures, including the use of electric razor
- alter the formation of the platelet plug, or and avoidance of contact sports
- decrease the formation of the platelet plug by decreasing the 4. provide increase precautions against bleeding
responsiveness of the platelet to stimuli that would cause them 5. Mark the chart of any patient teaching receiving this drug
to stick and aggregate a vessel wall 6. Provide thorough patient teaching, including the name of the
- effectively to treat cardiovascular diseases that are prone to drug, prescribed, measures to avoid adverse effects, warning
produce occluded vessels; for the maintenance of venous and signs of problems, the need for periodic monitoring and
arterial grafts; to prevent cerobrovascular occlusion, and evaluation
adjuncts to thrombolytic therapy in the treatment of MI and II. ANTICOAGULANTS
prevention of infarction
Interfere with coagulation process by interfering with the
Prototype: Aspirin ( generic) clotting cascade and thrombin formation
- reduction of the risk if recurrent TIAs or strokes in males with
history of TIA due to fibrin or platelet emboli; reduction of Therapeutic Actions and Indications
death or nonfatal MI patients with history of infarction or stable
CHAPTER 48 – Drugs Affecting Blood angina; MI prophylaxis, also used as anti-inflammatory, Anticoagulants interfere with the normal cascade of events
Coagulation analgesics, and anti-pyretic involved in the clotting process. Warfarin causes a decrease in
the production of vit. K—dependent clotting factors in the liver.
Therapeutic Actions: Heparin, argatroban and bivalirudin block while Antithrombin
• inhibit platelet adhesion and aggregation by blocking formationof thrombinfrom prothrombin. These drugs are used
CARDIOVASCULAR SYSTEM receptor sites on the platelet membrane, preventing to treat thromboembolic disorders such as atrial fibrillation, MI,
- is a closed system platelet- platelet interaction of the interaction of platelets pulmonary embolus, and evolving dtroke and to prevent the
• Consistently, the system must maintain an intricate w/ other clotting chemicals formation of thrombi.
balance between the tendency to clot or form a solid state,
Pharmacokinetics Prototype: Heparin (generic) half-life 30-180 minutes,
called coagulation, and the need to “unclot” or reverse
coagulation to keep the vessel open and the blood • well absorbed metabolize in the cells and excreted in the urine
flowing… • highly bound to plasma proteins SQ onset 20-6- minutes, peak 2-4 hours, duration 8-12 hours
• metabolized in the liver IV – immediate onset, peak minute, duration 2-6 hours
Warfarin – effects last 4-5 days, onset of action in 3 days
• Blood coagulation • excreted in urine
- is a complex process that involves vasoconstriction, platelet • increased bleeding Contraindications
clumping or aggregation, and a cascade of clotting factors
produced by the liver that eventually react to break down Contraindications Contraindicated to known allergy to the drugs. They should not
fibrinogen ( a protein also produced in the liver) into soluble 1. presence of allergy be use with conditions that can increase bleeding tendencies;
fibrin threads . 2. during pregnancy and lactation hemorrhagic disorders, recent trauma, spinal puncture, GI
ulcers, recent surgery, intraunterine device placement,
• Vasoconstriction Caution tuberculosis, presence of indwelling catheter, and threatened
- can seal off any break and allow the area to heal 1. Presence of Known bleeding disorder abortion.Contratindicated to pregnancy, lactation, renal or
2. recent surgery hepatic disease
• Platelet aggregation 3. closed head surgeries
- causes platelets in the circulating blood to stick or adhere to Cautions
the site of injury platelets release ADP (adenosine Adverse Effects
triphosphate- precursor of prostaglandin) and other chemicals 1. Bleeding ( increased bruising and bleeding while bruising the In patients with CHF, thyrotoxicocic, saenility, or psychosis,
that attract other platelets, causing them to gather or aggregate teeth) diarrhea, fever
and to stick as well thromboxane A2 cause local 2. Headache, dizziness, and weakness
vasoconstriction = platelet aggregation and adhesion 3. Nausea and GI distress may occur Adverse effects
4. Skin rash
• Hageman Factor
The most common adverse effect is bleeding (bleeding in gums mother out ways the potential risks to the fetus. Cautions should Replace normal clotting factors and are processed as such by
with tooth brushing to severe intrernal hemorrhage), clotting be used during lactation. the body.
shoud be monitored. Nausea, GI upset, diarrhea, and hepatic
dysfunctiondue to toxicity. Warfarin can cause Contraindications and cautions Contraindications and cautions
alopecia,dermatitis, bone marrow depression and prolonged and Contraindicated to allergy of these drugs, should not be used Contraindicated in the presence of known allergy to mouse
painful with conditions that could worsen the dissolution of clots, proteins. Factor IX is contraindicated in the presence of liver
erections. recent surgery, active internal bleeding, cerebrovascular disease with signs of Intravascular coagulation or fibrinolysis.
accident within the last two months, aneurysm, recent serious Coagulation factor VII is contraindicated with known allergies
Drug to drug Interaction GI bleeding, liver disease. to mouse, hamster or bovine products. Not recommended
during lactation and pregnancy.
Heparin + (oral anticoagulants, salicylates, penicillins, Adverse effects
cephalosporins) =Increase bleeding Adverse effects
Heparin + nitroglycerin = Decrease coagulation The most common adverse effect is bleeding, cardiac
arrhythmias and hypotensions The most common is risks with the use of blood products, e.g.
Nursing Considerations Drug to drug interaction hepatitis, aids. Headache, flushing, chills, fever and lethargy.
Risk of hemorrhage increases if thrombolytic agents are used Nausea, vomiting and itching, stinging and burning at injection
-screen for allergy with anticoagulant or antiplatelet drug. site
-evaluate for therapeutic effects of warfarin --prothrombin time
(PT) 1.5 to 2.5 times control value or ratio of PT to INR Nursing consideration Nursing consideration
(International Normalized Ratio) of 2 to 3 -administer by IV only
-Evaluate for herapeutic effects of heparin—whole blood -Discontinue heparin if given before administration of -monitor clinical response and clotting factor levels regularly.
clotting time (WBCT) 2.5 to 3 times control or activated thrombolytic agent, unless ordered for coronary artery infusion. -monitor for sign of thrombosis
partial thromboplastin time (APTT) 1.5 to 3 times the control -evaluate for signs of blood loss (bleeding gums, bruises, dark -decrease the rate of infusion if headache, chills, fever or
value colored stools and urine, petechiae) tingling occurs.
- evaluate for signs of blood loss -institute treatment within 6 hours after the onset of symptoms -arrange to type and cross match blood.
-maintain antidotes on standby (protamine sulfate for heparin, of acute MI
vit, K for warfarin) -arrange to type and cross match blood. Systemic hemostatic agents
-monitor the patient when a drug is added or withdrawn from -monitor cardiac rhythm
the drug regimen of a patient receiving warfarin -increase precautions against bleeding during invasive A used to stop bleeding. Some situation result in fibrinolytic
-make sure patient receives regular follow up and monitoring procedures. state with excessive plasminogen activity and risk of bleeding
-provide health teaching, name of drug and its effects from clot dissolution.
