Hematologic Pharm
This antiplatelet is an ADP antagonist that inhibits platelet aggregation and often used after MI or stroke to prevent recurrence.
What is clopidogrel (Plavix).
-Blocks the chemical messenger ADP that promotes platelet aggregation.
-More potent that aspirin.
-More effective if used with aspirin.
Hypovolemic shock and edema are the primary concerns during this phase of burn management.
What is the emergent phase.
-The emergent phase is the time needed to resolve immediate, life-threatening concerns in the immediate aftermath of a burn. It begins at the initial time of injury and can last up to 72 hrs.
-The primary focus care is fluid management and hemodynamic stability, to stabilize cardiovascular and respiratory function.
-The emergent phase ends when fluid mobilization and diuresis begin.
This virus can lead to viral keratitis, causing a corneal ulcer and potentially resulting in corneal blindness.
What is the herpes simplex virus (HSV).
-Herpes simplex keratitis (HSK) is the most common infectious cause of corneal blindness in the Western Hemisphere.
-It is especially problematic among immunosuppressed individuals.
-It can cause pain and photophobia.
-Tx for HSK includes antiviral drugs (such as acyclovir) and may involve corneal debridement.
-Corticosteroids are usually contraindicated because they can prolong the course of the condition and potentially deepen the corneal ulcer.
This is an infection of the tympanum, ossicles, and space of the middle ear that can lead to vertigo, mastoiditis, and hearing loss if not treated promptly.
What is acute otitis media.
-Can be caused by viruses or bacteria.
-Pain, fever, malaise, drainage, and reduced hearing are signs and symptoms.
-Tx includes PO abx and eardrops.
-Surgical intervention may be needed if not responding to medical tx. A myringotomy is an incision to the tympanum to release pressure and exudate from middle ear. A tympanostomy tube may be used for short-term or long-term ventilation of the ear.
These are topical agents that typically consist of mineral oil and hydrogen peroxide that are used for cerumen removal from the ears.
What are cerumenolytics.
-Typically consist of mineral oil and hydrogen peroxide.
-BONUS: What is an example of a cerumenolytic?
This lab value evaluates the clotting cascade of the intrinsic pathway (inside the blood vessels).
What is PTT.
-PTT is used for heparin.
-Measured in seconds – how long it takes for clotting to occur.
-Normal PTT is 25-35 sec.
-Therapeutic range for heparin therapy will vary by patient’s baseline and facility policy.
-Heparin dose will be adjusted based on PTT levels.
-BONUS: What lab value evaluates the clotting time in the extrinsic pathway?
These are the signs and symptoms of CO poisoning.
What are cherry-red skin, headache, dyspnea, tachypnea, confusion, impaired judgment, cyanosis, and respiratory depression.
-CO poisoning results from excess carboxyhemoglobin (COHgb) in the blood that leads to tissue hypoxia and metabolic asphyxiation.
-Death can occur with COHgb greater than 20%.
These are activity restrictions often recommended to patients following cataract removal surgery.
What are bending, stooping, lifting, coughing (activities that could increase intraocular pressure).
-Usually can go home as soon as sedative agents have worn off, as long as no complications.
-Post-op meds: antibiotic drops and corticosteroid drops to decrease inflammatory response.
-Typically little visual impairment after surgery due to intraocular lens implantation which provides immediate visual improvement.
This type of hearing loss results from impaired function of the inner ear or vestibulocochlear nerve (CN VIII) and can be caused by congenital and hereditary factors, noise exposure, aging, Meniere's disease, trauma, and ototoxicity.
What is sensorineural hearing loss.
-Manifests as sounds becoming muffled, diminished ability to hear pitched sounds, and inability to understand speech. Often, the problems caused by this condition are not understood by others.
-A hearing aid may help, but it will only make sounds and speech louder, not clearer.
-BONUS: What types of drugs are ototoxic?
This class of drugs directly act to constrict pupils and contract the ciliary muscle and help reduce IOP.
What are cholinergic agonists.
-Are used for glaucoma tx.
-Example: pilocarpine (Isopto Carpine).
-Increase the PNS response and cause miosis, which increases the outflow of aqueous humor, thereby reducing IOP and providing relief.
This drug is often given to patients in the hospital for VTE prophylaxis, is more stable and has a longer half-life than heparin, and requires lower doses.
What is enoxaparin sodium (Lovenox).
-Is a low molecular weight heparin (LMWH).
-Given SQ.
