Actual Pharmacologic Management (Drug Study)

Drug # 1 Date Ordered: Dec. 09, 2010 Generic Name: esomeprazole magnesium Brand Name: Nexium Classification: Antiulcer drugs Dosage: 40 mg 1 tab OD P.O Mechanism of Action: Proton pump inhibitor that reduces gastric acid secretion and decreases gastric acidity. Indications:

Indicated to Gastroesophageal reflux disease (GERD) Healing erosive esophagitis Reduce the risk of gastric ulcers in patients receiving continuous NSAID therapy.

Contraindications: Contraindicated to patients hypersensitive to drug or components of esoprazole or omeprazole.

Patients receiving continuous NSAID therapy who are at increased risk for gastric ulcers include those age 60 and older or those with a history of gastric ulcers.

Adverse Reactions: CNS: headache GI: dry mouth, diarrhea, abdominal pain, nausea, flatulence, vomiting, constipation Nursing Responsibilities: Give drug at least 1 hour before meals. Antacids can be used while taking drug, unless otherwise directed by prescriber. Monitor patient for rash or signs and symptoms of hypersensitivity or worsening. Monitor GI symptoms for improvement or worsening. Instruct patient to take drug exactly as prescribed.

Health Teachings: Tell patient to take drug at least 1 hour before a meal. Advise patient that antacids can be used while taking drug unless otherwise directed by prescriber. Warn patient not to chew or crush drug pellets because this makes the drug ineffective. Tell patient to inform prescriber of worsening signs and symptoms or pain.

Rationale: To reduce gastric acid secretion.

Drug # 2 Date Ordered: Dec. 09, 2010 Generic Name: potassium chloride Brand Name: Kalium Durule Classification: Electrolytes and minerals Dosage: 1 tab tid x 6 doses Mechanism of Action: Supplemental potassium in the form of high potassium food or potassium chloride may be able to restore normal potassium levels. Indications:

For hypokalemia As prophylaxis during treatment with diuretics Indicated when potassium is depleted by severe vomiting, and prolonged dieresis

Contraindications:

Severe renal impairment Severe hemolytic reactions Acute dehydration Heat cramps Hyperkalemia Cautious use in: cardiac or renal disease; systematic acidosis

Adverse Reactions:

Renal insufficiency Hyperkalemia Nausea and Vomiting Irritability and Muscle Weakness Difficulty in swallowing

Nursing Responsibilities: Some patients find it difficult to swallow the large sized KCl tablet. Administer while patient is sitting up or standing (never in recumbent position) to prevent drug- induced esophagus. Dont crush sustained-release potassium products. Monitor ECG and electrolyte levels during therapy. Monitor for adverse effect that may reflect by perkalemia.

Health Teachings:

Tell patient to take with or after meals with full glass of water or fruit juice to lessen GI distress.

Teach patient signs and symptoms of hyperkalemia, and tell patient to notify prescriber if they occur.

Warn patient not to use salt substitutes concurrently, except with prescribers permission.

Rationale: To provide a direct replacement of potassium in the body.

Drug # 3 Date Ordered: Dec. 09, 2010 Generic Name: domperidone Brand Name: Motilium Classification: Antidiarrheal and Antiemetic Dosage: 10 mg 1 tab tid Mechanism of Action: Gastrointestinal emptying (delayed) adjunct; peristaltic stimulant: The gastroprokinetic properties of domperidone are related to its peripheral dopamine receptor blocking properties. Motilium facilitates gastric emptying and decreases small bowel transit time by increasing esophageal and gastric peristalsis and by lowering esophageal sphincter pressure. Antiemetic: The antiemetic properties of domperidone are related to its dopamine receptor blocking activity at both the chemoreceptor trigger zone and at the gastric level. Indication: For management of dyspepsia, heartburn, epigastric pain, nausea, and vomiting Contraindications: Known hypersensitivity to domperidone or any of the excipients Prolactin-releasing pituitary tumour (prolactinoma). Motilium should not be used when stimulation of the gastric motility could be harmful: Gastro-intestinal haemorrhage, mechanical obstruction or perforation.

Adverse Reactions: Immune System Disorder: Very rare; Allergic reaction Endocrine disorder: Rare; increased prolactin levels Nervous system disorders: Very rare; extrapyramidal side effects Gastrointestinal disorders: Rare; gastro-intestinal disorders, including very rare transient intestinal cramps Skin and subcutaneous tissue disorders:Very rare; urticaria Reproductive system and breast disorders: Rare; galactorrhoea, gynaecomastia, amenorrhoea Nursing Responsibilities:

If clinical symptoms dont improve within 48 hours, stop therapy and consider other alternatives.

