Pharm IV

• transports nutrients,
• wastes, gases, and hormones through the body

removes wastes from the circ. System to regulate pH and ion levels

Maintains H2O balance = regulation of Bp, fluids and electrolytes

direct/indirect action

when the heart cannot pump enough blood to meet tissue needs for oxygen and nutrients

impaired myocardial contraction during systole

impaired relaxation and filling of ventricles during diastole

• congestive heart failure (CHF)
• there is frequently congestion (fluid accumulation) in the lungs and peripheral tissues

dysfunction of contractile myocarial cells and the endothelial cells that line the heart and blood vessels

• allows processes that narrow the blood vessel lumen such as atherosclerotic plaque build up
• leading to blood clot formation and vasoconstriction which further narrows the blood vessel lumen

• Coronary artery disease
• hypertention

• hyperthyroidism
• excessive IV fluids/blood transfusions
• drugs that decrease the force of mycocardial contractions
• drugs that cause sodium & water retention

impairing maintanance of an adequate cardiac output by impairing the pumping ability or increaseing the workload of the heart

increased sympathetic activity & circulating catecholamine

activation of renin angiotension-aldosterone system

increase the force of myocardial contraction increase heart rate causes vasoconstriction

the baroreceptors in the aortic arch & carotid sinus that normally inhibit undue symapthetic stimulaiton

intensified effects of high catecholamine levels

An enzyme produced in the kidneys in response to impaired blood flow and tissue perfusion

stimulates the production of a powerful vasoconstrictor - angiotensin II

impairs cardiac function by increasing the resistance against which ventricle ejects blood (afterload)

• raises filling pressures inside heart
• increases stretch & stress on myocardial walls
• redisposes to subendocardial ischemia

constricted arterioles in cerebral myocardial, renal, hepatic & mesenteric vascular beds

increased organ hypofusion & dysfunction

constricted arterioles

• diastolic ventricular filling pressure
• amount of venous blood returning to the heart

• stimulating aldosterone release from adrenal cortex &
• vasopressin (antidiuretic hormone) from posterior pituitary

these promotes sodium & water retention

amount of resistance in the aorta peripheral blood vessels that the heart must overcome to pump effectively

dyspnea & fatigue --> exercise intolerance & fluid retention--> pulmonary congestion & peripheral edema

asymptomatic

usually no s/s @ rest & no edema

dyspnea & fatigue usually only w/ moderate to higher level exertion activities

symptoms that do occur w/ min exertion or @ rest are accompanied by ankle edema & distention of jugular vein

congestion of veins & leakage of fluid into tissues

pulmonary edema (req immediate treatment)

• to try to improve circulation
• alter compensatory mechanis
• reverse heart damage

Digoxin (lanoxin)

prevention and treatment of cardiac dysrhythmia

when they interfere with cardiac function & the ability to perfuse body tissues

the heart's ability to generate an electrical impulse

electrical impulse formation

the ability of cardiac muscle cell to respond to electrical stimulus

ability of cardiac tissue to transmit electrical impulses

any disturbance or abnormality in the normal cardiac rhythm

- feels as a skipped beat

when the interfere with cardiac function

alter the heart's electrical conduction system

• according to their mechanisms of action
• effects on conduction system

• to prevent/relieve symptoms
• prolong survival

• reduce automaticity
• slow conduction of electrical impulses through heart
• prolong refactory period of myocardial cells

• Norpace
• Procanamide
• Quinidine
• Lidocaine

Sodium Channel Blockers (membrane stablizers)

interferes with the sodium channels and stabilizes the hearts excitability

• slow conduction velocity
• thus prolong refraction & decrease automaticity of
• sodium dependent tissue
• •Decreases the hearts excitability
• •Slows the inward current caused by Na electrolyte
• Decreases heart rate
• causing reduced irregular heartbeats

• reduces automaticity
• slows conduction
• prolongs refractory period

accelerate their rate

• loss of hearing,
• blurred vision,
• GI upset,
• tinitus,
• diarrhea,
• n/v
• vertigo
• thrombocytopenic pupura (TTP)
• decreased blood flow to the brain

-blood disorder that causes blood clots to form in small blood vessels around the body, and leads to a low platelet count.

