CHAPTER 42: INTRODUCTION TO THE mitral or bicuspid valve- valve on the left side of the heart;
CARDIOVASCULAR SYSTEM composed of two leaflets or cusps
Cardiovascular System
- responsible for delivering oxygen and nutrients to all of
the cells of the body and for removing waste products for
excretion
- consists: 1. heart 2. pump3. interconnected series of tubes
THE HEART
- hollow, muscular organ divided into 4 chambers: atriums (
“porch” or entryway) and ventricles ( lower part)
- is the pump that keeps blood flowing through 60,000 miles
of tubes, constituting the cardiovascular system
*auricle- attached to each atrium; collects blood that is
pumped into the ventricles by arterial contraction
** a partition called a septum separates the right half of the
heart from the left. The right receives deoxygenated blood
from everywhere in the body through the veins ( vessels that
carry blood toward the heart) and directs that blood into the
lungs…
*** arteries- where aorta delivers blood into the systemic
circulation
- vessels that carry blood away from the heart
CARDIAC CYCLE
- … each period of the ventricles followed by a period of
systole= cardiac cycle…
* myocardium
- fibers of cardiac muscle
- form two intertwining networks called atrial and
ventricular syncytia
* Starling’s law of the heart
-occurs when muscle fibers of the heart are stretched by the
increase volume of blood that has returned spring back to
normal size; is similar to stretching a rubber band…
* Diastole
- the period of cardiac muscle relaxation where the heart
from the systemic and pulmonic veins, w/c flow into the
right and left…
* tricuspid- valve on the right side of the heart; composed
of 3 leaflets or cusps
CONDUCTIVITY
- where the specialized cells of the heart can conduct an
* systole
- the contraction of ventricles
* The heart’s series of one- way valves keeps the blood
flowing on the correct direction, as follows:
1. Deoxygenated blood: right atrium, though tricuspid valve
to right ventricle, through pulmonary valve to the lungs
2. Oxygenated blood: through the pulmonary veins to
ventricle, through aortic valve to the aorta
CONDUCTION SYSTEM OF THE HEART
- consist of:
1. SA node- located in top of the right atrium, acts as the
pacemaker of the heart
2. AV nodes- slows the impulse, allowing for the delay
needed for ventricular filling, and sends it from the atria into
the ventricles by way of the bundle of His
3. Bundle of His- w/c enters the septum and divides into
three bundle branches
4. Bundle branches- w/c conduct impulses through the
ventricles
5. Purkinje fibers- w/c delivers the impulse the ventricular
cells
***Sinoatrial (SA) node
AUTOMATICITY
- where the cells can generate action potentials or electrical
impulses without being excited to do so by external stimuli
5 phases:
1. Phase 0- points of stimulation; where: sodium gates open
along the cell membrane, and sodium rushes into the cell,
resulting in a positive state—an electrical potential called
depolarization
2. Phase 1- when Na ions concentrations are equal inside
and outside of the cell
3. Phase 2 (plateau stage)- cell membrane becomes less
permeable to Na Ca slowly enters the cell K slowly
leaves the cell
4. Phase 3- rapid repolarization  K rapidly moves out of
the cell
5. Phase 4- cell comes to rest as the sodium- potassium
pump returns the membrane spontaneous repolarization
begins again
impulse rapidly through the system so that the muscle cells
of the heart are stimulated at approximately the same time…
* absolute refractory period
***** SA node is the dominant influences most of the time,
keeping the resting heart rate at 70 to 80 beats per minute
* Sarcomere- the basic unit of the cardiac muscle
- made up of two contractile proteins: actin (thin filament)
and myosin (thick filament) kept apart by the protein
troponin
* Degree of shortening- determined by the amount of Ca
present—the more Ca is present, the more bridges will be
formed…
ARRYTHMIA OR DYSRYHTHMIA
- a disruption in cardiac rate or rhythm
- interfere with the work of the heart and can disrupt cardiac
output, which affects every cell in the body
- occurs when there is a shift in the pacemaker of the heart
from the SA node to some other sit, called ectopic focus
FIBRILLATION
- very serious arrhythmias arise when the combination of
ectopic foci and altered conduction set off an irregular,
uncoordinated twitching of the atrial or ventricular muscle
ELECTROCARDIOGRAPHY
-is a process of recording the patterns of electrical impulses
as they move through the heart
- an important diagnostic tool in the care of the cardiac
patients
ELECTROCARDIOGRAPHY MACHINE
- detects the patterns of electrical impulse generation and
conduction though the heart and translates that information
to a recorded pattern
ELECTROCARDIOGRAM
-a measure of electrical activity; provides no information
about the mechanical activity of the heart
The normal ECG pattern is made up of main waves:
1. P wave- formed as impulses originating in the SA node or
pacemaker pass through the atrial tissue
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 :
1. P-R interval: reflects the delay of conduction at the AV
node
2. Q-T interval: reflects the critical timing of repolarization
of the ventricles
3. S-T segment: reflects the important information about the
repolarization of the ventricles
TYPES OF ARRHYTHMIAS
1. Sinus arrhythmias
- has a slower- than- to normal heart rate (usually less than
60 beats/ min) w/ Normal- appearing ECG pattern
2. Supraventricular Arrhythmias
- arrhythmias that originate above the ventricles but not in
the SA node
- feature an abnormally shaped P wave
- includes the following:
a. Premature atrial contractions (PAC’s)- reflect an ectopic
focus in the atria that is generating an impulse out of the
normal rhythm
b. Paroxysmal atrial tachycardia (PAT)- runs of rapid heart
originating in the atria
c. Atrial flutter- characterized b sawtooth- shaped P waves
reflecting a single ectopic focus that is generating a regular,
fast atrial depolarization
d. Atrial fibrillation- w/ irregular P waves representing many
ectopic foci firing in an uncoordinated manner through the
atria
3. Ventricular Arrhythmias
- impulses that originate below the AV node originate from
ectopic foci that do not use the normal conduction pathways
ATRIOVENTRICULAR BLOCK
- also called heart block
- reflects a slowing or lack of conduction at the AV node
-occur because of structural damage, hypoxia, or injury to
the heart muscle
- First degree of heart block= P-R interval beyond the
normal 0.16 to 0.20 seconds
CARDIOVASCULAR SYSTEM
CIRCULATION
- follows two courses:
1. Heart lung or pulmonary circulation: the right side of the
heart sends blood to the lungs, where carbon dioxide and
some waste products are removed from the blood and
oxygen is picked up by the red blood cells
2. Systemic circulation: the left side of the heart sends
oxygenated blood out to all of the cells in the body
* resistance system
- also referred as arterial system
- where the vessels can either constrict or dilate, increasing
or decreasing resistance, based on the needs of the body
* capillary system
- where blood from tiny arterioles flows
- connects the arterial and venous system
* capillary fluid shift
- shifting of fluid in the capillaries
- carefully regulated between hydrostatic (fluid pressure)
forces in the arterial end of the capillary and oncotic
pressure ( the pulling pressure of the large, vascular
proteins)
*Capacitance system
- also referred as venous system
- where the veins has the capacity to hold large quantities of
fluid
* sinuses of Valsalva
- where the myocardium receives its blood through 2 main
coronary arteries that branch off the base of the aorta
*coronary arteries
- these arteries encircle the heart in pattern resembling a
crown
*pulse pressure
- the pressure that fills the coronary arteries
- it is systolic minus diastolic blood pressure readings
* end- artery circulation
- a pattern of circulation
The main forces hat determine the heart’s use of oxygen or
oxygen consumption are as follows:
1. Heart rate: the more the heart has to pump, the more
