By D. Peer. Potomac College.

If anginal symptoms occur during sleeping hours purchase 10 mg alfuzosin free shipping mens health 20 worst drinks, cokinetics of diltiazem and verapamil are quite similar in short-acting nitrates may be beneficial in relieving the clients with normal and impaired renal function effective 10mg alfuzosin mens health six pack, caution is symptoms. Dosage reductions are considered unnecessary with verap- amil and diltiazem but may be needed with nifedipine and Use in Children several other dihydropyridine derivatives. With nifedipine, protein binding is decreased and the elimination half-life is The safety and effectiveness of antianginal drugs have not prolonged with renal impairment. Nitroglycerin has been given elevations in blood urea nitrogen and serum creatinine have IV for heart failure and intraoperative control of blood pres- occurred. With nicardipine, plasma concentrations are higher sure, with the initial dose adjusted for weight and later doses in clients with renal impairment, and dosage should be re- titrated to response. Bepridil should be used with caution because its metabolites are excreted mainly in urine. Use in Older Adults Use in Hepatic Impairment Antianginal drugs are often used because cardiovascular disease and myocardial ischemia are common problems in Nitrates, beta blockers (see Chap. Adverse drug effects, such as hypotension and blockers are metabolized in the liver, and all should be used syncope, are likely to occur, and they may be more severe with caution in clients with significant impairment of hepatic than in younger adults. Blood pressure and ability to ambu- function from reduced blood flow or disease processes. Ambula- one hand, first-pass metabolism is reduced, which increases tory clients also should be monitored for their ability to take bioavailability (amount of active drug) of a given dose. In higher plasma concentrations of verapamil, diltiazem, nifedi- this case, more enzymes are available and the drug is metab- pine, and amlodipine. This is attributed to decreased hepatic olized more rapidly, possibly reducing therapeutic effects of metabolism of the drugs, probably because of decreased hepatic a given dose. In addition, older adults may experience more times given to counteract the drug tolerance (reduced hemo- hypotension with verapamil, nifedipine, and felodipine than dynamic effects) associated with chronic use. Blood pressure should be monitored with metabolism of nitroglycerin and isosorbide dinitrate nor- these drugs. Thus, if metabolism is re- CHAPTER 53 ANTIANGINAL DRUGS 785 duced by liver impairment, drug effects may be decreased Use in Critical Illness and shorter in duration. With calcium channel blockers, impairment of liver Antianginal drugs have multiple cardiovascular effects and function has profound effects on the pharmacokinetics and may be used alone or in combination with other cardio- pharmacodynamics of most of these drugs. They are probably should be used with caution, dosages should be substan- used most often to manage severe angina, severe hypertension, tially reduced, and clients should be closely monitored for or serious cardiac dysrhythmias. For example, IV nitroglycerin drug effects (including periodic measurements of liver en- may be used for angina and hypertension; an IV beta blocker zymes). These recommendations stem from the following or calcium channel blocker may be used to improve cardio- effects: vascular function with angina, hypertension, or supraventricu- • An impaired liver produces fewer drug-binding plasma lar tachydysrhythmias. This means that a greater pro- be carefully titrated and clients must be closely monitored for portion of a given dose is unbound and therefore active. Both of these effects heart failure, hypotension, or other conditions that impair increase plasma levels of drug from a given dose (es- blood flow to the gastrointestinal tract or skin. The effects result from shunting of blood around the liver so that drug molecules circu- lating in the bloodstream do not come in contact with Home Care drug-metabolizing enzymes and therefore are not me- tabolized. Initially, the nurse should double and their clearance is approximately one third assess the frequency and severity of anginal attacks and how that of clients without cirrhosis. In addition, the nurse can assess the • Although hepatotoxicity is uncommon, clinical symp- home setting for lifestyle and environmental factors that may toms of hepatitis, cholestasis, or jaundice and elevated precipitate myocardial ischemia. When causative factors are liver enzymes (eg, alkaline phosphatase, creatine kinase identified, plans can be developed to avoid or minimize them. These changes resolve if the causative drug ensure a constant supply; and discussing circumstances for is stopped. NURSING Antianginal Drugs ACTIONS NURSING ACTIONS RATIONALE/EXPLANATION 1. Check blood pressure and heart rate before each dose of an Hypotension is an adverse effect of antianginal drugs. Withhold the drug if systolic blood pressure dia is an adverse effect of propranolol and nadolol. If the dose is omitted, record and report to justments may be necessary if these effects occur. Give antianginal drugs on a regular schedule, at evenly To increase effectiveness in preventing acute attacks of angina spaced intervals. If oral nitrates and topical nitroglycerin are being used con- To minimize risks of additive hypotension and headache currently, stagger times of administration.

