What document do patients with a CGM need to sign?

patient supplied complex therapeutic equipment agreement form

High Risk Medications

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)

Measuring the Effectiveness of police strategies and operations Clearance rates Def: The proportion of incidents known to the police that result in teh identification of a suspect Crime Displacement Def: relocation-due to the effective crime prevention, crime response initiates criminal activity from one local to another Professional Model of Policing Model of police work, reactive, incident driven and centred on random patrol Three Rs: random patrol, rapid response and reactive investigation Community policing Def: policing centred on police-community partnership and problem-solving The three ps: prevention, problem solving and partnership with the proactive role Community-based strategic policing Def: The model incorporates community policing with prevention, crime response and crime attack approaches Community engagement, police services strategic in their policies and operations Crime Analytics Sophisticated programs, and crime maps, provide intelligence to police officers in patrol and investigative units Intelligence-led policing: guided by collection, and analysis of information informs police decision-making Compstat: Increase effectiveness, and efficiency of police service while holding police personnel accountable for crime reduction Predictive policing: statistical analysis, identify time and location likely to occur Limited analytical capacity and not able to provide their officers with real-time information Biased policing certain areas, or persons, being identified as important for police attention in predictive policing How Predictive Policing Software Works The Police and the community Public Attitudes toward and Confidence in the police Community-based strategic policing: Recruitment, and deployment of volunteers in community police stations, storefronts Foot and bike patrols Team policing Restorative Justice Approaches Alternative for addressing, and resolving crime, needs of victims, offenders and the community Victim offender meditation Circle sentencing Community holistic healing programss Family group conferences Crime Prevention and Response Strategies Crime Prevention progemas Aimed at reducing crime, generating community involvement and heightening citizens; perceptions of safety Primary crime prevention programs opportunities for criminal offences and alter those conditions Secondary crime prevention programs focus on areas that produce crime and disorder Tertiary crime prevention programs are designed to prevent youth and adults from reoffending The Broken Windows Approach If minor crimes are left unaddressed in an environment, more serious crimes will emerge (originated in New York City in the 1980’s) “The exictsnce of unchecked and uncontrolled mirror incivilites in a neighbourhood- for example, panhandling, public drunkenness, vandalism and graffiti-produces an atmosphere conducive to more serious crime.” R.H. Burke Zero tolerance policing Zero tolerance policing: Strict order maintenance approach- specific area, coupled with high police visibility and presence Quality of life policing: Increased police visibility improves conditions in an area by targeting disruptive and annoying behaviour Problem Oritented policing (POP) Strategy, the idea that police should address teh cause of recurrent crime and disorder Root causes of recurring problems Solutions to problems Collabortaion with community SARA (scanning, analysis, response and assessment) problem-solving model helps officers identify, and respond to problems with the assistance of agencies, organizations, community groups The Police and Vulnerable/ At risk groups Persons with Mental Illness Patrol officers encountering more and more persons with mental illness (PwMi) Number of these end trragically Number of incidents increased significantly following deinstitutionalization of the mentally ill - in 1960 and 1970 De facto (in fact) mental health workers, first responders Crisis intervention training (CIT) Assertive outreach teams Assertive community treatment (ACT) teams Indigenouse, Vulnerable, and Marginalized women Sexual assault one of most underreported crimed. 1 in 20 incidents report to police. Many Women Do not want to deal with police Believe police would not take allegation seriously Language, cultural barriers Distrust the police Fear repercussions Missing and Murdered Indigenous women Canada, unknown number of missing and murdered indigenous women 2016, federal government announced National inquiry into Missing and Murdered Indigennouse women and girls Three goals of MMIWG 1. Finding the truth 2. Honouring the truth 3. Giving life to the truth as a path of healing

High-Risk Traffic Stops

Write 5 multiple choice questions for the following transcript ...Setting goals and budgeting. [tranquil music] Getting where you want to be involves three important skills. Setting realistic goals, knowing your net worth, and budgeting. [energetic music] Setting goals is a way to get control of your life. A goal is not the same as a dream. It's not pie in the sky stuff. It's something that's achievable and it comes with a time frame. If you have a big goal, like buying a house in five years' time, you might need a plan that involves a whole series of mini goals to get you there in stages. The important is finding something you know you can do. Most people find longterm goals hard to stick to. Don't worry about it. If 10 years seems too far away, set your horizons a little closer. Give yourself a set sum of money to save in the next few years. You can use it as a springboard to get to your next goal and it'll get you in the savings habit. Changes in your life circumstances may also affect your goal, so use this opportunity to review them. Think about your financial goals when you have some quiet time. It may sound a little obsessive, but write down what they are and how you're going to achieve them. Be specific, be realistic, and always, always keep your goals within reach. Achieving a goal is a great excuse to celebrate, so don't forget to reward yourself for your achievement. [energetic music] Imagine if tomorrow you had to sell everything you own and pay off everything you owe the bank or anyone else, would you be left with much? Would you be left with anything? That figure is called your net worth. It's a measure of your actual financial wealth and growing it over time is what getting sorted is all about. Use Sorted's net work calculator to find out where you're at. Decide what you want your net worth to be in a year's time. Think about your cash and other assets and work out how you might get there. Monitoring and growing your net worth over time is the thing that will eventually get you to retirement in good shape. [energetic music] Budgeting is another one of those, I can't believe I didn't do something so basic, type of things. Do a budget. Stick to it and you're in control. There are two approaches to budgeting. The first is what we call cold turkey. Each time you get paid, you work out what you need to pay for all your essentials. Use Sorted's budget calculator to do this. You then take the rest and put it straight into savings. Going cold turkey on all those other things that you usually throw your money away on. Be realistic with your savings. Don't be too hard on yourself as it could take time for you to get into the saving habit. But if you remove the temptation to spend, you'll improve your financial position each month. If that seems a bit rigorous, try the alternative nip and tick approach. Do a budget using Sorted's budget calculator and then take a hard look at where your money's going. We're prepared to bet there's a nip here and a tuck there that will result in savings and every month you save, you increase your net worth. So go to it. ChatGPT What are the three important skills needed to achieve your financial goals? A) Budgeting, investing, and saving B) Setting realistic goals, knowing your net worth, and budgeting C) Planning, tracking, and monitoring How can you make a big goal more achievable? A) By dreaming about it often B) By breaking it down into a series of mini goals C) By setting a longer time frame What is net worth? A) The amount of money you have in savings B) The value of everything you own minus what you owe C) The amount of money you earn each year What are the two approaches to budgeting mentioned in the transcript? A) Cold turkey and warm turkey B) Nip and tuck and cold turkey C) Nip and tick and warm turkey How can you increase your net worth every month? A) By dreaming about your financial goals B) By sticking to a budget and removing the temptation to spend C) By investing in high-risk stocks

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