Drugs used to control bleeding
Low Molecular-Weight Heparins On the other end of the spectrum of coagulation problems are Prototype: Aminocaproic acid (amicar)
various bleeding disorders: hemophilia, a genetic lack of
These drugs inhibit thrombus and clot formation by blocking clotting factor that leaves the patient vulnerable to excessive Pharmacokinetics
factors Xa and IIa. Because of size and nature of their bleeding with injury.
molecules, theses drugs do not greatly affect thrombin, clotting Parameters are different for each drug
or PT; they cause fewer adverse effects. They block Liver disease, clotting factors and proteins needed for clotting
angiogenesis, process that allows cancer cells to develop new are not produce. Therapeutic actions and indications
blood vessels. Bone marrow disorders, insufficient platelets are formed. Stop the natural plasminogen clot – dissolving mechanism by
blocking its activation or by directly inhibiting plasmin. These
Prototype: Strptokinase (streptase, kabikinase) Antihemophilic agents drugs are used to prevent or treat excess bleeding in
Drugs used to treat hemophilia are replacement factors for the hyperfibrinolytic states, including repeat CABG surgery.
Therapeutic actions and indications specific clotting factors that are genetically missing.
Thrombolytic agents work to activate the natural clotting Contraindications and cautions
system, conversion of plasminogen to plasmin, which in turn Prototype: Antihemophilic factor (bioclate, others) Contraindicated to allergy to these drugs and with acute DIC.
breaks down fibrin threads in a clot to dissolve a formed clot. Caution should be used in the following conditions: cardiac
They are indicated for the treatment of MI, to treat pulmonary Therapeutic actions and indications disease, renal and hepatic dysfunction, pregnancy and lactation
emboli and ischemic stroke and to open clotted IV catheter.
Replace clotting factors that are either genetically missing or Adverse effects
Pharmacokenetics low in a particular type of hemophilia. Used to prevent blood The most common is excessive clotting. CNS effects include
Must me injected and cleared from the body after liver loss from injury or surgery and treat bleeding episode. hallucinations, drowsiness, dizziness, headache and psychotic
metabolism, crosses the placenta and have adverse fetal effects, states. GI effects including nausea, cramps, and diarrhea.
should not be used during pregnancies unless benefits to the Pharmacokenetics
Drug to drug interaction
Increase risk of bleeding if combined with heparin - occurs when the bone marrow contains a - vitamin B12 deficiency may occur in:
large number of megaloblasts, or large, o strict vegetarians
Nursing considerations immature RBCs
-monitor clinical response and clotting factor levels
- because these RBCs are so large, they
o inability of the GI tract to absorb the
-monitor for signs of thrombosis needed amounts of vitamin B12
-orient patients and offer support and safety measure if become crowded in the bone marrow
hallucinations or psychoses occur. and fewer RBCs are produced - treated with vitamin B12 replacement therapy
- patients usually have a lack of vitamin
Topical hemostatic agents B12 or folic acid Pernicious Anemia
Used to injuries that involve damage to the small vessels in the
- occurs when the gastric mucosa cannot
area that clotting does not occur and blood is slowly and Iron Deficiency Anemias produce intrinsic factor and vitamin B12
continually lost - a negative iron balance cannot be absorbed
- occurs in situations in which blood is being - person may complain of fatigue, lethargy, and
Absorbable gelatin (gellfoam) and microfibrilar collagen lost (such as heavy menstrual flow, internal CNS effects because of damage to the
(avitene), are apllied directly to the injured area until the bleeding) myelin sheath
bleeding stops
- treated with injections of vitamin B12 to
- only enough iron is absorbed to replace the replace the amount
Thrombin (thrombinar, thrombostat) derived from bovine
sources and mixed with the blood amount of iron lost each day
- only about 1 mg of iron is lost every day ERYTHROPOIETINS

CHAPTER 49: DRUGS USED TO TREAT Megaloblastic Anemias - for patients who are no longer able to
ANEMIAS - there is no sufficient folic acid or vitamin B12 produce erythropoietin in the kidneys
to adequately create the stromal structure
BLOOD needed in a healthy RBC Prototype: epoetin alfa (Epogen, Procrit)

- essential for cell survival Therapeutic Actions


o contains oxygen and nutrients and - acts like the natural glycoprotein
removes waste products that could be Folic Acid Deficiency erythropoietin to stimulate the production of
toxic to the tissues - folic acid is essential for cell division in all RBCs in the bone marrow
o contains clotting factors that help maintain types of tissue
- deficiencies in folic acid are first noticed in Indications
the vascular system and keep it sealed
rapidly growing cells - treatment of anemia with renal failure
o contains important components of the - may occur in: - to ↓ the need for blood transfusion in patients
immune system that protect the body from o certain malabsorption states (such as undergoing surgery
infection sprue or celiac diseases) - treatment of anemias related to treatment for
o malnutrition that accompanies alcoholism AIDS
Blood Components
- composed of liquid and formed elements:
o repeated pregnancies - treatment of anemia associated with cancer
o extended treatment with certain chemotherapy (Procrit only)
plasma, leukocytes, erythrocytes, platelets
antiepileptic medications
Types of Anemia - treated by the administration of folic acid or Pharmacokinetics
folate - metabolized through the normal kinetic
1. Deficiency Anemia process
- occurs when the diet cannot supply Vitamin B12 Deficiency - half life of 4 to 13 hours
enough of a nutrient, or enough of a - vitamin B12 is used in minute amounts by the
nutrient cannot be absorbed body and is stored for use Contraindications
- it is necessary for the health of the RBCs and - presence of uncontrolled hypertension
2. Megaloblastic Anemia for the formation and maintenance of the - allergy
myelin sheath in the CNS - lactation
- normal iron balance o lack of intrinsic factor in the stomach
Adverse Effects - peptic ulcer, colitis, regional enteritis
- result of cellular response to glycoprotein: Prototype: hydroxocobalamin (Hydro-Crysti 12)
CNS effects Adverse Effects - given IM everyday for 5 to 10 days, then
- nausea, vomiting, diarrhea - direct GI irritation once a month for life
- related to ↑ in RBC numbers: CV symptoms - with increasing serum levels, iron can be - used in states of ↑ demand or dietary
CNS toxic, causing coma and death deficiency
Nursing Considerations - parenteral iron: severe anaphylactic
- confirm chronic, renal failure before drug reactions, local irritation, staining of the Therapeutic Actions
administration tissues, phlebitis - folic acid and vitamin B12 : for cell growth and
- give epoetin alfa 3 times a week, IV or SQ division, and production of strong stroma in
- do not mix with any other drug solution Drug-Drug Interactions RBCs
- monitor access lines for clotting - antacids, tetracyclines, cimetidine = ↓ iron
- arrange for hematocrit reading before drug - Vitamin B12: maintenance of the myelin
absorption sheath in nerve tissue
administration - ciproflaxin, norfloxacin, ofloxacin = ↓ anti-
- evaluate iron stores before and during infective response
therapy Indications
- chloramphenicol = ↑ iron levels - replacement therapy for dietary deficiencies
- maintain seizure precautions on standy - levodopa = ↓ effects of levodopa - replacement in high-demand states (such as
IRON PREPARATIONS pregnancy and lactation)
Drug-Food Interactions - treat megaloblastic anemia
- antacids, eggs, milk, coffee, tea = iron is not - folic acid: rescue drug for cells exposed to
