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• NURS3415 Pharmacological Concepts, Module 2B, includes a didactic learning guide.

Elimination: Furosemide - High Ceiling Loop Diuretic

• Furosemide's mechanism of action involves blocking the reabsorption of sodium and chloride in the loop of Henle, leading to increased excretion of water, potassium, sodium, chloride, magnesium, and calcium.
• Therapeutic applications include rapid mobilization of fluid in conditions such as pulmonary edema and edema unresponsive to other diuretics, and unlabeled use for hypercalcemia.
• Complications include dehydration, hypotension, ototoxicity, hypokalemia (K+ less than 3.5mEq/L), and other electrolyte imbalances, as well as hyperglycemia, hyperuricemia, and altered cholesterol and triglyceride levels.
• Furosemide is contraindicated in pregnant/lactating women and those with anuria; use with caution in clients with liver disease, diabetes, dehydration, electrolyte depletion, gout, or those taking digoxin, lithium, ototoxic meds, NSAIDs, or antihypertensives.
• Interactions include digoxin toxicity in hypokalemia and additive hypotensive effects with antihypertensives; lithium carbonate levels can increase, leading to toxicity if hyponatremia occurs.
• NSAIDs reduce the diuretic effect by decreasing blood flow to the kidneys.
• Nursing involves obtaining baseline data, daily weight monitoring, monitoring BP and I&O, administering medication as prescribed (IV bolus at 20 mg/min or slower), monitoring potassium levels (report if below 3.5mEq/L), and implementing fall precautions.
• Evaluation includes decrease in edema, weight loss, decrease in blood pressure, increase in urine output, and decrease in calcium level; client education includes self-monitoring, slow position changes, reporting signs of hypovolemia, consuming potassium-rich foods, and monitoring blood glucose if diabetic.

Hydrochlorothiazide – Thiazide Diuretic

• Hydrochlorothiazide works in the early distal convoluted tubule, blocking reabsorption of sodium and chloride and promoting diuresis when renal function isn't impaired.
• Therapeutic uses include essential hypertension and edema from mild to moderate heart failure, liver, and kidney disease; it's also used with antihypertensives for BP control, reduces urine production in diabetes insipidus, and promotes calcium reabsorption to reduce post-menopausal osteoporosis risk.
• Complications include dehydration, hyponatremia, hypokalemia, hypochloremia, hyperglycemia, hyperuricemia, hypomagnesemia, and increased lipids.
• Contraindications/precautions include pregnancy, lactation, and renal impairment; caution is advised for cardiovascular disease, diabetes, hypokalemia, hyperlipidemia, hypomagnesemia, gout, and those taking digoxin, lithium, or antihypertensives.
• Drug interactions include digoxin toxicity in hypokalemia, additive hypotensive effects with antihypertensives, and increased lithium carbonate levels.
• Thiazide diuretics do not cause hearing loss and can be combined with ototoxic meds
• Nursing involves baseline data collection, monitoring of potassium levels, alternate-day dosing to decrease electrolyte imbalances, daily weight monitoring, and monitoring BP and I&Os; clients should be advised to rise slowly.
• Evaluation includes BP and edema decrease, urine output increase, urine output reduction in diabetes insipidus, and preserved bone integrity in postmenopausal clients; client education includes timing of doses, daily weights, potassium-rich foods, adequate fluid intake, taking with food if GI upset, self-monitoring BP, and keeping a weight log.

Spironolactone – Potassium Sparing Diuretic

• Potassium-sparing diuretics block aldosterone, causing potassium retention and sodium/water excretion.
• This drug class are used with loop/thiazide diuretics for potassium-sparing effects in hypertension and edema, and for heart failure.
• Treatment of primary hyperaldosteronism by blocking aldosterone actions, effective in 48-72 hours.
• Complications include hyperkalemia, endocrine effects (deep voice, impotence, menstrual irregularities, gynecomastia, hirsutism), and metabolic acidosis (drowsiness, restlessness).
• Do not administer to pregnant/lactating women, clients with hyperkalemia/potassium supplements, or those with severe kidney failure/anuria; caution with kidney/liver disease, electrolyte imbalance, or metabolic acidosis.
• Interactions include increased hyperkalemia risk with ACE inhibitors, angiotensin receptor blockers, direct renin inhibitors, potassium supplements, and salt substitutes.
• Nursing includes oral administration with food, baseline data collection, daily weights, monitoring I&Os, ECG, and potassium levels.

