CHAPTER TWENTY FOUR
1
Bone
 Composed of two different kinds of bony tissue
 Cancellous or “spongy” bone—porous, inner bone that
provides volume
 Compact bone—hard, outer covering that provides
strength and shape
 The rounded end of a bone is covered with
smooth, slippery articular cartilage
 Many bones are hollow, and contain marrow:
 Red marrow in children
 Fatty yellow marrow in adults
2
Bone and Muscle
3
Types of Muscle
 Skeletal muscles—attached to bones; provide body
movement
 Voluntary, striated in shape, contain multiple peripheral
nuclei
 Cardiac muscle—tissue that composes the heart
 Contracts rhythmically, coordinated by transmission of
electrical impulses from nerve to muscle fibers
Smooth or “visceral” muscle—attached to or lines other
organs such as the stomach, intestines, lungs, and blood
vessels
4
Five Categories of Bone:
 Flat bones—generally more flat than round
 Irregular bones—have no defined shape
 Sesamoid bones—have cartilage or fibrous tissue
mixed in
 Short bones—generally cube-shaped
 Long bones—the most common bone
 Epiphysis (the rounded end of the bone)
 Diaphysis (the main shaft or central part of the
bone)
5
Disorders of the Bone
Osteomyelitis
 Bacterial Infection Inside the Bone Destroys bone tissue
 Original site of infection is frequently in another part of
body
 Infection spreads to the bone via the blood
Osteoporosis—bone brittleness due to lack of calcium
• Prevalent in postmenopausal women because of estrogen
deficiency
Paget’s disease—changes the normal process of bone growth
• Causes bone to break down more quickly and grow back
softer than normal bone
6
Musculoskeletal
Diseases/Disorders
 Bursitis—inflammation of the small, fluid-filled
pouches between bones
 Tendonitis—inflammation of the cords of
connective tissue that attach muscle to bone
 Myalgia—muscle pain
7
Skeletal Muscle Relaxants
 MOA: may block action of calcium in muscles
 Indications: painful muscle spasms, neurological
spinal cord injury
 Main Side Effects: Drowsiness, weakness
Generic
Brand
Cyclobenzaprine
Flexeril
Methocarbamol
Robaxin
Baclofen
Lioresal
Arthritis—Inflammation of a Joint
 Rheumatoid—an autoimmune disorder
 Osteoarthritis—caused by physical degeneration of
connective tissue
 Gout—caused by crystals of uric acid in blood
9
Treatments
Osteomyelitis
 Anti-infective agent is best treatment for
osteomyelitis
Osteoporosis
 Vitamin D and mineral calcium replacement
therapy
 Hormone therapy (estrogen, calcitonin) and
bisphosphonates
 SERMs for postmenopausal women
 Gold compounds used to treat osteoarthritis
10
Treatments
Gout
 Colchicine used to alter ability of phagocytes to
attack uric acid crystals
 Anti-inflammatory analgesics can be used to
reduce pain and inflammation
Inflammation
 Salicylates relieve inflammation by inhibiting the
synthesis of prostaglandin
 Topical corticosteroids treat most causes,
including chemical, mechanical, microbiological,
and immunological
11
Musculoskeletal Pharmaceuticals
 ASA (acetylsalicylic acid)
 Relieves inflammation by inhibiting the synthesis of
prostaglandin
 Salicylates are also used as analgesics and antipyretics
 NSAIDs (nonsteroidal anti-inflammatory drugs)
 Inhibit or block the enzyme that starts the reaction of
inflammation by making prostaglandin
 COX-2 inhibitors
 Block only the cyclooxygenase II that makes PGE-2, but
not C-1 (PGE-1)
 Inflammation is inhibited, but not the viscosity of the
mucosal linin
12
Non Steroidal Anti Inflammatory
Drugs
 Called the NSAIDS
 Excellent drugs for pain relief and reducing fever and inflammation
 Developed as an alternative to corticosteroids
 MOA: blocks the COX enzyme to block prostaglandin formation
 Side effects are: severe GI bleeding (possible), GI upset and gastritis, kidney
insufficiency, edema and elevated blood pressure, hyperkalemia risk
Generic
Brand
Ibuprofen
Motrin, Advil
Naproxen
Naprosyn
Ketorolac
Toradol (IV available)
Diclofenac
Voltaren
Celecoxib
Celebrex (COX2
inhibitor)
Musculoskeletal Pharmaceuticals
 Bisphosphonates—indicated for osteoporosis
 Mimic the natural organic bisphosphonate salts found
in the body
 Inhibit bone resorption and osteoclast activity
 Restore bone mass and density
 SERMs (selective estrogen receptor modulators)
 Indicated for postmenopausal women
 Protective effect on bones and heart
 Skeletal muscle relaxants—used to relax specific muscles
in the body
 Relieve pain, stiffness, and discomfort
 Block muscle contraction at the neuromuscular junctio
14
CHAPTER TWENTY FIVE
15
The Respiratory System
 Divided into the upper respiratory tract and the lower
respiratory tract
 The upper respiratory tract consists of:
 Nose or nasal cavity
 Paranasal sinuses
 Pharynx and larynx
16
The Respiratory System (cont.)