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Why is the G-CSF given discount 10 mg alfuzosin overnight delivery man health lifestyles, and how will you immunostimulant drugs in children (younger than 18 years of evaluate its effectiveness? Filgrastim and sargramostim have been used pairment may delay elimination of other medications and in- in children with therapeutic and adverse effects similar to crease risks of adverse effects purchase alfuzosin 10 mg with amex androgen hormone imbalance. In clinical trials, filgrastim produced a greater incidence of subclinical spleen enlargement in chil- dren than in adults, but whether this affects growth and Use in Hepatic Impairment development or has other long-term consequences is un- known. Oprelvekin has been given to a few children with In some clients with preexisting hepatic impairment, sar- adverse effects similar to those observed in adults. Val- indicate that tachycardia occurs more often in children and ues declined to baseline levels when the drug was stopped or that larger doses are needed (eg, a dose of 75 to 100 mcg/kg its dosage reduced. Hepatic function tests are recommended in children produces similar plasma levels to a dose of every 2 weeks in clients with preexisting impairment. Long-term effects on growth and de- With aldesleukin, hepatic impairment occurs during ther- velopment are unknown. This impairment may be increased if other hepatotoxic Little information is available about the use of interferons in drugs are taken concomitantly. Interferon alfacon-1 (Infergen) is not recommended patic impairment may delay metabolism and elimination of for use in children. Interfer- ons alfa-2b, alfacon-1, and alfa-n1 are contraindicated in Use in Older Adults clients with decompensated liver disease (ie, signs and symp- toms such as jaundice, ascites, bleeding disorders, or de- In general, hematopoietic and immunostimulant agents have creased serum albumin), autoimmune hepatitis, a history of the same uses and responses in older adults as in younger adults. Worsening of liver disease, with jaundice, hepatic adverse effects, especially if large doses are used. Oprelvekin encephalopathy, hepatic failure, and death, has occurred in should be used with caution in clients with a history of or risk these clients. The drugs should be discontinued in clients with factors for atrial fibrillation or flutter; these arrhythmias oc- signs and symptoms of liver failure. In addition, older adults are more likely to have fluid retention, with resultant symptoms of peripheral edema, dyspnea on ex- Home Care ertion, and dilutional anemia. Darbepoetin alfa (Aranesp), epoetin alfa (Epogen), filgrastim (Neupogen, Neulasta), oprelvekin (Neumega), and the inter- Use in Renal Impairment ferons are often self-administered or given by a caregiver to chronically ill clients. The home care nurse may need to teach Except for darbepoetin alfa and epoetin alfa, which are used to clients or caregivers accurate drug preparation and injection treat anemia in clients with chronic renal failure, little informa- techniques, as well as proper disposal of needles and sy- tion is available about the use of hematopoietic and immuno- ringes. Assistance may also be needed in obtaining appropri- stimulant drugs in clients with renal impairment. Renal function tests For example, epoetin alfa is not effective unless sufficient are recommended every 2 weeks in clients with preexisting iron is present, and most clients need an iron supplement. When an iron preparation is prescribed, the home care nurse With aldesleukin, renal impairment occurs during therapy. With fil- This impairment may be increased if other nephrotoxic drugs grastim, the nurse may need to help the client and family with are taken concomitantly. In addition, drug-induced renal im- techniques to reduce exposure to infection. CHAPTER 44 HEMATOPOIETIC AND IMMUNOSTIMULANT DRUGS 667 NURSING Hematopoietic and Immunostimulant Agents ACTIONS NURSING ACTIONS RATIONALE/EXPLANATION 1. Administer accurately For hospitalized clients, the drugs may be prepared for adminis- tration in a pharmacy. Give darbepoetin alfa intravenously (IV) or subcutaneously Outpatients may be taught self-administration techniques. Give epoetin alfa IV or SC; do not shake the vial; and dis- For clients with chronic renal failure on hemodialysis, epoetin alfa card any remainder of multidose vials 21 d after opening. For patients with- out an IV line or who are ambulatory, the drug is injected SC. Shaking can inactivate the medication; the manufacturer does not ensure sterility or stability of multidose vials after 21 days. With aldesleukin, review institutional protocols or the man- This drug has limited uses and is rarely given. With interferons, (1) Read drug labels carefully to ensure having the correct Available drugs have similar names but often differ in indications drug preparation. With intravesical Bacillus Calmette-Guérin (BCG): (1) Reconstitute solution (see Drugs at a Glance: Hematopoi- Reconstituted solution should be used immediately or refrigerated. Then, allow to ambulate but ask to retain solution for a total of 2 h before urinating, if able.

