Anemia and chronic dialysis, what causes it, how is it treated?

Anemia is a condition in which there is a reduction in the number of circulating red blood cells (RBCs) that is associated with a decrease in hemoglobin concentration. Anemia may be caused by many different factors & the book considers nutritional deficit as the most common. Anemia is not generally considered a disease, but rather a symptom complex caused by one or more underlying disorders such as- Excessive Red Blood Cell Destruction -i.e. drug hypersensitivity; transfusion reactions; autoimmune reactions; certain enzyme deficiencies; chemotherapy. Inadequate Red Blood Cell Production- i.e. endocrine dysfunction (hypopituitarism, hypothyroidism); bone marrow failure (aplastic anemia caused by radiation therapy or some drugs); nutrient deficiency (iron, B12, folic acid deficiency); renal failure; idiopathic aplastic anemia. Both Increased Destruction & Decreased Production of RBCs - i.e. hemoglobinopathy (sickle cell disease); malignancies; infection; antineoplastic therapy. The most common form of anemia is iron deficiency anemia & affects at least 10% of the U.S. population. Blood loss is the most common cause of this type of anemia. Iron deficiency anemia can be a complication of chronic dialysis.  If iron supplements do not resolve the anemia adequately, parenteral IV administration may be required.  

How is iron administered?

PO & IV, The % of iron absorbed diminishes with increasing dose, so it should be given in divided doses rather than as a large single dose.  Doses should be spaced at least 4 hrs apart. Administer on an empty stomach with water. If gastrointestinal upset occurs, give after meals or with food.  Avoid administration with antacids or tetracycline

Which drugs may cause anemia due to blood loss?

Alcohol, indomethacin (Indocin), NSAIDs, antiplatelet agents, anticoagulants, SA, steroids

How are antacids administered?

PO, liquid, chewable tabs (chew well & drink small amount of water or milk to facilitate passage into stomach), quick-dissolving tabs, effervescent solutions or tabs or granules (be sure fizzing has stopped before ingested). Usually taken 1 hr after eating. Do not take other oral drugs within 1-2 hrs of antacid administration, as other drugs or food may reduce the absorption.  Do not give Digoxin with antacids. Shake liquid antacid products well prior to use.

Factors that aggravate ulcer conditions-

Contributing factors are stress, smoking, alcohol, coffee, colas, SA (salicylates), indomethacin (Indocin), fruit juices or acidic foods.  A Peptic ulcer is a local lesion of the gastrointestinal lining; in the duodenum- duodenal ulcer; in the stomach- gastric ulcer. Recent studies indicate the cause of peptic ulcer disease (PUD) is related to the invasion of the gastrointestinal lining by H.pylori bacterium.  The constant bathing of the ulcerated area with gastric juices will potentially encourage further erosion and inhibit healing.  There is little evidence that antacids enhance healing, decrease the frequency, or prevent a recurrence of PUD.

Side effects of anticholinergic antemetics

Dry mouth, urinary retention, blurred vision, increased heart rate, disorientation, decreased resp rate, & used with caution in clients with benign prostatic hypertrophy & narrow-angle glaucoma.

Uses for ipecae syrup

Ipecac syrup is the most commonly used emetic (agent to induce vomiting) in the U.S. It is used in the tx of oral drug overdose & other kinds of poisoning. Persons with bulimia may misuse ipecac syrup as part of the binge-purge cycle. This can result in ipecac toxicity, (muscle weakness & cardiotoxic effects.  

Cause of laxative dependence

When people overreact & use a multitude of drugs to treat constipation, laxative dependence may result. Larger & larger doses will be required for appropriate defecation. Availability of OTC laxatives enhances the problem or misuse. Especially prevalent in the elderly population.

Effects of barbiturates on the body

Barbiturates exert a depressant effect on the CNS; the extent may range from mild sedation to deep anesthesia. They act primarily by interfering with the chemical transmission of impulses across synaptic junctions in the ascending reticular formation of the brainstem. Barbiturates have the ability to potentiate the inhibitory effects on nerve impulse transmission of 

gamma-aminobutyric acid (GABA). Phenobarbital exerts a fairly selective action on the motor cortex & produces and anticonvulsant action as well.

Differentiate between sedatives & hypnotics

Sedatives are agents that produce a diminished responsiveness to stimuli without producing sleep. They reduce anxiety, nervousness, excitability, & irritability. They are also referred to as antianxiety agents, or anxiolytics.  Hypnotics have a more intense depressant effect on the CNS and usually produce sleep.  Many drugs can act as either sedatives or hypnotics, depending on the dose and are sometimes referred to as sedative-hypnotics.

What is the primary pharmacological use of alcohol?

Alcohol is a fairly potent CNS depressant.  Depending on the amount consumed and the rate of ingestion, alcohol may produce sedations, sleep, & or general anesthesia by a direct action on the CNS. Alcohol also depresses CNS control mechanisms that inhibit certain brain functions; this may disrupt normal thought processes (i.e., memory, concentration, etc.) Alcohol is sometimes used as a mild sedative, particularly in elderly clients; its actions are relatively transient & usually pleasant.  Alcohol may also used as a social facilitator to encourage better interaction.