Potassium levels before during and after use

• Increased potassium = increased effects of the medication
• And vice vers

• metab: liver
• excreted: urine

2-5 mcg/mL

> 5 mcg/mL

• severe, uncompensated HF
• w/ heart block

atrial and ventricular tachy-dysrhythmias

• suppressing premature Vent contractions
• preventing the recurrence of V tach

high incidence of adverse effects

• lupus-like syndrome
• n/v/d- anorexia
• fever,
• leucopenia,
• maculopapular rash,
• itching/flushing

• Lupus,
• complete heart block,
• 2nd and 3rd degree heart block

4-8 mcg/mL

Norpace

adults w/ life-threatening ventricular tachydysrhthmias

> 8mcg/mL

2-8 mcg/mL

kidneys & liver in almost equal proportion

• wider QRS
• hypotension

• prodysrhthmiic
• anti-cholinergic

with poor left vent function

less than that of Procanamide

beta blockers

• selective (1)
• nonselective (1&2)

• slowingm the sympathetic nervous system stimulation of beta receptors
• slow SA & AV nodal conduction
• block receptors in SA node & ectopic pacemker

dysrhythmia from excessive sympathetic activit

to slow the ventricular rate of contraction in atrial flutter & a-fib

• Blocks (or slows) the SNS stimulation to the heart-REDUCES THE HEART RATE and force contraction
• help slow heart down
• decrease force

after an MI

because many catecholamines are released at that time and can make the heart hyperirritable

25%

Beta 1, 2 & 3 adrenergic receptors

- part of the SNS (fight or flight)

in the heart and in the kidneys

• in the lungs,
• gastrointestinal tract,
• liver,
• uterus,
• vascular smooth muscle,
• skeletal muscles

in fat cells

• “lol”
• ex: Metoprolol

Dizziness

• pulse: <60
• Systolic BP <90mmHg

withhold the beta blocker and contact a Dr.

• Propranalol
• Tenormin (Atenolol)
• Breviblock (Esmolol)
• Lopressor (Metoprolol)
• Inderal (Propranolol)
• Betapace (Sotalol)

for acute sinus tachy

assess closely for Bradycardia


it will cause a decrease in heart rate which can = Bradycardia

• Bradycardia
• rash and itch
• Erratic blood sugars up and down
• Chest pain
• Joint pain

inderal

• SOB
• skin rash

beta-1’s on the heart

Atenolol

angina and hypertension

with severe bradycardia, CHF and cardiogenic shock

shorter acting beta-blocker

Beta 1

SVT (supraventricular tachycardia)

dysrythmias that originate above the ventricals and are fast

• tachyarrythmias that occur after an acute MI
• to control hypertension

breviblock

• during anesthesia
• surgery
• other emergency situations when vent rate must be rapidly reduced

Esmolol

chronic

• with asthma
• for those with 2nd or 3rd degree heart block or CHF

asthma

Metoprolol

given after an MI to reduce risk of cardiac death

• hypertension,
• angina,
• acute myocardial infarction,
• supraventricular tachycardia,
• ventricular tachycardia,
• congestive heart failure
• prevention of migraine headaches

treatment of hypertension and angina

a hydrochlorathiazide diuretic

To diurese the patient, thus decreasing Bp

Selective- beta 1’s

• hypotension,
• dizziness,
• blurred vision
• etc

Safety will be an issue at first

• electrolytes
• bp
• I&O
• daily wt

Bp

is nonspecific (beta 1 and 2- works on receptors in the heart and lungs!)

• HR
• myocardial contractility

Inderal (propranolol)

• hypertension,
• angina
• VTach,
• supervent dysrhythmias,
• pheocromocytoma*
• Used post MI, and for migraines

Adrenal gland tissue tumor

rarely canerous

the release of too much epinephrine and norepinephrine- controling heart rate, metabolism, and blood pressure

problems in controlling HR< metab, BP

early middle-adulthood

• tachy,
• weight loss,
• irritability
• palpitations

treatment of DOCUMENTED life-threatening vent dysrythmias such as sustained V tach

Sotalol

new dysrhythmias

• bronchial asthma ,
• sinus brady or cardiogenic shock

to treat dysrhythmias that are difficult to treat

Potassium Channel blockers

the conversion of A-fib and flutter to a NSR(normal sinus rhythem)

difficult to treat dysrhthmia

Class III

pacerone

life-threatening vtack or V-fib that is resistant to other drugs (Drug of last resort!)

