03.01 Disease Specific Medications

So, let’s talk about Disease Specific Medications. What do I mean by this? Well, what I mean is, each disease, each pathology in the body is going to require a different set of medications, different combination of different medications to manage the symptoms of the specific disease. So, what I wanna do, I wanna go over some of the most common diseases that you’re going to see as a nurse and we’re gonna talk about what combination of medications are gonna be required for that. I think this is gonna be really helpful for you in understanding the pathology as well as understanding kind of how different medications work, common classes of medications and basically what you need to know for these diseases. So, this data that I’m using for this lecture comes from an Agency for Healthcare Research and Quality also known as AHRQ. I’m sure you’ve already heard of this website and used it in different projects and things during nursing school. So, if you go to this website here, you can print out this lecture and visit this website and I’ll also put a link below the video here. You go to AHRQ.gov. What we’re doing here is I pulled up the most frequent conditions in US hospitals were and this is taken from about 39 million hospital admissions. And these are the 10 most common diagnosis of patients in the hospital. Okay. So, we’re gonna go over these 10 most common diagnosis and then we’re going to talk about the medications required to treat these patients. Okay.

So, the first disease we’re gonna talk about is Sepsis. Now, with this lecture, we’re not gonna go over the pathology of the disease very much. What we’re gonna focus on is really the pharmacology. And with that, we’ll talk about some pathophysiology. Okay. So, with sepsis, what we’re gonna see, is we’re gonna see a rapid decrease in blood pressure. So, one of the first things that we’re gonna do is we’re going to bolus IV fluids, and the reason for that, is we’re going to try to restore perfusion. Okay. You’ll probably see your patient with blood pressures in the 60’s / 30’s or so. And so, we’ll run usually about 2 liters of NS or whatever fluid is appropriate for the patient. Generally, we’ll run up 1 to 2 liters of NS and we’ll try to bring that blood pressure up. So, that’s really what we’re doing, is we’re doing volume replacement. Another thing we’re gonna do, is we’re gonna draw our cultures very quickly when we’re suspecting sepsis. And then we’re gonna start antimicrobials and the reason for that is we’re gonna try to kill this infection. A lot of times, we’ll do Vancomyacin, like Clindamycin, and multiple other antimicrobials / antibiotics to try to fight the infection and determine what is actually happening with this patient, first of all, and then try to kill that. The second thing we’re gonna do, or the last thing we’re gonna do, we’re also gonna throw vasopressors to the patient. Now, what vasopressors do, is they constrict the vessels and we are giving this to try to increase blood pressure and improve perfusion. Now, what will happen when your physician orders vasopressors? They usually order in a set. They usually have 1, 2, 3, 4 different vasopressors ordered and you’re going to give these to the patient as each successive one does not meet our goal. So, we’ll give blood pressure medications to our patient as each successive medication fails to attain our goal blood pressure. So, usually, the physician will order vasopressors. And so, they order vasopressors for systolic blood pressure, let’s say of 90, or possibly like MAP greater than 65. So, that’s kinda our goal, is to either get our systolic blood pressure up to 90 or MAP of up to 65 or something like that. And then, what they’ll do, is they’ll start a hierarchy of medications. So, maybe, it would be like Levophed, Phenylephrine, and then maybe Epi, and then lastly like vasopressin. So, each of these medications has a maximum dose and so what we’ll do, is we’ll start the Levophed and once we get to our maximum dose with Levophed, then we’ll keep it at our maximum dose, add the Phenylephrine on there. Once we get to maximum dose of Phenylephrine, then we’ll add our epinephrine on there. And once we get to the maximum dose there, we’ll add the vasopressin on there. Each successively trying to reach our goal blood pressures with our patient. Okay. So, that’s kinda the different medications that we’re gonna give for sepsis and why.