oxygen it will require to do that
2. Preload ( amount of blood that is brought back to the
heart to be pumped around): the more blood that is returned
to the heart, the harder it will have to work to pump the
blood around. The volume of blood that is determinant of
preload
3. Afterload ( resistance against which the heart has to beat):
The higher the resistance in the system, the harder the heart
will have to contract to force open the valves and pump the
blood along. The blood pressure is measure of afterload
SYTEMIC ARTERIAL PRESSURE
* Hypotension
- occur if the blood pressure falls, either from the loss of
blood flowing from high- pressure to low pressure areas
- if severe, it can progress to shock and even death as cells
are cut off from their oxygen supply
* Hypertension
- excessive high blood pressure
- can damage the fragile lining of blood vessel
- cause disruption of blood flow to the tissues
- caused by neurostimulation of the blood vessels that cause
them to constrict and to raise pressure
* Vasomotor Tone
- work to dilate the vessels if more blood flow is needed in
an area
*Cardiovascular center
- the coordination of these impulses through the medulla
RENIN – ANGIOTENSIN SYSTEM
-determinant of Blood pressure
- activated when the blood flow to the kidneys is decreased
-…cells in the kidney release an enzyme called rennin
- Angiotensin I travels to lungs  Angiotensin- converting
enzyme (ACE)  reacts  Angiotensin II =
Vasoconstriction
(read: p. 635)
CONGESTIVE HEART FAILURE
- if the heart fails to do its job of effectively pumping
through the system, blood backs up and system becomes
congested
- results: hydrostatic pressure on the venous end of the
capillaries
 CHAPTER 43: DRUGS AFFECTING BLOOD
PRESSURE
- altering the body’s regulatory mechanisms
- alter the normal reflexes that control BP
- does not cure the disease but is aimed at
maintaining the BP within normal limits to
prevent the damage that hypertension can
cause
Stepped-Care Approach to Treating
Hypertension
- by the Seventh Joint National Committee
on Prevention, Detection, Evaluation, and
Treatment of Hypertension, from the
National Institute of Health
Step 1: Lifestyle Modifications
o weight reduction
o reduction of sodium intake
o moderation of alcohol intake
o smoking cessation
o increased physical activity
Step 2: Inadequate Response
o continue lifestyle modifications
o initial drug selection
1. diuretic or β-blocker
2. ACE inhibitor, calcium channel
blocker, α-blocker, α- and β-
blocker
Step 3: Inadequate Response
o increase drug dose, or
o substitute another drug, or
o add a second drug from another
class
Step 4: Inadequate Response
o add a second or third agent or
diuretic if not already prescribed
Diuretics
- ↑ the excretion of sodium and water from
the kidney
- first agents tried in mild hypertension
- ↑ urination and disturb electrolyte and
acid-base balances
Sympathetic Nervous System Blockers
- block the effects of the SNS
- useful in blocking many of the
compensatory effects of the SNS
β-blockers block vasoconstriction; ↓ HR; ↓
muscle cardiac contraction; ↑
blood flow to kidneys; used in
monotherapy in Step 2
α- and β- blocking of all receptors in SNS;
blockers patients complain of fatigue,
loss of libido, inability to sleep,
GI and GU disturbances
α-adrenergic inhibit postsynaptic α1-
blockers adrenergic receptors, ↓
sympathetic tone in the
vasculature and causing
vasodilation; diagnose and
manage episodes of
pheochromocytoma
α1-blockers block postsynaptic α1-receptor
sites, ↓ vasculature and
causing vasodilation; do not
block presynaptic α2-receptor
sites
α2-agonists stimulate α2-receptors in the
CNS and inhibit the CV centers,
↓BP; many adverse CNS, GI
effects, cardiac dysrhythmias
Angiotensin-Converting Enzyme (ACE)
Inhibitors
- block the conversion of angiotensin I to
angiotension II in the lungs
- as monotherapy or combined with
diuretics
Prototype: captopril (Capoten)
- for hypertension, congestive heart failure
(CHF), diabetic neuropathy, left
ventricular dysfunction after MI
- associated with fatal pancytopenia,
cough, GI distress
Therapeutic Actions and Indications
- ↓ BP and aldosterone release
- indicated for treatment of hypertension,
alone or with other drugs
Pharmacokinetics
- well absorbed, widely distributed
- metabolized in liver, excreted in urine
and feces
- cross the placenta and associated with
serious fetal abnormalities
Contraindications
- allergy
- impaired renal function
- pregnancy and lactation
Caution
- CHF
- salt/volume depletion
Adverse Effects
- effects of vasodilation and alterations in
blood flow
o reflex tachycardia, chest pain,
angina, CHF, cardiac arrhythmias
o GI irritation, ulcers, constipation,
liver injury
o renal insufficiency, renal failure,
proteinuria
o rash, alopecia, dermatitis,
photosensitivity
- unrelenting cough
- associated with fetal pancytopenia and
MI
Drug-Drug Interactions
- allopurinol = risk of hypersensitivity
reactions ↑
Food-Food Interactions
- food = absorption of oral ACE inhibitors ↓
Nursing Considerations
- encourage patient to implement lifestyle
changes
- administer on empty stomach, 1 or 2
hours before meals
- monitor fluid volume
Angiotensin II Receptor Blockers (ARBs)
- selectively bind the angiotensin II
receptors in blood vessels to prevent
vasoconstriction
- prevents the release of aldosterone in the
adrenal cortex

Prototype: losartan (Cozaar)
- used alone or as part of combination
therapy
- treatment of diabetic neuropathy with an
elevated serum creatinine an d
proteinuria
Therapeutic Actions and Indications
- selectively bind with angiotensin II
receptor sites in vascular smooth muscle
and in the adrenal gland to block
vasoconstriction and aldosterone release
- treatment of hypertension and for CHF in
patients who are intolerant to ACE
inhibitors
Pharmacokinetics
- well absorbed, metabolized in liver
- excreted in urine and feces
- crosses the placenta, associated with
serious fetal abnormalities and death
Contraindications
- allergy
- pregnancy and lactation
Cautions
- hepatic or renal dysfunction
- hypovolemia
Adverse Effects
- headache, dizziness, syncope, weakness
- hypotension, GI complaints
- symptoms of upper respiratory tract
infections and cough
- rash, dry skin, alopecia
Drug-Drug Interactions
- phenobarbital = risk of ↓ serum levels
and loss of effectiveness ↑
Nursing Considerations
- encourage patient to implement lifestyle
changes
- administer without regard to meals; give
with food
- suggest use of barrier contraceptives
- monitor fluid volume
Calcium Channel Blockers - treatment of hypertensive crisis and
- prevent the movement of calcium into maintain controlled hypertension during
the cardiac and smooth muscle cells surgery
- when the cells are stimulated - toxic levels cause cyanide toxicity
- leading to loss of smooth muscle tone,
vasodilation, ↓ peripheral resistance Therapeutic Actions and Indications
- ↓ BP - act directly on vascular smooth muscle to
- very effective for treatment of angina cause muscle relaxation, leading to
vasodialtion and drop in BP
Prototype: diltiazem (Cardizem, Tiamate)
- sustained-release preparation Pharmacokinetics
- treatment of hypertension - rapidly absorbed and widely distributed
- metabolized in the liver and excreted in
Therapeutic Actions and Indications urine
- inhibit the movement of calcium ions - cross the placenta and enter breast milk
across the membranes of myocardial and
arterial muscle cells Contraindications
- allergy
Pharmacokinetics - pregnancy and lactation
- well absorbed, metabolized in liver, - cerebral insufficiency
excreted in urine
- cross the placenta, enters breast milk Cautions
- peripheral vascular disease, CAD, CHF,
Contraindicaitons tachycardia
- allergy
- heart block or sick sinus syndrome Adverse Effects
- renal or hepatic dysfunction - related to changes in BP
- pregnancy or lactation - cyanide toxicity may occur with
nitroprusside
Adverse Effects o dyspnea o imperceptible
- CNS effects o headache pulse
o vomiting o absent reflexes
- GI effects o dizziness o dilated pupils
- CV effects o ataxia o pink color
- skin flushing, rash distant heart