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Dopamine Older adults often have disorders such as atherosclerosis discount 10 mg alfuzosin mastercard mens health august 2013, varies in clearance rate in adult and pediatric clients cheap alfuzosin 10 mg with mastercard prostate inflammation symptoms. How- peripheral vascular disease, and diabetes mellitus and may ever, this variance may result from the use of non–steady- not demonstrate common symptoms of volume depletion state plasma concentrations in calculating the clearance rate. Also, when adrenergic drugs When a dopamine IV infusion is started, it may take 1 to are given, their vasoconstricting effects may decrease blood 2 hours to achieve a steady-state plasma level. Epinephrine and norepinephrine are also widely used in critically ill clients. All clients receiving drugs for management of hypotension and Although adrenergic drugs may be lifesaving, they can re- shock should be closely monitored regarding drug dosage, duce renal blood flow and cause renal failure because of their vital signs, relevant laboratory test results, and other indi- vasoconstrictive effects. Continuous invasive hemodynamic clients with previously normal renal function and may be monitoring with an arterial catheter and a pulmonary artery worsened in clients whose renal function is already impaired. Close monitoring of the fusion in oliguric clients, but the effectiveness of this practice critically ill is essential as these clients often have multiple is being questioned. Dilute drugs for continuous infusion in 250 or 500 mL of To avoid adverse effects, which are more likely to occur with intravenous (IV) fluid. A 5% dextrose injection is compatible concentrated drug solutions with all of the drugs and is most often used. Dilute drugs for bolus injections to at least 10 mL with sodium chloride or water for injection. This allows the adrenergic drug solution to be regulated or dis- continued without disruption of other IV lines. Use an infusion pump To administer the drug at a consistent rate and prevent wide fluc- tuations in blood pressure and other cardiovascular functions e. Epinephrine and iso- proterenol decompose on exposure to light, producing a brownish discoloration. Start the adrenergic drug slowly, and increase as necessary Flow rate (dosage) is titrated according to client response. Abnormal monitor readings (ie, blood pressure monitors) should be confirmed with a manual reading before adjusting medication dosage. Systolic blood pressure of 80–100 mm Hg These levels are adequate for tissue perfusion. Higher levels may increase cardiac workload, resulting in reflex bradycardia and de- creased cardiac output. However, higher levels may be necessary to maintain cerebral blood flow in older adults. Heart rate of 60–100, improved quality of peripheral pulses These indicate improved tissue perfusion and cardiovascular function. Improved urine output Increased urine output indicates improved blood flow to the kidneys. Improved skin color and temperature These indicate improved peripheral tissue perfusion. Pulmonary capillary wedge pressure between 15 and Normal pulmonary capillary wedge pressure is 6–12 mm Hg. Higher 20 mm Hg in cardiogenic shock levels are required to maintain cardiac output in cardiogenic shock. Bradycardia Reflex bradycardia may occur with norepinephrine, metaraminol, and phenylephrine. Tachycardia This is most likely to occur with isoproterenol, but may occur with dopamine and epinephrine. Dysrhythmias Serious dysrhythmias may occur with any of the agents used in hy- potension and shock. Causes may include high doses that result in excessive adrenergic stimulation of the heart, low doses that result in inadequate perfusion of the myocardium, or the production of lactic acid by ischemic tissue. Hypertension This is most likely to occur with high doses of norepinephrine, metaraminol, and phenylephrine. Hypotension This is most likely to occur with low doses of dopamine and iso- proterenol, owing to vasodilation. Angina pectoris—chest pain, dyspnea, palpitations All pressor agents may increase myocardial oxygen consumption and induce myocardial ischemia. Tissue necrosis if extravasation occurs This may occur with solutions containing dopamine, norepineph- rine, metaraminol, and phenylephrine, owing to local vasoconstric- tion and impaired blood supply.

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