 The lower
respiratory tract
consists of:
 Trachea
 Two lungs
 Two main bronchi
17
The lower respiratory tract.
18
Respiration
 Diaphragm—dome-shaped layer of muscle that lies
across bottom of chest cavity
 Breathing occurs as diaphragm contracts and relaxes
 Carbon dioxide pushed out of the lungs during
relaxation
 Oxygen pulled into the lungs during contraction
19
Structure of Lungs
 About 10 percent solid tissue
 Remainder of structure filled with air and blood
 The functional structure can be divided into two parts:
 Conducting airways (bronchi and bronchioles)—tubes
lined by cilia and respiratory mucosa
 Cartilage—supports and cushions the bronchi
20
Common Cold
 Caused by a viral infection that inflames the membranes in
nose and throat
 Antibiotics will not cure a cold or any other viral infection
 Treatment is considered symptomatic
Cough
 May be a symptom of a cold, flu, respiratory problems, or
nonrespiratory diseases
 Most likely begins with an irritation of nerves in the
respiratory tract
 Nonproductive cough treated with cough suppressant
 Productive cough treated with an expectorant
21
Allergies and Asthma
Allergies
 Caused by the immune system reacting to a substance that
does not cause disease
 Treatment may be palliative, with antihistamines and
antitussives
 Treatment may be preventive, with mast cell stabilizers
Asthma
 Chronic respiratory disease
 Characterized by inflammation of airways, tightening of
muscles around airways
 Treatment is palliative with albuterol and other
bronchodilators
22
Emphysema
 Chronic destruction of alveoli
 External exchange interrupted when alveoli become
permanently damaged
 Treatment may be palliative, with stimulant inhalers
 Treatment may be preventive, with anti-inflammatory
corticosteroids
23
Nasal Congestion and Rhinitis
Nasal Congestion
 Inflamed, stuffy nose
 Treatment may be palliative, to promote easier breathing
 Indications for use of decongestants are nasal and bronchial congestion
Rhinitis
 Inflammation of nasal membranes, and/or runny nose
 Common component of colds and allergies
 Treatment is considered symptomatic
 Drugs to treat include:
Generic
Brand
Oxymetazoline
Afrin Nasal Spray
Phenylephrine
NeoSynephrine Nasal Spray
Fluticasone
Flonase (Nasal Steroid
preparation)
Mometasone
Nasonex (Nasal Steroid
preparation)
Oxymetazoline and Phenylephrine are sympathomimetic and can raise
blood pressure. They also should be used with caution in gluacoma
patients
24
Chronic Obstructive Pulmonary
Disease (COPD)
 Umbrella term for emphysema and chronic bronchitis, and asthma
 Characterized by partially blocked bronchi and bronchioles, mucus
plugging and bronchoconstriction
 Causes shortness of breath
 Treatment may be palliative, with bronchodilators
 Drugs
Generic
Brand
Albuterol
Proventil
Pirbuterol
Maxair
Ipratropium
Atrovent
Fluticasone/Salmeterol
Advair Diskus
Budesonide/Formoterol
Symbicort
Albuterol and Pirbuterol and Beta 2 agonist but can cause tachycardia in
some people.