also for the treatment of sustained V-tack

• big gun
• not 1st line

atrial dysrhythmias that are resistant

Has a lot of unwanted s/e-

IODINE in it’s structure (watch for allergies)

therefore can cause hyper or hypo- thyroidism

thyroid function

Doses exceeding 400mg/D

corneal microdeposits- causes halo’s, dry eyes & photophobia

Occurs in almost all adults on the med for 6 months or more

vasodilating effect

decrease systemic vascular resistance prolongs conduction in all cardiac tissue decreases heart rate

• serious/potentially fatal pulmonary toxicity
• may begin w/ progressive dyspnea
• cough w/ crackles
• dercreased breath sounds
• pleurisy
• heart failure
• hepatotoxicity

pulmonary toxicity

it is lipophilic- loves to migrate to adipose tissue

Only available IV

to treat life-threatening V-tach or fib

Used primarily in a code situation

postural hypotension in 50% of patients

Slows conduction of ventricular portion of muscle

adrenergic blocking (slows release of norepi)

n/v

Given slow IV to reduce s/e

usually only in ICU/ambulance

recent onset of ATRIAL dysrhythmias (A-fib and flutter)

Electrocardioversion

Covert

in a setting w/ ER personal & equipment close by

4 hours apart from other antidysrhythmics

very cautiously

Only IV and specifically weight based

(Calcium channel blockers)

for the treatment of hypertension and angina

Slows or blocks the calcium channels of the cell into the myocardium

• Cardizem
• Verapamil

Diltiazem

Calan

• MI,
• pulmonary congestion,
• severe hypotension,
• cardiogenic shock,
• sick-sinus syndrome,
• 2nd/3rd degree heart block

• Angina
• Antidysrhythmic

• to prevent and convert recurrent PSVT( paroxysmal SVT) to control vent response in a-fib or flutter
• Angina

digoxin toxicity


may worsen heart block

•Precipitates with Nafcillin and Sodium Bicarb

beta blockers

often taken WITH Calcium Channel Blockers

increased side effects- weakness and dizziness (safety)

decrease effectiveness

increase hypotensive episodes

can have a rebound effect

• •Not used in: Hypersensitivity
• CHF- can worsen effects of CHF
• Complete heart block*
• Hypotension
• MG
• Urinary retention
• Hepatic/renal insufficiency
• EKG/TELEMETRY

A heart block can be a blockage at any level of the electrical conduction system of the heart

• •NMBA’s
• Anticholinergic’s- causes increased anti-cholinergic effects
• Anticoags- with quinidine
• Dig. and quinidine- increases serum dig levels
• Cimetadine/Nefedipine
• Anticonvulsants

• Initial EKG and VS
• monitor these closely throughout course

have on pump

continous cardiac monitor

• heart block
• dysrhythmias
• hypotensioin

• Any increased cough,
• SOB,
• weight gain

IV

It increase the electricalimpulses and weak impulses are weeded out

it slows the heart rate overall

• tinitus,
• blurred vision,
• HA/dizziness,
• seizures,
• hallucinations

unclassified

cardioversion

several seconds of asyystole when cardioverting tach to NSR

anxiety

converting abnormally fast heart rate or cardiac arrhythmia to a normal rhythm

by rapid bolus injection

needed?

• Educate
• be supportive

The ACHING of the heart muscle due to insufficient oxygen in the blood

yes

• Chronic Stable Angina
• Unstable Angina (USA)
• Vasospastic Angina

atherosclerosis

exertion or stress (cold, fear, emotions)

Smoking, drugs, etoh, caffeine, coffee

Intense pain that subsides in about 15 minutes

early stage of progressive CAD

May end in MI in sunsequent years

Pain increases in severity with each attack and attacks become more frequent

Can happen at rest when condition progresses

spasms of the smooth muscle layers that surround the atherosclerotic coronary arteries

at rest

Seems to follow a regular pattern- occurring around the same time of day

• NITRATES/NITRITES
• BETA-BLOCKERS
• CALCIUM CHANNEL BLOCKERS

NITRATES/NITRITES

Act on vascular smooth muscle- relaxes arterial and venous circulation

NITROGLYCERIN: (Rapid acting)

• with ICP,
• inadequate cerebral perfusion,
• pericarditis,
• pericardial tamponade (fluid accumulation in the heart causing increased pressure),
• severe hypotension,
• severe anemia

metabolized in the liver- a lot is removed from circulation (LARGE first-pass effect)

