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-blockers blocking of all receptors in SNS; patients
complain of fatigue, loss of libido, inability to
sleep, GI and GU disturbances - associated with fetal pancytopenia and MI
α-adrenergic inhibit postsynaptic α1-adrenergic receptors,
blockers ↓ sympathetic tone in the vasculature and Drug-Drug Interactions
causing vasodilation; diagnose and manage - allopurinol = risk of hypersensitivity reactions ↑
episodes of pheochromocytoma
α1-blockers block postsynaptic α1-receptor sites, ↓ Food-Food Interactions
vasculature and causing vasodilation; do - food = absorption of oral ACE inhibitors ↓
not block presynaptic α2-receptor sites
α2-agonists stimulate α2-receptors in the CNS and Nursing Considerations
inhibit the CV centers, ↓BP; many adverse - encourage patient to implement lifestyle changes
CNS, GI effects, cardiac dysrhythmias - administer on empty stomach, 1 or 2 hours before meals
- monitor fluid volume
Angiotensin-Converting Enzyme (ACE) Inhibitors
Angiotensin II Receptor Blockers (ARBs)
- block the conversion of angiotensin I to angiotension II in the - selectively bind the angiotensin II receptors in blood vessels
lungs to prevent vasoconstriction
- as monotherapy or combined with diuretics - prevents the release of aldosterone in the adrenal cortex
Prototype: captopril (Capoten) Prototype: losartan (Cozaar)
- for hypertension, congestive heart failure (CHF), diabetic - used alone or as part of combination therapy
neuropathy, left ventricular dysfunction after MI - treatment of diabetic neuropathy with an elevated serum
- associated with fatal pancytopenia, cough, GI distress creatinine an d proteinuria
Therapeutic Actions and Indications Therapeutic Actions and Indications
- ↓ BP and aldosterone release - selectively bind with angiotensin II receptor sites in vascular
- indicated for treatment of hypertension, alone or with other smooth muscle and in the adrenal gland to block
drugs vasoconstriction and aldosterone release
- treatment of hypertension and for CHF in patients who are
Pharmacokinetics intolerant to ACE inhibitors
- well absorbed, widely distributed
- metabolized in liver, excreted in urine and feces Pharmacokinetics
- well absorbed, metabolized in liver
- cross the placenta and associated with serious fetal
abnormalities - excreted in urine and feces
- crosses the placenta, associated with serious fetal
abnormalities and death
Contraindications
- allergy
- impaired renal function Contraindications
- pregnancy and lactation - allergy
- pregnancy and lactation
Caution
- CHF Cautions
- salt/volume depletion - hepatic or renal dysfunction
- hypovolemia
Adverse Effects
- effects of vasodilation and alterations in blood flow Adverse Effects
o reflex tachycardia, chest pain, angina, CHF, - headache, dizziness, syncope, weakness
cardiac arrhythmias - hypotension, GI complaints
- symptoms of upper respiratory tract infections and cough
o GI irritation, ulcers, constipation, liver injury
- rash, dry skin, alopecia
o renal insufficiency, renal failure, proteinuria
o rash, alopecia, dermatitis, photosensitivity
Drug-Drug Interactions
- unrelenting cough
 - phenobarbital = risk of ↓ serum levels and loss of Prototype: nitroprusside (Nitropress)
effectiveness ↑ - used intravenously
- treatment of hypertensive crisis and maintain controlled
Nursing Considerations hypertension during surgery ANTIHYPOTENSIVE AGENTS
- encourage patient to implement lifestyle changes - toxic levels cause cyanide toxicity
- administer without regard to meals; give with food - severe hypotension leads to shock
- suggest use of barrier contraceptives Therapeutic Actions and Indications - sympathomimetic drug: first choice drug for treating shock
- monitor fluid volume - act directly on vascular smooth muscle to cause muscle
relaxation, leading to vasodialtion and drop in BP Sympathetic Adrenergic Agonists
Calcium Channel Blockers - effects of a sympathetic stress response:
- prevent the movement of calcium into the cardiac and Pharmacokinetics o ↑ BP
smooth muscle cells - rapidly absorbed and widely distributed o ↑ blood volume
- when the cells are stimulated - metabolized in the liver and excreted in urine o ↑ strength of cardiac muscle contraction
- leading to loss of smooth muscle tone, vasodilation, ↓ - cross the placenta and enter breast milk
peripheral resistance only drug: midodrine (ProAmatine)
- ↓ BP Contraindications - treat orthostatic hypotension
- very effective for treatment of angina - allergy
- pregnancy and lactation Therapeutic Actions and Indications
Prototype: diltiazem (Cardizem, Tiamate) - cerebral insufficiency - activates alpha-receptors in arteries and veins to ↑ in
- sustained-release preparation vascular tone and BP