Nursing Evaluation of Medication Effectiveness - Spironolactone

• Nurses should monitor potassium levels (3.5 to 5mEq/L).
• Weight loss can be an effect of the medication.
• Decrease in blood pressure and edema can both be expected.
• When educating the client, tell them to avoid salt substitutes and to self-monitor and report if the experience cramps, thirst, altered menstration, or a deepened voice.

Mannitol – Osmotic Diuretic

• Raises serum osmolality to reduce intracranial/intraocular pressure.
• Prevents kidney failure by osmotic action in the nephron, decreasing ICP by drawing fluid from the brain, decreases intraocular pressure, promotes sodium/water excretion, and manages oliguria.
• Complications include heart failure, pulmonary edema, increased ICP, fluid/electrolyte imbalances, and metabolic acidosis.
• Contraindicated in intracranial bleeds, anuria, severe pulmonary edema, dehydration, and renal failure; use cautiously in heart failure, pregnancy, breastfeeding, renal insufficiency, and electrolyte imbalances.
• Interactions include increased lithium excretion and increased hypokalemia risk with cardiac glycosides.
• Administer by continuous IV with a filter needle and IV tubing filter to prevent microscopic crystals, monitor daily weight, I&Os, and blood electrolytes.
• Monitor for dehydration and increased edema and obtain baseline data.
• Nursing includes monitoring potassium levels, ECG (if low potassium), increased ICP, and metabolic acidosis.
• Normal kidney function includes urine output of at least 30mL/hr, blood creatinine (0.6 to 1.3 mg/dL for males, 0.5 to 1.1 mg/dL for females), and BUN levels of 10 to 20 mg/dL.

Medication instructions include

• Rise slowly, monitor BP, and assess for hypovolemia; significant weight loss, lightheadedness.

Perfusion: Captopril – Angiotensin-Converting Enzyme Inhibitor

• Mechanism reduces angiotensin II production, increases bradykinin, causing vasodilation, sodium/water excretion, potassium retention, and reduced pathological changes related to angiotensin II and aldosterone.
• Captopril is used for hypertension, heart failure, myocardial infarction, and diabetic/nondiabetic nephropathy; ramipril prevents MI, stroke, or death in high-risk clients.
• Complications include orthostatic hypotension, cough, hyperkalemia, rash, altered taste, angioedema (treat with epinephrine), and neutropenia; diuretics contribute to first-dose hypotension.
• ACE inhibitors increase lithium levels; NSAIDs decrease antihypertensive effect and ACE Inhibitors
• Interaction occurs with antihypertensive meds increasing the risk of hyperkalemia.
• Administer orally, except enalaprilat (IV); monitor BP after first dose for 2 hours, take captopril/moexipril 1 hour before meals, notify provider for cough/rash/altered taste/infection signs, rise slowly, and avoid alertness-required activities.

Losartan – Angiotensin II Receptor Blockers (ARBs)

• This drug class blocks angiotensin II, resulting in vasodilation and sodium/water excretion.
• ARBs are utilized for hypertension, heart failure (valsartan & candesartan), stroke prevention (losartan), diabetic nephropathy delay (losartan), and diabetic retinopathy slowing (losartan).
• ARBs have less risk of cough vs ACE inhibitors; however, major ARB complications include angioedema (treat with epinephrine), fetal injury, hypotension, dizziness, and lightheadedness.
• The drug class is contraindicated for pregnant/lactating women and those with bilateral renal artery stenosis or a single kidney; use cautiously in angioedema with ACE inhibitors.
• Nursing involves oral administration with/without food and monitoring weight/edema for heart failure; client education includes single formulation/combination administration, and what actions to take if experiencing side effects or noticable bodily changes.

Verapamil, Diltiazem – Calcium Channel Blockers

• This medication blocks calcium channels, leading to vasodilation and decreased heart contraction force, heart rate, and AV node conduction.
• These meds act on arterioles and the heart. Veins are not significantly impacted.
• They are used for angina pectoris, hypertension, and cardiac dysrhythmias, and potential complications include orthostatic hypotension, peripheral edema(monitor swelling, BP, and diuretic can be prescribed), constipation, suppressed cardiac function, and dysrhythmias.
• Toxicity results in hypotension, bradycardia, AV block, and ventricular tachydysrhythmias.
• Consumption of grapefruit juice leads to toxicity (decreased BP, heart rate, and AV block); verapamil can increase digoxin levels, increasing digoxin toxicity risk; concurrent use of beta-blockers can lead to heart failure, AV block, and bradycardia.
• Admininster IV verapamil slowly over 2 to 3 minutes, and keep BP record.
• Do not chew or crush sustained-release tablets.

