HillcrestLPNPharmacology

Causes
http://www.mayoclinic.com/health/chest-pain/DS00016/DSECTION=2

Diagnostics
http://www.mayoclinic.com/health/chest-pain/DS00016/DSECTION=4

Treatment
http://www.mayoclinic.com/health/chest-pain/DS00016/DSECTION=5

EKG Interpretations
http://www.e-ekg.com/

Informational
http://en.wikipedia.org/wiki/Angina
http://www.nhlbi.nih.gov/health/dci/Diseases/Angina/Angina_WhatIs.html
http://www.nlm.nih.gov/medlineplus/angina.html

Original article:

Where on the web?
http://www.webmd.com/hw/brain_nervous_system/hw97809.asp



--------------------------------------------------------------------------------
USE THIS WEBSITE and ATI chapter 5 to
Distinguish between adrenergic and Cholinergic
Sympathetic and parasympathetic
Neuromuscular blockers
Skeletal muscle relaxants
Distinguish between alpha and beta 1 and 2 receptors
What is the role of the vagal nerve?
Drugs to know
Inderal, lopressor, tenormin, pilocar for glaucom, reglan anti-nauseant, atropine is used as a nerve agent, flexeril as a muscle relaxant, calcium reducers for skeletal relaxerds, theophylline as stimulant, benzodiazepines like valium for sedative or hypnotic effects.
How are cholinerics used for respiratory?
Parkinson's?
Belladonna is made into atropine, what can it be used for?
Do crtical exercises on page 195and 196
Check e mail for dates etc of exams.








Topic Overview
Emergencies
Check Your Symptoms
Home Treatment
Prevention
Preparing For Your Appointment
Related Information
Credits



Nervous System Problems

Topic Overview


The nervous system is a complex, highly specialized network. It organizes, explains, and directs interactions between you and the world around you. The nervous system controls:

Sight, hearing, taste, smell, and feeling (sensation).
Voluntary and involuntary functions, such as movement, balance, and coordination. The nervous system also regulates the actions of most other body systems, such as blood flow and blood pressure.
The ability to think and reason. The nervous system allows you to be conscious and have thoughts, memories, and language.
The nervous system is divided into the brain and spinal cord (central nervous system, or CNS) and the nerve cells that control voluntary and involuntary movements (peripheral nervous system, or PNS).

The symptoms of a nervous system problem depend on which area of the nervous system is involved and what is causing the problem. Nervous system problems may occur slowly and cause a gradual loss of function (degenerative), or they may occur suddenly and cause life-threatening problems (acute). Symptoms may be mild or severe. Some serious conditions, diseases, and injuries that can cause nervous system problems include:

Blood supply problems (vascular disorders).
Injuries (trauma), especially injuries to the head and spinal cord.
Problems that are present at birth (congenital).
Problems that cause a gradual loss of function (degenerative). Examples include:
Parkinson's disease.
Multiple sclerosis (MS).
Amyotrophic lateral sclerosis (ALS).
Alzheimer's disease.
Huntington's disease.
Peripheral neuropathies.
Infections. These may occur in the:
Brain (encephalitis or abscesses).
Membrane surrounding the brain and spinal cord (meningitis).
Sinuses (sinusitis), which only rarely spread into brain tissue.
Overuse of or withdrawal from prescription and nonprescription medications, street drugs, or alcohol.
A brain tumor.
Organ system failure. Examples include:
Respiratory failure.
Heart failure.
Liver failure (hepatic encephalopathy).
Kidney failure (uremia).
Other conditions. Some examples include:
Thyroid dysfunction (overactive or underactive thyroid).
High blood sugar (diabetes) or low blood sugar (hypoglycemia).
Electrolyte problems.
Nutritional deficiencies, such as vitamin B1 (thiamine) or vitamin B12 deficiency.
Guillain-Barré syndrome.