- iron deficiency anemia is common in certain absorbed
groups: some toxic chemotherapeutic agents
o menstruating women Nursing Considerations
o pregnant and nursing women Pharmacokinetics
- confirm deficiency anemia before drug - well absorbed after injection
o rapidly growing adolescents
administration - metabolized mainly in liver
o persons with GI bleeding and slow - administer with meals - excreted in urine
bleeding - have patients drink solutions through a straw - highly protein bound
- caution patient that stool may be dark or - considered essential during pregnancy and
Prototype: ferrous sulfate (Feosol) green lactation
- administer IM only through Z-track technique
Therapeutic Actions
- arrange for hematocrit and hemoglobin Contraindication
- elevate the serum iron concentration
measurements before and during therapy - allergy
Indications
FOLIC ACID DERIVATIVES AND VITAMIN B12 Cautions
- treatment of iron deficiency anemias
Folate deficiencies usually occur - pregnant or lactating who have anemias
- adjunctive therapy in patients receiving
epoetin alfa
o secondary to ↑ demands - nasal cyanocobalamin
o absorption problems in the small intestine - presence of nasal erosion or ulcers
Pharmacokinetics o secondary to the malnutrition of
alcoholism Adverse Effects
- absorbed from small intestine
- pain and discomfort at injection sites
- transported in the blood
Prototype: folic acid (Folvite) - nasal irritation with the use of nasal sprays
- used during pregnancy and lactation
- parenteral drugs are preferred for patients
Contraindications with potential absorption problems
Nursing Considerations
- allergy
Vitamin B12 deficiencies usually occur - confirm the nature of megaloblastic anemia
- hemochromatosis (excessive iron)
- give both types of drugs in pernicious anemia
- hemolytic anemias o with poor diet or increased demand
- parenteral Vitamin B12 must be given IM each • system and depositing them into
day for 5 to 10 days, then once a month for 4 major functions of the renal system: the tubule
life
- arrange for nutritional consultation • Maintain the value and
- monitor for hypersensitivity reactions composition of the body fluids c.) Absorption – removing from the
- arrange for hematocrit and hemoglobin
w/in normal range tubule to return them to the
measurements before and during therapy
• Regulating vitamin D activation capillary system and circulation
>about 99% of the water filtered at
• Regulating blood pressure
the glomerulus is reabsorbed
• Regulating red blood cell >the filtrate components include
production the vitamins, glucose, electrolytes,
• sodium bicarbonate, and sodium
>the kidneys are two small organs that chloride
receive about 25% of the cardiac output >precision of the reabsorption
process allows the body to
Nephron maintain the correct extracellular
• the functional unit of the kidneys fluid volume and composition
• is composed of the Bowman’s
capsule, proximal convoluted Maintenance of Volume and composition
tubule, loop of Henle, distal of Body Fluids
convoluted tubule, and collecting
duct Sodium Regulation
• Sodium
Renal Processes  Is one the body’s major
a.) Filtration - straining fluid into the cations(positively charged ions)
nephron  Reabsorbed via transport system
>approximately 125 mL of fluid is that functions under the influence
filtered each minute, or 180L/day if the catalyst carbonic
>99% of the filtered fluid is anhydrase, à carbonic acid à
Chapter 50 - Introduction to the returned to the bloodstream sodium bicarbonate
Kidneys and the Urinary Tract >approx. 1% of the filtrate, less 2 hormones that influence sodium levels
than 2 L of fluid is excreted each in the filtrate:
Renal system: day in the form of urine  Aldosterone-a hormone produced
• Urinary tract the adrenal gland
• Ureters b.) Secretion – actively removing - is released into the
• Urinary bladder components from the capillary circulation in response to
• Urethra the high potassium levels,
sympathetic stimulation, or the urine until it is
angiotensin III Chloride Regulation excreted from the body.
- stimulates Na-K exchange Chloride Uterus- have smooth endothelial lining
pump in the cells of the  Is an important negatively charged and circular muscular linings.
distal tubule, w/c reabsorbs ion that helps to maintain electrical • The female urethra is very short
Na in exchange for K, as a neutrality with the movement of and leads to an area populated by
result Na is reabsorbed into cations across the cell membrane normal flora including e.coli.
the system and K lost in the  Primarily absorbed in the loop of • The male urethra is much longer
filtrate Henle, where it promotes the and passes through the prostate
 Natriuretic Hormone- probably movement of sodium out of the gland.
produced by the hypothalamus cell Prostate Gland- a small gland that
- causes decrease in Na *the kidneys play a role produces an acidic fluid that is
reabsorption from the distal important in maintaining the sperm
tubules w/ a resultant dilute Sodium Regulation and lubricating the tract.
urine or increase volume
- is released in response to Calcium
the fluid overload or  Is important in muscle function,
hemodilution blood clotting, bone formation,
Countercurrent Mechanism contraction of cell membranes and
 in the medullary nephrons allow muscle movement.
for the concentration or dilution of  Filtered at the glomerulus and
urine under the influence of ADH mostly reabsorbed in the proximal
secreted by the hypothalamus convoluted tubule and ascending
Loop of Henle.
Potassium Regulation  Fine tuning reabsorption occurs in
Potassium the distal convoluted tubule.
 is another cation that ios vital to
proper functioning of the nervous
system, muscles, and cell
membranes
 65% is filtrated at the glumerulus
is reabsorbed at the Bowman’s Urinary Tract
capsule and proximal convoluted
tubule Urinary Bladder- is the muscular pouch
 25%-30% is r5eabsorbed at the that stretches and holds
loop of Henle
- drugs that increase the amount of urine THIAZIDE AND THIAZIDE- LIKE DIURETICS
- the greater significance of diuretics is their ability to
increase sodium excretion. - Hydrochlorothiazide (hydroDIURIL), the most
frequently used of the thiazide diuretics, often used
Therapeutic actions and indications:
in combination with other drugs for the treatment of
hypertension.
- prevent the cell’s lining the renal tubule from
- Chlorothiazide (Diuril), the oldest of this class, and
reabsorbing an excessive proportion of the sodium
considered the prototype.
ions in the glomerular filtrate.
- Bendroflumethiazide (Naturetin)
- as a result, sodium and other ions are lost in the
- Hydroflumethiazide (Diucardin)
urine instead of being return to the blood, where they
- Methyclothiazide (Aquatensen)
would cause increase intravascular volume and
- Trichlormethiazide (Diurese)
therefore increase hydrostatic pressure, which could
result in leaking of fluids at the capillary level.
*Thiazide- like drugs
- Indicated for the treatment of edema associated with
- Chlorthalidone (Hygroton)
congestive heart failure, acute pulmonary edema,
- Indapamide (Lozol)
liver disease, and renal disease, and for the treatment
- Metolazole (Mykrox)
of hypertension.
- Quinethazone (Hydromox)
- Also use to decrease fluid pressure in the eye
(intraocular pressure), which is useful in treating
Therapeutic actions and indications:
glaucoma.
- Diuretics that decrease potassium levels may also be
- Thiazide diuretics belong to a chemical class of
indicated in the treatment of conditions that cause
drugs called sulfonamides.
hyperkalemia.
- Thiazide- like diuretics has a slightly different
chemical structure but work in the same way that
Contraindications and cautions:
thiazide diuretics do.
- Their action is to block the chloride pump.
- presence of allergy to any of the drugs given
- Usually indicated for the treatment of edema
- fluid and electrolyte imbalances
associated with CHF or with liver or renal disease.