Next, so, let’s talk Pneumonia. So, penumonia is a very common diagnosis in the hospital. It’s a very common complication as well in the hospital. A lot of times, patients can come in and obtain pneumonia while in the hospital. So, there’s a couple of different kinds of pneumonia. We have of course, bacterial versus viral. We have community acquired versus hospital acquired. But with pneumonia, our goal is really to, a couple of things, we’re trying to improve ventilation, as well as trying to fight the infection. Okay, so, pneumonia is an infection, you’ll get these infiltrates at the base of the lungs and that’s really, and we’re trying to kill that infection and we’re trying to improve respiration. But the best thing we can do for pneumonia is to get Influenza/Pneumonia Vaccine especially for vulnerable patients, the young people, elderly patients, the patients who already have other respiratory issues. Now, depending on the type of pneumonia that our patient has, we’ll want to give antibiotics or antivirals. Now, 2 of the common antibiotics that are given are Cephalosporins and Floroquinolones. Now, Cephalosporins are going to begin with like a Ceph- prefix and that’s gonna be really easy way to remember Cephalosporins. Floroquinolones, a lot of times, will end in -quinolone suffix. So, that’s gonna be an easy way to remember that. Now, your patient might have pain with breathing. This isn’t incredibly common to provide your patient analgesic when they have pneumonia, really the biggest thing we’re going to try to do, is we’re going to try to kill the infection. Again, a lot of times, the Cephalosporin or Flouroquinolone. Another thing we might do is provide bronchodilators, something like Albuterol. These are, albuterols are beta adrenergic agonist. So, it’s gonna open up the airway and help our patient breathe a little bit better. Now, remember this is an infection, this is a virus or bacteria. So, the patient, due to this infection is generally going to run a fever. So, medications that we give to fight fever are called antipyretics. Okay. One of the most common ones that we’re gonna give is usually Acetaminophen, also known as Tylenol. A lot of times, the dose of that will be like 650 mg, you can give it oral, you can get it rectally, you can give it through OG tube. But a lot of times, this will be the medication that we’ll give to try to fight fever. A lot of times, you’ll have a range for that as well like if temp is greater than 101.1 or whatever, it will say, give Tylenol 650 mg Q6 PRN, okay, orally, or whatever. So, that’s kind of how the order would be written for that. And then with your Cephalosporins, these are gonna be like Q6 or Q8 hours that we’re going to continuously giving our patient this medication. Drawing respiratory cultures, looking at our WBCs and seeing if we’ve actually eradicated the infection.

Next. Let’s talk about Acute Renal Failure. Acute renal failure happens quite often in hospitals. It can happen due to a decreased blood flow, you know, like from decreased blood pressure, it can happen for just stress on the body. It can happen for a lot of reason while the patient is on the hospital. In a lot of patient, this will resolve, but with some patients, this can actually cause long term renal damage, and, will lead to chronic renal failure. So, a couple of things we want to do when we’ve notice a patient in acute renal failure, we want to restore blood flow to our kidneys, okay. One of the most popular medications for that is going to be dopamine. In low dose, dopamine is actually going to restore blood flow to the kidneys and prevent them, prevent this longer term more chronic damage from happening. So, dopamine, low dose, is very helpful in restoring renal blood flow. At higher doses, you know, it can help with the heart. But with lower doses, we’re going to have a good effect on the kidneys. Another thing we want to give is Loop diuretics, something like furosemide also known as Lasix. Okay, the reason we give that, again, you know we have this renal failure but what Lasix can do, or what furosemide can do, is it can help remove toxins. We’re gonna help try to kinda waste and, we have all these nephrons in our kidney, right? And so, what we’re trying to do is, we’re gonna try to kinda empty all the waste out of these nephrons and rid it out in the urine rather than having all that waste build up in the kidneys. This can also prevent the oliguric phase of renal failure. Okay. One of the thing that we wanna do, is we want to prevent hypertension. With hypertension, we can cause, that can also cause renal damage. So, one of the medications we get for that are ACE inhibitors. Now, with ACE inhibitors, you are always looking for -pril. Okay. That’s your -pril suffix. So, lisinopril is very common one and that’s gonna prevent hypertension and help to improve or prevent renal damage. Another medication is very important or one complication of acute renal failure is GI bleed. So, a medication we can give for that, there’s two that we give very commonly in the hospital, we give H2-receptor antagonists and proton pump inhibitors also known as PPIs. So, a very common H2-receptor antagonist is like Famotidine. A lot of times, you’ll see the -dine. Famotidine, Ranitidine. These are gonna be our H2-antagonists or histamine blockers. And then you also, histamine 2 blockers. And then we also have our proton pump inhibitors like Pantoprazole. Okay, -prazole. Omeprazole is another proton pump inhibitor. These work very differently but these both work in the stomach to basically prevent gastric bleeding. Okay, so this is gonna be a very important medication for our renal failure patients. One last thing we want to give our patients, so, another goal is with renal damage, because we can’t get rid of potassium, what we’ll see, so potassium is not able to get out or not able to rid it or filter it. So, what we’ll see is we’ll see increased in potassium levels also known as hyperkalemia. Now, you know, obviously, this is gonna be very damaging to the body because hyperkalemia can lead to arrhythmias, very lethal arrythmias within the heart. There’s a couple different medications and we are going to get into this. This is kinda more of an advance concept once you get working in critical care unit, or whatever you end up working, but there’s a couple of different methods for reducing potassium levels. One of those is calcium chloride, another one is actually insulin, then you have bicarbonate, and I wrote insulin twice, so, you don’t need to read that again, and glucose. Okay, so, calcium chloride, insulin, bicarbonate, or glucose can help to reduce potassium levels since our kidneys are no longer able to function appropriately. Okay, so those are the medications that will help you, or that are going to be prescribed for your patient with Acute Renal Failure. These medications as well as dialysis will be, you know, you have different modes of dialysis. But, we’ll not really get into that. But, that’s gonna be added on top once your patient goes in a chronic renal failure like end stage renal disease, stage 4, stage 5 renal failure. Okay. But for acute renal failure, these are meds you’re gonna wanted to use. So, go out and print this lecture. You can go down print the screens of this lecture and that’s gonna help you with your studying this.