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Nervous System Problems: Topic Overview Previous Next





Topic Overview




Nervous System Problems

Topic Overview


A sudden (acute) nervous system problem can cause many different symptoms, depending on the area of the nervous system involved. Stroke and transient ischemic attack (TIA) are common examples of acute problems. You may experience the sudden onset of one or more symptoms, such as:

Numbness, tingling, weakness, or inability to move a part or all of one side of the body (paralysis).
Dimness, blurring, double vision, or loss of vision in one or both eyes.
Loss of speech, trouble talking, or trouble understanding speech.
Sudden, severe headache.
Dizziness, unsteadiness, or the inability to stand or walk, especially if other symptoms are present.
Confusion or a change in level of consciousness or behavior.
Severe nausea or vomiting.









Nervous System Problems

Topic Overview


Seizures can also cause sudden changes in consciousness, feeling (sensation), emotion, or thought. Abnormal body movements, such as muscle twitching, may or may not be present. How often the seizures occur and how severe they are depend on the cause of the seizures and the area of the brain involved.

Diabetes can cause problems with balance, either as a result of peripheral neuropathy or stroke.

Vertigo and dizziness are problems of balance and coordination (equilibrium). Vertigo is often caused by a medication or a problem of the inner ear or brain. Emotional distress, dehydration, blood pressure problems, and other diseases can all cause feelings of dizziness.

Most headaches are not caused by serious central nervous system problems. The pain that comes with a headache can range from a throbbing or a piercing pain, such as with a migraine, to severe pain that comes and goes over several days, such as with cluster headaches. Headaches are usually caused by problems with the sinuses, scalp, or muscles of or around the head.

Review the Emergencies and Check Your Symptoms sections to determine if and when you need to see a health professional.