Uses for diuretics? (pg 482)

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  • Diuretics are clinically employed in clients with edema or ascites, both of which are pathologically increases in extracellular fluid volume. Diuretics are also used in the treatment of hypertension, as they can promote blood pressure reduction while reducing the adverse effects of other antihypertensive drugs.

Primary ingredient in OTC sleep aids-

Virtually all of the OTC sleep aids contain an antihistamine.  Some products may also contain an analgesic such as aspirin or acetaminophen to reduce minor pain that might prevent or disrupt sleep.

Changes to the body caused by Alzheimer’s Disease-

Loss of cognitive function & memory. Alzheimer is a progressive, degenerative, & terminal disease of the brain tissue.  Alzheimers involves the acceleration of the aging process in the brain. Among the changes are decreased size of the brain, enlargement of ventricles, cerebral sulci, & fissures, and abnormalities of the superior temporal gyrus, hippocampus, precentral frontal love gyrus, and substantia nigra.  It affects memory, microscopic changes include the presence of abnormal amounts of senile plaque & neurofibrillary tangles (snarled masses of fibrous cells in the neurons) in the brain tissues are well documented. Decreased levels of acetylcholine, norepinephrine, dopamine, & serotonin are noted, which create a lag in the transmission of impulses within the brain. Acetylcholine is the most dramatically affected with as much as 75% of it absent.

Other uses for anorectic drugs

Anorectic and/or anorexiants are drugs that reduce appetite. They cause CNS & cardiovascular stimulation. Other uses for anorectics are the tx of narcolepsy, & ADHD.  

Multiple uses of dyphenhydramine? (pg 383)

Diphenhydramine, a potent antihistamine, also has been approved for use as an antitussive. Because of its anticholinergic properties it must be used with caution in clients with glaucoma, prostatic hypertrophy, or obstructive pulmonary disease. When used with alcohol or other CNS depressants, excessive sedation may occur. The client should therefore be made aware of possible impairment of physical or mental capabilities, or both, while taking this drug. Also, in the main drug in most sleepaids.

Differentiate between LDL, HDL, VLDL (pg 515)

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  • • VLDL-very low density lipoprotein- contain a relatively high proportion of lipid. They are secreted in the liver their triglyceride component is partially derived from dietary carbohydrate intake . Because of the high triglyceride content of the chylomicrons and VLDL particles, an increase in their concentration in the blood results in an increase in plasma triglyceride levels.
  • LDL- low density lipoprotein- contains the greatest proportion of cholesterol of all the lipoproteins. When their levels in the blood is increased, therefore plasma cholesterol levels usually also increased.
  • HDL- high density lipoprotein- are the smallest lipoprotein and contain the greatest proportion of protein. Although, their role in the development of atherosclerosis is still controversial, there is evidence that abnormally low serum levels of HDL tend to promote coronary artery disease.

Uses for neuromuscular blocking agents? (pg 680)

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  • • The most common reason for using these agents is to expedite intubation and to facilitate mechanical ventilation by preventing clients form “fighting the ventilation”. 
  • Aid in the treatment of Tetanus 
  • Facilitate electroconvulsive therapy (ECT)  by reducing excessive muscular contraction.
  • Facilitate surgery by reducing muscle movement and/or to permit use of lower anesthetic doses.

Side effects  of centrally acting skeletal muscle relaxants? (pg 682-683)

Causes sedation and CNS depressant

Antispasmodic drugs used for urinary retention?

Oxybutynin chloride (Ditropan) is used for urinary antispasmodic, used orally or transdermal patch, apply to abdomen, hip, or buttocks. Do not use with pregnancy, should not be exposed to sunlight, should expect mild erythema at site of the patch.

Categories of CNS depressants?

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  • • Barbituates- Phenobarbital
  • Benzodiazpines – (Versed, Ativan).
  • nonBenzodiazepines – zolpidem (Ambiam)
  • Alcohol
  • Anticholinergics – Cogentin
  • Dopaminergics – levodopa, Sinemet
  • Hydantoins – Phenytoin
  • Carbamazepines – Tegretol
  • Gabapentin (neurontin)
  
  

Diferentiation between alpha and beta receptors and their effects? (pg772)

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  • • Alpha1- these receptors are found primarily in the smooth muscle tissue of peripheral blood vessels and in the sphincters of the gastrointestinal and genitourinary tracts. When alpha 1 receptors are stimulated by a neurotransmitter or by a drug, the smooth muscle associated with the contracts may cause increased blood pressure due ot the constriction of peripheral blood vessels.
  • Alpha 2 – receptors are found on the presynaptic neuron. Function as “controllers” of neurotransmitter release by the presynaptic neuron. their stimulation reduces the release of neurotransmitter.
  • Beta 1 – located primarily in the muscles of the heart and the fatty tissues their stimulation increases heart rate and force contraction.
  • Beta 2 – located primarily in bronchial smooth muscle. Their stimulation results in bronchodilator.