Drug produces antidiarrheal action similar to that of diphenoxylate but without as many adverse CNS effects.

Know the patients sensitivity to domperidone before giving it.

Health Teachings: Advise patient not to exceed recommended dosage. Tell patient with acute diarrhea to stop drug and seek medical attention if no improvement occurs within 48 hours. In chronic diarrhea, tell patient to notify

prescriber and to stop drug if no improvement occurs after taking 16 mg daily for at least 10 days. Advise patient with acute colitis to stop drug immediately and notify prescriber about abdominal distention. Warn patient to avoid activities that require mental alertness until CNS effects of drug are known. Rationale: To increase the movements or contractions of the stomach and bowel. It is also used to treat nausea and vomiting.

Drug # 4 Date Ordered: Dec. 10, 2010 Generic Name: senna Brand Name: Senokot Forte Classification: Laxatives Dosage: 2 tabs bid x3 doses Mechanism of action: Unknown. Stimulant laxative that increases peristalsis, probably by direct effect on smooth muscle of the intestine. Its thought to either irritate the musculature or stimulate the colonic intramural plexus. Drug also promotes fluid accumulation in colon and small intestine. Indication: Acute constipation, preparation for bowel examination. Contraindications: Contraindicated in patients with ulcerative bowel lesions, fecal impaction, intestinal obstruction, intestinal perforation, or signs and symptoms of acute surgical abdomen, such as nausea, vomiting, and abdominal pain. Adverse reactions: GI: nausea, vomiting, diarrhea, loss of normal bowel function with excessive use, abdominal cramps, especially in severe constipation, malabsorption of nutrients,

yellow or yellow-green cast to feces, darkened pigmentation of rectal mucosa with long-term use, protein losing enteropathy.

GU: red-pink discoloration in alkaline urine, yellow-brown discoloration in acidic urine.

Metabolic: electrolyte imbalance such as hypokalemia. Other: laxative dependence with long-term or excessive use.

Nursing Responsibilities: Before giving drug for constipation, determine whether patient has adequate fluid intake, exercise and diet. Limit diet to clear liquids after X-prep liquid is taken. Avoid exposing product to excessive heat or light. Drug is for short-term use.

Health Teachings: Teach patient about dietary sources of bulk, including bran and other cereals, fresh fruit, and vegetables. Tell patient to report persistent or severe reactions.

Rationale: To stimulate peristalsis and increase intestinal motility.

Drug # 5 Date Ordered: Dec. 12, 2010 Generic Name: lactulose Brand Name: Duphalac Classification: Laxatives Dosage: 30 cc now Mechanism of Action: Produces an osmotic effect in colon; resulting distention promotes peristalsis. Also decreases ammonia, probably as a result of bacterial degradation, which lowers the pH of colon contents. Indication: Constipation Contraindications: Contraindicated in patients on a low galactose diet and in those with diabetes mellitus. Adverse Reactions: GI: abdominal cramps, belching, diarrhea, gaseous distention, flatulence, nausea, vomiting.

Nursing Responsibilities: To minimize sweet taste, dilute with water or fruit juice or give with food. Prepare enema by adding 200 g (300 ml) to 700 ml of water or normal saline solution. The diluted solution is given as retention enema for 30 to 60 minutes. Use a rectal balloon. If enema isnt retained for at least 30 minutes, be prepared to repeat dose. Monitor sodium level for hypernatremia, especially when giving to patients with hepatic encephalopathy. Monitor mental status and potassium level when giving to patients with hepatic encephalopathy. Be prepared to replace fluid loss.

Health Teachings: Show home care patient how to mix and use drug. Inform patient about adverse reactions and tell him to notify prescriber if reactions become bothersome or if diarrhea occurs. Instruct patient not to take other laxatives during lactulose therapy.

Rationale: To increase water content in colon and enhances peristalsis and for the breakdown of products in colon that lead to acidification of colonic contents, softening of feces, and decreased ammonia absorption from colon to systemic circulation.