All of the above drugs are available as MDI
Advair is a DPI (Dry powder inhaler system) (no CFC propellants)
With Advair and Symbicort advise the patient to rinse the mouth with water to
prevent candida infection (Trush or moniliasis)
25
CHAPTER TWENTY SIX
26
The heart.
27
Anatomy of the Heart
 Composed of four chambers: two upper and two lower
 Atria—top two chambers
 Ventricles—bottom two chambers
 Septum—divides heart into right and left sides
28
Valves of the Heart
 Tricuspid valve—located between the right atrium and
the right ventricle
 Pulmonary valve—located between the right ventricle
and the pulmonary artery
 Mitral or bicuspid valve—located between the left
atrium and the left ventricle
 Aortic valve—located between the left ventricle and
the aorta
29
Layers of the Heart
 Pericardium—fluid-filled sac that surrounds and
protects the heart
 Permits free movement of the heart during contraction
 Endocardium—innermost wall layer; covers the inside
surface of the heart
 Myocardium—surrounds heart and causes chamber
contractions
30
Function of the Heart
 Provides oxygenated blood throughout the body by a
pumping mechanism
 Oxygenated blood deposits materials necessary for
growth and nourishment
 Receives from tissues the waste products resulting
from metabolism
31
Hypertension
 Sustained elevation of systemic arterial blood pressure
 Symptoms include:
 Severe headache
 Chest pain
 Irregular heartbeat
 Fatigue
• Pharmaceutical treatment includes diuretics, vasodilators,
ACE inhibitors, beta blockers, and calcium channel
blockers
32
Congestive Heart Failure
 Heart pumps out less blood than it receives
 Results in weakened and enlarged heart
 Symptoms of CHF include:
 Upright posture or leaning forward
 Anxiety and restlessness
 Cyanotic and clammy skin
 Persistent cough
 Rapid breathing
 Fast heart rate
 Edema of the lower limbs
• Pharmaceutical treatment includes cardiac glycosides,
diuretics, vasodilators, ACE inhibitors, beta-adrenergic
blockers, and phosphodiesterase inhibitors
33
Coronary Artery Disease
 Occurs when there is insufficient blood flow to the heart
 Can lead to:






Angina
Heart attack
Arrythmias
Stroke
Pulmonary embolism
Heart failure
 Early CAD is closely monitored and symptomatic relief is
given by the use of nitroglycerin and other nitrate drugs.
 NTG
 ISDN (isosorbide dinitrate)
 Once CAD has progressed to the point where a patient has
angina at rest. Two procedures can be taken
 PCI with stents
 CABG (Coronary artery bypass graft)
34
Cardiovascular Pharmaceuticals
 Antiarrhythmic drugs—restore normal rhythm
patterns but do not cure the cause of the irregular
heartbeat
 Cardiac glycosides—used to increase the force of
myocardial contraction, without causing an increase in
the consumption of oxygen
 Diuretics—used to eliminate excess sodium and water
via the urinary tract
 Vasodilators—allow more blood to exit the heart,
preventing or mitigating congestion; lower blood
pressure
35
Cardiovascular Pharmaceuticals
(cont.)
 Angiotensin-converting enzyme inhibitors (ACE
inhibitors)—lower high blood pressure; thought to
reshape the heart; prevent the body from producing
natural vasodilators
 Angiotensin II receptor blockers—similar to ACE
inhibitors; block the body’s natural vasodilators
 Beta-adrenergic blockers—used to block cells from
receiving natural vasoconstrictors
 Platelet aggregation inhibitors—reduce the ability of
the blood to coagulate
36
Cardiovascular Pharmaceuticals
(cont.)