- treatment of hypertension Cautions - indicated for the symptomatic treatment of orthostatic
- peripheral vascular disease, CAD, CHF, tachycardia hypotension
Therapeutic Actions and Indications
- inhibit the movement of calcium ions across the membranes Adverse Effects Pharmacokinetics
of myocardial and arterial muscle cells - related to changes in BP - rapidly absorbed in GI tract
- cyanide toxicity may occur with nitroprusside - metabolized in liver and excreted in urine
Pharmacokinetics o dyspnea o imperceptible pulse
- well absorbed, metabolized in liver, excreted in urine o headache o absent reflexes Contraindications
- cross the placenta, enters breast milk o vomiting o dilated pupils - supine hypertension, CAD, pheochromocytoma
o dizziness o pink color - acute renal disease
Contraindicaitons o ataxia o distant heart sounds - urinary retention
- allergy o loss of o shallow breathing
- heart block or sick sinus syndrome Cautions
consciousness
- renal or hepatic dysfunction - pregnancy and lactation
- pregnancy or lactation - visual problems
Nursing Considerations
- monitor BP and fluid volume - renal or hepatic impairment
Adverse Effects
- CNS effects Adverse Effects
Other Hypertensive Agents
- GI effects - related to stimulation of alpha-receptors
- CV effects o piloerection, chills, rash
only drug: mecamylamine (Inversine)
- skin flushing, rash o hypertension, bradycardia
- ganglionic blocker that occupies cholinergic receptor sites of
autonomic neurons, blocking the effects of acetylcholine at o dizziness, vision changes, vertigo, headache
Drug-Drun Interactions
both sympathetic and parasympathetic ganglia o problems with urination
- cyclosporine = ↑ serum levels and toxicity of cyclosporine
- can cause
o severe hypotension, CHF Drug-Drug Interactions
Vasodilators
o CNS symptoms of dizziness, syncope, weakness, - risk of ↑ effects and toxicity of cardiac glycosides, beta-
- produce relaxation of the vascular smooth muscle, ↓
vision changes blockers, alpha-adrenergic agents, corticosteroids if taken
peripheral resistance and reducing BP
o parasympathetic blocking symptoms of dry mouth, with midodrine
- do not block reflex tachycardia
- reserved for use in severe hypertension and hypertensive glossitis, nausea, vomiting, constipation, urinary
retention Nursing Considerations
emergencies
o impotence - monitor BP
 - do not administer to bedridden patients
- monitor HR regularly
- monitor patients with visual problems
- encourage patients to void before taking drug
CHAPTER 44: CARDIOTONIC
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 7. electrolyte abnormalities
-decreased blood flow
- relieve CHF ****CAUTION
- has two types: 1. pregnant or lactating women
2. **pediatric and geriatric patients
A. CARDIC GYCOSIDES
- used for hundred of years *****ADVERSE EFFECTS
- derived form foxglove or digitalis plant 1. headache, weakness, drowsiness and vision
Drugs: changes
1. Digoxin (Lanoxin, Lanoxicaps) 2. GI upset and anorexia
-treatment of acute congestive heart failure, 3. risk of arrhythmia development
atrial arrhythmias
*****DRUG-DRUG INTERACTION
1. taken with veramil, aminodarone, quinidine,
quinine, erythromycin, tetracycline or
* THERAPEUTIC ACTIONS cyclosporine = increased therapeutic effects
1.increase intracellular calcium and allow
more calcium to enter myocardial cells during NURSING CONSIDERATION
depolarization, causing following effects:
a. Increased force of myocardial contraction DIAGNOSIS
b. Increased cardiac output and renal perfusion 1. Risk for deficient fluid volume related to
c. Slowed heart rate diuresis
d. decreased conduction velocity through the 2. Ineffective Tissue perfusion related in
artrioventricular node cardiac output
3. Impaired Gas exchanged related to changes
**PHARMACOKINETICS in Cadiac Output
1. absorbed widely 4. Deficient Knowledge regarding drug
2. excreted unchanged in urine therapy
3. caution w/ presence of renal impairements
4. not given during pregnancy IMPLEMENTATION
5. enters breast milk 1. Consult with the prescriber about the end
for a loading dose when beginning therapy
*** CONTRAINDICATION 2. Monitor apical pulse for 1 full minute
1. presence of allergy before administration of drugs
2. tachycardia or fibrillation 3. Monitor pulse for any change in quality or
3. heart block or sick sinus syndrome rhythm
4. idiopathic hypertrophic subaortic stenosis 4. check for dosage and preparation carefully
(IHSS) 5. Check pediatric dosage with extreme extra
5. acute MI care
6. renal insufficiency 6. follow dilution instructions
7.administer IV doses very slowly at least 5
minutes
8. Avoid IM administration
9. Arrange the patient to be weighed
10. Avoid administering oral drug with food or
antacids
11. Monitor patient digoxin level ( 0.5 to 3
ng/mL)