Renal Urinary
Date: 5/3/2006
To: Senior Pharmacology
From: Sylvester
Drugs to Know
Answer this for all these drugs as they relate to the Renal and urinary system
DrugsLasixAldactoneDiurilMannitol
Lanoxin
Cardizem
HeparinCoumadinMorphine sulfate
fluconazole
methylprednisolone
ElavilUsesAdverseEffectsPrecautionsInterventionsEducation UsesAdverseEffectsPrecautionsInterventionsEducationUsesAdverseEffectsPrecautionsInterventionsEducation
UsesAdverseEffectsPrecautionsInterventionsEducation
BUN:CREATININE RATIO
BUN:creatinine ratio is usually >20:1 in prerenal and postrenal azotemia, and <12:1 in acute tubular necrosis. Other intrinsic renal disease characteristically produces a ratio between these values
CRETININE
Creatinine 0.6-1.3 Increase in serum creatinine is seen any renal functional impairment. Because of its insensitivity in detecting early renal failure, the creatinine clearance is significantly reduced before any rise in serum creatinine occurs. The renal impairment may be due to intrinsic renal lesions, decreased perfusion of the kidney, or obstruction of the lower urinary tract.
Creatine Clearance(140-AGE) Wt kg/72Serum Creatine
POTASSIUM
Potassium K Normal - 3.5-5.0 Increase in serum potassium is seen in states characterized by excess destruction of cells, with redistribution of K+ from the intra- to the extracellular compartment, as in massive hemolysis, crush injuries, hyperkinetic activity, and malignant hyperpyrexia. Decreased renal K+ excretion is seen in acute renal failure, some cases of chronic renal failure, Addison's disease, and other sodium-depleted states. Hyperkalemia due to pure excess of K+ intake is usually iatrogenic.
Drugs causing hyperkalemia include amiloride, aminocaproic acid, antineoplastic agents, epinephrine, heparin, histamine, indomethacin, isoniazid, lithium, mannitol, methicillin, potassium salts of penicillin, phenformin, propranolol, salt substitutes, spironolactone, succinylcholine, tetracycline, triamterene, and tromethamine. Spurious hyperkalemia can be seen when a patient exercises his/her arm with the tourniquet in place prior to venipuncture. Hemolysis and marked thrombocytosis may cause false elevations of serum K+ as well. Failure to promptly separate serum from cells in a clot tube is a notorious source of falsely elevated potassium.
Decrease in serum potassium is seen usually in states characterized by excess K+ loss, such as in vomiting, diarrhea, villous adenoma of the colorectum, certain renal tubular defects, hypercorticoidism, etc. Redistribution hypokalemia is seen in glucose/insulin therapy, alkalosis (where serum K+ is lost into cells and into urine), and familial periodic paralysis. Drugs causing hypokalemia include amphotericin, carbenicillin, carbenoxolone, corticosteroids, diuretics, licorice, salicylates, and ticarcillin.
RBC (Red Blood Cell) COUNT
The RBC count is most useful as raw data for calculation of the erythrocyte indices MCV and MCH [see below]. Decreased RBC is usually seen in anemia of any cause with the possible exception of thalassemia minor, where a mild or borderline anemia is seen with a high or borderline-high RBC. Increased RBC is seen in erythrocytotic states, whether absolute (polycythemia vera, erythrocytosis of chronic hypoxia) or relative (dehydration, stress polycthemia), and in thalassemia minor [see "Hemoglobin," below, for discussion of anemias and erythrocytoses].
HEMOGLOBIN, HEMATOCRIT, MCV (Mean Corpuscular Volume), MCH (Mean Corpuscular Hemoglobin), MCHC (Mean Corpuscular Hemoglobin Concentration)
SODIUM
Increase in serum sodium is seen in conditions with water loss in excessof salt loss, as in profuse sweating, severe diarrhea or vomiting,polyuria (as in diabetes mellitus or insipidus), hypergluco- ormineralocorticoidism, and inadequate water intake. Drugs causingelevated sodium include steroids with mineralocorticoid activity,carbenoxolone, diazoxide, guanethidine, licorice, methyldopa,oxyphenbutazone, sodium bicarbonate, methoxyflurane, and reserpine.
Decrease in sodium is seen in states characterized by intake of free water or hypotonic solutions, as may occur in fluid replacement following sweating, diarrhea, vomiting, and diuretic abuse. Dilutional hyponatremia may occur in cardiac failure, liver failure, nephrotic syndrome, malnutrition, and SIADH. There are many other causes of hyponatremia, mostly related to corticosteroid metabolic defects or renal tubular abnormalities. Drugs other than diuretics may cause hyponatremia, including ammonium chloride, chlorpropamide, heparin,aminoglutethimide, vasopressin, cyclophosphamide, and vincristine
BUN (UREA NITROGEN)
Blood Urea Nitrogen 7-18 Serum urea nitrogen (BUN) is increased in acute and chronic intrinsic renal disease, in states characterized by decreased effective circulating blood volume with decreased renal perfusion, in postrenal obstruction of urine flow, and in high protein intake states.
Decreased serum urea nitrogen (BUN) is seen in high carbohydrate/low protein diets, states characterized by increased anabolic demand (late pregnancy, infancy, acromegaly), malabsorption states, and severe liver damage.
URIC ACID
Increase in serum uric acid is seen idiopathically and in renal failure, disseminated neoplasms, toxemia of pregnancy, psoriasis, liver disease, sarcoidosis, ethanol consumption, etc. Many drugs elevate uric acid, including most diuretics, catacholamines, ethambutol, pyrazinamide, salicylates, and large doses of nicotinic acid.
Decreased serum uric acid level may not be of clinical significance. It has been reported in Wilson's disease, Fanconi's syndrome, xanthinuria, and (paradoxically) in some neoplasms, including Hodgkin's disease, myeloma, and bronchogenic carcinoma.

Marking Period 2 Checklist and study sheet
Complete
ATI chapter 9
Know Meds for Renal systems
NCLEX PN test book in ethics room questions 390, 391, 397, 402, and 405
Epogen and Procrit is an important therapy associated with erythropoiten anomalies. Know this drug what labs willyou need with epogen? How do you administer epogen? When does the therapeutic effects take place?
I am going to add to the drug list

Uses
Adverse
Effects
Precautions
Interventions
Education

Diuretics: Lower doses of thiazide diuretics (eg, hydrochlorothiazide or chlorthalidone 12.5 to 25 mg) can effectively control hypertension, with less risk of hypokalemia and hyperglycemia than higher doses (see also Ch. 199). Thus, potassium supplements may be required less often. Doses > 25 mg/day have been associated with increased mortality

Chapter 9 ATI
Functions of diuretics
Uses of Diuretics

Classes
Thiazide
loop
K sparing
CAI
Osmotic

Drugs
Lasix
Aldactone
Diuril
Mannitol

Know
Uses
Adverse Effects
Precautions
Interventions
Education

Critical Interactions
Lanoxin Lasix
Cardizem Lasix

What are some signs of hypokalemia?