 Anticoagulants—prevent clots from forming or
existing clots from getting bigger
 Tissue plasminogen activators—break down blood
clots by reversing the clotting order and interfering
with the synthesis of various clotting factors
 Thrombin inhibitors—inactivate bound thrombin by
binding to the enzyme and blocking its interaction
with its substrates of fibrin
 Antihyperlipidemics—help prevent the progression of
coronary artery disease by lowering plasma lipid levels
37
Anticoagulants
 Do not thin out the blood
 Prevent clots from forming
 Prevent existing clots from getting bigger
 Cannot dissolve existing blood clots
38
Warfarin
 Oral drug of choice
 Works by preventing the synthesis of clotting factors II,
VII, IX, and X
 Used in the long-term prevention or management of
venous thromboembolic disorders, including:
 Deep vein thrombosis
 Pulmonary embolism
 Clotting associated with atrial fibrillation and prosthetic
heart valves
 Vitamin K may be used as an antidote when too much
warfarin has been given
39
Heparin
 Parenterally administered drug of choice
 Works by inactivating clotting factors IX, X, XI,
and XII
 Used prophylactically to:
 Prevent and treat deep vein thrombosis
 Prevent and treat pulmonary embolism
 Treat thrombophlebitis
 Prevent clotting during cardiac and vascular surgery
• The only antidote for heparin overdose is protamine
sulfate
40
Cholesterol and Triglycerides
 HDL—high-density lipoproteins or “good” cholesterol
 LDL—low-density lipoproteins or “bad” cholesterol
 Triglycerides—a form of energy stored in adipose and muscle tissues
 Often measured to depict fat ingestion and metabolism
 Can be used to assess CAD risk factors
 Statins- drugs used to lower LDL cholesterol
Generic
Brand
Atorvastatin
Lipitor
Simvastatin
Zocor
Fluvastatin
Lescol
Rosuvastatin
Crestor
Major: Side effects are nausea, GI and a reaction called Rhabdomyolysis
and myopathy where patient experiences muscle pain and at the extreme
renal failure and hospitalization
Statins are drug interactions with medications that block the liver’s CYP450
systems: Diltiazem, amiodarone, HIV protease inhibitors, Ketoconazole
41
Generic
Brand
Simvastatin + Ezetimibe
Vytorin
Lovastatin + Niacin
Advicor
Simvastatin + Niacin
Simcor
Above medications are combination products that contain a
statin + one other drug. Exetimibe is a drug that block enteral
absorption of cholesterol. Niacin is a B vitamin used to high
doses to alter metabolism of triglycerides and raise HDL
One unique combination product is Caduet, which is a
combination of Atorvastatin and Amlodipine (calcium channel
blocker ). This product is used to treat metabolic syndrome
42
 Non Statin Antilipidemic drugs
 Other drugs that target lowing VLDL, triglycerides, and
raising HDL have a beneficially affect on coronary artery
disease
Generic
Brand
Indications
Gemfibrozil
Lopid
High VLDL
Fenofibrate
Tricor
High VLDL, low
HDL
Niacin
Niaspan
High VLDL, low
HDL
Omega 3 Fatty
acid
Lovaza
High VLDL, low
HDL
43
Drugs used in the Treatment of MI
 MI is a myocardial Infarction. Heart attacks occurs
because a arterial plaque raptures and triggers the
coagulation cascade completely occudding a coronary
artery. This cause necrosis of the heart muscle.
 If not treated MI result in death from cardiogenic shock
 Even if treat mortality is high from secondary ventricular
fibrillation
 Even if treated, patient will suffer irrevocable heart damage
resulting in CHF and/or damage to cardiac conduction
system leading to pacemaker or ICD placement
 The main goal is to relieve the blood vessel of the clot and
reestablish coronary blood flow
 Can use “clot busters” drugs or have percutaneous coronary
intervention (PCI) which the femoral artery undergo
catherization and a probe is guide to the site of occlusion
and a ballon is inflated to push aside the clot
44
Generic
Brand
Use
Aspirin
Ecotrin
To stop platelet action at
the clot
Clopidogrel
Plavix
To stop platelet action at
the clot
Nitroglycerin
Various
To vasodilate coronary
artery to relieve pain
Tissue plasminogen
activator
TPA
Alteplase (Activase)
Reteplase (Retavase)
Tenecteplase (Tnkase)
Activate plasmin, a blood
protein that opens blood
clots
Heparin
N/A
A potent blood
anticoagulant that stop
further coagulation
Metoprolol
Lopressor
A beta blocker that slows
heart rate and slows
spread of infarction
45
Drug used in the treatment of
Atrial Fibrillation
 Atrial Fibrillation is a heart rate disturbance in which the
atrium/ atria are beating extremely rapidly
 Can lead to cardiogenic shock if the rate reaches the ventricles
 Therapy is aimed blocking this rate disturbance from reaching
the ventricles (called rate control), preventing blood clots in the
heart muscle wall from forming embolus (anticoagulation), and
eventual cardioversion
 Rate control




Diltiazem
Verapamil
Beta blockers
Amiodarone
 Anticoagulation
 Warfarin
 Apixaban (Eliquis)
 Cardioversion
 Ibutilide (Tikosyn)