B. PHOSPHODIESTERASE INHIBITORS
- belong to a second class of drugs that act as
cardiotonic (intropic) agents
Drugs:
1. Inamripone (Inocor)
- treatment of adults with congestive heart
failure not responsive to digoxin, diuretics or
vasodilators
2. Milrinone (Pimacor)
- shorterm management of CHF in adults
receiving digoxin and diuretics
*THERAPEUTIC ACTIONS
1. block the enzyme phosphodiesterase
2. leads to an increase in myocardial cell
cyclic adenosine monophosphate (cAMP)
3. increases calcium levels in the cells
4. increased cellular calcium causes
contraction and prolongs effects of
sympathetic stimulation
5. indicated for shortterm CHF that has not
responded to digoxin or diuretics
**PHARMACOKINETICS
1. widely distributed after injection
2. metabolized in the liver
3. excreted in the urine
***CONTRAINDICATIONS
1. has allergy
2. w/ severe aortic or pulmonic valvular
disease
3. fluid volume deficit
****CAUTIONS
1. Elderly
2. pregnant or lactating women
***** ADVERSE EFFECTS
1. ventricular arrhythmias, hypotension and
chest pain
2. GI effects: nausea, vomiting, anorexia,
abdominal pain
3. Thrombocytopenia
4. hypersensitivity reactions: vasculitis,
pericarditis, pleurititis, and ascites
*******DRUG-DRUG INTERACTION
1. avoid Fluosemide ( Diuretics)
NURSING CONSIDERATIONS
DIAGNOSIS
1. decreased cardiac output related to
arrhythmias or hypotension
2. risk for injury related to CNS or
Cardiovascular effects
3. Innefective tissue perfusion related to
hypotension or arrythmias
4. Deficient knowledge regarding drug
therapy
IMPLEMENTATION
1. Protect drug form light
2. monitor input and output
3. monitor platelet count
4. monitor injection sites
 o moricizine (Ethmozine) - rash, hypersensitivity reactions, loss of hair, bone marrow
o procainamide (Pronestyl) depression
o quinidine (Quinaglute)
Drug-Drug Interactions
Class IB Drugs - digoxin, beta-blockers = ↑ risk for arrhythmias
- depress Phase 0 somewhat and actually shorten the - digoxin = ↑ digoxin levels and digoxin toxicity
CHAPTER 45 - cimetidine = ↑ serum levels and toxicity
duration of the action potential
ANTIARRHYTHMIC AGENTS - oral anticoagulants = ↑ risk for bleeding
o lidocaine (Xylocaine)
CORONARY ARTERY DISEASE (CAD) o mexiletine (Mexitil)
Drug-Food Interactions
Class IC Drugs - foods that alkalize urine (citrus juices, vegetables, antacids,
- progressive growth of atheromatous plaques, or milk products) = ↑ quinidine levels and toxicity
atheromas in the coronary arteries - markedly depress Phase 0, with a resultant extreme
slowing of conduction - grapefruit juice = ↑ serum levels and toxic effects
→ plaques begin as fatty streaks in the endothelium
→ they injure the endothelial lining o flecainide (Tambocor)
Nursing Considerations
→ development of foam cells (by inflammatory o propafenone (Rythmol)
- monitor cardiac rhythm
process) - maintain life support equipment on standby
→ platelets, fibrin, other fats, and remnants collect on Therapeutic Actions and Indications
- give parenteral forms only if the oral form is not feasible
the injured vessel lining - binding to Na channels, depressing Phase 0 of action
- titrate the dose to the smallest amount needed
→ cause atheroma to grow potential, changing the duration of action potential
→ blood vessel narrows and limits blood flow - have a local anesthetic effect
Class II Antiarrhythmics
- injury to the vessel also causes scarring and thickening - treatment of potentially life-threatening ventricular
of cell wall arrhythmias
- beta-adrenergic blockers that block beta receptors, causing
a depression of Phase 4 of the action potential
 the softer, more lipid atheromas appear to be more likely Pharmacokinetics
- slow the recovery of cells, leading to slowing of conduction
to rupture than stable, harder cores - widely distributed after injection of after rapid absorption
and ↓ automaticity
through the GI tract
- undergo hepatic metabolism
ANTIARRHYTHMIC DRUGS - excreted in urine
Prototype: propanolol (Inderal)
- cross the placenta and enter breast milk
- used as an antihypertensive, antianginal, antimigraine
- affect the action potential of the cardiac cells, altering their headache drug and as an antiarrhythmic to treat
automaticity, conductivity, or both Contraindicaitons
supraventricular tachycardias caused by digoxin or
- proarrhythmic: can also produce new arrhythmias - allergy
catecholamines
- used in emergency situations when the hemodynamics - bradycardia or heart block
arising from the patient’s arrhythmia are severe and fatal - CHF, hypotension, shock
Therapeutic Actions and Indications
- may block reflex arrhythmias and help keep the CV system - electrolyte disturbances
- competitively block beta-receptor sites in the heart and
in balance, or they may precipitate new, deadly arrhythmias kidneys