Next, let’s talk Osteoarthrits. Osteoarthritis, obviously, a very common disease that elderly patients are going to get. You’re gonna see this over and over and over again. A lot of times, when a patient is coming to our hospital, are not really coming in for osteoarthritis, they are coming in, you know, with fractured hips. They’re coming in with other chronic issues, cardiac, respiratory, psychological disorders, but they have this osteoarthritis on top of this. So, some of the things that we’re going to give our patients for osteoarthritis, well, is analgesics, right? Here, analgesic, you’re thinking pain. So, we’re trying to relieve pain and some of the popular ones, you know, are gonna be aspirin, acetaminophen and NSAIDs. Now, each of these medications, of course, has side effects and different contraindications with them. But these are gonna be common medications for your patient. Now, aspirin, of course, can lead to GI bleed. So in acetaminophen, with acetaminophen, we wanna keep it to 4 grams/day. And with NSAIDs, NSAIDs also can lead to GI bleed. You could also take topical analgesics. You can see here this lady rubbing a nice topical analgesic. A lot of these are available over the counter, so they can get topical analgesics over the counter. Another popular and useful medication class is gonna be COX-2 inhibitors. These are actually NSAIDs. The only one that’s only approved for use right now and common one is Celecoxib, also known as Celebrex. And that’s gonna help with the information, it’s gonna help with the pain. A more extreme option for this patient is gonna be corticosteroid injections. So, it can actually go into the joints that are causing pain and they can give a corticosteroid injection, okay. And that can help with the osteoarthritis. Okay. That’s pretty simple when we’re treating pain, we’re treating inflammation, right? Very simple.