 High dose Amiodarone
46
Ventricular Fibrillation
 Ventricular Fibrillation, VF, is a cardiac arrythmia where
the ventricles beat extremely rapidly to the point where no
coordinated contraction occurs
 Medical emergency
 VF lasting more than the 90 seconds leads to asystole,
sudden cardiac death and cardiogenic shock. Brain death
from cerebral hypoxia
 Therapy
 Direct DC shock with ACD: delivery of DC shock with about
360 Joules of electricity to bring about normal sinus rhythm.
Best chance at survival but not always successful
 Drug treatment used in conjunction with ACD if shock
initially unsuccessful




Amiodarone: 300 mg IV push with 150 mg IV supplemental doses
Lidocaine: 100 mg IV push
Epinephrine or Atropine can be tried after failed attempts at shock
Other drugs include calcium chloride 10%, magnesium sulfate and
vasopressin
47
Beta Blockers
 Very useful in extending the life expectancy of patients
post MI and in CHF patients
 Due to evidence from clinical trials like the
scandinavian Timolol study and the BHAT (beta block
heart attack trial with propranolol) beta blocker are
now an important drug in the therapy of post MI
patients
Generic
Brand
Propranolol
Inderal
Metoprolol
Lopressor
Timolol
Blocadren
Atenolol
Tenormin
Carvedilol
Coreg
48
ACE Inhibitors
 Used to decrease mortality in post MI and CHF
patients
 Used with beta blockers and often in combination
with them
Generic
Brand
Captopril
Capoten
Enalapril
Vasotec
Lisinopril
Zestril, Prinivil
Benazapril
Lotensin
Ramipril
Altace
Potassium levels should be monitored
ACE inhibitors are pregnancy category X
May cause relentless coughing in some patient requiring
discontinuation due to potent edema and closure of the airway
49
CHAPTER TWENTY EIGHT
50
The renal system.
51
The Renal System
 Composed of two kidneys, two ureters, one bladder,





and the urethra
Filtering system of the kidneys is composed of millions
of nephrons
Waste from food and drug metabolization is filtered
through the nephrons
Wastes exit the kidneys as urine via the ureters
Ureters lead to the bladder, where urine is stored until
released
The kidneys are located in the posterior abdomen just
above the waist
52
Nephron
 Smallest, most basic part of the kidney
 Filters the blood that passes through the kidneys
 Produces urine through the processes of filtration,
reabsorption, and secretion
 Enables blood to reabsorb water, electrolytes, and
nutrients
53
Kidney and Bladder
Kidney
 Built almost entirely of nephrons
 Organ that filters blood and produces urine
 Urine produced by the kidneys is conducted to the
bladder
Bladder
 Organ used for waste storage
 Can collect approximately 350 mL to 500mL of
urine
 Allows for discretionary voiding
54
Urinary Tract Infections
 Bacterial infections of the urinary system
 Symptoms include:
 Frequent urge to void
 Burning sensation when voiding
 Cloudy or strong-smelling urine
 Blood in the urine
55
Treating UTIs
 Cranberry juice:
 A substance in cranberry juice keeps infection-causing
bacteria from attaching to the walls of the urethra
 Also makes the urine more acidic
 Anti-infectives
 Destroy or inhibit bacterial growth
 Phenazopyridine (200 mg tid pc)
 Can be used to manage the symptoms of a burning and
itching urethra
56
Kidney Stones
 Common and painful urinary tract disorder
 Solid mineral deposits accumulate in the urinary tract
 Treatment is palliative, with pain management
 Oral analgesics for mild to moderate pain may be used
 Treatment is preventative, with diet
 Mineral and vitamin supplements
 Increased fluid intake
57
Edema and Hypertension
 Consistently elevated blood pressure levels
 Lead to damage of the kidney arteries
 Treatment is with diuretics
 Reduce high blood pressure
58