o loss of o
consciousne sounds
Drug-Drun Interactions
- cyclosporine = ↑ serum levels and
ss o shallow breathing
toxicity of cyclosporine
Nursing Considerations
- monitor BP and fluid volume
Vasodilators
- produce relaxation of the vascular
Other Hypertensive Agents
smooth muscle, ↓ peripheral resistance
and reducing BP
only drug: mecamylamine (Inversine)
- do not block reflex tachycardia
- ganglionic blocker that occupies
- reserved for use in severe hypertension
cholinergic receptor sites of autonomic
and hypertensive emergencies
neurons, blocking the effects of
acetylcholine at both sympathetic and
Prototype: nitroprusside (Nitropress)
parasympathetic ganglia
- used intravenously
- can cause
o severe hypotension, CHF
 o CNS symptoms of dizziness, syncope,
weakness, vision changes
parasympathetic blocking symptoms
o headache
of dry mouth, glossitis, nausea,
vomiting, constipation, urinary
retention
o impotence
ANTIHYPOTENSIVE AGENTS
- severe hypotension leads to shock
- sympathomimetic drug: first choice drug for
treating shock
Sympathetic Adrenergic Agonists
- effects of a sympathetic stress response:
↑ BP
o CHAPTER 44: CARDIOTONIC
o ↑ blood volume
o ↑ strength of cardiac muscle
contraction
only drug: midodrine (ProAmatine)
- treat orthostatic hypotension
Therapeutic Actions and Indications
- activates alpha-receptors in arteries and
veins to ↑ in vascular tone and BP
- indicated for the symptomatic treatment
of orthostatic hypotension
Pharmacokinetics
- rapidly absorbed in GI tract
- metabolized in liver and excreted in urine
Contraindications
- supine hypertension, CAD,
pheochromocytoma
- acute renal disease
- urinary retention
Cautions
- pregnancy and lactation
- visual problems
- renal or hepatic impairment
Adverse Effects
- related to stimulation of alpha-receptors
o piloerection, chills, rash
o hypertension, bradycardia
o dizziness, vision changes, vertigo,
o problems with urination
Drug-Drug Interactions
- risk of ↑ effects and toxicity of cardiac
glycosides, beta-blockers, alpha-
adrenergic agents, corticosteroids if
taken with midodrine
Nursing Considerations
- monitor BP
- do not administer to bedridden patients
- monitor HR regularly
- monitor patients with visual problems
- encourage patients to void before taking
drug
AGENTS
Congestive heart failure (CHF)
-condition where the heart fails to effectively
pump blood around the body
- called “dropsy’ or compensation
TREATMENTS OF CHF:
1. VASODILATORS
- used to treat CHF because they can decrease
the workload of the overworked cardiac
muscle
2. DIURETICS
- use to decrease blood volume, which
decreases venous return and blood pressure
- end result: decrease in afterload and preload
and a decrease in the heart’s workload
3. BETA- ADRENERGIC AGONISTS
- stimulate the beta receptors in the
sympathetic nervous system, increasing
calcium flow into the myocardial cells and
causing increased contraction, positive
inotropic effect
4. CARDIOTONIC DRUGS
- drugs that affect the intracellular calcium
levels in the heart muscle, leading to increased
contractility
- increase in contraction strength leads to
increased cardiac output, which causes
increased renal blood flow decreases rennin
release
-increases urine output
-decreased blood flow
- relieve CHF
- has two types:
A. CARDIC GYCOSIDES
- used for hundred of years
- derived form foxglove or digitalis plant
Drugs:
1. Digoxin (Lanoxin, Lanoxicaps)
-treatment of acute congestive heart failure,
atrial arrhythmias
* THERAPEUTIC ACTIONS
1.increase intracellular calcium and allow
more calcium to enter myocardial cells during
depolarization, causing following effects:
a. Increased force of myocardial contraction
b. Increased cardiac output and renal perfusion
c. Slowed heart rate
d. decreased conduction velocity through the
artrioventricular node
**PHARMACOKINETICS
1. absorbed widely
2. excreted unchanged in urine
3. caution w/ presence of renal impairements
4. not given during pregnancy
5. enters breast milk
*** CONTRAINDICATION
1. presence of allergy
2. tachycardia or fibrillation
3. heart block or sick sinus syndrome
4. idiopathic hypertrophic subaortic stenosis
(IHSS)
5. acute MI
6. renal insufficiency
7. electrolyte abnormalities
****CAUTION
1. pregnant or lactating women
2. **pediatric and geriatric patients
*****ADVERSE EFFECTS
1. headache, weakness, drowsiness and vision
changes
2. GI upset and anorexia
3. risk of arrhythmia development
*****DRUG-DRUG INTERACTION
1. taken with veramil, aminodarone, quinidine,
quinine, erythromycin, tetracycline or
cyclosporine = increased therapeutic effects
NURSING CONSIDERATION
DIAGNOSIS
1. Risk for deficient fluid volume related to
diuresis
2. Ineffective Tissue perfusion related in
cardiac output
3. Impaired Gas exchanged related to changes
in Cadiac Output
4. Deficient Knowledge regarding drug
therapy
4. increased cellular calcium causes
IMPLEMENTATION contraction and prolongs effects of
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
2. Monitor apical pulse for 1 full minute responded to digoxin or diuretics
before administration of drugs
3. Monitor pulse for any change in quality or **PHARMACOKINETICS
rhythm 1. widely distributed after injection
4. check for dosage and preparation carefully 2. metabolized in the liver
5. Check pediatric dosage with extreme extra 3. excreted in the urine
care
6. follow dilution instructions ***CONTRAINDICATIONS
7.administer IV doses very slowly at least 5 1. has allergy
minutes 2. w/ severe aortic or pulmonic valvular
8. Avoid IM administration disease
9. Arrange the patient to be weighed 3. fluid volume deficit
10. Avoid administering oral drug with food or
antacids
11. Monitor patient digoxin level ( 0.5 to 3 ****CAUTIONS
ng/mL) 1. Elderly
2. pregnant or lactating women
B. PHOSPHODIESTERASE INHIBITORS
- belong to a second class of drugs that act as ***** ADVERSE EFFECTS
cardiotonic (intropic) agents 1. ventricular arrhythmias, hypotension and
Drugs: chest pain
1. Inamripone (Inocor) 2. GI effects: nausea, vomiting, anorexia,
- treatment of adults with congestive heart abdominal pain
failure not responsive to digoxin, diuretics or 3. Thrombocytopenia
vasodilators 4. hypersensitivity reactions: vasculitis,
2. Milrinone (Pimacor) pericarditis, pleurititis, and ascites
- shorterm management of CHF in adults
receiving digoxin and diuretics *******DRUG-DRUG INTERACTION
1. avoid Fluosemide ( Diuretics)
*THERAPEUTIC ACTIONS
1. block the enzyme phosphodiesterase NURSING CONSIDERATIONS
2. leads to an increase in myocardial cell
cyclic adenosine monophosphate (cAMP) DIAGNOSIS
3. increases calcium levels in the cells 1. decreased cardiac output related to
arrhythmias or hypotension
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

CHAPTER 45
ANTIARRHYTHMIC AGENTS
CORONARY ARTERY DISEASE (CAD)
Class IA Drugs
- progressive growth of atheromatous
plaques, or atheromas in the coronary
arteries
→ plaques begin as fatty streaks in
the endothelium
→ they injure the endothelial lining
→ development of foam cells (by
inflammatory process)
→ platelets, fibrin, other fats, and
remnants collect on the injured
Class IB Drugs
vessel lining
→ cause atheroma to grow
→ blood vessel narrows and limits
blood flow
- injury to the vessel also causes
scarring and thickening of cell wall
membrane during an action potential
- local anesthetics or membrane-
stabilizing agents
- preferable in situations such as
tachycardia
- depress Phase 0 of the action potential
and prolong the duration of the action
potential
o disopyramide (Norpace)
o moricizine (Ethmozine)
o procainamide (Pronestyl)
o quinidine (Quinaglute)
- depress Phase 0 somewhat and actually
shorten the duration of the action
potential
o lidocaine (Xylocaine)
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

CHAPTER 46: ANTIANGINAL AGENTS
ANTIANGINAL DRUGS
- are used to help restore the supply- and- demand
ratio in oxygen delivery to the myocardium when
rest is not enough
- these drugs can work to improve blood delivery
to the heart muscle in 2 ways:
1. by dilating blood vessels ( e.i. increasing the
supply of oxygen)
2. by decreasing the work of the heart (i.e.