How can we spot digitalis toxicity?

Which diretic is used for glaucoma?


How can diuretic therapy be evaluated?

How are lectrolytes assessed?


What are some foods that would help with hypokalemia?

What is the antidote for heparin?
Comadin?
Morphine sulfate?

Candiduria may respond to flucytosine 50 to 150 mg/kg/day po q 6 hr for 1 to 2 wk but often is resistant. Of the newer antifungal azole derivatives, fluconazole appears best for fungal UTI because of high oral bioavailability, once-per-day dosing, and excellent penetration into urine and CSF. Flucytosine or fluconazole 200 mg/day po should be prescribed for asymptomatic candiduria.
Symptomatic cystitis in the noncatheterized patient can be treated with flucytosine or fluconazole for 1 to 4 wk. Excellent results have also been obtained with a single dose of amphotericin B 0.3 mg/kg IV. In the presence of permanent indwelling catheters, flucytosine and fluconazole may reduce but rarely eradicate the funguria; bladder irrigation may be successful.
In patients with renal candidiasis, amphotericin B and high-dose fluconazole (>= 400 mg/day) are equally effective in the primary treatment of invasive infection with C. albicans and C. tropicalis. Even when amphotericin B is used initially, oral fluconazole should be substituted early in the course of treatment. However, some less common candidal species are not susceptible to fluconazole.

Interstitial Cystitis
Interstitial cystitis (IC) is a chronic bladder disease occurring primarily in women. Etiology is unknown. The bladder wall shows inflammatory infiltration with mucosal ulceration and scarring that results in smooth muscle contraction, diminished urinary capacity, hematuria, and frequent, painful urination. Carcinoma in situ can mimic IC and must be ruled out.
Bladder distension may provide excellent, but transient, relief. Intravesical agents (eg, dimethyl sulfoxide [DMSO], methylprednisolone, heparin sulfate) and oral therapy with anticholinergics or tricyclic antidepressants offer some relief. Rarely, augmentation cystoplasty may be undertaken. Very rarely, cystectomy with urinary diversion is required.

DRUG CLASSES OF CONCERN
Some drug classes (including

1. diuretic,
2. antihypertensive,
3. antiarrhythmic,
4. antiparkinsonian,
5. anticoagulant,
6. psychoactive,
7. hypoglycemic, and
8. analgesic drugs

pose special risks for older patients.

Diuretics: Lower doses of thiazide diuretics (eg, hydrochlorothiazide or chlorthalidone 12.5 to 25 mg) can effectively control hypertension, with less risk of hypokalemia and hyperglycemia than higher doses (see also Ch. 199). Thus, potassium supplements may be required less often. Doses > 25 mg/day have been associated with increased mortality.

