Birth Order | Quizalize

The following vocabulary: abstract מופשט attempt ניסיון birth לידה / ללדת cultural תרבותי Democracy דמוקרטיה depressed מדוכא Depression דיכאון display להציג, תצוגה exhibition תערוכה, תצוגה experiment ניסוי, להתנסות extent היקף, שיעור, מידה influence השפעה lack of חוסר ב loss אובדן method שיטה no longer כבר לא order להזמין partner שותף, חבר plain פשוט poet מְשׁוֹרֵר reality מציאות recover להתאושש, להחלים ; לקבל בחזרה violent אלים

The Story of Ramayana by Maharshi Valmiki Long ago, Dasharatha, the wise king of Ayodhya of Sarayu, India had three wives. Though the King had three wives, he didn’t have any children with them. The Chief priest Vasishta advised the king to make fire sacrifice to obtain a blessing from the gods. After the gods were pleased, one of them appeared out of the flame and handed him a pot full of nectar. The god told the king to share the nectar with his three queens namely Kausalya, Kaikeye, and Sumitra. While the nectar had been shared, the three queens gave birth to sons: Kausalya had Rama; Kaikeye had Bharatha; and Sumitra had twins Lakshmana and Shatrughna. A sage took the boys out to train them in archery. In a neighboring city, the ruler's daughter was named Sita. When it was time for Sita to choose her bridegroom, at a ceremony called a Swayamvara, the princes were asked to string a giant bow. No one else could even lift the bow, but as Rama bent it, he did not only string it but also broke it into two. Sita indicated that she chose Rama as her husband by putting a garland around his neck. The disappointed suitors were watching. 6 CO_Q3_English8_Module 4 King Dasharatha, Rama's father, decided it was time to give his throne to his eldest son Rama and retired to the forest to seek moksha. Everyone seems pleased. This plan fulfilled the rules of dharma because an eldest son should rule and, if a son can take over one's responsibilities, one's last years may be spent in a search for moksha. In addition, everyone loved Rama. However, Rama's stepmother, the king's second wife, was not pleased. She wanted her son, Bharata, to rule. Because of an oath Dasharatha had made to her years before, she got the king to agree to banish Rama for fourteen years and to crown Bharata even though the king, on bended knee, begged her not to demand such things. Broken-hearted, the devastated king could not face Rama with the news that Kaikeyi must tell him. Rama, always obedient, was as content to go into banishment in the forest as to be crowned king. Sita convinced Rama that she would always be at his side and his brother Lakshmana also begged to accompany them. Rama, Sita, and Lakshmana set out to the forest. Bharata, whose mother's evil plot had won him the throne, was very upset when he found out what had happened. Not for a moment he did consider breaking the rules of dharma and becoming king in Rama's place. He went to Rama's forest retreat and begged Rama to return and rule, but Rama refused. "We must obey father," Rama says. Bharata then took Rama's sandals saying, "I will put these on the throne, and every day I shall place the fruits of my work at the feet of my Lord." Embracing Rama, he took the sandals and returned to Ayodhya. Years passed and Rama, Sita, and Lakshmana were very happy in the forest. Rama and Lakshmana destroyed the rakshasas (evil creatures) who disturbed the sages in their meditations. One day a rakshasa princess named Shurpanakha tried to seduce Rama, and Lakshmana wounded her and drove her away. She returned to her brother Ravana, the ten-headed ruler of Lanka (Sri Lanka, formerly Ceylon), and told her brother, who is always attracted to beautiful women, about lovely Sita. Ravana devised a plan to abduct Sita. He sent a magical golden deer which Sita desired Rama to hunt. A long time had passed, but Rama didn’t return. Thus, Lakshmana went off to find his brother. Before leaving Sita, Lakshmana drew a protective circle around Sita and warned her that she would be safe if she would stay within the circle. As they went off, Ravana, who could change his