- severe renal disease
- Also used as monotherapy or as adjuncts for the
- caution should be used with systemic lupus
treatment of hypertension.
erythematosus (SLE)
- glucose tolerance abnormalities or diabetes mellitus
Pharmacokinetics:
- gout
- liver disease
- onset of action: 1-3 hours
- pregnancy and lactation
- metabolize in the liver and excreted in the urine
- well absorbed in the GI tract
Adverse effects:
Contraindications and cautions:
- the most common adverse effects seen with diuretics
include GI upset, fluid and electrolyte imbalances,
- contraindicated with allergy to thiazides or
hypotension, and electrolyte disturbances.
sulfonamides, fluid or electrolyte imbalances and
renal and liver disease.
Drug- drug interactions:
- Additional cautions include: gout, SLE, diabetes,
hyperparathyroidism, bipolar disorder, and
drugs that altered the actions of diuretics:
pregnancy and lactation.
- antiarrhythmics (digoxin), drugs that depend on a
Adverse effects:
particular electrolyte balance for their therapeutic
effects.
- Hypokalemia (weakness, muscle cramps, and
- Quinidine, drugs that depend on urine alkalinity for
arrhythmias)
CHAPTER 51: Diuretic Agents proper excretion.
- Decrease calcium excretion, which leads to increase
- Antihypertensive ad antidiabetic agents, depend on
calcium level.
Diuretic Agents normal reflexes to balance their effects.
- Decrease uric acid excretion (gout, high level of uric
acid)
- Urine will slightly alkalinized - They should not be used during pregnancy, unless - Use as a drug adjuncts to other diuretics when a more
the benefit to the mother far outweigh the potential intense diuresis is needed
Drug- drug interactions: risk, it enters in the breastmilk. - Acetalozamide is used to treat mountain sickness
- Safety for use in children younger than 18 years of
- decrease absorption of this drugs if combined with age, has not been establish. Pharmacokinetics
cholestyramine or colestipol, if combination is used, - If one of this drug is used for a child, carefully -rapidly absorbed widely distributed excreted in the urine
it should be taken separated by at least 2 hours. monitor child’s fluid and electrolyte balance is - another method of feeding the infant should be used if
- Risk of digoxin toxicity increases due to potential needed. one of this drugs is needed during lactation.
changes in potassium levels; serum potassium level
should be monitored if this combination is used. Contraindicaions and Cautions
- Decrease effectiveness of antidiabetic agents may -Allergy to drugs or antibacterial sulfunamides or thyazide or
occur related to the changes in glucose metabolism; chronic noncongestive angle closure glaucoma
dosage adjustment of those agents may be needed. Contraindication and cautions: -cautios use is recommended in patients who are
- Risk of lithium toxicity may increase if these drugs breastfeeding, who have fluid imbalances, renal or hepatic
are combined. Serum lithium levels should be - allergy to loop diuretics, electrolyte depletion, disease, adrenocortical insufficiency, respiratory acidosis
monitored and appropriate dosage adjustment made anuria, severe renal failure, hepatic coma, pregnancy or COPD
as needed. and lactation.
- Caution on patient with SLE, gout, and/or diabetes Adverse Effects
LOOP DIURETICS mellitus. - metabolic acidosis
-work in the loop in henle - hypokalemia
Adverse effect: - paresthesias (tingling), confusion and drowsiness
- Furosemide (Lasix), most common less powerful
than new loop diuretics. - hyperkalemia is a very common adverse effect. Drug to Drug Interaction
- Bumetanide (Bumex) - Alkalosis (a drop in serum pH to an alkaline state.) - there maybe an increase excretion of salicylates and lithium if
- Torsemide (Demadex) - Hypotension, dizziness, ototoxicity, deafness. they are combined with this drugs
- Ethacrynic acid (Edecrine) - This may occur in conduction of fragile nerve in
CNS.
Therapeutic action and indications: Potassium- Sparring Diuretics
Drug- drug interactions: - These drugs are used for patients wha are at risk for
- referred to as high-ceiling diuretics because they hypokalemia associated with diuretic use.
cause greater degree of diuresis. - risk for ototoxicity increase with amino glycosides - Retain potassium instead of wasting it.
- Block the chloride pump in the ascending loop of or cysplapin.
henle, where normally 30% of all filtered sodium is - Anticoagulation effect may increase with Amiloride (Midamore)
reabsorbed. anticoagulant. Spironolactone (Aldactone)
- These drugs work even in the presence of acid- base - Decrease loss of sodium and decrease Triamterene (Dyrenium)
disturbances, renal failure, electrolyte imbalances, or antihypertensive effect with indomethacin,
nitrogen retention. ibuprofen, salicylates, or another NSAIDs. Therapeutic Actions and Indication
- A drug of choice when rapid and extensive diuresis
is needed. - These drugs are often used as adjuncts with thiazide
- In case of severe edema, it is important to remember or loop diuretics.
that these drugs can have an effect only on the blood CARBONIC ANHYDRASE INHIBITOR - Spironolactone is the drug of choice for treating
the nefron. hyperaldosteronism, a condition seen in cirrhosis of
- In pulmonary edema, this fluid then circulates back - relatively mild diuretics. the liver and nephronic syndrome.
to the lungs pulls fluid out of the interstitial spaces - Used to treat glaucoma
by its oncotic pull, and delivers fluid to the kidneys Pharmacokinetics
where the water is pulled out completing the cycle. Acetazolamide (Diamox) - These drugs are well absorbed, protein bound and
- Commonly indicted for treatment of acute CHF, Methazolamide (Meptazane) widely distributed.
pulmonary edema, edema associated with CHF or - These drugs cross the placenta and enter breast milk.
with renal or liver disease and hypertension. Therapeutic Actions and Indication
- the enzyme carbonic anhydrase is a catalyst for the Contraindicaions and Cautions
Pharmacokinetics: formation of sodium bicarbonate. - Allergy to the drug
-This diuretics lacks the effects of carbonic anhydrase that - Hyperkalemia
- metabolized and excreted through urine. slows down the movement of hydrogen ions, as a result - Renal disease
more sodium and bicarbonate are lost in the urine - Anuria
- Patients who are taking Amiloride or triamterene
to destroy bacteria, either through a
Adverse Effects direct antibiotic effect or through
- Hyperkalemia acidification of the urine.
Urinary Tract Anti-Infectives

DRUGS: PHARMACOKINETICS:
OSMOTIC DIURETICS
- Pull water into the renal tubule without sodium loss.
- Drug of choice for Increase cranial pressure or acute Because these drugs are from
2 types: antibiotics & anti infectives
renal failure. several different chemical classes,
works to acidify the urine
the pharmacokinetic data are different
for each drug.
Antibiotics
CONTRAINDICATIONS:
Glycerin (osmoglyn)
Mannidol (Osmitrol) • Cinoxacin(Cinobac)- interferes These drugs are contraindicated
Urea (ureaphil) with the DNA replication in in the presence of any of these drugs.
gram negative bacteria They should be used with caution in
Therapeutic Actions and Indication
- It acts to pull large amounts of fluid into the urine by • Norfloxacin (Noroxin)- a newer the presence of renal dysfunction,
the osmotic pull of the large sugar molecule. and more broad spectrum drug, which could interfere with the
- These drugs are often used in acute situation . is effective against even more excretion and action of these drugs,
- Prevent oliguric phase of renal failure, and to gram negative strains than and with pregnancy and lactation
promote of toxic substances through the kidneys. cinoxacin because of the potential for adverse
• Fosfomycin (Monurol)- has the effects on the fetus or neonate.
Pharmacokinetics
- These drugs are freely filtered at the renal convenience of only one dose.