Antihypertensives: Treatment of hypertension is effective in older patients; recent analysis of several studies indicates that only 18 older patients must be treated for 5 yr to prevent one cardiovascular event. Different classes of
antihypertensives
have comparable efficacy in older white patients; however,
Ca channel blockers and diuretics
are most effective in older black patients. Whether any antihypertensives are preferable because they best preserve quality of life in the elderly is unclear.
If tolerated, diuretics and -blockers are the first choice because they reduce the risk of cardiovascular complications in older patients.
Contraindications to -blockers include chronic obstructive pulmonary disease and peripheral vascular disease; to clonidine, depression; and to vasodilators and -adrenergic blockers, underlying orthostatic hypotension. Short-acting
dihydropyridines (eg, nifedipine) should not be used because of concern about increased mortality risk.
Antiarrhythmics: Antiarrhythmics (see also Ch. 205) have the same indications and efficacy in older as in younger patients. However, because of altered pharmacokinetics, the dose of some (eg, procainamide, quinidine, lidocaine) should be reduced in the elderly. In addition, the risk of significant adverse reactions to certain drugs (eg, mexiletine; class IC drugs, such as encainide and flecainide) increases with age. Digoxin clearance decreases an average of 50% in elderly patients with normal serum creatinine levels. Therefore, maintenance doses should be started low (0.125 mg/day) and adjusted according to response and serum digoxin levels.
Antiparkinsonian drugs: Levodopa clearance is reduced in older patients, who are also more susceptible to postural hypotension and confusion. Therefore, older patients should receive low starting doses of levodopa and should be carefully monitored for adverse effects (see also Ch. 179). Patients who become confused while taking levodopa may not tolerate newer dopaminergic agonists (eg, bromocriptine, pergolide, pramipexole, ropinirole) better. Because older patients with parkinsonism may be cognitively impaired, anticholinergic drugs should be avoided.
Anticoagulants: Aging does not alter the pharmacokinetics of warfarin but may increase sensitivity to its anticoagulant effect. (Studies have not confirmed that aging per se increases the overall risk of bleeding, but in some studies, patients who had atrial fibrillation and were > 75 yr had an increased risk of cerebral hemorrhage.) Older patients generally require lower loading (<> of warfarin (see also Ch. 72). If the drug has to be stopped (eg, before surgery), return to normal clotting status may be slower in older patients.
Psychoactive drugs: In nonpsychotic, agitated patients, antipsychotics control symptoms only marginally better than do placebos. Although antipsychotics can reduce paranoia, they may worsen confusion (see also Ch. 171). Older patients, especially women, are at increased risk of tardive dyskinesia, which is often irreversible. Sedation, postural hypotension, anticholinergic effects, and akathisia (subjective motor restlessness) can occur in up to 20% of older patients taking an antipsychotic, and drug-induced parkinsonism can persist for up to 6 to 9 mo after stopping the drug. When an antipsychotic is used, the starting dose should be about 1/4 the usual adult dose and increased gradually. Risk of extrapyramidal dysfunction appears to be less with the new atypical antipsychotics (eg, olanzapine, quetiapine, risperidone)--a potential advantage in the elderly. However, experience with these drugs in the elderly is limited, and dose reduction is required (eg, for risperidone, a typical dose is 1 to 2 mg/day). The elderly appear to tolerate olanzapine reasonably well.
The use of anxiolytics and hypnotics is problematic (see also Ch. 173). Different benzodiazepines appear equally effective in relieving anxiety symptoms; selection depends on the drug's pharmacokinetics and pharmacodynamics. Treatable causes of insomnia should be sought and managed before using hypnotics (see also Ch. 173). In general, short- to intermediate-acting benzodiazepines with half-lives <> (eg, alprazolam, lorazepam, oxazepam, temazepam) are preferable to induce sedation or sleep. Longer-acting benzodiazepines should be avoided because risk of accumulation and of toxicity is increased, leading to drowsiness, memory impairment, and impaired balance with falls and fractures. Treatment of anxiety or insomnia should be limited in duration if possible because tolerance and dependence may develop; withdrawal may lead to rebound insomnia and anxiety. Buspirone, a partial serotonin agonist, is as effective as benzodiazepines in the treatment of general anxiety disorder; elderly patients tolerate doses up to 30 mg/day well. Its slow onset of anxiolytic action (up to 2 to 3 wk) can be a disadvantage in urgent cases. Zolpidem is a nonbenzodiazepine hypnotic that binds mainly to a benzodiazepine receptor subtype; older patients with insomnia appear to tolerate doses of 5 to 10 mg well. Zolpidem's advantages over benzodiazepines are less disturbance of the sleep profile, fewer rebound effects, and less dependence potential. Histamine blockers (eg, diphenhydramine, hydroxyzine) are not recommended because of their anticholinergic effects.