Cautions
- stabilize excitable cardiac tissue and ↓ BP
Class I Antiarrhythmics - renal or hepatic dysfunction
- indicated for the treatment of supraventricular tachycardias
- pregnancy
or PVCs
- block the sodium channels in the cell membrane during an
action potential Adverse Effects
Pharmacokinetics
- local anesthetics or membrane-stabilizing agents - associated with their membrane-stabilizing effects and
- absorbed from GI tract, hepatic metabolism, excreted in
- preferable in situations such as tachycardia effects on action potentials
urine
o CNS effects
- used only when the benefit to the mother outweighs the
Class IA Drugs o GI effects risk to the fetus
- depress Phase 0 of the action potential and prolong the o CV effects
duration of the action potential - respiratory depression and respiratory arrest Contraindications
o disopyramide (Norpace)
 - sinus bradycardia (rate less than 45 beats/min) and AV
block
- cardiogenic shock, CHF, asthma, respiratory depression
- pregnancy and lactation
Cautions
- diabetes and thyroid dysfunction
- renal and hepatic dysfunction
Adverse Effects
- related to the effects of blocking beta receptors in the SNS
o CNS effects
o CV effects
o respiratory effects
o GI effects
- loss of libido, ↓ exercise tolerance, alterations in blood
glucose levels
Drug-Drug Interactions
- verapamil = ↑ risk of adverse effects
- insulin = ↑ hypoglycemia
Nursing Considerations (same as Class I Antiarrhythmics)
Class III Antiarrhythmics
- block K channels, prolonging Phase 3 of the action
potential, which prolongs repolarization and slows the rate
and conduction of the heart
Prototype: sotalol (Betapace, Betapace AF)
- indicated for the treatment of documented life-threatening
arrhythmias and maintenance of normal sinus rhythm
- proarrhythmic
Therapeutic Actions and Indications
- block K channels and slow the outward movement of K
during Phase 3 of the action potential
- indicated for
o life-threatening ventricular arrhythmias
o conversion of recent-onset atrial fibrillation or atrial
flutter to normal sinus rhythm
o maintenance of sinus rhythm after conversion of atrial
arrhythmias
- excreted in the urine
- used only when the benefit to the mother outweighs the
risk to the fetus
Cautions
- shock, hypotension, respiratory depression, prolonged QTc
interval
- renal or hepatic disease
Adverse Effects
- related to the changes they cause in action potentials
o nausea, vomiting, GI distress
o weakness and dizziness
o hypotension, CHF, arrhythmias
- fever toxicity, ocular abnormalities, serious cardiac
arrhythmias
Drug-Drug Interactions
- digoxin or quinidne = serious toxic effects
Class IV Antiarrhythmias
- block Ca channels in the cell membrane, leading to
depression of depolarization and a prolongation of Phases
1 and 2 of repolarization, slowing automaticity and
conduction
Prototype: diltiazem (Cardizem)
- administered IV
- treat paroxysmal supraventricular tachycardia
Therapeutic Actions and Indications
- block the movement of Ca ions across the cell membrane,
depressing the generation of action potentials, delaying
Phases 1 and 2 or repolarization, and slowing conduction
through the AV node.
- treatment of supraventricular tachycardia and to control the
ventricular response to rapid atrial rates
Pharmacokinetics
- well absorbed
- metabolized in liver and excreted in the urine
- used only when the benefit to the mother outweighs the
risk to the fetus
- CHF or hypotension
Caution
- idiopathic hypertrophic subaortic stenosis (IHSS)
- impaired renal or liver function
Adverse Effects
- related to their vasodilation of blood cells throughout the
body
o CNS effects
o GI effects
- hypotension, CHF, shock, arrhythmias, edema
Drug-Drug Interactions
- beta-blockers = ↑ risk of cardiac depression
- digoxin = additive AV slowing
- dogixin, carbamazepine, prazosin, quinidine = ↑ serum
levels and toxicity
- atracurium, gallamine, metocurine, pancuronium,
rocuronium, tubocurarine, vecuronium = ↑ respiratory
depression
- calcium products or rifampin = ↓ effects
- given IV within 48 hours if IV beta-adrenergic drugs = risk
of severe cardiac effects
- diltiazem + cyclosporine = ↑ serum levels and toxicity
Nursing Considerations (same as Class I Antiarrhythmics)
Other Drugs Used to Treat Arrhythmias
adenosine (Adenocard)
- convert supraventricular tachycardia to sinus rhythm
- drug of choice for terminating supraventricular tachycardia
o very short duration of action (15 sec), picked up by
circulating RBCs, and cleared through the lvier
o associated with very few adverse effects
digoxin (Lanoxin, Lanoxicaps)
- slows Ca from leaving cell, prolonging the action potential
and slowing conduction and HR
- treatment for atrial arrhythmias
- positively inotropic, leading to ↑ cardiac output