shape, appeared as a holy man begging alms. The moment Sita stepped outside the circle to give him food, Ravana grabbed her and carried her off to his kingdom in Lanka. Rama was broken-hearted when he returned to the empty hut and could not find Sita. A band of monkeys led by Hanuman offered to help him find Sita. Ravana carried Sita to his palace in Lanka, but he could not force her to be his wife. So, he put her in a grove and alternately sweet-talked her and threatened her in an attempt to get her to agree to marry him. Sita would not even look at him but thought only of her beloved Rama. Hanuman, the general of the monkey band could fly since his father was the wind, and he flew to Lanka and found Sita in the grove, comforted her, and told her Rama would come soon and save her. 7 CO_Q3_English8_Module 4 Ravana's men captured Hanuman, and Ravana ordered them to wrap Hanuman's tail in cloth and to set it on fire. With his tail burning, Hanuman hopped from house-top to house-top, setting Lanka a fire. He then flew back to Rama to tell him where Sita was. Rama, Lakshmana, and the monkey army built a causeway from the tip of India crossing over to Lanka. A mighty battle took place. Rama killed several of Ravana's brothers and then Rama confronted ten-headed Ravana. Rama finally killed Ravana and freed Sita. After Sita gained her freedom from Ravana, she proved her purity through the trial by fire. Then, they returned to Ayodhya and Rama became the king. As Rama became the king, he ruled Ayodhya with Ramrajya - an ideal time when everyone does his or her duties and responsibilities

Chapter 22 Antihypertensive Drugs Hypertension Defined (JNC-8) Pharmacology Overview 7 main categories of drugs to treat HTN Adrenergic drugs (old friend) Angiotensin-converting enzyme (ACE) inhibitors Angiotensin II receptor blockers (ARBs) Calcium channel blockers (CCBs) Diuretics Vasodilators Direct renin inhibitors A. Adrenergic Drugs: 5 Subcategories and where they act A1. Adrenergic neuron blockers (central and peripheral)- we won’t talk about this A2. Alpha1 receptor blockers (peripheral) A3. Alpha2 receptor agonists (central) A4. Beta receptor blockers (peripheral) A5. Combined α and β receptor blockers (peripheral) A2. Peripherally Acting Adrenergic DrugAlpha1 Blockers (we’ve met these) Doxazosin, prazosin, alfuzosin Block alpha1-receptors which causes BP to decrease Reduces peripheral vascular resistance and BP by dilating both arterial and venous blood vessels Main Use: benign prostatic hyperplasia (BPH) Alpha1 Blockers REMEMBER Tamsulosin (Flomax)* is an α1 blocker BUT *Tamsulosin is not used to control BP, just for BPH. A3. Centrally Acting Adrenergic DrugsAlpha 2 agonist Clonidine and methyldopa 1- Stimulate alpha2-adrenergic receptors. in the brain Decreases sympathetic outflow from the CNS which decreases NE production 2. Stimulate alpha2-adrenergic receptors in kidneys remember alpha 2 opposes alpha 1 Dilates peripheral blood vessels → lowers peripheral resistance → Results in decreased BP So ….Clonidine (Catapres) Used primarily for its ability to decrease blood pressure in an urgent setting Also use in opioid withdrawal as previously discussed Oral (multiple times a day), and topical patch formulations Do not stop abruptly as it may lead to rebound hypertension In reality, Clonidine and methyldopa Not prescribed as first-line home antiHTN drugs High incidence of unwanted adverse effects: orthostatic hypotension, fatigue, and dizziness MIGHT be uses as adjunct drugs after other drugs have failed, in conjunction with other antiHTN such as diuretics A4. Adrenergic Drugs Selective Beta 1 Blockers Metoprolol, Atenolol Reduction of HR through β1 receptor blockade (remember adrenergic blocking of this receptor???) HR results in BP Cause reduced secretion of renin = BP A4. Adrenergic Drugs Selective Beta1 Blockers Nebivolol (Bystolic) Uses: hypertension and HF Action: blocks β1 receptors and produces vasodilatation, which results in a decrease in SVR High doses loses selectivity and blocks both β1 and β2 Less sexual dysfunction All