Congestive Heart Failure. Now, with this kidney, with this lung, with these cardiac issues, you’re going to see a much more complex set of medications, that’s because once we start affecting blood flow and waste elimination, we really start to affect a tremendous amount of organs. Okay. So, there’s gonna be a lot of other medications involved. With congestive heart failure, one of the first medications we’re going to give are our ACE inhibitors, again -prils, and we’re gonna also give Angiotensin Receptor Blockers, that are gonna be or -sartans. Okay. We have videos, we have lectures on these medications in greater detail. But the point of these medications basically, they work in very, they work in different ways and in different locations. But they are both affecting the renin-angiotensin-aldosterone system. Watch that video, that’s gonna help you greatly. But what they’re basically going to do, is they’re going to decrease the afterload, increased cardiac output, increased renal blood flow, we’ve talked about that, they’re gonna help with decreasing edema. Now, you think, afterload, so, here’s one of our valves here. Or, it looks like, this is probably, this is probably our aorta right here. So, with your aorta, so, when you think afterload, afterload is the pressure that the ventricle has to squeeze to get blood basically out of the system. Okay, let’s think of it that simply. We won’t go into it whole lot more here. So, the higher the afterload, the more resistance, basically, that these valves, or these vessels are exerting on the entire system. So, by decreasing that, we’re allowing blood to get out easier and that’s going to lead to decrease or increase our cardiac output, decreased blood pressure. Okay. And then, we’re gonna get that renal blood flow going as well. Beta blockers, we talked about beta blockers a lot before. These are gonna be your -olol. What beta blockers are going to do is they’re going to, basically decrease myocardial oxygen demands, they’re gonna make it work, decrease the workload of the heart, make it easier for the heart to beat. One of the goals with heart failure is to decrease the progression, okay. Heart failure is really a combination of disorders. And one of the things that we want to do, is we want to try to slow the progression of heart failure. One thing that we can give for that is diuretics. There’s loop diuretics, Thiazide, and potassium-sparing. But basically with diuretics are going to do, among a lot of things, is gonna help decrease blood pressure, etc, etc. But they’re also going to reduce these symptoms. We know, one of the symptoms with heart failure is volume overload. So, diuretics can help to decrease that volume overload by helping to rid the system of fluid. Whether that’s pulmonary edema, or whether that is kinda more systemic edema with the different types of heart failure. Diuretics are going to help rid the body of that. Okay, another medication we’re going to give are Inotropics like Digoxin. What Digoxin does, it’s going to increase contractility, what that means, it’s gonna increase the squeeze of these ventricles, helping to increase our cardiac output. That can also decrease our oxygen demand of the heart and really kind of help get more blood in the system and decrease that volume overload, decrease the workload of the heart. Okay. Another medication we’re going to give are Sympathomimetics. If you think about our sympathetic nervous system, and mimetic means kind of increases. So, sympatho, sympathetic nervous system increasing medications, okay. Dopamine and Dobutamine are both sympathomimetics and we’ve talked, we have lectures in length about the difference between Dopamine and Dobutamine. We won’t go into that a lot here. But, basically, what these medications are going to do, is they’re going to increase the contractility, the contraction of the heart, and further aid in improving heart function. Vasodilators, again, we’re gonna open these vessels up throughout the system and that’s going to decrease the symptoms. Antidysrhythimics. So, as heart failure progresses, we can create dysrhythmias within the heart and providing the patient with antidysrhythmic is going to prevent, it’s kinda preventive measure for these arrhythmias like can come on. Alright, let’s leave heart failure for now, come back to this lecture and study it in your leisure.

So, one of the most common arrhythmias that patient is experiencing is Atrial Fibrillation. The problem with atrial fibrillation, is that, it can lead to stroke, MI, PE, it can lead to a lot of these vasoocclusive type disorders. So, obviously, brain, heart and respiratory. So, with atrial fibrillation, we run the risk of really a lot of very life threatening conditions, okay. So, our goal is to try to control this atrial fibrillation and to really prevent these even worse conditions that can happen. So, with atrial fibrillation, we have our heart, our atria just quivering, and what can happen with that quivering, is clots can form and those clots can break out, okay. They can get into the coronary circulation, like I said, they can go up to the heart, they can get into the lungs. Okay. And when any of those things happen, here’s gonna be our MI, here’s gonna be our PE, and here’s gonna be our stroke. Okay, so, that’s what we’re kinda trying to prevent is that from happening. We wanna control this quivering and then bust up these clots that can form. Okay, first of all, Antidysrhythmics. Very important medication with Atrial Fibrillation. So, what, Amiodarone is one of the ones that we’re going to give. What we’re trying to do, is we’re trying to stop this dysrhythmia, so, you can see here, here’s our atrial fibrillation. We have no P waves, indicating atrial fibrillation, increased rate, absent P waves and then we can see the little fibrillating waves here. So, that’s atrial fibrillation. So, amiodarone is going to try, it’s an antidysrhythmic, meaning, it’s going to break that dysrhythmia. Another medication we’re going to give are going to be beta blockers, and the point of this, is to reduce the ventricular rate. Okay. So, if our atria is firing this quickly, all these signals can be getting to our AV node. Let’s draw another heart real quick. Oops, that’s really bad. So, as our atria fire up all these ectopic beats, they are all getting pass along here to our AV node. If these beats all get into our ventricles, that is called RVR or Rapid Ventricular Response. So, if we’re getting these really incredibly fast, you know, 180 to 200 beats a minute, ectopic beats here in our atria, that pass down to our AV node, and our AV node does not control those. What will end up with this RVR, Rapid Ventricular Response which can either lead to a V-tack or a V-fib. Okay, so, we really want to try to reduce this ventricular rate so that it doesn’t respond to this fibrillating rhythm in the atria. So, one thing that we can do to get that is gonna be metoprolol, another one we’re gonna give to do that, it’s very common, it’s Diltiazem or Cortizem. Okay, so, what that does, is that really works specifically on our AV node and is gonna try to slow or reduce our ventricular rate there. So, first thing we really gonna do, is we’re gonna do an amio bolus, and what that amio bolus can do is it can hopefully convert the A-fib back to sinus rhythm. Okay, so, we’re trying to convert our A-fib to sinus rhythm with our amio bolus. If that doesn’t happen, we can put them on Cardizem drip and the goal of that is to reduce our ventricular rate, okay? Another thing that we’re going to do, like I said, is we’re gonna wanna prevent clot formation. So, we’ll give anticoagulants. Even something as simple as Aspirin, you know, like blood thinners. You know, we can give anticoagulants like a heparin. Then, we can also give like blood thinners like an Aspirin, Flavix, to try to prevent, you know, these clots from forming. Okay, so, that’s kinda Atrial Fibrillation.