Pharmacokinetics Contrindications Nursing Considerations (same as Class I Antiarrhythmics)

- well absorbed and widely distributed - allergy
- metabolized in the liver - sick sinus syndrome or heart block
- lactation

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,
and cough
Drug- Drug interaction
1. beta blockers= paradoxical hypertension
2. w/ clonidine= withdrawal
NURSING CONSIDERATIONS ( same with beta
blockers : Chapter 31)
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
2. GI effects: nausea and hepatic injury
3. Cardiovascular effects: hypotension,
bradycardia, peripheral edema, and heart block
4. Skin effects: flushing and rash
Drug-Drug interactions
1. toxicity of cyclosporines if taken w/ diltiazem
2. increased risk of heart block and digoxin toxicity
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

CHAPTER 47
LIPID-LOWERING AGENTS
CORONARY ARTERY DISEASE (CAD)
- 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 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
 the softer, more lipid atheromas appear to be
more likely to rupture than stable, harder cores
ANTIHYPERLIPIDEMIC AGENTS
- often used in combination
- 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 Therapeutic Actions
complex that is excreted in the feces → block the formation of cellular cholesterol
→ liver must use cholesterol to make more bile → ↓ serum cholesterol and LDLs, slight ↑ or no
acids change in HDLs
→ ↓ serum levels of cholesterol and LDLs
Indications
Indications - adjuncts with diet and exercise for the treatment
- reduce serum cholesterol in patients with of ↑ cholesterol and LDL levels
primary hypercholesterolemia as an adjunct to - slow the progression of CAD
diet and exercise - prevent first MI
- cholestyramine: treat pruritus associated with
partial biliary obstruction Pharmacokinetics
- absorbed from GI tract
Pharmacokinetics - first-pass metabolism in liver
- form an insoluble complex - excreted through feces and urine
- excreted in feces - pregnancy category X
- not absorbed systematically
Contraindications
Contraindications - allergy
- allergy - active liver disease or history of alcoholic liver
- complete biliary obstruction disease
- abnormal intestinal function - pregnancy or lactation
- pregnancy or lactation
Caution
Adverse Effects - impaired endocrine function
- direct GI irritation
- ↑ bleeding times Adverse Effects
- vitamin A and D deficiencies - GI system
- muscle aches and pains - CNS effects
- ↑ concentration of liver enzymes
Drug-Drug Interactions - rhabdomyolysis with acute renal failure
- ↓ or delay the absorption of thiazide diuretics,
digoxin, warfarin, thyroid hormones, Drug-Drug Interactions
corticostreriods: - erythromycin, cyclosporine, gemfibrozil, niacin,
antifungal drugs = ↑ risk for rhabdomyolysis
Nursing Considerations - digoxin, warfarin = ↑ serum levels and resultant
- do not administer powdered agents in dry form toxicity
(mix with juices, soups, etc.) - oral contraceptives = ↑ estrogen levels
- ensure tablets are not cut, chewed, or crushed - grapefruit juice = ↑ serum levels and risk of
- give drug before meals toxicity
- administer oral medicatiosn 1 hour before or 5 to
6 hours after the bile acid sequestrant Nursing Considerations
- arrange for bowel program - administer drug at bedtime
- monitor serum cholesterol and LDL levels,
HMG-CoA REDUCTASE INHIBITORS (“statins”) including liver function, before and during
therapy
Prototype: atorvastatin (Lipitor) - arrange for ophthalmic medications
- associated with severe liver complications
 - 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)
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

Therapeutic Actions Other Drugs Used to Affect Lipid Levels

→ works in the brush border of the small intestine
to ↓ absorption of dietary cholesterol fibrates
→ drop in serum cholesterol levels → stimulate the breakdown of lipoproteins from
the tissues and their removal from the plasma
Indications → ↓ in lipoprotein and triglyceride synthesis and
- lower cholesterol level secretion
- treatment for homozygous familial
hypercholesterolemia - absorbed from GI tract
- reduce elevated sitosterol and campesterol - metabolized in liver
levels - excreted in urine

Pharmacokinetics vitamin B3
- absorbed well → inhibits release of free fatty acids from adipose
- metabolized in the liver and small intestine tissue
- excretion is through feces an urine → ↑ rate of triglyceride removal from plasma
→ ↓LDL and triglyceride level, ↑ HDL levels
Contraindications → also ↓ levels of apoproteins needed to form
- allergy chylomicrons
- pregnancy, lactation, severe liver disease (if in
combination with statin) - associated with intense cutaneous flushing,
nausea, abdominal pain, development of gout
Cautions - given at bedtime
- pregnancy or lactation - administer 4 to 6 hours after the bile acid
- elderly patients or with liver disease sequestrant