Clonidine – Centrally Acting Alpha2 Agonist

• Used in hypertension management, severe cancer pain, and ADHD, clonidine reduces sympathetic outflow, causing bradycardia, decreased cardiac output, and vasodilation.
• Investagative uses include migraine headache, flushing from menopause, Tourette Syndrome, and withdrawal management from alcohol, tobacco, and opioids
• Drowsiness and sedation (decreases over time), dry mouth are expected side effects.
• Serious complications inclue rebound hypertension is abruptly discontinued, should avoid patch use on affected skin for those with scleroderma and systemic lupus erythematosus
• Additive CNS depression occurs with other CNS depressants (ETOH).
• Meds are given orally, epidurally, and transdermally (clonidine only); usually administered twice daily and take the larger dose at bedtime to decrease daytime sleepiness
• Patches are applied every 7 days, and should only be applied to hairless, intact skin

Metoprolol, Propranolol: Beta-Adrenergic Blockers (Sympatholytics)

• Resulting in decreased heart rate, decreased heart muscle contractility, and a decreased rate of conduction through the AV node.
• Vasodialation and excretion of sodium from the reduced release of renin.
• Used for primary hypertension, chest pain/discomfort, tachydyshythmias, heart failure, and myocardial infarction; they also suppress reflex tachycardia due to vasodilators; other uses include hyperthyroidism, migraine headaches, pheochromocytoma, lung issues, and glaucoma.
• For, Metoprolol and propranolol: Bradycardia, decreased cardiac output, AV block, orthostatic hypotension, and rebound myocardium excitation.
• Do not use in with clients in AV block, pregnant/lactating women.
• Interactions include calcium channel blockers intensify the effects of beat blockers.

Nitroprusside

• Centrally acting vasodilator that targets the arteries and veins to rapidly reduce the patient's blood pressure.
• A side effect of the medication is excessive hypertension
• The medication comes with a series of precautions, being ineffective for pregnant and lactating women
• If a patient is under its effect, always measure vital signs

Digoxin – Cardiac Glycosides

• The goal is to provide an increased force of cardiac contraction, and decrease the heartrate
• Can result in dysrhythmias and cardiotoxity.
• Side effects can include vomitting, the patient feeling very tired, and feeling anxious.
• Contraindicated for pregnant women, or people with tachycardia
• Ineffective if taken with thiazide diuretics and loop diuretics
• Monitor heart rate and administer IV over at least 5 minutes.

Epinephrine - Adrenergic Agonist

• Vasoconstriction, cardiac tissue perfusion, and bronchodilation are all effects of using epinephrine.
• Treats heart failure and cases of cardiac arrest.
• Complications can include hypertensive crisis and cardiac complications.
• Contraindications consist of being pregnant; use only if the risk is outweighed by the benefits
• Use an IV pump to control infusion

Medication for shock

• Medication is dopamine
• It can dialate blood cells, particularly beta1 receptors

Nitroglycerin – Organic Nitrate

• • Dilates veins which decreases cardiac oxygen demand
• • Prevents or reduces coronary artery spasms , thus increasing oxygen supply
• Contraindications: Do not use for clients with closed-angle glaucoma and traumatic head injury
• If a patient has angina, take note of how often it happens and what the level of pain is
• Long-term nitroglycerin should not be stopped abruptly

Atorvastatin – HMG -CoA Reductase Agents

• Decreases the production of LDL and cholesterol and liver triglycerides
• • Can protect against cardiac risks
• Contraindications: Pregnant, or if client has lived disease
• Side effect includes muscle pain
• • Grapefruit juice can increase certain statins, thus it should be avoided

Gemfibrozil - Fibrates

• • decreases liver triglyceride levels
• • Increases production of HDL
• • side effect can include minor GI discomfort or gallstones
• Contraindications: clients with liver disease, clients who are pregnant

Amiodarone – Potassium Channel blockers (Class III)

• Reduces contractility with SA and AV nodes and dialates vessels
• • It assists with a-fib
• *Side effects include pulmonary toxicity and visual disturbance
• Contraindications: Do not give to pregnant clients
• • Consuming grapefruit juice can lead to toxicity
• Side effect is very toxic, must be monitored

Adenosine - Others

• Assists with irregular heart beats or if there is an origin in the upper chambers
• Side effects dyspnea and hypotension -Monitor ECGs
• Contraindications, do not give to pregnant patients
• The drug has a short half life and the adverse reactions are mild