It is not recommended for ADVERSE EFFECTS:
glomerulus, poorly reabsorbed by the renal tubules
and not secreted by the tubule, and resistant to patients younger than 18 years
metabolism. of age • nausea, vomiting, diarrhea,
• Nalidixic (NegGram)- is an anorexia, bladder irritation,
Contraindications and Cautions older drug that is not and dysuria
- Renal disease and anuria from sever renal disease, • infrequent symptoms include
effective against as many
pulmonary congestion, intracranial bleeding, pruritus, urticaria, headache,
dehydration and CHF.
strains of gram-negative
bacteria as the other dizziness, nervousness, and
antibiotics used for UTIs confusion
Adverse Effects • Nitrofurantion (Furadantin)- is • GI irritation caused by the
- Sudden drop of fluid levels another older drug with a very agent, which is alleviated if
- Cardiac decompensation and even shock short half-life (20-60 minutes) drug is taken with food
Anti-infective works to acidify urine
DRUG-DRUG INTERACTIONS:
• Methenamine (Hiprex)- undergoes
metabolism in the liver and is Drug interactions that can
excreted in the urine occur are very specific to the drug
• Methylene blue (Urolene Blue)- being used.
is widely distributed,
metabolized in the tissues, and
excreted in urine, bile, and Urinary Tract Antispasmodics
feces
DRUGS:
ACTION:
Chapter 52- Drugs affecting the • Flavoxate (Urispas)- prevent
Urinary Tract and the Bladder The urinary anti-infectives act smooth muscle spasm
specifically within the urinary tract specifically in the urinary
tract, but it is associated in urine. Caution should be used in urinary tract mucosa. It is used to
with CNS effects (blurred the presence of hepatic or renal relieve symptoms related to urinary
vision, dizziness, confusion) impairment because of the potential of tract irritation from infection,
that make it less desirable to alterations in metabolism or excretion trauma, or surgery.
use in certain patients of the drugs.
• Oxybutynin (Ditropan)- is a PHARMACOKINETICS:
potent urinary antispasmodic, CONTRAINDICATIONS:
but it has numerous Phenazopyridine is rapidly
anticholinergic effects, making These drugs are contraindicated absorbed and has a very rapid onset of
it undesirable in certain in the presence of any allergy to action. It is widely distributed,
conditions or situations that these drugs; with pyloric or duodenal crossing the placenta and entering
might be aggravated by obstruction or recent surgery because breast milk. It is metabolized in the
decreased sweating, urinary anticholinergic effects can cause liver and excreted in the urine.
retention, tachycardia, and serious complications.
changes in the GI activity. CONTRAINDICATIONS:
• Tolterodine (Detrol,Detrol LA)- ADVERSE EFFECTS:
is a newer agent that blocks This drug is contraindicated in
muscarinic receptors, • adverse effects of urinary the presence of any allergy to the
preventing bladder contraction antispasmodics are related to drug and serious renal dysfunction,
and spasm blocking of the parasympathetic which would interfere with the
system excretion and effectiveness of the
• Trospium (Sanctura)- is the
• nausea and vommitng, dry mouth, drug.
newest drug approved to block
urinary tract spasms. It also nervousness, tachycardia, and
vision changes ADVERSE EFFECTS:
specifically blocks muscarinic
receptors and reduces the
muscle tone of the bladder. It DRUG-DRUG INTERACTIONS: • GI upset, headache, rash,
is specifically indicated for reddish-orange coloring of
the treatment of overactive Decreased effectiveness of urine
bladder with symptoms of urge phenothiazines and haloperidol has • Hepatic toxicity, this drug
urinary incontinence, urgency, been associated with the combination should not be used for longer
and urinary frequency. of these drugs with oxybutynin. If any than 2 days because the toxic
such combinations must be used, the effects may be increased.
ACTION: patient should be monitored closely
and appropriate dosage adjustments DRUG-DRUG INTERACTIONS:
Inflammation in the urinary made.
tract, such as cystitis, prostatics, The risk of toxic effects of
urethritis, and this drug increases if it is combined
euthrocystitis/urethrotrigonitis, Urinary Tract Analgesic with anti-bacterial agents used for
causes smooth muscle spasms along the treating UTIs. If this combination is
urinary tract. Irritation of the DRUGS: used, the phenazopyridine should not
urinary tract leading to muscle spasm be used for longer than 2 days.
also occurs in patient with neurologic • Phenazopyridine (Azo-Standard,
bladder. Baridium, and others) is a dye
that is used to relieve pain.
PHARMACOKINETICS: ACTION:

These drugs are rapidly When phenazopyridine is


absorbed, widely distributed, excreted in urine, it exerts a direct,
metabolized in the liver, and excreted topical analgesic effect on the
The respiratory system’s function is to irritation. When receptors in the walls
supply the blood with oxygen in order for are stimulated, a central nervous system
the blood to deliver oxygen to all parts reflex is initiated and a cough reflex
of the body. The respiratory system does results, which causes air to be pushed
this through breathing, thus allowing gas through the bronchial tree to clean out
exchange to occur. The normal functioning any foreign irritant. This reflex, along
of the respiratory system depends on an with the sneeze reflex, forces foreign
intricate balance of the nervous system, materials directly out of the system.
cardiovascular, and musculoskeletal
systems. It is composed of two parts Around the airways, many macrophage
namely the upper respiratory tract and the scavengers freely move about the
lower respiratory tract. epithelium and destroy invaders. Mast
cells are present in abundance and release
THE UPPER RESPIRATORY TRACT histamine, serotonin, and adenosine
The upper respiratory tract or conducting triphosphate (ATP), and other chemicals to
airways is composed of the nose, mouth, ensure rapid and intense inflammatory
pharynx, larynx, trachea, and the upper reaction to any cell injury. The end
bronchial tree. In here, air usually moves result of these various defense mechanisms
into the body through nose and into nasal is that the lower respiratory tract is
cavity. The structures of the upper virtually sterile-an important protection
respiratory tract are moist with mucus against respiratory infection that could
(which are produced by the goblet cells in interfere with essential gas exchange.
the epithelial lining of the nasal cavity)
and are lined with cilia (microscopic THE LOWER RESPIRATORY TRACT
hair-like projections of the cell The lower respiratory tract is composed of
membrane). The cilia constantly move and the smallest bronchioles and alveoli which
direct mucus and any trapped substances both are the functional units of the
down toward the throat. lungs. Within the lungs are network of
bronchi, alveoli, and blood vessels. The
Pairs of sinuses (air-filled spaces, lung tissue receives its blood supply from
communicating with the nasal cavity, the bronchial artery, which branches
within the bones of the skull and face) directly off the aorta. The alveoli
open into the nasal cavity. From the receives unoxygenated blood from the right
sinus, the mucus drains into the throat ventricle via the pulmonary artery. This
and is swallowed into the gastrointestinal delivery of blood to the alveoli is
tract, where stomach acid destroys foreign referred to as perfusion.
materials.