BB- Do not stop abruptly; must be tapered over 1 to 2 weeks A4. Adrenergic Drugs NONSelective Beta Blockers Propranolol Acts equally on β1 and β2 Other uses include situational anxiety associated with public speaking, test taking As mentioned on previous slide, nebivolol at high doses becomes beta nonselective A5. Dual-Action Adrenergic Drugs α1 and β Receptor Blockers Dual antihypertensive effects of reduction in heart rate (beta1 receptor blockade) and vasodilation (alpha1 receptor blockade) Examples are carvedilol (common) and labetalol (not as common) A5. Dual-Action Adrenergic Drugs α1 and β Receptor Blockers Carvedilol (Coreg) Widely used drug that is well tolerated Uses: HTN, mild to moderate HF in conjunction with digoxin, diuretics, and ACE inhibitors Contraindications: severe bradycardia or unstable HF, bronchospastic conditions such as asthma, and various cardiac conduction problems Adrenergic Drugs Indications - HTN But also for Glaucoma (topical) BPH: doxazosin, prazosin, and terazosin (2 for 1) Management of severe HF when used with cardiac glycosides and diuretics Contraindications Acute HF- have to stabilize first MOAIs- yeah doesn’t everything interact with MAOIs? Peptic ulcers Severe liver/kidney disease Asthma (with beta blockers) Adrenergic Drugs: Adverse Effects Orthostatic hypotension 1st-dose syncope Rebound hypertension with abrupt discontinuation Most common: Dry mouth, drowsiness, constipation, sedation Interactions- always check for specific drug interactions Can cause additive CNS depression with alcohol, benzodiazepines, opioids Question #1 When administering an alpha-adrenergic drug for hypertension, it is most important for the nurse to assess the patient for the development of what response? Hypotension Hyperkalemia Oliguria Respiratory distress Answer A Hypotension This is a key point in patient education These drugs have strong vasodilating properties and may cause severe hypotension, especially at the beginning of therapy. B. Angiotensin-Converting Enzyme Inhibitorsaka ACE Inhibitors or ACEi Large group of safe and effective drugs Currently are 10 ACEi Often used as first-line drugs for HF and hypertension May be combined with a thiazide diuretic, loop diuretic, or Calcium Channel Blocker (CCB) You need to understand the basics ACE Inhibitors: Review RAAS ACE converts angiotensin I, formed through the action of renin, to angiotensin II Angiotensin 2 is a potent vasoconstrictor and also induces aldosterone secretion by the adrenal glands Aldosterone stimulates sodium resorption (H20 follows Na Both act to raise BP which causes kidneys to reduce renin production ACEi= Great drug to treat HTN BUT contraindicated in pregnancy (2nd,3rd trimester due to fetal renal damage) and breastfeeding first few weeks after birth B. ACE Inhibitors - PRIL Lisinopril (Prinivil) super common, often the 1st drug Enalapril (Vasotec) also common Captopril (Capoten) great if liver disease present Benazepril (Lotensin) Fosinopril (Monopril) Perindopril (Aceon) Quinapril (Accupril) Ramipril (Altace) Trandolapril (Mavik) Primary Effects of the ACE Inhibitors Prevent Na (and H2O) resorption by inhibiting aldosterone secretion (volume reduction) (GO BACK TO RAAS DIAGRAM) blood volume decreases work of the heart preload, or the left ventricular end-diastolic volume which is important in HF ACE SUMMARY OF ACTIVITY 1) Prevent vasoconstriction caused by angiotensin 2 (2) Prevent aldosterone secretion  less sodium and water resorption Cardioprotective Effects of ACEi They slow progression of left ventricular hypertrophy (ventricular remodeling) after MI so considered cardioprotective ACE inhibitors have been shown to decrease morbidity and mortality in patients with HF Renal Protective Effects of ACEi ACE inhibitors: reduce glomerular filtration pressure by volume reduction Cardiovascular drug of choice for patients with diabetes since it helps protect kidneys by reducing pressure. Sometimes used low dose for kidney protection with DM without HTN B. ACEi Enalapril (Vasotec) Only ACEi available in both oral and IV