• given SL or Buccal so bypasses the first pass effect
• Can be administered transdermally

• acute MI,
• CHF,
• Pulmonary edema

bypasses first pass effect- allows for slow delivery of the drug

usually OFF for 8 hours at night, new patch in the AM (review)

•Dilates all blood vessels, but mainly effect those in the venous circulation

Slight arterial dilation in low doses

• HA is most common- can be very severe
• Tachycardia
• Postural Hypotension

• assess laying, sitting and standing
• educate safety

• ETOH,
• phenothiazines,
• CCB’s

safety is an issue

1-4 minutes- readily absorbed

• flushing,
• dizziness,
• sweating,
• syncope

with acute MI

recent MI

every 3 mo-loses strength

a throbbing headache- it is a potent medication

analgesic

• ETOH
• beta blockers,
• narcotics,
• antihypertensives,
• vasodilators

on an empty stomach

reduces effects

increases VMA (vanillylmandelic acid) levels (end stage metabolite of epi and norepi)

for CP- ASAP

•Educate to keep on their person at all times

lay down w/ feet up take dose

• call 911
• take 3rd dose

3-5 min

• dark glass
• it is light sensitive
• sunlight and light can decrease the effects of medication
• •No cotton in the bottle- decreases effectiveness

ICU monitoring

• blurred vision
• dry mouth

can cause sexual stimulation

fast acting

Isordil

in the liver

Used for acute angina and for the prophylaxis of

PO only

Imdur, Ismo, Monoket

•Provides a more steady, therapeutic response than Isordil

2X daily with 7 hours in between doses so as not to build a nitrate tolerance*

• slows she heart rate and decreases contractility
• Slows the contractility- decreasing energy needs

1st line drug for stable angina and “effort induced angina”*

angina w/ excersion

•Decreases O2 demand, therefore increases O2 availability to the myocardium

can increase Blood glucose

• Fatigue
• lethargy

• Hypotension- due to vasodilation- assess pulses can decrease peripheral blood flow
• Can cause bradycardia
• Dizziness,
• fatigue,
• lethargy
• Can cause impotence
• wheezing
• dyspnea

• COPD
• asthma

ATENALOL (Tenormin)

LOPRESSOR (Metoprolol

often used after an MI to decrease death rate

Good immediately after an MI because blood flow to GI tract is poor and most are intubated

• IV
• PO

LOPRESSOR (Metoprolol)

•Decreases myocardial O2 demand by causing peripheral arterial vasodilation, reduces myocardial contractility (decreases pain) decreases Bp

peripheral edema

Safe with few contraindications

• CARDIZEM, TIAZAC
• NIFEDIPINE (Adalat/Procardia)
• VERAPAMIL (Calan)

effective oral treatment of angina

• IV
• PO

puncture the liquid filled capsule and squeeze under the tongue

they have decided that this increases the mortality rate

• Hypotension
• Brady
• heart failure
• Constipation-esp in elderly
• nausea
• Rash
• Peripheral edema-esp pitting edema in extremeties
• Wheezing

I&O-hypotension

• Beta blocker-additive effect -both lower Bp
• Digoxin- can increase dig levels
• H2 blockers- increases CCB levels
• Theophyline
• Lithium
• ETOH
• Trycyclic antidepressants
• Tobacco

occlusive arterial disease (limited success)

Relaxes smooth muscle of peripheral arterial vessels increasing circulation to the extremities

• swelling to the lower legs and feet
• often ulcerations below the knees

treat Raynaud’s disease (vasospasms and thrombophlebitis)

no circ to extremeties

usually after a few weeks

vasodialators

• hypotension,
• dizziness,
• post. Hypotension,
• HA,
• dysrythmias,
• sweating,
• tingling,
• but disappear after a few weeks of txt.