decreasing the demand of oxygen)
I. Nitrates
- are drugs that act directly on smooth muscle to
cause relaxation and to depress muscle tone
- decreases: preload, afterload, myocardial
contractility , oxygen demand
Prototype: Nitrogylcerin (Nitro-Bid, Nitrostat)
- treatment of acute angina attack; prevention of
anginal attacks
Therapeutic Actions and Indications
- direct relaxation of smooth muscle with a
resultant decrease in venous return and decrease in
arterial pressure, effects that reduce cardiac
workload and decrease myocardial oxygen
consumption
Pharmacokinetics
1. rapidly absorbed
2. metabolized in liver
3. excreted in urine
4. cross placenta
5. enter breast milk
Contraindications:
1. presence of allergy
2. w/ severe anemia
3. w/ head trauma or cerebral hemorrhage
4. during pregnancy and lactation
Caution
1. patients with hepatic or renal disease
2. w/ hypotension, hypovolemia, and conditions
that limit cardiac output
Adverse Effects
1. CNS effects: headache, dizziness, weakness
2. GI effects: nausea, vomiting, incontinence
3. cardiovascular problems: hypotension, reflex
tachycardia, syncope, angina
4. skin related effects: flushing, pallor, increased
perspiration
5. dermatitis and local hypersensitivity reactions
Dug- drug interaction
• ergot derivatives= risk of hypertension
and decreased anti- anginal effects
• heparin = decreased effects
Nursing Considerations:
1. Give SQ preparations in the tongue or in buccal
pouch, and encourage the patient not to swallow
2. ask the patient if the tablet “ fizzles” or burns
3. Give sustained- release forms with water and
caution the patient not patient not to chew or crush
them
4. Rotate the sites of topical forms
5. Make sure that transligual spray is used to under
the tongue and not inhaled
6. Break an amyl nitrate capsule and wave it under
the nose of the angina patient
7. Taper the dosage gradually
II. Beta- Blockers
- used to block the stimulatory effects of the
sympathetic nervous system
- block beta- adrenergic receptors and
vasoconstriction
- prevent the increase in heart rate and increased
intensity of myocardial contractility that occur with
sympathetic stimulation such as exertion or stress
- decrease the cardiac workload
Prototype: metoprolol (Toprol, Toprol XL)
- treatment of stable angina pectoris and
hypertension; prevention of reinfarction in MI
patients, and treatment of stable, symptomatic CHF
Therapeutic Actions and Indications
1. completely block- adrenergic receptors in the
heart and juxtaglomerular apparatus, decreasing
the influence of the sympathetic nervous system on
these tissues and thereby decreasing the
excitability of the heart, decreasing cardiac output,
decreasing cardiac oxygen compensation and
lowering blood pressure
Pharmacokinetics
1. absorbed from the GI tract and undergo hepatic
metabolic
2. found to increase bioavailability of propranolol,
but this effect has not been found with other beta-
adrenergic blocking agents
3. excreted in the urine
4. has teratogenic effects
Contraindications:
1. w/ bradycardia, heart block, cardiogenic shock,
asthma, or COPD
2. pregnancy and lactation
Caution:
1. with diabetes, peripheral vascular disease or
thyrotoxicosis
Adverse Effects
1. CNS effects: dizziness, fatigue, emotional
depression and sleep disturbances
2. GI problems: gastric pain, nausea, vomiting ,
colitis and diarrhea
3. Cardiovascular effects: congestive heart failure,
reduced cardiac output, and arrhythmias
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
and smooth muscle cells when the cells are
stimulated, interfering with their ability to contract
Prototype: diltiazem ( Cardizem, Cardizem SR)
- treament of prinzmetal’s angina, effort-
associated angina, chronic stable angina; used to
treat essential hypertension, paroxysmal
supraventricular tachycardia
1.monitor patient’s blood pressure, cardiac rhythm,
cardiac output while the drug is titrated or dosage
is being changed
2. Monitor blood pressure very carefully if the
patient is also taking nitrates
3. Periodically monitor blood pressure and cardiac
rhythm while the patient is using these drugs

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
regimen that includes exercise, dietary
restrictions, and lifestyle changes to ↓ risk of
CAD
Bile Acid Sequestrants
Prototype: cholestyramine (Questran)
- powder mixed with liquids and taken up to 6
times a day
Therapeutic Actions
→ bind with bile acids in the intestine to form a
complex that is excreted in the feces
- do not administer powdered agents in dry - erythromycin, cyclosporine, gemfibrozil,
form (mix with juices, soups, etc.) niacin, antifungal drugs = ↑ risk for
- ensure tablets are not cut, chewed, or rhabdomyolysis
crushed - digoxin, warfarin = ↑ serum levels and
- give drug before meals resultant toxicity
- 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
- arrange for bowel program toxicity
HMG-CoA REDUCTASE INHIBITORS (“statins”) Nursing Considerations
- administer drug at bedtime
Prototype: atorvastatin (Lipitor) - monitor serum cholesterol and LDL levels,
- associated with severe liver complications including liver function, before and during
therapy
 - arrange for ophthalmic medications
- ensure patient has attempted a cholesterol-
lowering diet and exercise program for at
least 3 to 6 months before therapy
- encourage patient to make lifestyle changes
Cholesterol Absorption Inhibitors
Prototype: ezetimibe (Zetia)
Therapeutic Actions
→ works in the brush border of the small
intestine to ↓ absorption of dietary cholesterol
→ drop in serum cholesterol levels
Indications
- lower cholesterol level
- treatment for homozygous familial
hypercholesterolemia
- reduce elevated sitosterol and campesterol
levels
Pharmacokinetics
- absorbed well
- metabolized in the liver and small intestine
- excretion is through feces an urine
Contraindications
- allergy
- pregnancy, lactation, severe liver disease (if
in combination with statin)
- fibrate = ↑ risk of cholethiasis
- ezetimibe = ↑ warfarin levels
Nursing Considerations
- monitor serum cholesterol, triglyceride, LDL
levels, liver function test before and during
therapy
- ensure patient has attempted a cholesterol-
lowering diet and exercise program for
several months before therapy
- encourage patient to make lifestyle changes
Other Drugs Used to Affect Lipid Levels
fibrates
→ stimulate the breakdown of lipoproteins from
the tissues and their removal from the plasma
→ ↓ in lipoprotein and triglyceride synthesis and
secretion
- absorbed from GI tract
- metabolized in liver
- excreted in urine
vitamin B3
→ inhibits release of free fatty acids from
adipose tissue
→ ↑ rate of triglyceride removal from plasma
→ ↓LDL and triglyceride level, ↑ HDL levels
→ also ↓ levels of apoproteins needed to form
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

CHAPTER 48 – Drugs Affecting Blood
Coagulation
CARDIOVASCULAR SYSTEM
- is a closed system
• Consistently, the system must maintain an intricate
balance between the tendency to clot or form a solid state,
called coagulation, and the need to “unclot” or reverse
coagulation to keep the vessel open and the blood
flowing…
• Blood coagulation
- is a complex process that involves vasoconstriction, platelet
clumping or aggregation, and a cascade of clotting factors
produced by the liver that eventually react to break down
fibrinogen ( a protein also produced in the liver) into soluble
fibrin threads .
• Vasoconstriction
- can seal off any break and allow the area to heal
• Platelet aggregation
- causes platelets in the circulating blood to stick or adhere to
the site of injury platelets release ADP (adenosine
triphosphate- precursor of prostaglandin) and other chemicals
that attract other platelets, causing them to gather or aggregate
and to stick as well thromboxane A2 cause local
vasoconstriction = platelet aggregation and adhesion
• Hageman Factor
ANTICOAGULANTS
- are drugs that interfere with the normal coagulation process
- affect the process at any step to slow or prevent clot formation
I. ANTIPLATELET DRUGS
- alter the formation of the platelet plug, or
- decrease the formation of the platelet plug by decreasing the
responsiveness of the platelet to stimuli that would cause them
to stick and aggregate a vessel wall
- effectively to treat cardiovascular diseases that are prone to
produce occluded vessels; for the maintenance of venous and
arterial grafts; to prevent cerobrovascular occlusion, and
adjuncts to thrombolytic therapy in the treatment of MI and
prevention of infarction
Prototype: Aspirin ( generic)
- reduction of the risk if recurrent TIAs or strokes in males with
history of TIA due to fibrin or platelet emboli; reduction of
death or nonfatal MI patients with history of infarction or stable
angina; MI prophylaxis, also used as anti-inflammatory,
analgesics, and anti-pyretic
Therapeutic Actions:
• inhibit platelet adhesion and aggregation by blocking
receptor sites on the platelet membrane, preventing
platelet- platelet interaction of the interaction of platelets
w/ other clotting chemicals
Pharmacokinetics
• well absorbed
• highly bound to plasma proteins
• metabolized in the liver
• excreted in urine
• increased bleeding
Contraindications
1. presence of allergy
2. during pregnancy and lactation
Caution
1. Presence of Known bleeding disorder
2. recent surgery
3. closed head surgeries
Adverse Effects
1. Bleeding ( increased bruising and bleeding while bruising the
teeth)
2. Headache, dizziness, and weakness
3. Nausea and GI distress may occur
4. Skin rash
Drug- Drug interactions
• risk of excessive bleeding increases if any of these drug is
combined with another drug that affects blood clotting
Nursing considerations
1. provide small and frequent meals
2. provide comfort measures and analgesia for headache
3. suggest safety measures, including the use of electric razor
and avoidance of contact sports
4. provide increase precautions against bleeding
5. Mark the chart of any patient teaching receiving this drug
6. Provide thorough patient teaching, including the name of the
drug, prescribed, measures to avoid adverse effects, warning
signs of problems, the need for periodic monitoring and
evaluation
II. ANTICOAGULANTS
Interfere with coagulation process by interfering with the
clotting cascade and thrombin formation
Therapeutic Actions and Indications
Anticoagulants interfere with the normal cascade of events
involved in the clotting process. Warfarin causes a decrease in
the production of vit. K—dependent clotting factors in the liver.