Now, let’s talk about Myocardial Infarction. We all know the good old adage or mnemonic “MONA.” Okay, always remember MONA. That is going to help you remember cardiac or myocardial infarction treatment. You can see, here’s an EKG showing a STEMI (ST Elevation Myocardial Infarction. Okay, so there’s our STEMI. These are gonna cause a severe amount of pain. Okay, one of the ways that you can tell, that a patient is having an MI, is you simply, you can see that they have this crashing chest pain, and they’re freaking out. Okay. So, what we’re going to do is we’re going to give them morphine, 1 - 2 mg usually, and we’re trying to treat the pain. Okay, so, morphine and nitro. Okay, so, morphine, nitro, and what we’re trying to do here, is we’re trying to decrease the pain and also create a vasodilation. Okay. Nitroglycin is a very potent coronary vasodilator. And so, what happens, remember, with MI, is one of our coronary arteries has a little clot in it. We’re trying to draw. So, there’s a little clot here. So, everything distal to this area is ischemic. It’s not getting any oxygen, it’s not getting any blood. So, with our nitroglycerin, we’re occuring this vasodilation and we’re trying to get oxygen restored to that area and that should help with the angina. And then, the morphine as well is gonna help with the pain. Another thing that we’re gonna do, okay, we have this clot, how can we get rid of that clot? We can get rid of the clot with a Fibrinolytic therapy. We’re trying to lyse the clot, the fibrin clot, one thing that’s very common with that is gonna be t-PA. It’s common with MI’s and strokes. And what it does, it goes in there and it breaks up that clot, lyses the fibrin clot and just destroys it. And then, it’s going to restore blood flow to that area again. Okay. Let’s see. Another thing we’re gonna wanna give is Antidysrhythmics. Once a patient has an MI, there’s a good chance to go into A-fib once they restore, A-flutter or potentially more deadly rhythyms. So, we’re gonna try to give antidysrhythmics as prophylactic treatment, dysrhythmias. And another reason for that is, and then, we’re also wanna give beta blockers. Beta blockers can help to limit the size, reduce the pain and decrease oxygen demand of the heart. So, sometimes, you’ll see maybe a patient put on propranolol drip, where they’ll be given metoprolol, or atenolol. And these beta blockers, remember, they’re going to decrease or stop the stimulation of these beta receptors in the heart. Good one for that is going to be Propranolol. Okay. So, that’s very important, to try to limit the size, we don’t want the death of this tissue to increase, we wanna decrease the oxygen demand of the heart since we already have limited oxygen available. And propranolol is a good medication for that. So, once the patient has an MI, it’s likely they’ll be placed also on ACE inhibitor. What is a ACE inhibitor do? Well, it decreases the risk of future MI and decreases the risk of CHF occurring after this MI. Okay, so, the patient has the MI, all these tissue kinda starts to die, so what we can do, is we can give ACE inhibitor to prevent this ventricle from leading to like a right side heart failure. Okay. From that dead tissue, not being able to pump or to perfuse. Okay, so, ACE inhibitor can help that. We’ll also place the patient on anticoagulants like aspirin or abciximab, these decrease platelet aggregation and it help maintain artery patency. So, basically, what we’re trying to do here is maintain blood flow and prevent any further clots from forming and to keep blood going where it needs to go especially with these kind of occluded arteries, okay. That’s MI. Again, this is another one you probably wanna come back to and study a bit.