Differentiate between sympatomimetic, adrenergic, anticholinergic, cholinergic, and other terms used to describe the ANS?

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  • Sympathomimetic – (adrenergic) – drugs that produce actions that stimulate or mimic the actions of the sympathetic neuron system. Referred to as direct acting  or indirect acting. They either do or don’t work on the receptor but still stimulate the sympathetic, postganglion neurons to release norepinepherine.
  • Sypmpatholytic (adrenergic) – blocking drugs interfere with the action of the sympathetic nervous system. May act by blocking alpha or beta adrenergic receptors, by depleting the store of norepinepherine in the neuronal vesicles, or by inhibiting sympathetic activity by direct action on the CNS.
  • Parasympathomimetic (cholinergic) – drugs that produce actions that stimulate or mimic the actions of the parasympathetic nervous system. May be classified as direct or indirect acting, (direct- mimics the action of the acetylcholine) (indirect- inhibits the action of the enzyme acetyl cholinesterase). AS this enzyme acts in the body to destroy acetylcholine inhibition of its action would sustain the action of acetylcholine released by neuron.
  • Parasympatholytic (ant cholinergic) – drug interferes with action of the parasympathetic nervous system. Some of these may act by blocking acetylcholine receptors at the neuromuscular junction and/or in the ganglia. These may be specific for muscarinic or nicotinic receptors or they may nonspecific in their action.

Match neurotransmitters with sympathetic and parasympathetic arms of ANS? 

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  • Sympathetic – norepinepherine, dopamine, epinephrine
  • Parasympathetic – acetylcholine

Differentiate s & s of hyperthyroidism and hypothyroidism? (pg 789, 792-793)

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  • Hyper- Signs- excessive secretion of thyroid hormones by the thyroid gland results in increased levels of metabolism in virtually all physiological systems within the body.
  • Hyper- symptoms- excessive production of heat, motor activity, and excessive activity of the sympathetic nervous system. Weight loss accompanied by increased appetite, muscle weakness, fatigue, palpitation, irritability, nervousness, sleep disorders, flushing, altered menstrual flow diarrhea and exophthalmus. 
  • Hypo- signs- the deficiency may result in primary, secondary, and tertiary hypothyroidism.
    • Primary- abnormality of the thyroid gland
    • Secondary- disorder of the anterior pituitary gland in which inadequate concentration of TSU is released
    • Tertiary- may stem from a reduction in the secretion of thyrotropin-releasing hormones by the hypothalamus.
  • Hypo- symptoms- thickened skin, hair loss, lethargy, constipation, and anorexia.

How do parathyroid hormones impact serum calcium level? 

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  • PTH appears to increase the serum calcium levels by three different mechanism 
    • It promotes bone re absorption
    • In increases the absorption of calcium from the intestine 
    • It any increase the re absorption of calcium by the renal tubules.

Nursing diagnosis for clients taking thyroid medications? 

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  • • Ineffective health maintenance related to thyroid dysfunction
  • Disturbed sleep pattern related to thyroid dysfunction and thyroid medication
  • Disturbed body image related to exophthalmus
  • Imbalanced nutrition, less then body requirements related to hyperthyroidism
  • Risk for injury to side effects of thyroid medication
  • Deficient knowledge related to disease process and medication

Adverse effects of prophylthiouracid (PTU)

• Not very common, some clients develop a mild skin rash that often subsides spontaneously or an changing drugs the development of agraneously has been reported in a small number of clients. This condition develops rapidly should report signs of sore throat or fever immediately, as they often precede adverse effects.

How is propanolol (lindoral) used for treatment of hyperthyroidism?

Have been used successfully in suppression some of the signs and symptoms of hyperthyroidism. Although, these agents do not inhibit the functioning of the thyroid gland, their ability to clock the tachycardia, tremor, and anxiety often associated with hyperthyroidism makes them useful adjunct to other forms of therapy, particularly before the other measures have begun exerting their effects. 

All are RXs that heart action!  

INOTROPE (think ‘a contraction in’)

+inotrope ↑ force of contraction, -inotrope ↓ force of contraction.

CHRONOTROPE (think time…hr hour and HR is Heartrate)

+chronotrope ↑HR, -chronotrope ↓HR (SA node controls HR)

dROMotropic (ROM; computer; electricity) +dROM↑rate of electrical conduction, while – dROM slows rate of electrical conduction.  (conduction travels down the heart muscle, these affect myocardium)

Surface-active agent (detergent like)

germacidal 

wetting agent (water-soluable substance that enables spreading of a liquid on a surface or penetration into a material)

Does not kill spores, therefore only moderetly effective

gradual reduction in stomach acid 

gastric emptying rate appears to be prolonged 

diminished intestinal movement 

decreased blood flow to the gi tract 

decrease of absorption area in small intestine 

desloratadine (clarinex)

loratadine (claritin, alavert) 

Fexofenadine (allegra) 

cetirizine HCI (zyrtec)