Adverse Effects Combination Therapy

- mild abdominal pain and diarrhea - if the patient shows no response to strict dietary
- headache, dizziness, fatigue, upper respiratory modifications, exercise, and lifestyle changes,
tract infection (URI), back pain, muscle aches and the use of lipid-lowering agent, combination
and pains of therapy may be initiated to achieve desirable
serum LDL and cholesterol levels
Drug-Drug Interations
- cholestyramine, fenofibrate, gemfibrozil,
antacids = ↑ risk of elevated serum levels of
ezetimibe
- cyclosporine = ↑ risk of toxicity
- fibrate = ↑ risk of cholethiasis
- ezetimibe = ↑ warfarin levels

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 Megaloblastic Anemias
CHAPTER 49: DRUGS USED TO TREAT
ANEMIAS
BLOOD
Folic Acid Deficiency
- essential for cell survival
o contains oxygen and nutrients and
removes waste products that could be toxic
to the tissues
o contains clotting factors that help maintain
the vascular system and keep it sealed
o contains important components of the
immune system that protect the body from
infection
Blood Components
- composed of liquid and formed elements:
plasma, leukocytes, erythrocytes, platelets
Types of Anemia
Vitamin B12 Deficiency
1. Deficiency Anemia
- occurs when the diet cannot supply enough
of a nutrient, or enough of a nutrient cannot
be absorbed
2. Megaloblastic Anemia
- 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 Pernicious Anemia
- 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
- there is no sufficient folic acid or vitamin B 12 to
adequately create the stromal structure needed
in a healthy RBC
- folic acid is essential for cell division in all types
of tissue
- deficiencies in folic acid are first noticed in
rapidly growing cells
- may occur in:
o certain malabsorption states (such as sprue
or celiac diseases)
o malnutrition that accompanies alcoholism
o repeated pregnancies
o extended treatment with certain antiepileptic
medications
- treated by the administration of folic acid or
folate
- vitamin B12 is used in minute amounts by the
body and is stored for use
- it is necessary for the health of the RBCs and for
the formation and maintenance of the myelin
sheath in the CNS
- 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
- 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
- for patients who are no longer able to produce
erythropoietin in the kidneys
Prototype: epoetin alfa (Epogen, Procrit)
Therapeutic Actions
- acts like the natural glycoprotein erythropoietin
to stimulate the production of RBCs in the bone
marrow
Indications
- treatment of anemia with renal failure
- to ↓ the need for blood transfusion in patients
undergoing surgery
- treatment of anemias related to treatment for
AIDS
- treatment of anemia associated with cancer
chemotherapy (Procrit only)
Pharmacokinetics
- metabolized through the normal kinetic process
- half life of 4 to 13 hours
Contraindications
- presence of uncontrolled hypertension
- allergy
- 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
 - stimulates Na-K exchange
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
 >precision of the reabsorption
>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
  Is one the body’s major
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
system and depositing them into
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,
sodium bicarbonate, and sodium
chloride
process allows the body to
maintain the correct extracellular
fluid volume and composition
Maintenance of Volume and composition
of Body Fluids
Sodium Regulation
Sodium
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
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
Chloride Regulation
Chloride
 Is an important negatively charged
ion that helps to maintain electrical
neutrality with the movement of
cations across the cell membrane
 Primarily absorbed in the loop of
Henle, where it promotes the
movement of sodium out of the
cell
*the kidneys play a role
Sodium Regulation
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
the urine until it is
excreted from the body.
Uterus- have smooth endothelial lining
and circular muscular linings.
 The female urethra is very short
and leads to an area populated by
normal flora including e.coli.
 The male urethra is much longer
and passes through the prostate
gland.
Prostate Gland- a small gland that
produces an acidic fluid that is
important in maintaining the sperm
and lubricating the tract.