Antidepressants are the mainstay of treatment of depression in the elderly (see also Ch. 189), and selective serotonin reuptake inhibitors (SSRIs--eg, fluoxetine, paroxetine, sertraline) are generally considered the antidepressant of choice. These drugs appear to be as effective as tricyclic antidepressants and produce less toxicity, especially in overdose. One possible disadvantage of fluoxetine is its long elimination half-life, especially of its active metabolite. Paroxetine is more sedating, has anticholinergic action, and can inhibit hepatic cytochrome P-450 2D6 enzyme activity, with risk of impairing the metabolism of several drugs, including some antipsychotics, antiarrhythmics, and tricyclic antidepressants. Sertraline is more activating; diarrhea is a common adverse effect. Doses of these drugs should be reduced by up to 50%.
Tricyclic antidepressants are effective. Those with the least adverse effects are best for the elderly, and those with significant anticholinergic (eg, amitriptyline, imipramine), antihistaminic (eg, doxepin), and antidopaminergic (eg, amoxapine) effects are best avoided. The norepinephrine reuptake inhibitors nortriptyline and desipramine, starting at 10 to 25 mg/day, are most suitable. Both have low anticholinergic potency, and nortriptyline has the least -adrenergic blocking (hypotensive) action. Overdose produces cardiac and neurologic toxicity, precluding the use of these drugs in patients at risk of suicide. Trazodone is useful in agitated patients, has low anticholinergic potency, and is less cardiotoxic than tricyclics, but it can produce priapism. Bupropion is noncardiotoxic but can increase risk of seizures. Newer drugs (eg, mirtazapine, nefazodone, venlafaxine) should be reserved for patients not responding to or intolerant of SSRIs. Methylphenidate can be useful in treating selected elderly patients with depression who have had a stroke or who have a medical illness. The drug's onset of action is rapid.
Hypoglycemics: Doses of hypoglycemics, including insulin and sulfonylureas, should be titrated to prevent symptomatic hyperglycemia without causing hypoglycemia (see also Ch. 13). Aging can reduce insulin clearance, but dose requirements depend on the level of insulin resistance, which varies widely among patients with type II diabetes. The incidence of hypoglycemia due to sulfonylurea use may increase with age. Chlorpropamide is not recommended because older patients are at increased risk of hyponatremia and because the drug's prolonged duration of action is dangerous if toxicity or hypoglycemia occurs.
Metformin, a biguanide excreted by the kidney, increases peripheral tissue sensitivity to insulin and can be effective in older patients alone or in combination with sulfonylureas. However, long-term efficacy and safety in older patients is not well established. Risk of lactic acidosis, a rare but serious complication, increases with the degree of renal impairment and the patient's age.
Troglitazone, which can be used with insulin or oral hypoglycemics, sensitizes peripheral tissue to insulin's effects. Older patients appear to tolerate it well. However, concern about hepatotoxicity makes it a reserve drug. Troglitazone should be withdrawn if efficacy (eg, reduction of Hb A1c by > 1%) is not shown.
Acarbose, administered with food, reduces postprandial glucose elevations and, in combination with other hypoglycemics, can help improve blood sugar control in some patients. GI intolerance may be a problem.
Analgesics: NSAIDs are among the most widely used drugs, and several are available without prescription (see Ch. 167 and Rheumatoid Arthritis in Ch. 50). Some data indicate that the clearance of salicylate, oxaprozin, and naproxen is decreased in older patients. Peptic ulceration and upper GI bleeding are serious consequences of NSAIDs; risk is greater when an NSAID is begun and when dose is increased. Certain NSAIDs (eg, ibuprofen, diclofenac, salsalate) may be slightly less likely to cause upper GI bleeding. Aging does not seem to increase risk of NSAID-induced adverse GI effects, but if such complications occur, morbidity and mortality are considerably greater in elderly patients. The risk of upper GI hemorrhage increases more than tenfold when NSAIDs are combined with warfarin. For patients with a high risk of NSAID-induced gastropathy complications, misoprostol or a more potent gastric acid inhibitor (eg, omeprazole, lansoprazole) can be added. Such drugs can reduce the risk of peptic ulcer formation. The risk of NSAID-induced renal impairment may be increased in older patients. Monitoring serum creatinine is a reasonable approach, especially for patients with other risk factors (eg, heart failure, renal impairment, cirrhosis with ascites, volume depletion, diuretic use). Cyclooxygenase-2 (COX-2) inhibitors, or coxibs, may decrease risk of GI complications, however, one member of the class, rofecoxib (withdrawn from market), appears to increase the risk of cardiovascular events after long-term use. The risk for cardiovascular events with other coxibs is undergoing evaluation. Because one study has shown a 2.5-fold increase in cardiovascular events with celecoxib, FDA recommendations, pending further evidence, are to limit use of any coxib to patients who are at a high risk of GI bleeding, have a history of intolerance to nonselective NSAIDs, or are not doing well on nonselective NSAIDs. Use of coxibs for long periods or in patients with cardiovascular risk factors should be approached cautiously.