Gas exchange or ventilation occurs in the
Air moves from the nasal cavity into the alveoli where carbon dioxide is lost from
pharynx and larynx. The larynx contains the blood and oxygen is to the blood. The
the vocal chords and the epiglottis (which alveolar sac holds the gas, allowing
closes during swallowing). From the needed oxygen to diffuse across the
larynx, air proceeds to the trachea, the respiratory membrane into the capillary
main conducting airway to the lungs. The while carbon dioxide, which is more
trachea divides into two main bronchi, abundant in the capillary blood, diffuses
which further divide into smaller and across the membrane and enters the
smaller branches. These bronchial tubes alveolar sac to be expired.
are composed of three layers: cartilage,
muscle, and epithelial cells. All of these The respiratory membrane is made up of the
tubes contain mucus-producing goblet cells capillary endothelium, the capillary
and cilia. The cilia in these tubes moves basement membrane, the interstitial space,
Chapter 53 – Introduction to the mucus up to the trachea and into the and the surfactant layer. The sac is able
the Respiratory System throat, where again it is swallowed. to stay open because of the surface
tension of the cells is decreased by the
The walls of the trachea and conducting lipoprotein surfactant which is produced
bronchi are highly sensitive to by the type II cells in the alveoli.
Absence of surfactant leads to alveolar Seasonal rhinitis or commonly called as with fever and noisy breath sounds, and
collapse. hay fever occurs when the upper airways poor oxygenation.
respond to specific antigen with vigorous
The oxygenated blood is returned to the inflammatory response, resulting in nasal • Bronchitis
left atrium via the pulmonary veins; from congestion, sneezing, stuffiness, and
there it is pumped throughout the body to watery eyes. Acute bronchitis occurs when bacteria,
deliver oxygen to the cells and to pick up viruses, or foreign materials infect inner
waste products. • Sinusitis layer of the bronchi. The person with
bronchitis may have a narrowed airway
RESPIRATION Sinusitis occurs when the epithelial during the inflammation; this condition
The central nervous system controls the lining of the sinus cavities becomes can be very serious in a person with
respiration or the act of breathing. The inflamed. The resultant swelling often obstructed or narrowed airflow. Chronic
respiratory center in the medulla causes severe pain. The danger of sinus the bronchi that does not clear.
stimulates the inspiratory muscle to
contract, it also receives input from
infection is that, if left untreated, • Bronchiectasis
microorganisms can move up the sinus
chemoreceptors and increase the rate of passages and into brain tissue. Bronchiectasis is a chronic disease that
depth and/or rate of respirations to Pharyngitis and Laryngitis Pharyngitis and
maintain homeostasis. involves the bronchi and bronchioles. It
Laryngitis are infections frequently is characterized by dilation of the
caused by common bacteria or viruses.
The vagus nerve, a predominantly bronchial tree and inflammation of the
These conditions are frequently seen with bronchial passages. With chronic
parasympathetic nerve, plays a key role in influenza.
stimulating diaphragm constriction and inflammation, the bronchial epithelial
inspiration. Vagal stimulation also leads cell membranes, combined with the dilation
to bronchoconstriction or tightening. The of the bronchial tree, leads to chronic
LOWER RESPIRATORY TRACT CONDITIONS infections in the now unprotected lower
sympathetic system also innervates the
respiratory sytem by increasing rate and areas of the lung tissue. Patients with
depth of respiration and dilation of the • Atelectasis this condition often have an underlying
bronchi. medical condition that makes them more
Atelectasis, the collapse of once- susceptible to infections. Patients
RESPIRATORY PATHOLOGY expanded lung tissue, can occur as a present with the signs and symptoms of
UPPER RESPIRATORY TRACT CONDITION result of outside pressure against the acute infection, including fever, malaise,
alveoli or pleural effusion. Atelectasis myalgia, arthalgia, and a purulent,
• The Common Cold most commonly occurs as a result of airway productive cough.
blockage, which prevents air from entering
the alveoli, keeping the lung expanded. Obstructive Pulmonary Diseases
Common cold is caused by a number of This condition occurs when a mucus plug,
different viruses that invade the upper edema of the bronchioles, or a collection • Asthma
respiratory tract, initiating the release of pus or secretions occludes the airway
of histamine and prostaglandins and and prevents movement of air. Patients may It is characterized by reversible
causing an inflammatory response. As a present rales, dyspnea, fever, cough, bronchospasm, inflammation and hyperactive
result, mucous membranes become engorged hypoxia, and changes in chest wall airways. The hyperactivity is triggered by
movement. allergens or nonallergic inhaled irritants
with blood, the tissues swell, and the
goblet cells increase the production of or by factors such as exercise and
• Pneumonia emotions. The triggers cause an immediate
mucus. These effects cause the person to
release of histamine, which result in
complain sinus pain, nasal congestion,
Pneumonia is an inflammation of the lungs bronchospasm in about 10 minutes. The
runny nose, sneezing, watery eyes, caused either by bacterial or viral later response (3 to 5 hours) is
scratchy throat, and headache. In invasion of the tissue or by inspiration cystokine-mediated inflammation, mucus
susceptible, this swelling can block the of foreign substances into the lower production, and edema contributing to
outlet of Eustachian tube, which may lead respiratory tract. The respiratory tract obstruction. The extreme case of asthma is
to an ear infection (otitis media). leads to a localized swelling, the status asthmaticus which can be life-
engorgement, and exudation of protective threatening because bronchospasm does not
sera. The respiratory membrane is respond to usual treatment and occludes
• Seasonal Rhinitis affected, resulting in decreased gas air flow into the lungs.
exchange. Patients complain of difficulty
breathing and fatigue, and they present
• Chronic Obstruction Pulmonary These drugs work to keep the airways open - caution pts. not to use the drug longer than 5
Disease (COPD) and gas to move freely. days to facilitate detection of the underlying
 Antitussives- blocks the cough reflex medical conditions that may require treatment.
COPD is a permanent, chronic obstruction
of airways, often related to cigarette  Decongestants- decrease the blood flow to - provide safety measures if dizziness occurs
smoking. It is caused by two related the upper respiratory tract and decrease the to prevent patient injury
disorders, emohysema and chronic overproduction of secretions - offer support and encouragement to help the
bronchitis. Emphysema is characterized by patient cope with the disease and the drug regimen
loss of elastic tissue of the lungs,  Antihistamines- block the release or action of
destruction of the alveolar walls, and a histamine, a chemical released during
resultant hyperinflation and tendency to inflammation that increases secretions and narrows Decongestants
collapse with expiration. Chronic
airways. - Drugs that cause local vasoconstriction
bronchitis is a permanent inflammation of
the airways with mucus secretion, edema,  Expectorants- increase productive cough to - Decrease the blood flow to the irritated and
and poor inflammatory defenses. Persons clear the airways. dilated capillaries of the mucous membranes lining
with COPD are characterized by both
 Mucolytics- increase or liquefy respiratory the nasal passages and sinus cavities.
disorders.
secretions to aid the clearing of the airways.