Heparin, argatroban and bivalirudin block while Antithrombin
formationof thrombinfrom prothrombin. These drugs are used
to treat thromboembolic disorders such as atrial fibrillation, MI,
pulmonary embolus, and evolving dtroke and to prevent the
formation of thrombi.
Prototype: Heparin (generic) half-life 30-180 minutes,
metabolize in the cells and excreted in the urine
SQ onset 20-6- minutes, peak 2-4 hours, duration 8-12 hours
IV – immediate onset, peak minute, duration 2-6 hours
Warfarin – effects last 4-5 days, onset of action in 3 days
Contraindications
Contraindicated to known allergy to the drugs. They should not
be use with conditions that can increase bleeding tendencies;
hemorrhagic disorders, recent trauma, spinal puncture, GI
ulcers, recent surgery, intraunterine device placement,
tuberculosis, presence of indwelling catheter, and threatened
abortion.Contratindicated to pregnancy, lactation, renal or
hepatic disease
Cautions
In patients with CHF, thyrotoxicocic, saenility, or psychosis,
diarrhea, fever
Adverse effects
The most common adverse effect is bleeding (bleeding in gums
with tooth brushing to severe intrernal hemorrhage), clotting
shoud be monitored. Nausea, GI upset, diarrhea, and hepatic
dysfunctiondue to toxicity. Warfarin can cause
alopecia,dermatitis, bone marrow depression and prolonged and
painful
erections.
Drug to drug Interaction
Heparin + (oral anticoagulants, salicylates, penicillins,
cephalosporins) =Increase bleeding
Heparin + nitroglycerin = Decrease coagulation
Nursing Considerations
-screen for allergy
-evaluate for therapeutic effects of warfarin --prothrombin time
(PT) 1.5 to 2.5 times control value or ratio of PT to INR
(International Normalized Ratio) of 2 to 3
-Evaluate for herapeutic effects of heparin—whole blood
clotting time (WBCT) 2.5 to 3 times control or activated
partial thromboplastin time (APTT) 1.5 to 3 times the control
value
- evaluate for signs of blood loss
-maintain antidotes on standby (protamine sulfate for heparin,
vit, K for warfarin)
-monitor the patient when a drug is added or withdrawn from
the drug regimen of a patient receiving warfarin
-make sure patient receives regular follow up and monitoring
-provide health teaching, name of drug and its effects
Low Molecular-Weight Heparins
These drugs inhibit thrombus and clot formation by blocking
factors Xa and IIa. Because of size and nature of their
molecules, theses drugs do not greatly affect thrombin, clotting
or PT; they cause fewer adverse effects. They block
angiogenesis, process that allows cancer cells to develop new
blood vessels.
Prototype: Strptokinase (streptase, kabikinase)
Therapeutic actions and indications
Thrombolytic agents work to activate the natural clotting
system, conversion of plasminogen to plasmin, which in turn
breaks down fibrin threads in a clot to dissolve a formed clot.
They are indicated for the treatment of MI, to treat pulmonary
emboli and ischemic stroke and to open clotted IV catheter.
Pharmacokenetics
Must me injected and cleared from the body after liver
metabolism, crosses the placenta and have adverse fetal effects,
should not be used during pregnancies unless benefits to the
mother out ways the potential risks to the fetus. Cautions should
be used during lactation.
Contraindications and cautions
Contraindicated to allergy of these drugs, should not be used
with conditions that could worsen the dissolution of clots,
recent surgery, active internal bleeding, cerebrovascular
accident within the last two months, aneurysm, recent serious
GI bleeding, liver disease.
Adverse effects
The most common adverse effect is bleeding, cardiac
arrhythmias and hypotensions
Drug to drug interaction
Risk of hemorrhage increases if thrombolytic agents are used
with anticoagulant or antiplatelet drug.
Nursing consideration
-Discontinue heparin if given before administration of
thrombolytic agent, unless ordered for coronary artery infusion.
-evaluate for signs of blood loss (bleeding gums, bruises, dark
colored stools and urine, petechiae)
-institute treatment within 6 hours after the onset of symptoms
of acute MI
-arrange to type and cross match blood.
-monitor cardiac rhythm
-increase precautions against bleeding during invasive
procedures.
Drugs used to control bleeding
On the other end of the spectrum of coagulation problems are
various bleeding disorders: hemophilia, a genetic lack of
clotting factor that leaves the patient vulnerable to excessive
bleeding with injury.
Liver disease, clotting factors and proteins needed for clotting
are not produce.
Bone marrow disorders, insufficient platelets are formed.
Antihemophilic agents
Drugs used to treat hemophilia are replacement factors for the
specific clotting factors that are genetically missing.
Prototype: Antihemophilic factor (bioclate, others)
Therapeutic actions and indications
Replace clotting factors that are either genetically missing or
low in a particular type of hemophilia. Used to prevent blood
loss from injury or surgery and treat bleeding episode.
Pharmacokenetics
Replace normal clotting factors and are processed as such by
the body.
Contraindications and cautions
Contraindicated in the presence of known allergy to mouse
proteins. Factor IX is contraindicated in the presence of liver
disease with signs of Intravascular coagulation or fibrinolysis.
Coagulation factor VII is contraindicated with known allergies
to mouse, hamster or bovine products. Not recommended
during lactation and pregnancy.
Adverse effects
The most common is risks with the use of blood products, e.g.
hepatitis, aids. Headache, flushing, chills, fever and lethargy.
Nausea, vomiting and itching, stinging and burning at injection
site
Nursing consideration
-administer by IV only
-monitor clinical response and clotting factor levels regularly.
-monitor for sign of thrombosis
-decrease the rate of infusion if headache, chills, fever or
tingling occurs.
-arrange to type and cross match blood.
Systemic hemostatic agents
A used to stop bleeding. Some situation result in fibrinolytic
state with excessive plasminogen activity and risk of bleeding
from clot dissolution.
Prototype: Aminocaproic acid (amicar)
Pharmacokinetics
Parameters are different for each drug
Therapeutic actions and indications
Stop the natural plasminogen clot – dissolving mechanism by
blocking its activation or by directly inhibiting plasmin. These
drugs are used to prevent or treat excess bleeding in
hyperfibrinolytic states, including repeat CABG surgery.
Contraindications and cautions
Contraindicated to allergy to these drugs and with acute DIC.
Caution should be used in the following conditions: cardiac
disease, renal and hepatic dysfunction, pregnancy and lactation
Adverse effects
The most common is excessive clotting. CNS effects include
hallucinations, drowsiness, dizziness, headache and psychotic
states. GI effects including nausea, cramps, and diarrhea.
Drug to drug interaction
Increase risk of bleeding if combined with heparin
Nursing considerations
-monitor clinical response and clotting factor levels
-monitor for signs of thrombosis
-orient patients and offer support and safety measure if
hallucinations or psychoses occur.