CHAPTER 51: Diuretic Agents
Diuretic Agents
- drugs that increase the amount of urine
- the greater significance of diuretics is their ability to
increase sodium excretion.
Therapeutic actions and indications:
- prevent the cell’s lining the renal tubule from
reabsorbing an excessive proportion of the sodium
ions in the glomerular filtrate.
- as a result, sodium and other ions are lost in the
urine instead of being return to the blood, where they
would cause increase intravascular volume and
therefore increase hydrostatic pressure, which could
result in leaking of fluids at the capillary level.
- Indicated for the treatment of edema associated with
congestive heart failure, acute pulmonary edema,
liver disease, and renal disease, and for the treatment
of hypertension.
- Also use to decrease fluid pressure in the eye
(intraocular pressure), which is useful in treating
glaucoma.
- Diuretics that decrease potassium levels may also be
indicated in the treatment of conditions that cause
hyperkalemia.
Contraindications and cautions:
- presence of allergy to any of the drugs given
- fluid and electrolyte imbalances
- severe renal disease
- caution should be used with systemic lupus
erythematosus (SLE)
- glucose tolerance abnormalities or diabetes mellitus
- gout
- liver disease
- pregnancy and lactation
Adverse effects:
- the most common adverse effects seen with diuretics
include GI upset, fluid and electrolyte imbalances,
hypotension, and electrolyte disturbances.
Drug- drug interactions:
drugs that altered the actions of diuretics:
- antiarrhythmics (digoxin), drugs that depend on a
particular electrolyte balance for their therapeutic
effects.
- Quinidine, drugs that depend on urine alkalinity for
proper excretion.
- Antihypertensive ad antidiabetic agents, depend on
normal reflexes to balance their effects.
THIAZIDE AND THIAZIDE- LIKE DIURETICS
- Hydrochlorothiazide (hydroDIURIL), the most
frequently used of the thiazide diuretics, often used
in combination with other drugs for the treatment of
hypertension.
- Chlorothiazide (Diuril), the oldest of this class, and
considered the prototype.
- Bendroflumethiazide (Naturetin)
- Hydroflumethiazide (Diucardin)
- Methyclothiazide (Aquatensen)
- Trichlormethiazide (Diurese)
*Thiazide- like drugs
- Chlorthalidone (Hygroton)
- Indapamide (Lozol)
- Metolazole (Mykrox)
- Quinethazone (Hydromox)
Therapeutic actions and indications:
- Thiazide diuretics belong to a chemical class of
drugs called sulfonamides.
- Thiazide- like diuretics has a slightly different
chemical structure but work in the same way that
thiazide diuretics do.
- Their action is to block the chloride pump.
- Usually indicated for the treatment of edema
associated with CHF or with liver or renal disease.
- Also used as monotherapy or as adjuncts for the
treatment of hypertension.
Pharmacokinetics:
- onset of action: 1-3 hours
- metabolize in the liver and excreted in the urine
- well absorbed in the GI tract
Contraindications and cautions:
- contraindicated with allergy to thiazides or
sulfonamides, fluid or electrolyte imbalances and
renal and liver disease.
- Additional cautions include: gout, SLE, diabetes,
hyperparathyroidism, bipolar disorder, and
pregnancy and lactation.
Adverse effects:
- Hypokalemia (weakness, muscle cramps, and
arrhythmias)
- Decrease calcium excretion, which leads to increase
calcium level.
- 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
Adverse Effects
- Hyperkalemia
OSMOTIC DIURETICS
- Pull water into the renal tubule without sodium loss.
- Drug of choice for Increase cranial pressure or acute
renal failure.
Glycerin (osmoglyn)
Mannidol (Osmitrol)
Urea (ureaphil)
Therapeutic Actions and Indication
- It acts to pull large amounts of fluid into the urine by
the osmotic pull of the large sugar molecule.
- These drugs are often used in acute situation .
- Prevent oliguric phase of renal failure, and to
promote of toxic substances through the kidneys.
Pharmacokinetics
- These drugs are freely filtered at the renal
glomerulus, poorly reabsorbed by the renal tubules
and not secreted by the tubule, and resistant to
metabolism.
Contraindications and Cautions
- Renal disease and anuria from sever renal disease,
pulmonary congestion, intracranial bleeding,
dehydration and CHF.
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
to destroy bacteria, either through a tract, but it is associated
direct antibiotic effect or through with CNS effects (blurred
Urinary Tract Anti-Infectives vision, dizziness, confusion)
acidification of the urine.
that make it less desirable to
DRUGS: use in certain patients
PHARMACOKINETICS:
 Oxybutynin (Ditropan)- is a
2 types: antibiotics & anti infectives
Because these drugs are from potent urinary antispasmodic,
works to acidify the urine
several different chemical classes, but it has numerous
the pharmacokinetic data are different anticholinergic effects, making
Antibiotics
for each drug. it undesirable in certain
CONTRAINDICATIONS: conditions or situations that
 Cinoxacin(Cinobac)- interferes might be aggravated by
with the DNA replication in These drugs are contraindicated decreased sweating, urinary
gram negative bacteria in the presence of any of these drugs. retention, tachycardia, and
 Norfloxacin (Noroxin)- a newer They should be used with caution in changes in the GI activity.
and more broad spectrum drug, the presence of renal dysfunction,  Tolterodine (Detrol,Detrol LA)-
is effective against even more which could interfere with the is a newer agent that blocks
gram negative strains than excretion and action of these drugs, muscarinic receptors,
cinoxacin and with pregnancy and lactation preventing bladder contraction
 Fosfomycin (Monurol)- has the because of the potential for adverse and spasm
convenience of only one dose. effects on the fetus or neonate.  Trospium (Sanctura)- is the
It is not recommended for newest drug approved to block
patients younger than 18 years ADVERSE EFFECTS: urinary tract spasms. It also
of age specifically blocks muscarinic
 Nalidixic (NegGram)- is an  nausea, vomiting, diarrhea, receptors and reduces the
older drug that is not anorexia, bladder irritation, muscle tone of the bladder. It
effective against as many and dysuria is specifically indicated for
strains of gram-negative  infrequent symptoms include the treatment of overactive
bacteria as the other pruritus, urticaria, headache, bladder with symptoms of urge
antibiotics used for UTIs dizziness, nervousness, and urinary incontinence, urgency,
confusion and urinary frequency.
 such combinations must be used, the than 2 days because the toxic
ACTION: patient should be monitored closely effects may be increased.
and appropriate dosage adjustments
Inflammation in the urinary made. DRUG-DRUG INTERACTIONS:
tract, such as cystitis, prostatics,
urethritis, and The risk of toxic effects of
euthrocystitis/urethrotrigonitis, Urinary Tract Analgesic this drug increases if it is combined
causes smooth muscle spasms along the with anti-bacterial agents used for
urinary tract. Irritation of the DRUGS: treating UTIs. If this combination is
urinary tract leading to muscle spasm used, the phenazopyridine should not
also occurs in patient with neurologic  Phenazopyridine (Azo-Standard, be used for longer than 2 days.
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
in urine. Caution should be used in urinary tract mucosa. It is used to
the presence of hepatic or renal relieve symptoms related to urinary
impairment because of the potential of tract irritation from infection,
alterations in metabolism or excretion trauma, or surgery.
of the drugs.
PHARMACOKINETICS:
CONTRAINDICATIONS:
Phenazopyridine is rapidly
These drugs are contraindicated absorbed and has a very rapid onset of
in the presence of any allergy to action. It is widely distributed,
these drugs; with pyloric or duodenal crossing the placenta and entering
obstruction or recent surgery because breast milk. It is metabolized in the
anticholinergic effects can cause liver and excreted in the urine.
serious complications.
CONTRAINDICATIONS:
ADVERSE EFFECTS:
This drug is contraindicated in
 adverse effects of urinary the presence of any allergy to the
antispasmodics are related to drug and serious renal dysfunction,
blocking of the parasympathetic which would interfere with the
system excretion and effectiveness of the
 nausea and vommitng, dry mouth, drug.
nervousness, tachycardia, and
vision changes ADVERSE EFFECTS:

DRUG-DRUG INTERACTIONS:  GI upset, headache, rash,

reddish-orange coloring of
Decreased effectiveness of urine
phenothiazines and haloperidol has  Hepatic toxicity, this drug
been associated with the combination should not be used for longer
of these drugs with oxybutynin. If any
 into the gastrointestinal tract, where blood to the alveoli is referred to as
stomach acid destroys foreign materials. perfusion.

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

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,

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
The gastrointestinal (GI) system is the
only system in the body that is open to the
external environment. The GI system is
composed of one continuous tube that
begins at the mouth; progresses through
the esophagus, stomach and small and
large intestines; and ends at the anus. The
pancreas, liver and gallbladder are
accessory organs that support the
functions of the GI system.
Composition of the Gastrointestinal Tract
The GI tube is composed of
four layers:
 The Mucosa – provides the inner
lining of the GI tract
 The Muscularis Mucosa – is made
up of muscles. It helps the tube
open and squeezing the tube to aid
digestion and motility. It also helps
propel the gastrointestinal contents
down the tract.
 The Nerve Plexus – these gives the
GI tract local control of movement,
secretions, and digestion.
 The Adventitia – outer layer of the
GI tract, serves as a supportive
layer and helps the tube maintain
its shape and stay in position.
Gastrointestinal Activities
The system has four major activities:
 Secretion
 Absorption
 Digestion
 Motility
Secretion – secretes various compounds to
aid the movement of the food bolus
through the GI tube, to protect the inner
layer of the GI tract from injury and to
facilitate the digestion and absorption of
nutrients.
- Saliva – contains water and
digestive enzymes and
facilitate swallowing by
making bolus slippery
- Histamine 2 receptors –
gastrin and
parasympathetic system
stimulates it, causing the
cells to release
hydrochloric acid into the
lumen of the stomach.
- Bile – contains detergent
like substance that breaks
apart fat molecules so that
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  Somatointestinal reflex
contracts.
Central Reflexes
Two centrally mediated reflexes -
Swallowing reflex and Vomiting reflex –
are very important to the functioning of
the GI tract.

Local Gastrointestinal Reflexes  Swallowing – is a centrally

 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.
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.

Other local GI reflexes:

 Ileogastric reflex
 Intestinal-intestinal reflex
 Peritoneointestinal reflex
 Renointestinal reflex
 Vesicointestinal reflex