• Cystic Fibrosis
• Topical Nasal Congestants
Antitussives - are sympathomimetics
Cystic fibrosis is a hereditary disease - Drugs that suppress the cough reflex. - cause vasoconstriction, leading to decreased
that results in the accumulation of
- Act directly on the medullary cough center edema and inflammation of the nasal membranes
copious amounts of very thick secretions
of the brain to depress the cough reflex. - caution in patients with lesions or erosions
in the lungs. Eventually, the secretions
obstruct the airways, leading to - Acts as a local anesthetic on the respiratory in the mucous membranes.
destruction of the lung tissue. Treatment passages, lungs, and pleurae, blocking the - T ½ of 0.4-0.7 hr; absorbed systematically,
is aimed at keeping the secretions fluid metabolized in the liver and excreted in the urine.
and moving and maintaining airway patency effectiveness of the stretch receptors that stimulate
as much as possible. a cough reflex. - Side effects include: disorientation,
- Contraindicated for patients w/ postoperative confusion, light headedness, nausea, vomiting,
• Respiratory Distress Syndrome (RDS) and those who have undergone abdominal or fever, dyspnea, rebound congestion
thoracic surgery. Drugs in this class: P ephedrine(Kondon’s Nasal);
Respiratory distress syndrome is
- Caution should be used in patients who are oxymetazoline(Afrin, Allerest);
frequently seen in premature babies whose
lungs are not yet fully developed and hypertensive or have a history of addiction to phenylephrine(Coricidin); trahydrozoline(Tyzine);
their surfactant levels are still very narcotics xylometazoline(Otrivin)
low. Surfactant is necessary for lowering - T ½ of 2-4 hrs; metabolized in liver and
the surface tension in the alveoli so that • Oral Decongestants
they can stay open to allow the flow of excreted in urine
gases. Treatment is aimed at instilling - Side effects include: dizziness, respiratory -decrease nasal congestion related to common
surfactant to prevent atelectasis and to depression and dry mouth colds,sinusitis,and allergic rhinitis.
allow the lungs to expand. Adult -relieve pain and congestion of otitis media
respiratory distress syndrome (ARDS) is
Drugs in this class:
characterized by progressive loss of lung benzonatate(Tessalon); codeine(generic); P - shrink the nasal mucous membrane by
compliance and increasing hypoxia. This dextromethorpan(Benylin); stimulating the alpha-adrenergic receptors in the
syndrome occurs as a result of severe hydrocodone(Hydocan) nasal mucus membrane,promoting drainage of the
insult to the body. sinuses and improving air flow.
Implemetation: -Pseudoephedrine peak levels- 20 to 45 minutes.
- teach the pt. the proper administration of the -ask the patient to void before taking the drug.
Chapter 54- Drugs Acting on the Upper drug to ensure therapeutic effect -contraindicated to patient with
Respiratory Tract glaucoma,hypertension,diabetes,thyroid
disease,coronary disease and prostate problems.
-Adverse effects: rebound -Adverse effects: drying of the respiratory and GI Mucolytics
congestion,anxiety,tenseness mucous membranes,GI upset ,
tremors,hypertension,arrythmias,sweating,and nausea,dysuria,urinary hesitancy,and skin eruption -aid in high –risk respiratory patient in
pallor. and itching associated with dryness. coughing up thick secretions,tenacious secretions.
-encourage patient not to use this drug for more -increase effect if taken with MAOI, -for COPD, cystic
than 1 week. ketoconazole,and erythromycin. fibrosis,pneumonia,tuberculosis,atelectasis,diagnos
-administer drug in an empty stomach tic bronchoscopy,
• Topical Nasal Steroid Decongestants -have patient void before each dose Postoperative patients with tracheostomy.
- treatment for allergic rhinitis,been found to -Avoid alcohol -administer through instillations or
be effective in patient that doesn’t respond with Drugs in this class: P Diphenhydramine (Benadryl) nebulization.
other decongestants. T ½ of 2.5-7 hours -caution with acute brochospasm,peptic
- Has an anti-inflammatory action that 1st generation: Azelastine ulcer,and esophageal varices.
produce direct local effect. (Astelin),Brompheniramine, Buclizine ( Bucladin -splits links in mucoproteins contained in
- Onset of action may not be immediate, and S),Cetirizine(Reactine),Chlorpheniramine (Aller- secretions,decreasing viscosity.
may require up to a week to cause any changes. chlor),Clemastine (Tavist),Cyclizine Drugs in this class : P Acetylcysteine
- If no effects after 3 weeks , discontinue the (Marezine),Cyproheptadine(Periactin),Dexclorphe (Mucomyst) T ½ 6.25 hr ,Dornase alfa
drug. niramine(Dexchlor),Dimenhydrinate (Pulmozyme)
- Relieve inflammation after removal of nasal (Dimentabs),Hydroxyzine (Vistaril),Meclizine
polyps. (Bonine),Phenindamine
- Contraindicated with Candida Albicans (Nolohist),Promethazine(Phenergan).
infection,caution to those with TB,chickenpox,and 2nd generation : Desloratadine
measles. (Clarinex),Fexofenadine (Allegra),Loratadine
Drugs in this class: P flunisolide, Beclomethasone ( Claritin).
(Beclovent), Budesonide (Rhinocort)
,Dexamethasone (Decaderm),Fluticasone Expectorants
(AeroBid),Triamcinolone ( Kenacort)
-liquefy lower respiratory tract secretions,reducing
viscosity of these secretions, and making it easier
Antihistamines for patient to cough them out.
-reduces adhesiveness and surface tension of
-blocks the effect of histamine 1 receptor sites, secretions,movement of less viscous secretions
bringing relief to the patient to patients suffering -more productive cough, decreased frequency of
from itchy eyes,swelling,congestion,and drippy coughing.
nose. -P Guaifenesin (symptomatic reliefof respiratory
-treatment for seasonal and perennial allergic condition characterized by dry, nonproductive,
rhinitis,uncomplicated urticaria,angioedema cough, and in the presence of mucus in respiratory
-also has anticholinergic effects and antipruritic cough)
effect. -adverse effects:
-most effective if used before the onset of Nausea,vomiting,headache,dizziness,rash.
symptoms. -Not to use this drug for more than 1 week.
-Onset of action 1-3 hours. -Advise the use of small,frequent meals.
-caution to those with arrythmias and prolonged
Q-T intervals.
Chapter 55 - Drugs Used To Treat -dilates the bronchi and increased the rate
Obstructive Pulmonary Disease and depth of respiration.
-beta2 selective adrenergic agonists.
Bronchodilators/ Antiasthmatics- -Adverse effects: increase
dilating airways BP,HR,vasoconstriction,decreased renal
Xanthines and GI bloodflow.
-main treatment for bronchospasm and
asthma. -rapidly absorb after injection.
-has direct effect on the smooth muscles Half life of < 1 hour.
of respiratory tract,both in the bronchi and
in the blood vessels. -Caution on those with cardiac
- stimulate 2 prostaglandins resulting in disease,vascular
smoothe muscle relaxation, which then disease,diabetes,hyperthyroidism,
increase the vital capacity. pregnancy and lactation

- inhibit the SRSA. - avoid combination with


- Unlabeled use: stimulation in bronchodilators,general anesthetics
respiration Cheyne Stokes respiration. cyclopropane,and halogenated
- Peak levels within 2 hours. hydrocarbon.
- Caution with patient with GI
problems,coronary disease,respiratory - administer with small frequent meals.
dysfunction,renal or hepatic lung
disease,alcoholism,hyperthyroidism. Drugs in this class: P Epinephrine (Sus –
Phrine, EpiPen), Albuterol(Proventil),
- Increases with nicotine. Bitolterol (Tornalate),
Drugs in the class: P Theophylline ( Sio- Ephedrine,Formoterol (Foradil),
bid ,Theo Dur) Isoetharine(Bronkosol), Isoproterenol
T ½ of 3-15 hr (nonsmoker),4-5 hr (Isuprel), Levalbuterol (Xopenex),
(smoker), Metaproterenol (Alupent).
Aminophylline(Truphylline), Caffeine,
Dyphylline (Dilor). Anticholinergic Bronchodilators
-administer drug with food or milk.