Enalapril IV does not require cardiac monitoring Oral enalapril: prodrug (metabolized in liver) Improves patient’s chances of survival after an MI Reduces the incidence of HF B. ACEi Captopril (Capoten) Uses: prevention of ventricular remodeling after MI; reduce the risk of HF after MI Shortest half-life Must be administered multiple times throughout the day so this limits its use Not a prodrug so good for patient with liver disease Question #2 A patient with diabetes has a new prescription for the ACE inhibitor lisinopril. She questions this order because her provider has never told her that she has hypertension. What is the best explanation for this order? The doctor knows best The patient is confused This medication has cardioprotective properties This medication has a protective effect on the kidneys for patients with diabetes Answer D ACE inhibitors have been shown to have a protective effect on the kidneys because they reduce glomerular filtration pressure. This property makes them the cardiovascular drug of choice for patients with diabetes. Question #3 A patient with a history of pancreatitis and cirrhosis is also being treated for hypertension. Which drug will most likely be ordered for this patient? Clonidine Prazosin Diltiazem Captopril Answer D Captopril Captopril is not a prodrug; therefore, it does not need to be metabolized by the liver to be effective. This is an advantage in patients with liver disease. ACE Inhibitors: Adverse Effects *Dry, nonproductive cough, which reverses when therapy is stopped. This is a class effect Dizziness- Note: First-dose hypotensive effect may occur Headache & Fatigue Possible hyperkalemia ** Angioedema: rare but potentially fatal Not safe in pregnancy-are contraindicated during the second and third trimesters of pregnancy because of increased risk of fetal renal damage C. Angiotensin II Receptor Blockers(ARB) Considered an alternative to ACEi Less likely to cause a dry cough and hyper K+ that is common with ACE inhibitors Angiotensin II Receptor Blockers: Mechanism of Action Go back to RAAS diagram! ARBs affect primarily 2 places 1. Vascular smooth muscle - blocks vasoconstriction 2. Adrenal gland -Selectively blocks the binding of Ang 2 to certain Ang 2 receptors inhibiting secretion of aldosterone Lowers volume retention and BP Angiotensin II Receptor Blockers -ARTAN Losartan (Cozaar)- very common Eprosartan (Teveten) Valsartan (Diovan) Irbesartan (Avapro) Candesartan (Atacand) Olmesartan (Benicar) Telmisartan (Micardis) Azilsartan (Edarbi) C. ARB Losartan (Cozaar) Beneficial in patients with HTN and HF Used with caution in patients with kidney or liver dysfunction and in patients with renal artery stenosis ***Not safe for breastfeeding women and should not be used in pregnancy (Cat C 1st trimester, Cat D 2nd-3rd trimester), potential fetal toxicity Appear to be equally effective for the treatment of hypertension and well tolerated ARBs less likely to cause cough and hyperK+ but can still happen Evidence that ARBs are associated with lower mortality after MI than ACE inhibitors Never take ACEi and ARBs at the same time* 5. Calcium Channel Blockers (CCB) Primary use: HTN, angina, some dysrhythmias Cause smooth muscle relaxation by blocking the binding of calcium to its receptors, preventing muscle contraction Results in: Relaxed blood vessels to the heart Decreased peripheral smooth muscle tone Decreased SVResistance Decreased BP E. Diuretics First-line antiHTN in JNC 8 guidelines Decreases fluid volume The results from diuresis: preload, Peripheral resistance Overall effect  Decreased workload of the heart and decreased BP Thiazide diuretics are the most commonly used diuretics for HTN Ie hydrochlorothiazide (HCTZ), chlorthalidone We will discuss diuretics further in the chapter on diuretics F. Vasodilators Directly relax arterial or venous smooth muscle (or both) Results in: Decreased SVR Decreased afterload Peripheral vasodilation Indicated for treatment of HTN May be used in combination with other drugs F. Vasodilators Hydralazine (Apresoline) Orally: routine cases