Drug # 6 Date Ordered: Dec. 13, 2010 Generic Name: cefuroxime Brand Name: Zegen Classification: Antibiotic Cephalosporin ( 2nd generation) Dosage: 750 mg q8 IVTT Mechanism of Action: Cefuroxime is a bactericidal antibiotic, which exerts antibacterial activity by inhibition of bacterial cell wall synthesis in susceptible species. Cefuroxime has good stability to several bacterial beta-lactamase enzymes and, consequently, is active against many penicillin-resistant and amoxicillin-resistant strains of susceptible species. Indications:

 Lower respiratory tract infections caused by S. pneumoniae, S. aureus, E. coli, Klebsiella, H. influenzae, S. pyogenes Dermatologic infections caused by S. aureus, S. pyogenes, E. coli, Klebsiella, Enterobacter UTIs caused by E. coli, Klebsiella Uncomplicated and disseminated gonorrhea caused by N. gonorrhoea Septicemia caused by S. pneumoniae, S. aureus, E. coli, Klebsiella, H. influenzae Meningitis caused by S. pneumoniae, H. influenzae, S. aureus, N. meningitidis Bone and joint infections caused by S. aureus
Perioperative prophylaxis

Contraindications: Allergy to cephalosporins or penicillins Renal failure Adverse Reactions:

CNS: Headache, dizziness, lethargy, paresthesias GI:

Nausea,

vomiting,

diarrhea,

anorexia,

abdominal

pain,

flatulence,

pseudomembranous colitis, liver toxicity

Hematologic: Bone marrow depression: decreased WBC, decreased platelets,

decreased Hct
GU: Nephrotoxicity

 Hypersensitivity: Ranging from rash to fever to anaphylaxis, serum sickness

reaction
Local: Pain, abscess at injection site; phlebitis, inflammation at IV site Other: Superinfections, disulfiram-like reaction with alcohol

Nursing Responsibilities: Assess for history of hepatic and renal impairment Observe the 12 rights when administering the drug Have vitamin K available in case hypoprothrombinemia occurs Discontinue if hypersensitivity occurs Observe for adverse reactions Do not mix with aminoglycosides Inject slowly over 3-5min

Health Teachings: Avoid alcohol while taking this drug and 3 days after because severe reactions often occurs May experience side effects Report diarrhea, difficulty in breathing, unusual tiredness or fatigue, pain at injection site Rationale: To treat the existing acute infection.

Drug # 7 Date Ordered: Dec. 13, 2010 Generic Name: metronidazole Brand Name: Rosex Classification: Amebicide; Antibacterial; Antibiotic; Antiprotozoal Dosage: 500mg q8 IVF @ am Mechanism of Action: Metronidazole exerts rapid bactericidal effects against anaerobic bacteria. It inhibits DNA synthesis, causing cell death. Indications:

 Acute infection with susceptible anaerobic bacteria Acute intestinal amebiasis Amebic liver abscess Trichomonias ( acute and partners of patients with acute infection) Bacterial vaginosis Preoperative, intraoperative, postoperative prophylaxis for patients undergoing colorectal surgery Prophylaxis for patients undergoing abdominal surgery Contraindications: Hypersensitivity to metronidazole Used cautiously with CNS, hepatic diseases, candidiasis, blood dyscrasias Adverse Reactions:
CNS: Headache, dizziness, ataxia, vertigo, incoordination, insomnia, seizures,

peripheral neuropathy, fatigue

GI : unpleasant metallic taste, anorexia, nausea, vomiting, diarrhea, GI upset,

cramps
GU:dysuria, incontinence, darkening of the urine Local: thrombophlebitis Other: Superinfections , disulfiram-like reaction with alcohol

Nursing Responsibilities:

 Assess for history of CNS or hepatic disease, candidiasis, blood dyscrasias Reduce dosage with hepatic disease Observe the 12 rights when administering the drug Discontinue if hypersensitivity occurs Observe for adverse reactions Do not refrigerate neutralized solution Do not administer solution that has not been neutralized Infuse over 1hr Discontinue other solutions while running metronidazole Protect medication from sunlight

Health Teachings: Take full course of drug therapy Avoid alcohol while taking this drug and 3 days after because severe reactions often occurs May experience side effects Expect dark colored urine Report severe GI upset, dizziness, unusual fatigue or weakness, fever, chills

Rationale: To treat the existing acute infection.

Drug # 8 Date Ordered: Dec. 13, 2010 Generic Name: diclofenac sodium Brand Name: Voltaren Classification: Analgesic (non-opioid); Antiinflammatory (NSAID); Antipyretic Dosage: 20cc/hr IV Mechanism of Action: Inhibits prostaglandin synthetase to cause antipyretic and antiinflammatory effects; the exact mechanism of action is not known. Indications:

Acute or long-term treatment of mild to moderate pain Rheumatoid arthritis Osteoarthritis Ankylating spondylitis Contraindications:

Contraindicated in the presence of significant renal impairment, and allergies to NSAIDs

Use caution in the presence of impaired hearing, allergies, hepatic, cardiovascular, and GI conditions and in elderly patients

Adverse Reactions:

CNS: Headache, dizziness, somnolence, insomnia, fatigue, tiredness, dizziness, tinnitus, ophthamologic effects