Topical hemostatic agents
Used to injuries that involve damage to the small vessels in the
area that clotting does not occur and blood is slowly and
continually lost
Absorbable gelatin (gellfoam) and microfibrilar collagen
(avitene), are apllied directly to the injured area until the
bleeding stops
Thrombin (thrombinar, thrombostat) derived from bovine
sources and mixed with the blood
- occurs when the bone marrow contains a
large number of megaloblasts, or large,
immature RBCs
- because these RBCs are so large, they
become crowded in the bone marrow
and fewer RBCs are produced
- patients usually have a lack of vitamin
B12 or folic acid
Iron Deficiency Anemias
- a negative iron balance
- occurs in situations in which blood is being
lost (such as heavy menstrual flow, internal
bleeding)
- only enough iron is absorbed to replace the
amount of iron lost each day
- only about 1 mg of iron is lost every day
- vitamin B12 deficiency may occur in:
o strict vegetarians
o inability of the GI tract to absorb the
needed amounts of vitamin B12
- treated with vitamin B12 replacement therapy
Pernicious Anemia
- occurs when the gastric mucosa cannot
produce intrinsic factor and vitamin B12
cannot be absorbed
- person may complain of fatigue, lethargy, and
CNS effects because of damage to the
myelin sheath
- treated with injections of vitamin B12 to
replace the amount
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

Adverse Effects
- result of cellular response to glycoprotein:
CNS effects
- nausea, vomiting, diarrhea
- related to ↑ in RBC numbers: CV symptoms
Nursing Considerations
- confirm chronic, renal failure before drug
administration
- give epoetin alfa 3 times a week, IV or SQ
- do not mix with any other drug solution
- monitor access lines for clotting
- arrange for hematocrit reading before drug
administration
- evaluate iron stores before and during
therapy
- maintain seizure precautions on standy
IRON PREPARATIONS
- iron deficiency anemia is common in certain
groups:
o menstruating women
o pregnant and nursing women
o rapidly growing adolescents
o persons with GI bleeding and slow
bleeding
Prototype: ferrous sulfate (Feosol)
Therapeutic Actions
- elevate the serum iron concentration
Indications
- treatment of iron deficiency anemias
- adjunctive therapy in patients receiving
epoetin alfa
Pharmacokinetics
- absorbed from small intestine
- transported in the blood
- used during pregnancy and lactation
Contraindications
- allergy
- hemochromatosis (excessive iron)
- hemolytic anemias
- normal iron balance
- peptic ulcer, colitis, regional enteritis
Adverse Effects
- direct GI irritation
- with increasing serum levels, iron can be
CNS toxic, causing coma and death
- parenteral iron: severe anaphylactic
reactions, local irritation, staining of the
tissues, phlebitis
Drug-Drug Interactions
- antacids, tetracyclines, cimetidine = ↓ iron
absorption
- ciproflaxin, norfloxacin, ofloxacin = ↓ anti-
infective response
- chloramphenicol = ↑ iron levels
- levodopa = ↓ effects of levodopa
Drug-Food Interactions
- antacids, eggs, milk, coffee, tea = iron is not
absorbed
Nursing Considerations
- confirm deficiency anemia before drug
administration
- administer with meals
- have patients drink solutions through a straw
- caution patient that stool may be dark or
green
- administer IM only through Z-track technique
- arrange for hematocrit and hemoglobin
measurements before and during therapy
FOLIC ACID DERIVATIVES AND VITAMIN B12
Folate deficiencies usually occur
o secondary to ↑ demands
o absorption problems in the small intestine
o secondary to the malnutrition of
alcoholism
Prototype: folic acid (Folvite)
- parenteral drugs are preferred for patients
with potential absorption problems
Vitamin B12 deficiencies usually occur
o with poor diet or increased demand
o lack of intrinsic factor in the stomach
Prototype: hydroxocobalamin (Hydro-Crysti 12)
- given IM everyday for 5 to 10 days, then
once a month for life
- used in states of ↑ demand or dietary
deficiency
Therapeutic Actions
- folic acid and vitamin B12 : for cell growth and
division, and production of strong stroma in
RBCs
- Vitamin B12: maintenance of the myelin
sheath in nerve tissue
Indications
- replacement therapy for dietary deficiencies
- replacement in high-demand states (such as
pregnancy and lactation)
- treat megaloblastic anemia
- folic acid: rescue drug for cells exposed to
some toxic chemotherapeutic agents
Pharmacokinetics
- well absorbed after injection
- metabolized mainly in liver
- excreted in urine
- highly protein bound
- considered essential during pregnancy and
lactation
Contraindication
- allergy
Cautions
- pregnant or lactating who have anemias
- nasal cyanocobalamin
- presence of nasal erosion or ulcers
Adverse Effects
- pain and discomfort at injection sites
- nasal irritation with the use of nasal sprays
Nursing Considerations
- confirm the nature of megaloblastic anemia
- give both types of drugs in pernicious anemia
 - parenteral Vitamin B12 must be given IM each
day for 5 to 10 days, then once a month for
life
- arrange for nutritional consultation
- monitor for hypersensitivity reactions
- arrange for hematocrit and hemoglobin
measurements before and during therapy
Chapter 50 - Introduction to the
Kidneys and the Urinary Tract
Renal system:
• Urinary tract
• Ureters
• Urinary bladder
• Urethra
• system and depositing them into
4 major functions of the renal system:
• Maintain the value and
composition of the body fluids
w/in normal range
• Regulating vitamin D activation
• Regulating blood pressure
• Regulating red blood cell
production
• sodium bicarbonate, and sodium
>the kidneys are two small organs that
receive about 25% of the cardiac output
Nephron
• the functional unit of the kidneys
• is composed of the Bowman’s
capsule, proximal convoluted
tubule, loop of Henle, distal
convoluted tubule, and collecting
duct
• Sodium
Renal Processes
a.) Filtration - straining fluid into the
nephron
>approximately 125 mL of fluid is
filtered each minute, or 180L/day
>99% of the filtered fluid is
returned to the bloodstream
>approx. 1% of the filtrate, less
than 2 L of fluid is excreted each
day in the form of urine
b.) Secretion – actively removing
components from the capillary
the tubule
c.) Absorption – removing from the
tubule to return them to the
capillary system and circulation
>about 99% of the water filtered at
the glomerulus is reabsorbed
>the filtrate components include
the vitamins, glucose, electrolytes,
chloride
>precision of the reabsorption
process allows the body to
maintain the correct extracellular
fluid volume and composition
Maintenance of Volume and composition
of Body Fluids
Sodium Regulation
 Is one the body’s major
cations(positively charged ions)
 Reabsorbed via transport system
that functions under the influence
if the catalyst carbonic
anhydrase, à carbonic acid à
sodium bicarbonate
2 hormones that influence sodium levels
in the filtrate:
 Aldosterone-a hormone produced
the adrenal gland
- is released into the
circulation in response to
the high potassium levels,
 sympathetic stimulation, or
angiotensin III
- stimulates Na-K exchange
pump in the cells of the
distal tubule, w/c reabsorbs
Na in exchange for K, as a
result Na is reabsorbed into
the system and K lost in the
filtrate
 Natriuretic Hormone- probably
produced by the hypothalamus
- causes decrease in Na
reabsorption from the distal
tubules w/ a resultant dilute
urine or increase volume
- is released in response to
the fluid overload or
hemodilution
Countercurrent Mechanism
 in the medullary nephrons allow
for the concentration or dilution of
urine under the influence of ADH
secreted by the hypothalamus
Potassium Regulation
Potassium
 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
capsule and proximal convoluted
tubule
 25%-30% is r5eabsorbed at the
loop of Henle
the urine until it is
Chloride Regulation excreted from the body.
Chloride Uterus- have smooth endothelial lining
 Is an important negatively charged and circular muscular linings.
ion that helps to maintain electrical • The female urethra is very short
neutrality with the movement of and leads to an area populated by
cations across the cell membrane normal flora including e.coli.
 Primarily absorbed in the loop of • The male urethra is much longer
Henle, where it promotes the and passes through the prostate
movement of sodium out of the gland.
cell Prostate Gland- a small gland that
*the kidneys play a role produces an acidic fluid that is
important in maintaining the sperm
Sodium Regulation and lubricating the tract.
Calcium
 Is important in muscle function,
blood clotting, bone formation,
contraction of cell membranes and
muscle movement.
 Filtered at the glomerulus and
mostly reabsorbed in the proximal
convoluted tubule and ascending
Loop of Henle.
 Fine tuning reabsorption occurs in
the distal convoluted tubule.
Urinary Tract
Urinary Bladder- is the muscular pouch
that stretches and holds
 - 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
Drug- drug interactions:
- decrease absorption of this drugs if combined with
cholestyramine or colestipol, if combination is used,
it should be taken separated by at least 2 hours.
- Risk of digoxin toxicity increases due to potential
changes in potassium levels; serum potassium level
should be monitored if this combination is used.
- Decrease effectiveness of antidiabetic agents may
occur related to the changes in glucose metabolism;
dosage adjustment of those agents may be needed.
- Risk of lithium toxicity may increase if these drugs
are combined. Serum lithium levels should be
monitored and appropriate dosage adjustment made
as needed.