“tartrazine”

allergic reaction with s/s like bronchial asthma

allergies to ASA

• those w/ COPD,
• Asthma
• other brancoconstriction

• •Assess and list all other drugs
• any allergies
• Medical and surgical Hx
• Caution with head injuries
• pregnant/lactating women
• VS, EKG, RESP status
• Not used with liver/kidney disease if possible

• in a glass bottle only*
• •Covered in aluminum foil or in a dark bottle and dark tubing
• NO filters

96 hrs

always on a pump

•Not mixed IV with any other drugs

• Decrease caffeine containing foods/drinks,
• cardiac diet
• decrease sodium

tshould be tapered off

• Bp before giving meds
• check electrolytes

Blood vessels decrease in elasticity

has to work much harder-This causes stress on the heart muscle and vessels, veins and arteries

needs to be identified and treated early in the game

<130 S / <85 D

140-159/ 90-99

160-179/ 100-109

180-209/110-119

> or = to 210/> or = to 120

• Diastolic below 90
• decrease damage risks to kidneys,
• heart
• brain

• Adrenergics
• Alpha 1 -adrenergic blockers
• Minipress
• Regitine
• Alpha 2- adrenergic receptor stimulators

• Clonidine- (Catapres)
• Methyldopa
• ACE Inhibitors
• Lisinopril (Zestril, Prinivil)
• Captopril (Capoten)
• Vasotec
• Angiotensin II Receptor Blockers

catacholamines like epi and norepi

Alph 1&2,Beta 1&2

• They inhibit or block stimulation of epi/norepi
• Decreases BP and heart rate

postural and post-exercise hypotension

• to treat Migraines
• Can be used for severe dysmennhorea and menopausal
• flushing

• Constipation
• drowsiness, constipation
• HA
• Nausea
• Rash
• Ortho hypotension

• CNS depressants- ETOH, barbituarates, opioids
• Epi and beta-blockers can increase effect, decreasing BP too much!

•Block alpha 1 receptors in the arteriesOnly

PO only

• MInipress
• Flomax

• Dilates arterial and venous blood vessels
• This decreases blood pressure

urinary symptoms with BPH

cardiac glycocides and diuretics fro CHF

• severe orthohypotension,
• but most will develop a tolerance after the first dose

estravasated epi, norepi and dopamine infusion sites

pheocromocytoma

If pheocromocytoma is suspected: pt has HTN and an IV dose of Regitine is given- this will cause a decrease in Bp and diagnosis can be made

•This class will be used if all other classes fail

• HIGH incidence of severe orthostatic hypotension,
• fatigue
• dizziness

Clonidine- (Catapres

Methyldopa-

decreases Bp and can also be used for opioid

used for severe pain in cancer patients

pregnent woman

Beta blockers decrease the SNS stimulation in the heart and decrease heart rate and Bp more so than this drug- so think fetus effects

Angiotensin-Converting Enzymes

mediate extracellular volume and arterial vasoconstriction component of the Bp regulating system

•They prevent Na+ and H2O reabsorption

diuresis

ACE inhibiters

•Safe first line agent to treat CHF and hypertension

decrease in the blood volume and return to the heart which decrease the Bp.

Hyperkalemia

•Monitor k+ levels, and educate about K+ in the diet!

• •Fatigue,
• HA,
• mood changes,
• dizziness
• Dry non-productive cough* that reverses if med stopped
• Loss of taste
• Anemia
• Proteinuria
• Rash and itching
• Hyperkalemia

renal disease

Severe hypotension

Give IVF’s to expand the volume and blood volume

HD

•Do not give with ASA, NSAIDS, K+ sparing diuretics or K+ supplements

No lithium b/c it increases lithium levels

•Fatigue, HA, mood changes, dizziness•Dry non-productive cough* that reverses if med stopped•Loss of taste•Anemia•Proteinuria •Rash and itching•Hyperkalemia Not used in renal disease- can cause acute failure

•patients in fragile state

•Only available PO

Low Na+ and low K+ diet suggested

• Zestril,
• Prinivil

• •Lisinopril is used to improve survival after a heart attack
• Used to treat CHF

•NOT used in pregnancy

used alone or in combination for hypertension

•Oral an IV preps

•To be converted into an “active metabolite”- must have proper liver function

•Improves survival rates of those post MI

-The blockers relax the blood vessels to decrease Bp by decreasing the narrowing effect

•These are fairly well tolerated and do not cause the cough!•Improves survival rates s/p MI•Used to treat CHF•Can be used cautiously with DM, and renal dysfunction in those that have shown a tolerance for the medication without side effects**•Can cause birth defects- not a great idea with pregnancy

•URI symptoms•Nasal congestion•Dizziness•Dyspnea •Diarrhea, heart burn•Back pain•HA and fatigue•OD/Toxicity- expand circulatory volume and support systems•Hyperkalemia

•Lithium- increases levels•Cimetadine, Rifampin, and Phenobarbitol reduce the effectiveness of Cozaar •Diflucan decreases the conversion of Cozaar into its active form•Report any side effects to physician