GI: Nausea, dyspepsia, GI pain, vomiting, constipation, flatulence, diarrhea, GI bleed

Hematologic: Bleeding, platelet inhibition with higher doses GU: Dysuria, renal impairment Dermatologic: Rash, pruritus, sweating, dry mucous membranes, stomatitis Other: Peripheral edema, anaphylactoid reactions to fatal anaphylactic shock

Nursing Responsibilities: Assess for history of hepatic and renal impairment, CV and GI conditions, impaired hearing Observe the 12 rights when administering the drug Administer drug with food Institute emergency procedures if overdose occurs Observe for adverse reactions Monitor with use of anticoagulants ( increased risk of bleeding)

Health Teachings: Take drug with food Take only the prescribed dosage May experience side effects
Report sore throat, fever, rash, itching, weight gain, swelling in ankles or fingers,

changes in vision, black, tarry stools Rationale: This drug is given to alleviate the pain perceived and experienced.

Drug # 9 Date Ordered: Dec. 13, 2010 Generic Name: omeprazole Brand Name: Omepron

Classification: Antisecretory drug; Proton pump inhibitor Dosage: 40mg IVTT OD Mechanism of Action: Gastric acid pump inhibitor: Suppresses gastric acid secretion by specific inhibition of the hydrogen-potassium ATPase enzyme system at the secretory surface of the gastric parietal cells; blocks the spinal step of acid production Indications: Short-term treatment of active duodenal ulcer Treatment of heartburn or symptoms of GERD Short-term treatment of active benign gastric ulcer GERD Eradication of H. Pylori Reduction of risk of upper GI bleeding in critically ill patients Contraindications: Hypersensitivity to omeprazole or its components

Adverse Reactions:

CNS: Headache, dizziness, asthenia, vertigo, insomnia, apathy, anxiety, paresthesia, dream abnormalities

GI: Nausea, vomiting, constipation, diarrhea, abdominal pain, dry mouth, tongue atrophy

Dermatologic: Rash, inflammation, urticaria, pruritus, alopecia, dry skin Respiratory : cough, epistaxis Other: back pain, fever Nursing Responsibilities: Assess for hypersensitivity to omeprazole or its components Observe the 12 rights when administering the drug
Administer with antacids if needed administer before meals

Observe for adverse reactions Health Teachings:

Take drug before meals and take only the prescribed dosage May experience side effects and report severe headache, worsening of

symptoms, fever, chills Rationale: This is given to suppress the gastric secretion and thus, reduce the pain perceived.

Drug # 10

Date Ordered: Dec. 13, 2010 Generic name: nalbuphine Brand name: Nubain Classification: Opioid agonist-antagonist analgesic Dosage: 5mg q6 x 12 doses IVTT Mechanism of Action: Nalbuphine acts as an agonist at specific opioid receptors in the CNS to produce analgesia and sedation. It inhibits the ascending pain pathways, altering the perception of and response to pain by binding to opiate receptors in the CNS but also acts to cause hallucinations and is an antagonist at mu receptors.

Indications: Relief to moderate to severe pain Preoperative analgesia, as a supplement to surgical anesthesia Prevention and treatment of intrathecal morphine-induced pruritus after CS Contraindications: Hypersensitivity to nalbuphine, sulfites Use cautiously with emotionally unstable patients or those with history of opioid abuse, bronchial asthma, COPD, respiratory depression, anoxia, increased ICP,acute MI

Adverse Reactions:

CNS: sedation, clamminess, sweating, headache, nervousness, restlessness, depression, crying, confusion, faintness, unusual dreams, hallucinations, dizziness, vertigo, floating feeling, feeling of heaviness, numbness, tingling, flushing, warmth, blurred vision

GI: Nausea, vomiting, cramps, dyspepsia, bitter taste dry mouth GU: urinary urgency Respiratory : respiratory depression, dyspnea, asthma

Nursing Responsibilities: Assess for hypersensitivity to nalbuphine, sulfites, emotional instability or history of opioid abuse, bronchial asthma, COPD, respiratory depression, anoxia, increased ICP, and MI Observe the 12 rights when administering the drug Taper dosage when discontinuing after prolonged use to avoid withdrawal symptoms Reassure patient about addiction liability Discontinue if hypersensitivity occurs Observe for adverse reactions Health Teachings: May experience side effects Avoid performing tasks that require alertness For loss of appetite, lying quietly and eating small frequent meals may help

 Report severe nausea, vomiting, palpitations, shortness of breath, or difficulty in breathing Rationale: It is given to alleviate the pain experienced by the patient.