LOOP DIURETICS
-work in the loop in henle
- Furosemide (Lasix), most common less powerful
than new loop diuretics.
- Bumetanide (Bumex)
- Torsemide (Demadex)
- Ethacrynic acid (Edecrine)
Therapeutic action and indications:
- referred to as high-ceiling diuretics because they
cause greater degree of diuresis.
- Block the chloride pump in the ascending loop of
henle, where normally 30% of all filtered sodium is
reabsorbed.
- These drugs work even in the presence of acid- base
disturbances, renal failure, electrolyte imbalances, or
nitrogen retention.
- A drug of choice when rapid and extensive diuresis
is needed.
- In case of severe edema, it is important to remember
that these drugs can have an effect only on the blood
the nefron.
- In pulmonary edema, this fluid then circulates back
to the lungs pulls fluid out of the interstitial spaces
by its oncotic pull, and delivers fluid to the kidneys
where the water is pulled out completing the cycle.
- Commonly indicted for treatment of acute CHF,
pulmonary edema, edema associated with CHF or
with renal or liver disease and hypertension.
Pharmacokinetics:
- metabolized and excreted through urine.
- They should not be used during pregnancy, unless
the benefit to the mother far outweigh the potential
risk, it enters in the breastmilk.
- Safety for use in children younger than 18 years of
age, has not been establish.
- If one of this drug is used for a child, carefully
monitor child’s fluid and electrolyte balance is
needed.
Contraindication and cautions:
- allergy to loop diuretics, electrolyte depletion,
anuria, severe renal failure, hepatic coma, pregnancy
and lactation.
- Caution on patient with SLE, gout, and/or diabetes
mellitus.
Adverse effect:
- hyperkalemia is a very common adverse effect.
- Alkalosis (a drop in serum pH to an alkaline state.)
- Hypotension, dizziness, ototoxicity, deafness.
- This may occur in conduction of fragile nerve in
CNS.
Drug- drug interactions:
- risk for ototoxicity increase with amino glycosides
or cysplapin.
- Anticoagulation effect may increase with
anticoagulant.
- Decrease loss of sodium and decrease
antihypertensive effect with indomethacin,
ibuprofen, salicylates, or another NSAIDs.
CARBONIC ANHYDRASE INHIBITOR
- relatively mild diuretics.
- Used to treat glaucoma
Acetazolamide (Diamox)
Methazolamide (Meptazane)
Therapeutic Actions and Indication
- the enzyme carbonic anhydrase is a catalyst for the
formation of sodium bicarbonate.
-This diuretics lacks the effects of carbonic anhydrase that
slows down the movement of hydrogen ions, as a result
more sodium and bicarbonate are lost in the urine
- Use as a drug adjuncts to other diuretics when a more
intense diuresis is needed
- Acetalozamide is used to treat mountain sickness
Pharmacokinetics
-rapidly absorbed widely distributed excreted in the urine
- another method of feeding the infant should be used if
one of this drugs is needed during lactation.
Contraindicaions and Cautions
-Allergy to drugs or antibacterial sulfunamides or thyazide or
chronic noncongestive angle closure glaucoma
-cautios use is recommended in patients who are
breastfeeding, who have fluid imbalances, renal or hepatic
disease, adrenocortical insufficiency, respiratory acidosis
or COPD
Adverse Effects
- metabolic acidosis
- hypokalemia
- paresthesias (tingling), confusion and drowsiness
Drug to Drug Interaction
- there maybe an increase excretion of salicylates and lithium if
they are combined with this drugs
Potassium- Sparring Diuretics
- These drugs are used for patients wha are at risk for
hypokalemia associated with diuretic use.
- Retain potassium instead of wasting it.
Amiloride (Midamore)
Spironolactone (Aldactone)
Triamterene (Dyrenium)
Therapeutic Actions and Indication
- These drugs are often used as adjuncts with thiazide
or loop diuretics.
- Spironolactone is the drug of choice for treating
hyperaldosteronism, a condition seen in cirrhosis of
the liver and nephronic syndrome.
Pharmacokinetics
- These drugs are well absorbed, protein bound and
widely distributed.
- These drugs cross the placenta and enter breast milk.
Contraindicaions and Cautions
- Allergy to the drug
- Hyperkalemia
- Renal disease
- 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

Chapter 53 – Introduction to
the Respiratory System
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,
the mucus up to the trachea and into the and the surfactant layer. The sac is able
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
congestion,anxiety,tenseness
tremors,hypertension,arrythmias,sweating,and
pallor.
-encourage patient not to use this drug for more
than 1 week.
• Topical Nasal Steroid Decongestants
- treatment for allergic rhinitis,been found to
be effective in patient that doesn’t respond with
other decongestants.
- Has an anti-inflammatory action that
produce direct local effect.
- Onset of action may not be immediate, and
may require up to a week to cause any changes.
- If no effects after 3 weeks , discontinue the
drug.
- Relieve inflammation after removal of nasal
polyps.
- Contraindicated with Candida Albicans
infection,caution to those with TB,chickenpox,and
measles.
Drugs in this class: P flunisolide, Beclomethasone
(Beclovent), Budesonide (Rhinocort)
,Dexamethasone (Decaderm),Fluticasone
(AeroBid),Triamcinolone ( Kenacort)
Antihistamines
-blocks the effect of histamine 1 receptor sites,
bringing relief to the patient to patients suffering
from itchy eyes,swelling,congestion,and drippy
nose.
-treatment for seasonal and perennial allergic
rhinitis,uncomplicated urticaria,angioedema
-also has anticholinergic effects and antipruritic
effect.
-most effective if used before the onset of
symptoms.
-Onset of action 1-3 hours.
-caution to those with arrythmias and prolonged
Q-T intervals.
-Adverse effects: drying of the respiratory and GI Mucolytics
mucous membranes,GI upset ,
nausea,dysuria,urinary hesitancy,and skin eruption -aid in high –risk respiratory patient in
and itching associated with dryness. coughing up thick secretions,tenacious secretions.
-increase effect if taken with MAOI, -for COPD, cystic
ketoconazole,and erythromycin. fibrosis,pneumonia,tuberculosis,atelectasis,diagnos
-administer drug in an empty stomach tic bronchoscopy,
-have patient void before each dose Postoperative patients with tracheostomy.
-Avoid alcohol -administer through instillations or
Drugs in this class: P Diphenhydramine (Benadryl) nebulization.
T ½ of 2.5-7 hours -caution with acute brochospasm,peptic
1st generation: Azelastine ulcer,and esophageal varices.
(Astelin),Brompheniramine, Buclizine ( Bucladin -splits links in mucoproteins contained in
S),Cetirizine(Reactine),Chlorpheniramine (Aller- secretions,decreasing viscosity.
chlor),Clemastine (Tavist),Cyclizine Drugs in this class : P Acetylcysteine
(Marezine),Cyproheptadine(Periactin),Dexclorphe (Mucomyst) T ½ 6.25 hr ,Dornase alfa
niramine(Dexchlor),Dimenhydrinate (Pulmozyme)
(Dimentabs),Hydroxyzine (Vistaril),Meclizine
(Bonine),Phenindamine
(Nolohist),Promethazine(Phenergan).
2nd generation : Desloratadine
(Clarinex),Fexofenadine (Allegra),Loratadine
( Claritin).
Expectorants
-liquefy lower respiratory tract secretions,reducing
viscosity of these secretions, and making it easier
for patient to cough them out.
-reduces adhesiveness and surface tension of
secretions,movement of less viscous secretions
-more productive cough, decreased frequency of
coughing.
-P Guaifenesin (symptomatic reliefof respiratory
condition characterized by dry, nonproductive,
cough, and in the presence of mucus in respiratory
cough)
-adverse effects:
Nausea,vomiting,headache,dizziness,rash.
-Not to use this drug for more than 1 week.
-Advise the use of small,frequent meals.
Chapter 55 - Drugs Used To Treat
Obstructive Pulmonary Disease
Bronchodilators/ Antiasthmatics-
dilating airways
Xanthines
-main treatment for bronchospasm and
asthma.
-has direct effect on the smooth muscles
of respiratory tract,both in the bronchi and
in the blood vessels.
- stimulate 2 prostaglandins resulting in
smoothe muscle relaxation, which then
increase the vital capacity.
- inhibit the SRSA.
- Unlabeled use: stimulation in
respiration Cheyne Stokes respiration.