•Cozaar/Hyzaar (Cozaar with HCT)- used for txt. Of hypertension and CHF•May have slightler lower mortality rates than seen with ACE inhibitors in CHF•No breast feeding- crosses into the milk•Diovan (Diovan HCT (with diuretic)Can be used along with other anytihypertens

Cozaar/Hyzaar

Diovan

used for txt. Of hypertension and CHF•

May have slightler lower mortality rates than seen with ACE inhibitors in CHF

breast feeding women

crosses into the milk•

Can be used along with other anytihypertens

•Many as you see- come with a diuretic in on preparation

•These decrease extracellular fluid volumes so there is a decrease in preload which decreases the effort of the heart

relax the smooth muscle of the heart and long-term constriction will cause major damage to heart, brain and kidneys!

decreases Bp

• used for hair growth,
• but can it cause hypotension
• educate

• •Assess liver and kidney function
• Assess stress
• Any PVD?
• Any history or suspect of pheocromocytoma?

Use all cautiously with kiddos and elderly- they are more sensitive and the diuretics can cause an increased lyte imbalance

•Watch K+

Can take some meds with OJ unless contraindicated

• they should eat K+ rich foods unless contraindicated
• Avoid increased Na+ intake
• Garlic can be taken to decrease Bp, but not with coumadin, NSAIDS, anti-platelets or ASA!

• Baseline VS and weight and then along the way
• QD weights
• I/O
• Baseline EKG, telemetry

• •Watch for syncope
• Swelling in the feet, ankles, eyes
• Assess CP and palpitations

• Loose weight,
• avoid stress,
• exersize safely
• Watch sodium intake

•Leg cramps?

the OTC’s•

• Change positions slowly
• Stay hydrated
• Oral formulas with meals to decrease GI upset

smoking or ETOH

the process of blood cell formation (RBC's/WBC's & Plateltets)

tissue respiration

a O2 carrier in Hgb & myoglobin

many enzyme reations in the body

• liver,
• spleen
• bone marrow

anemia

women

found in meat certain veggies grains

must be converted by gastric juices before they can be absorbed

• OJ,
• veal
• fish

• eggs,
• corn
• beans
• cereal

• Nausea
• stomach upset
• vomiting
• diarrhea
• abd cramping
• constipation
• black or red tarry stools
• can discolor tooth enamel & eyes
• causes pain upon injection

• iron toxicity
• enteric coated & resemble candy

• symptomatic treatment & supportive measures
• MAINTAIN the airway
• correct acidosis
• control shock & dehydration w/ IVF's or blood
• O & vasopressors
• Iron preparations are radiopaque & may be seen in x-ray

300 >ug/dl

• stomach should be emptied via ipecac syrup or lavage
• whole gut lavage

coma/shock/seizure

chelation therapy w/ deferoxamine should be initiated(ring shaped molecules that bind to metal)

when given w/ absorbic acid

when taking antacids

• thyroid
• tetracycline
• quinolones (antibiotics)

• ferrous fumarate (feostat, Hemocyte)
• Iron Dextran (INFeD)

iron salts

the highest amount of iron per gram of salt consumed

Colloid solution of iron and dextran

iron deficiency Anemia

IM & IV

anaphylaxis

• 1st give test dose (25mg)
• if there is an anaphylactic reaction it will be within a few minutes after test dose given

water soluble B compelx vit

• neural tube defects
• such as spina bifida, encephaly & enecphalocele

at least one month before pregnanay

megaloblastic anemia-resulting from folic acid deficiency

oral

• dried beans,
• peas,
• oranges
• green veggies

a bile acid blocker

• diarrhea, back pain, and abdominal pain.
• works spec on GI tract

LDL <100

raise HDL lower LDL

borderline high lipidemia

can help reduce lipid

flushing

usually stops after 2 days

blut w/ ASA 45 min prior if not contraindicated

• Vit D
• esp in elderly women

many meds fight w/ vit D

help raise blood cells

often given to CA pt

• gi stuff
• constipation

• vit b12
• erythropoieten (procrit, epogen)

• calc
• iron sulf
• vit b complex
• vit c in same solution

• through straw
• no teeth discolor

z-track

it is thick

emer equip

• diet high in b12
• fish oysters egg yolk
• organ meet
• dairy
• clams