Let’s talk COPD very quickly. With COPD, again, it’s important for the patient to, remember, COPD is like emphysema and bronchitis -- chronic bronchitis. Okay, so, we’ll wanna prevent the patient from getting pneumonia or influenza since they already have damaged lung. Another thing we want to do is dilate the bronchioles. That can be done by Beta-Adrenergic Agonists, it can also be done with anticholinergics. Okay, we talked a lot about these before. So, that’s where is kinda want out, we wanna open up the airway. Another thing you can give is corticosteroids like Fluticasone and that’s kinda also improve airflow and keep the patient breathing. Okay. So, these are kinda be the medications for COPD.

Asthma is very very similar. We’re gonna give beta adrenergic agonist that’s gonna open up our airway and then we’re gonna give steroids as well. So, always give bronchodilators first, corticosteroids, second. Of course, the reason for that is to open our airway up so that our corticosteroid can get down into the lung tissue, decrease that inflammation, and help the patient to breathe better. Okay. Beta adrenergic agonist. These are basically the exact opposite of beta blockers. Okay. So, giving beta adrenergic agonist with the beta blocker might decrease the effectiveness of either one and when we’re messing with lungs and heart, we wanna make sure we’re getting the maximum effectiveness of each medication. Okay, so, probably don’t administer those at the same time.

Alright, last one here. We’re going on 30 minutes, so I wanna make sure, I don’t want to lose you attention before we talk about this next one. Another very common diagnosis for patients in the hospital, is UTI. What happens with UTI, a little bacteria, boom boom boom, get up here, climb up the urethra, sit right here and we get UTI. Okay. This happens a lot. You can maybe put a fall in, right? We have our fall in sitting here and bacteria love to come in from outside, kinda get in here, bladder infection, UTI, okay. So, what do we give to a patient with a UTI? Well, first of all, we wanna give antibiotics. Okay, this is bacterial infection, so we wanna give antibiotics to try to eliminate the infection. Popular one for this is TMP-SMZ known as Bactram. There’s a lot of other medications used for this. Bactram’s one that can be used, we’re just gonna try to kill this infection, okay? Of course, whenever we notice our patient having a fever, raise in heart rate, etc, we’re gonna wanna draw our cultures. So, we don’t necessarily know that it’s going to be a UTI. So, we can draw respiratory cultures, blood cultures, and we can also draw urinary cultures. Once we identify that organism, then we can become much more focused with our antibiotic to kill the exact organism that has crawled into the urinary tract, okay. Couple of other things we’re going to wanna give, something like a urinary anti infectives, trimethoprim, this is kinda like a prophylactic prevention of UTI, so if a patient is very susceptible to UTI, had a lot of UTIs in the past, we can get something like trimethoprim to prevent them. Okay. Another thing you might wanna give is gonna be urinary analgesics, this is something like pyridium. What it does, it relieves the pain, decreases the urgency and decreases the burning of urinating once the patient has the UTIs. So, this UTI, this bacteria here will cause a lot of pain. It can make it very hard to pee and it can make it very painful and burning to pee. So, something like pyridium can help with that. This is gonna change fluid color a bit with the patient. One more thing that I wanna mention, you can give here a something called ‘Belladona’ and what this does, it decreases the spacicity. So, especially on patients who’ve had like a cathether. Cathether really messes with the bladder tone, okay, so, when we pull that out, patient get like a neurogenic bladder, or get like a splastic bladder where there’s a lot of contractions here and they’re not able to urinate. So, giving something like Belladona can help with that and make sure the patient is still able to urinate.

Okay, those are 10 of the most common diagnosis that you’re gonna see in the hospital on your patients. And those are the medications that are going to be given for that and why.