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Conjunction by Miss Gita
Quiz by Gita Yusanti
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The roads are all blocked ..... the snow.
because of
because
We heard it was Rizky's birthday. .... we bought him a present
But
So
The roads are all blocked ..... the snow.
We heard it was Rizky's birthday. .... we bought him a present
I knew she didn’t feel very well; …, I tried to cheer her up.
She took up yoga a few months ago, … she always looks so relaxed.
You should keep the dog on a lead ..... it won’t attack other dogs.
Arya is very sad .... his class is very hot.
Keisyah can ..... sing nor dance well.
.... Made or Malvino often come home very late.
They do exercise. ..... , they rarely get sick.
He woke up earlier .... he missed the bus.
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 Drug Alpha1 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 Drugs Alpha 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 Inhibitors aka 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 HTN Treatment 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 quiz for age 10 about verb, noun, adverb, conjunction, adjective, pronoun, interejction for age 10Conjunctions or connectors have its functions in the sentences. This is especially if the conjunctions or connectors will be used in a format text like argumentative text. Transitions also serve the same purpose as conjunctions, but on a larger scale. They signal to the reader the relationship between ideas in a paragraph or even between paragraphs. By connecting larger ideas, they let readers know what to do with the information presented to them. Indicating these connections help reinforce the argument within a paper. Phrases like "for example" let the reader know the information that follows is meant to support an idea. Thus, the use of transitions cues readers into the writer's thinking process. Conjunctions improve the paper as a whole by giving the writing coherence, or flow. A conjunctive adverb such as "however" or "overall" joins two complete sentences, using either a semicolon or a period. These words and phrases serve different purposes: showing agreement, opposition, causality, support or emphasis, consequence and conclusion. They work like a bridge from one of the writer's points to another.Sure! Here's a solid list of **AP English Literature vocabulary**—terms that often come up in class, essays, and the AP exam. I'll break it down into categories to make it easier to study. --- ### 📚 **Literary Devices & Techniques** 1. **Alliteration** – Repetition of initial consonant sounds 2. **Allusion** – A reference to another text, event, or figure 3. **Anaphora** – Repetition of a word or phrase at the beginning of successive clauses 4. **Antithesis** – Contrast of ideas in a balanced or parallel construction 5. **Apostrophe** – Addressing someone absent, dead, or nonhuman as if present and able to respond 6. **Assonance** – Repetition of vowel sounds within nearby words 7. **Asyndeton** – Omission of conjunctions between parts of a sentence 8. **Consonance** – Repetition of consonant sounds, often at the end of words 9. **Diction** – Word choice (formal, informal, colloquial, etc.) 10. **Enjambment** – Continuation of a sentence without pause beyond the end of a line in poetry --- ### 🧠 **Figurative Language** 1. **Hyperbole** – Extreme exaggeration 2. **Imagery** – Descriptive language that appeals to the senses 3. **Irony** - *Verbal*: Saying the opposite of what’s meant - *Situational*: When the outcome is the opposite of what's expected - *Dramatic*: Audience knows something characters don’t 4. **Metaphor** – A direct comparison without using "like" or "as" 5. **Metonymy** – Substituting the name of one thing with something closely related (e.g. "The crown" for royalty) 6. **Synecdoche** – A part representing the whole (e.g. "All hands on deck") 7. **Personification** – Giving human traits to nonhuman things 8. **Simile** – A comparison using "like" or "as" 9. **Symbol** – An object, character, or color that represents something beyond itself --- ### ✍️ **Poetic & Rhetorical Terms** 1. **Caesura** – A pause in a line of poetry, often marked by punctuation 2. **Couplet** – Two lines of poetry that usually rhyme 3. **Iambic Pentameter** – A line with five iambs (unstressed-stressed syllables) 4. **Blank Verse** – Unrhymed iambic pentameter 5. **Free Verse** – Poetry with no fixed meter or rhyme 6. **Elegy** – A mournful poem, often for the dead 7. **Ode** – A lyric poem expressing emotion, often in honor of something 8. **Sonnet** – A 14-line poem with a