-Contraindications: stroke, recent brain surgery, recent spinal surgery, about to go into surgery, peptic ulcer, blood anomalies.
-Need monitor platelets (must be above 100,000).
-Patients can be sent home with enoxaparin sodium (Lovenox) and give themselves injections.
These are the characteristics of a deep partial thickness (second-degree) burn.
What are fluid-filled vesicles that are red, shiny, and wet (if vesicles have ruptured), severe pain (due to nerve injury), and mild to moderate edema.
-May form eschar.
-Involve the epidermis and the dermis to varying extents.
-Typically heal in 21-28 days.
-Will heal from wound edges and dermal bed below if kept clean, dry, and free of infection.
-Can be caused by chemicals, contact burns, electrical current, flame, flash, scald, tar, or cement.
-Infection can turn partial-thickness burns to full-thickness burns.
Patients with this condition may describe symptoms such as light flashes, floaters, and a "cobweb" or "hairnet" ring in their field of vision.
What is retinal detachment.
-Retinal detachment is a separation of the sensory retina and the underlying epithelium, with fluid accumulation between these two layers.
-If untreated, can lead to blindness in affected eye.
-Can have many causes; most common is retinal breaks (interruption in full thickness of retinal tissue, either tears or holes).
-Tx involves re-attachment of the retina and sealing any retinal breaks. Techniques can include: laser photocoagulation (using intense, focused light beam to create inflammatory reaction to cause an adhesion) and cryopexy (freezing the break to create scarring that seals it).
Rapid, involuntary eye movements (nystagmus), vertigo, light-headedness, loss of balance, and nausea with no hearing loss may be indicative of this inner ear disorder.
What is benign paroxysmal positional vertigo (BPPV).
-Common cause of vertigo. Cause of disorder often unknown.
-Free-floating debris (“ear rocks” made up of small calcium carbonate crystals) migrate into semi-circular canal causes vertigo with certain head movements (e.g. getting out of bed, rolling over, sitting up from lying down).
-Rarely serious unless it causes falls.
-Tx is Epley maneuver, which moves ear debris from areas in inner ear that cause symptoms to other, less sensitive areas. Changes the location of debris, not the presence of it. A trained HCP teaches the patient how to perform this.
Patients who have asthma should not be prescribed this class of drugs for glaucoma tx.
What are beta-adrenergic blockers.
-These drugs decrease IOP by decreasing production of aqueous humor.
-Examples: betaxolol (Betoptic) and timolol (Timoptic).
-They are non-selective beta blockers that can prevent adequate bronchodilation in patients with asthma and those with other obstructive pulmonary diseases as well.
A patient receiving alteplase tPA immediately following a stroke should be monitored via cardiac monitor for this potential complication.
What is a reperfusion dysrhythmia.
-If there is any clotting within the coronary vessels, the drug will dissolve them. The sudden restoration of blood flow to the heart muscle can alter electrical activity and cause life-threatening dysrhythmias.
These electrolyte imbalances are important concerns during the hypovolemic phase of burn management.
What are hyperkalemia and hyponatremia.
-Major electrolyte shifts occur during this phase.
-Damaged cells and hemolyzed RBCs release large amounts of potassium into circulation.
-Sodium rapidly moves into interstitial spaces and remains there until edema formation ends.
-BONUS: What are the s/s of hyperkalemia and hyponatremia?
These are risk factors for age-related macular degeneration (AMD).
What are family history, light-colored irises, high C-reactive protein levels, smoking, and HTN.
-AMD is the most common cause of irreversible central vision loss in people over age 60 in U.S.
-Classified as dry AMD (more common) and wet AMD (more severe form). Acute vision loss can occur from either form.
-Wet AMD may cause: blurred or darkened vision, scotomas (blind spots), and metamorphopsia (distorted vision). If only one eye affected, patient may not notice visual changes.
-Tx for wet AMD: meds injected into vitreous cavity at 4-6 week intervals to stop new vessel formation and slow vision loss; photodynamic therapy to damage abnormal vessels.
-Vitamin C, vitamin E, beta-carotene, and zinc, lutein/zeaxanthin can help slow progression. Encourage to eat green leafy vegetables containing lutein (e.g. kale, spinach) and fatty fish at least twice per week.
-Encourage to stop smoking.
This type of assistive device is used for severe to profound sensorineural hearing loss in one or both ears, bypassing damaged or missing portions of the ear and directly activating CN VIII.
What is a cochlear implant.