- Peak levels within 2 hours.
- Caution with patient with GI
problems,coronary disease,respiratory
dysfunction,renal or hepatic lung
disease,alcoholism,hyperthyroidism.
- Increases with nicotine.
Drugs in the class: P Theophylline ( Sio-
bid ,Theo Dur)
T ½ of 3-15 hr (nonsmoker),4-5 hr
(smoker),
Aminophylline(Truphylline), Caffeine,
Dyphylline (Dilor).
-administer drug with food or milk.
Sympathomimetics
-mimic the effects of the sympathetic
nervous system.
-dilates the bronchi and increased the rate
and depth of respiration.
-beta2 selective adrenergic agonists.
-Adverse effects: increase
BP,HR,vasoconstriction,decreased renal
and GI bloodflow.
-rapidly absorb after injection.
Half life of < 1 hour.
-Caution on those with cardiac
disease,vascular
disease,diabetes,hyperthyroidism,
pregnancy and lactation
- avoid combination with
bronchodilators,general anesthetics
cyclopropane,and halogenated
hydrocarbon.
- administer with small frequent meals.
Drugs in this class: P Epinephrine (Sus –
Phrine, EpiPen), Albuterol(Proventil),
Bitolterol (Tornalate),
Ephedrine,Formoterol (Foradil),
Isoetharine(Bronkosol), Isoproterenol
(Isuprel), Levalbuterol (Xopenex),
Metaproterenol (Alupent).
Anticholinergic Bronchodilators
-not as effective as sympathomimetics but
can provide some relief to those patient
who could not respond to other drugs.
-has an effect in the vagus nerve,which
block or antagonize the action of the
neurotransmitter acetylcholine at vagal-
mediated receptor sites, leading to
relaxation of smooth muscles by
bronchodilation.
Drugs in this class: P Ipratropium with an
onset of action of 15 minutes when
inhaled.Peak of 1-2 hours,Thiotropium
has rapid onset and longer duration with
half life of 5 to 6 days.
-Encourage client to void before each
dose.
-Provide small frequent meals and
sugarless lozenges.
-Caution patient not to use inhalator for
more than 12 inhalations in 24 hours.
Inhaled Steroids
-very effective for treatment of
bronchospasm.
-decrease inflammatory response in the
airway,thus increasing air flow and
facilitate respiration.
-Has 2 effects:
 Decreased swelling associated with
inflammation and promotion in the beta –
adrenergic receptor activity.
 Inhibit bronchoconstriction.
-used for prevention and treatment of
asthma,treat chronic steroid-dependent
bronchial asthma.
-should be taken 2-3 weeks to achieve
effects.
-Adverse effects: sore throat,coughing,dry
mouth,and pharyngeal and laryngeal
fungal infection.
-have patient use decongestant drops
before using inhaled steroid.
-Have patient rinse his mouth after inhaler.
Drugs in this class include:P Flunisolide
(AeroBid) T ½ of 1-2 hours.,
beclomethasone (beclovent),Budesonide
(Pulmicort),Fluticasone
(Flovent),Triamcinolone (Azmacort).
Leukotriene Receptor Anatagonist
-selectively,and competitively blocks the
receptor for production of leukotrienes D4
,E4 components of SRSA.
-blocks many signs and symptoms of
asthma,such as neutrophil,eosinophil
migration,neutrophil,and monocyte
aggregation,leukocyte adhesion,increased
capillary permeability,and smooth muscle
contraction.
-prophylaxis for bronchial asthma and in
patients younger than 12 years of age.Not
indicated for treatment of acute asthma
attack.
-metabolized via cytochrome P450 and
excreted in feces.
-Abverse effects:
headache,dizziness,myalgia,nausea,diarrhe
a,elevated liver
enzymes,vomiting,fever,pain.
-Increased toxicity if taken with
propanolol,theophylline,and warfarin
Drugs in this class : P Zafirlukast
(Accolate),Montelukast(Singulair),Zileuto
n (Zyflo).
-administer drug in an empty stomach.
-Caution patient not to stop meds in
symptom –free periods.
Lung Surfactant
-naturally occurring substance lipoproteins
containing lipids, and apoproteins that
reduce the surface tension within the
alveoli for gas exchange.
-used to replace the surfactant that is
missing in lungs of neonates with RDS.
-begin to act immediately on instillation
into the trachea.
-No contraindications
-Adverse effects: patent ductus arteriosus
in infants,hypotension,intraventricular
hemorrhage,pneumothorax,pulmonary air
leak,hyperbilirubinemia,and sepsis.
Drugs in this class: P Beractant
(Survanta),Calfactant(Infasurf),Colfosceril
(Exosurf, Neonatal ),
Poractant (Curosurf).
-suction the infant immediately before
administration,but do not suction for 2
hours after administration.
Mast Cell Stabilizers
-prevent release of inflammatory and
bronchoconstricting substances when mast
cells are stimulated to release these
substances because irritation.
Drugs in this class: P Cromolyn T ½ of 80
min(inhibit release of histamine and
SRSA,and is inhaled in a capsule but may
not reach its peak effect for 1
week).Nedocromil (inhibit mediators of
inflammatory cells including
eosinophils,neutrophils,macrphages,and
mast cells.
-treatment of mild-moderate bronchial
asthma of >12 years old patients.
-Cromolyn not recommended for children
younger than 2 years old,and nedocromil
not recommended for children younger
than 12.
-Adverse effects:
headache,dizziness,nausea,sore
throat,dysuria,cough and nasal congestion.
-Administer oral drug 30 minutes before
meals and at bedtime.
-Instruct patient not to wear contact lenses
if using Cromolyn eye drops.
-Dizziness and fatigue common problem
in takinh Nedocromil.
CHAPTER 56 – INTRODUCTION TO
THE GASTROINTESTINAL SYSTEM Gastrointestinal Activities
The gastrointestinal (GI) system is the The system has four major activities:
only system in the body that is open to the • Secretion
external environment. The GI system is • Absorption
composed of one continuous tube that • Digestion
begins at the mouth; progresses through • Motility
the esophagus, stomach and small and
large intestines; and ends at the anus. The Secretion – secretes various compounds to
pancreas, liver and gallbladder are aid the movement of the food bolus
accessory organs that support the through the GI tube, to protect the inner
functions of the GI system. layer of the GI tract from injury and to
facilitate the digestion and absorption of
Composition of the Gastrointestinal Tract nutrients.
The GI tube is composed of - Saliva – contains water and
four layers: digestive enzymes and
• 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.

Digestion – process of breaking food into
usable, absorbable nutrients.
Absorption – active process of removing
water, nutrients and other elements from
the GI tract and delivering them to the
bloodstream for use for the body.
Motility – GI tract depends on this to keep
things moving through the system.
- Peristalsis – basic
movement in the
esophagus. It is a constant
wave of contraction that
moves from the top to the
bottom of the esophagus.
- Swallowing – response to a
food bolus in the back of
the throat stimulates the
peristaltic movement that
directs the food bolus into
the stomach.
- Segmentation – involves
contraction of one segment
of small intestine while the
next segment then relaxes,
and the relaxed segment
contracts.
Local Gastrointestinal Reflexes
• Gastroenteric reflex: stimulatiuon
of the stomach by stretching, the
presence of food, or cephalic
stimulation causes an increase in
activity in the small intestine. It is
thought that this prepares the small
intestine for the coming chyme.
• Gastrocolic reflex: stimulation of
the stomach also causes increased
activity in the colon, again
preparing to empty any contents to
provide space for the new chime.
• Duodenal-colic reflex: the
presence of food or stretch in the
duodenum stimulates colon
activity and mass movement, again
to empty the colon for the new
chime.
Other local GI reflexes:
• Ileogastric reflex
• Intestinal-intestinal reflex
• Peritoneointestinal reflex
• Renointestinal reflex
• Vesicointestinal reflex
• Somatointestinal reflex
are very important to the functioning of
the GI tract.
 Swallowing – is a centrally
mediated reflex that is important in
delivering food to the GI tract for
processing. It is controlled by the
medulla and involves a complex
series of timed reflexes.
 Vomiting – is controlled by the
chemoreceptor trigger zone (CTZ)
in the medulla or by the emetic
zone in immature or injured brains.
The CTZ is stimulated by several
different processes and initiates a
complex series of responses that
first prepare the system for
vomiting and then cause a strong
backward peristalsis to rid the
stomach of its contents.

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