of essential hypertension Injectable: hypertensive emergencies BiDil: specifically indicated as an adjunct for treatment of HF in African-American patients F. Vasodilators Sodium Nitroprusside (Nitropress) *Sodium nitroprusside and IV diazoxide are reserved for the management of hypertensive emergencies. Contraindications: severe HF, known inadequate cerebral perfusion (especially during neurosurgical procedures) F. Vasodilators Adverse Effects Hydralazine: dizziness, headache, tachycardia, edema, dyspnea, N/V/D, vitamin B6 deficiency, rash Sodium nitroprusside: hypotension, bradycardia, decreased platelet aggregation, rash G. Direct Renin Inhibitors Aliskirin (Tekturna) Blocks the RAS pathway at the point of activation. Inhibiting renin production prevents the downstream production of Ang II (potent vasoconstrictor) Adverse effects: N/V, severe hypotension, hyponatremia, hyperkalemia… Contraindicated in patients with DM taking ACEi or ARB Miscellaneous Antihypertensives Eplerenone (Inspra) Newer class of drugs called selective aldosterone blockers (remember RAAS?) Reduces BP by blocking the actions of aldosterone at its corresponding receptors in the kidney, heart, blood vessels, and brain Indications: routine treatment of hypertension and for post-MI HF Contraindicated if serum potassium levels are high (above 5.6 mEq/L) A Special Form of HTNTreatment of Pulmonary Hypertension Sildenafil and Tadalafil Commonly used for erectile dysfunction Used for pulmonary hypertension but with different trade names Sildenafil: Revatio* (Viagra for ED) Tadalafil: Adcirca* (Cialis for ED)

Create a comprehension quiz for the following vocabulary; To be getting on in age: Growing older; advancing in years. Pet peeve: Something that annoys or bothers someone significantly. Pinhead: A small-minded or foolish person. Nit-pick: To find fault with small or trivial details. Whilst/while: During the time that; at the same time as. On a dig: Engaged in archaeological excavation. Mad vs crazy: "Mad" typically refers to anger or insanity, while "crazy" can denote insanity or extreme enthusiasm. Twitch: A sudden, quick movement or spasm. Dreamt/dreamed: Past tense forms of the verb "to dream." Eaves: The part of a roof that overhangs the walls. Burly man: A strong, muscular man. She’s a looker: A woman who is attractive or visually appealing. Breech birth: A birth in which the baby is delivered feet first instead of head first. Being too forward: Acting too boldly or presumptuously. Gooey: Soft and sticky, often used to describe certain textures or emotional situations. Spare tire: Excess fat around the waistline; a protruding belly. Twists and turns of fate: Unexpected changes or developments in life. Pompous: Self-important or arrogant. Play a prank on someone: To carry out a mischievous trick or joke on someone. Scamps: Mischievous or playful individuals, often used affectionately. To tend one's resignation: To formally submit one's resignation from a job. A sound judgment: A wise or rational decision. To set someone up with someone else: To arrange a meeting or date between two people. Loon: A colloquial term for a crazy or eccentric person. Duvet: A type of blanket filled with feathers, down, or synthetic fibers, used as a bed covering. Don't Meddle: Do not interfere or intervene. Croquet mallet: A hammer-like instrument used to strike croquet balls. Cut it out: Stop doing something annoying or inappropriate. Pop over: Visit briefly or unexpectedly. It was a riot: It was extremely funny or enjoyable. Spit Tspat spat: Sounds indicating a quick, spat-out expulsion of saliva. A hoot: Something that is amusing or enjoyable. Overhear: To unintentionally hear what others are saying without their knowledge. You're quite a package: You possess many appealing qualities or attributes. I'm quite a catch: I am an attractive or desirable partner. Limper: A person who walks with a limp. A hanky: A handkerchief, a small piece of cloth carried for personal hygiene or used as a fashion accessory.

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