-not as effective as sympathomimetics but
Sympathomimetics can provide some relief to those patient
-mimic the effects of the sympathetic who could not respond to other drugs.
nervous system. -has an effect in the vagus nerve,which
block or antagonize the action of the
neurotransmitter acetylcholine at vagal- -have patient use decongestant drops -Caution patient not to stop meds in
mediated receptor sites, leading to before using inhaled steroid. symptom –free periods.
relaxation of smooth muscles by -Have patient rinse his mouth after inhaler.
bronchodilation. Drugs in this class include:P Flunisolide Lung Surfactant
Drugs in this class: P Ipratropium with an (AeroBid) T ½ of 1-2 hours.,
onset of action of 15 minutes when beclomethasone (beclovent),Budesonide -naturally occurring substance lipoproteins
inhaled.Peak of 1-2 hours,Thiotropium (Pulmicort),Fluticasone containing lipids, and apoproteins that
has rapid onset and longer duration with (Flovent),Triamcinolone (Azmacort). reduce the surface tension within the
half life of 5 to 6 days. alveoli for gas exchange.
-Encourage client to void before each -used to replace the surfactant that is
dose. Leukotriene Receptor Anatagonist missing in lungs of neonates with RDS.
-Provide small frequent meals and -begin to act immediately on instillation
sugarless lozenges. -selectively,and competitively blocks the into the trachea.
-Caution patient not to use inhalator for receptor for production of leukotrienes D4 -No contraindications
more than 12 inhalations in 24 hours. ,E4 components of SRSA. -Adverse effects: patent ductus arteriosus
-blocks many signs and symptoms of in infants,hypotension,intraventricular
Inhaled Steroids asthma,such as neutrophil,eosinophil hemorrhage,pneumothorax,pulmonary air
migration,neutrophil,and monocyte leak,hyperbilirubinemia,and sepsis.
-very effective for treatment of aggregation,leukocyte adhesion,increased Drugs in this class: P Beractant
bronchospasm. capillary permeability,and smooth muscle (Survanta),Calfactant(Infasurf),Colfosceril
-decrease inflammatory response in the contraction. (Exosurf, Neonatal ),
airway,thus increasing air flow and -prophylaxis for bronchial asthma and in Poractant (Curosurf).
facilitate respiration. patients younger than 12 years of age.Not -suction the infant immediately before
-Has 2 effects: indicated for treatment of acute asthma administration,but do not suction for 2
 Decreased swelling associated with attack. hours after administration.
inflammation and promotion in the beta – -metabolized via cytochrome P450 and
adrenergic receptor activity. excreted in feces. Mast Cell Stabilizers
 Inhibit bronchoconstriction. -Abverse effects:
-used for prevention and treatment of headache,dizziness,myalgia,nausea,diarrhe -prevent release of inflammatory and
asthma,treat chronic steroid-dependent a,elevated liver bronchoconstricting substances when mast
bronchial asthma. enzymes,vomiting,fever,pain. cells are stimulated to release these
-should be taken 2-3 weeks to achieve -Increased toxicity if taken with substances because irritation.
effects. propanolol,theophylline,and warfarin Drugs in this class: P Cromolyn T ½ of 80
-Adverse effects: sore throat,coughing,dry Drugs in this class : P Zafirlukast min(inhibit release of histamine and
mouth,and pharyngeal and laryngeal (Accolate),Montelukast(Singulair),Zileuto SRSA,and is inhaled in a capsule but may
fungal infection. n (Zyflo). not reach its peak effect for 1
-administer drug in an empty stomach. week).Nedocromil (inhibit mediators of
inflammatory cells including CHAPTER 56 – INTRODUCTION TO
eosinophils,neutrophils,macrphages,and THE GASTROINTESTINAL SYSTEM Gastrointestinal Activities
mast cells.
-treatment of mild-moderate bronchial The gastrointestinal (GI) system is the The system has four major activities:
asthma of >12 years old patients. only system in the body that is open to the • Secretion
-Cromolyn not recommended for children external environment. The GI system is • Absorption
younger than 2 years old,and nedocromil composed of one continuous tube that • Digestion
not recommended for children younger begins at the mouth; progresses through • Motility
than 12. the esophagus, stomach and small and
-Adverse effects: large intestines; and ends at the anus. The Secretion – secretes various compounds to
headache,dizziness,nausea,sore pancreas, liver and gallbladder are aid the movement of the food bolus
throat,dysuria,cough and nasal congestion. accessory organs that support the through the GI tube, to protect the inner
-Administer oral drug 30 minutes before functions of the GI system. layer of the GI tract from injury and to
meals and at bedtime. facilitate the digestion and absorption of
-Instruct patient not to wear contact lenses Composition of the Gastrointestinal Tract nutrients.
if using Cromolyn eye drops. The GI tube is composed of - Saliva – contains water and
-Dizziness and fatigue common problem four layers: digestive enzymes and
in takinh Nedocromil. • The Mucosa – provides the inner
facilitate swallowing by
lining of the GI tract
making bolus slippery
• The Muscularis Mucosa – is made
up of muscles. It helps the tube - Histamine 2 receptors –
open and squeezing the tube to aid gastrin and
digestion and motility. It also helps parasympathetic system
propel the gastrointestinal contents stimulates it, causing the
down the tract. cells to release
• The Nerve Plexus – these gives the
hydrochloric acid into the
GI tract local control of movement,
lumen of the stomach.
secretions, and digestion.
• The Adventitia – outer layer of the - Bile – contains detergent
GI tract, serves as a supportive like substance that breaks
layer and helps the tube maintain apart fat molecules so that
its shape and stay in position. they can be processed and
absorbed.
- Gallstones – develop when
the concentrated bile
crystallizes.
are very important to the functioning of
Digestion – process of breaking food into Local Gastrointestinal Reflexes the GI tract.
usable, absorbable nutrients. • Gastroenteric reflex: stimulatiuon
of the stomach by stretching, the  Swallowing – is a centrally
Absorption – active process of removing presence of food, or cephalic mediated reflex that is important in
water, nutrients and other elements from delivering food to the GI tract for
stimulation causes an increase in
the GI tract and delivering them to the
activity in the small intestine. It is processing. It is controlled by the
bloodstream for use for the body.
thought that this prepares the small medulla and involves a complex
Motility – GI tract depends on this to keep intestine for the coming chyme. series of timed reflexes.
things moving through the system. • Gastrocolic reflex: stimulation of
- Peristalsis – basic the stomach also causes increased  Vomiting – is controlled by the
movement in the activity in the colon, again chemoreceptor trigger zone (CTZ)
esophagus. It is a constant preparing to empty any contents to in the medulla or by the emetic
wave of contraction that provide space for the new chime. zone in immature or injured brains.
moves from the top to the • Duodenal-colic reflex: the The CTZ is stimulated by several
bottom of the esophagus. presence of food or stretch in the different processes and initiates a
- Swallowing – response to a duodenum stimulates colon complex series of responses that
food bolus in the back of activity and mass movement, again first prepare the system for
the throat stimulates the to empty the colon for the new vomiting and then cause a strong
peristaltic movement that chime. backward peristalsis to rid the
directs the food bolus into stomach of its contents.
the stomach. Other local GI reflexes:
- Segmentation – involves • Ileogastric reflex
contraction of one segment • Intestinal-intestinal reflex
of small intestine while the • Peritoneointestinal reflex
next segment then relaxes, • Renointestinal reflex
and the relaxed segment • Vesicointestinal reflex
contracts. • Somatointestinal reflex

Central Reflexes
Two centrally mediated reflexes -
Swallowing reflex and Vomiting reflex –