specific rhyme scheme (Shakespearean or Petrarchan) --- ### 📖 **Narrative & Structure Terms** 1. **Tone** – The author's attitude toward the subject 2. **Mood** – The feeling or atmosphere the reader experiences 3. **Theme** – The central idea or message in a work 4. **Motif** – A recurring element that has symbolic significance 5. **Foil** – A character who contrasts with another character to highlight traits 6. **Foreshadowing** – Clues or hints about what will happen later 7. **Juxtaposition** – Placing two elements side by side to present a contrast 8. **Point of View** – Perspective from which the story is told (1st, 2nd, 3rd person) 9. **Stream of Consciousness** – Narrative style that mimics thoughts and feelings 10. **Frame Narrative** – A story within a story --- Want me to make flashcards, a quiz, or a PDF study guide with these? Or need help using them in a literary analysis essay?Positive/Negative/Neutral Objects - How are they different? Positive: has fewer electrons than protons Negative: Has more electrons than protons Neutral: has equal numbers of protons and electrons Laws of Electric Charges - What are they? How are they applied? Like charges repel, opposites charges attract, charged AND neutral objects attract Induced Charge Separation - Explain this process. A shift of the position of electrons when a charged object is brought near it. If the charged object is positive, the electrons will move toward it. If the charged object is negative, the electrons will move away from it. Charging by Friction (What is happening with the charges? - Know electrostatic series examples) Process in which objects made from different materials rub against each other, producing a net static charge on each object. When charged by friction, one material will have a stronger attraction to electrons and will pull the electrons off the other material Charging by Conduction (Be able to explain what the electrons are doing) Charging by contact with a charged object. An object that becomes charged by contact always gets the same type of charge that is on the object that charges it. Grounding (Be able to explain how it happens) A method of removing static charges from an object. Electrons from the ground move up to the charged object. If the object is negative, electrons leave the object. If the object is positive, electrons enter the object. The ground always remains neutral Conductors/Insulators/Semiconductors (Know examples for each and characteristics) Conductor: A material that allows electrons to flow through it easily. GOOD CONDUCTORS: Silver, copper, gold, aluminium, magnesium, iron, usually metals Insulator: A material that prevents electrons from flowing through it. Plastic, wood and glass are examples. To prevent electric shocks, conductive wires are wrapped in insulators. Semiconductors: Have special properties that make them fair conductors, they are the foundation of modern electronics, including radios, computers and telephones. Charging by Induction (How do we induce a PERMANENT charge?) You can permanently charge an object using induction by attaching a conducting wire to the neutral object that goes to the ground Electric Discharge - What causes it? Know everyday examples. How is lightning formed? When two objects that have a charge imbalance are brought close together or come in contact with each other, electrons are transferred rapidly. Electrons move from the object with a more negative charge to the object with the less negative charge. Lightning occurs through an imbalance of charge between clouds and the ground. Negative charge at the bottom of a cloud repels the electrons at the earth's surface which move away, causing the ground to become positively charged Current Electricity: Refers to the electrons that flow in a controlled way through a conductor Forms of Current Electricity - Alternating Current (AC) vs Direct Current (DC) - How do they differ? AC: Electrons move back and forth, alternating their direction. produced in generating stations and is then distributed over long distances ex. Something plugged into a wall outletSC.912.P.10.4-Describe heat as the energy transferred by convection, conduction, and radiation, and explain the connection of heat to change in temperature or states of matter.SC.912.P.10.4 Describe heat as the energy transferred by convection, conduction, and radiation, and explain the connection of heat to change in temperature or states of matter. PB-SC.912.P.10.4 (H) - Describe heat as the energy transferred by convection, conduction, and radiation, and explain the connection of heat to change in temperature or states of matter.