-Consists of an external microphone placed behind the ear, a speech processor, a transmitter placed under the skin that changes sounds into electrical impulses, and electrodes placed within the cochlea that stimulate the auditory nerves.
-The ideal candidate is someone who became deaf after acquiring speech and language.
Prostaglandin analogues, used for the tx of glaucoma, can cause these side effects.
What are darkening of iris and eyelids; excessive hair growth; blurred vision; redness of conjunctiva; and itching or stinging of eye.
-These drugs decrease IOP by improving outflow of aqueous humor through trabecular bone and by improving the uveoscleral pathway (an alternate pathway).
-They are very commonly prescribed to patients with glaucoma.
-Examples: Bimatroprost (Lumigan), latanoprost (Xalatan), and travoprost (Travatan).
This class of drugs directly inhibit thrombin from converting fibrinogen to fibrin to prevent the clot formation, and do not require routine coagulation monitoring.
What are direct thrombin inhibitors.
-Example: dabigatran (Pradaxa).
-Oral anticoagulant.
-Has rapid onset (peak action in 1-2 hrs). Do not need bridge with heparin to get them to therapeutic level.
-More predictable, fixed dosing (does not need to be adjusted for lab results).
-Tx for DVT, PE, and a-fib, reducing the formation of additional clots.
-High cost.
-Does not have quick antidote, but also has quick offset and is metabolized quickly.
-Depends on renal clearance – can’t be used with impaired kidney function.
According to the Parkland formula, this would be the necessary amount of fluid for the first 24 hours following a burn for a patient who weighs 60 kg and has 20% TBSA affected.
What is 4,800 mL.
-Parkland formula: 4 mL x kg x % TBSA = total mL/24 hrs.
4 mL x 60 kg x 20 = 4,800 mL/24 hrs.
BONUS: If the patient is ready to start receiving IV fluids in the ED one hour following the burn injury, what would be the mL/hr for the first 8 hrs?
This type of glaucoma is characterized by sudden, severe pain in or around the eye, nausea and vomiting, seeing colored halos around lights, blurred vision, and occular redness.
What is acute angle-closure glaucoma (AACG).
-Ocular emergency that may result from the pupil staying partially dilated long enough to cause an acute and significant increase in IOP (>50).
-Can occur due to drug-induced mydriasis (dilation), emotional excitement, or darkness.
-Tx includes miotics (drugs that cause pupil constriction) and PO and IV hyperosmotic agents (e.g. mannitol solution [Osmitrol] and glycerin solution [Opththalgan]) to decrease IOP.
-Laser peripheral iridectomy (creating a hole in the iris) or surgical iridectomy (removal of part of iris) are needed for longer-term tx and can help prevent further episodes.
These are nursing interventions for Meniere's disease.
What are providing a quiet, darkened room; teach to avoid sudden head movements and position changes; teach to close eyes until vertigo stops; teach to avoid fluorescent lights and television; have emesis basin available; fall precautions; parenteral fluids and meds; monitor I/O; help with ambulation after attack.
-Progressive disorder caused by build-up of endolymph in membranous labyrinth. Excess pressure leads to hearing loss and balance issues.
-Can cause sudden, severe attacks of vertigo with nausea, vomiting, and sweating that can last for hrs or days. Sense of fullness in ear, increasing tinnitus, and muffled hearing may precede attack.
-No cure. Interventions focus on minimizing vertigo and safety.
-Corticosteroids, antihistamines, anticholinergics, and benzodiazepines may be used to decrease abnormal sensation and decrease n/v. Acute vertigo may be treated with bed rest, sedation, antiemetics, and antivertigo drugs (e.g. meclizine).
-Management between attacks can include diuretics, corticosteroids, low-sodium diet, and stress reduction.
Patients who have been prescribed a carbonic anhydrase inhibitor for glaucoma management should be given these teachings about its use.
What are: potential for CNS side effects/refrain from driving or other activities requiring alertness; need to monitor electrolyte levels; how to recognize s/s of electrolyte imbalances; may increase glucose levels and mimic diabetes sx; need to periodically check liver enzymes.
-These drugs are typically prescribed when other meds have failed to manage glaucoma.
-Decrease IOP by decreasing the production of aqueous humor.
-Can be given PO or topically.
-Have a lot of side effects.
-Examples of topical: brinzolamide (Azopt) and dorzolamide (Trusopt).
-Examples of systemic: acetazolamide (Diamox) and methazolamide