CLASSIFICATIONS OF DRUGS

DRUGS AFFECTING THE CENTRAL AND AUTONOMIC SYSTEM

Cholinergic Agents (Parasympathomemitics ) Prototype : - synthetic acetylcholine, pilocarpine, carbachol, bethanecol (Urocholine), edrophonium (Tensilon), neostigmine (Prostigmine), pyridostigmine (Mestinon).

Mechanism of action : - stimulates cholinergic receptors by mimicking acetylcholine or inhibition of enzyme cholinesterase.

Indications : - glaucoma, urine retention, Myasthenia Gravis - antidote to neuromuscular blocking agents : tricyclic antidepressants and atropine

Adverse effects : - blurring of vision, miosis - increase in salivation, intestinal cramps - bronchoconstriction, wheezing, DOB -hypotension and bradycardia Nursing considerations : 1. Warn & monitor clients of the side effects. 2. Have atropine available for use as antidote.

Cholinergic Blocking Agents (Parasympatholytics, Anticholinergics) Prototype : atropine, scopalamine (Triptone), dicyclomine (Bentyl), propantheline (Pro-Banthine).

Mechanism of actions : block the binding of acetylcholine in the receptors of parasympathetic nerves.

Indications : - use preoperatively to dry up secretions. - treat spasticity of GI or urinary tract. - use for treatment of bradycardia, asthma, parkinsonism. - use for antidote in organophosphate poisoning. Adverse effects : - dry mouth , dilatation of pupils, tachycardia - urinary retention, ileus, heat stroke Nursing considerations : 1. Keep clients in cool environment. 2. Watch out for signs of heatstroke and dehydration. 3. Encourage clients to increase fluid intake and use of sugarless gum/candy for dry mouth. 4. For GI spasticity, administer 30 minutes before meals and at bed time.

Adrenergic Agents(Sympa thomimetics ) Prototype : - epinephrine, norepinephrine, ephedrine, dopamine, dobutamine, phenylephrine, terbutaline, albuterol, isoproterenol.

Mechanism of actions: - stimulate alpha and beta adrenergic receptor directly or trigger the release of catecholamines indirectly causing sympathetic effects.

Indications: - cardiopulmonary arrest, hypotension - COPD and asthma, nasal congestions - allergic reaction, anaphylactic shock

Adverse effects: - restlessness, insomnia, tremors, nausea - palpitations, angina, tachycardia, HPN

Nursing considerations: 1. Contraindicated in clients w/ hyperthyroidism, pheochromocytoma & cardiovascular disease. 2. Monitor vital signs and advice precautions. 3. Should be taken with food.

ADRENERGIC BLOCKING AGENTS Prototype : a. Alpha blockers - phentolamine (Regintine), phenoxybenzamine, prazosin (Minipress), reserpine (Serpasil), terazosin (Hytrin) - clonidine (Catapress), methyldopa (Aldomet) b. Beta blockers - atenolol (Tenormin), esmolol (Brevibloc), metoprolol (Lopressor), nadolol (Corgard), propanolol (Inderal), timolol ( Blocadren)

Mechanism of actions :

a. alpha blockers - inhibits action of a-receptors in vascular smooth muscle to cause vasodilatation. b. beta blockers - compete with epinephrine in b-receptors in heart, pulmonary airways, peripheral circulation and CNS. Indications : - Raynauds disease, hypertension, pheochromocytoma. - angina, arrhythmias, mitral valve prolapse, glaucoma Adverse effects : - orthostatic hypotension, bradycardia, CHF - depression, insomnia and vertigo - bronchospasm and dyspnea, nasal stuffiness, cold extremities Nursing considerations : 1. Administer oral alpha-blockers with milk to minimize GI side effects. 2. Administer oral beta-blockers before meals and at a.m. if insomnia occurs. 3. Check clients apical pulse rate before drug administration, refer if below 60 bpm. 4. Hypotensive precautions. 5. Warn clients not to drive or operate dangerous machinery until he/she has adjusted to medications Skeletal Muscle Relaxants Agents Prototype : methacarbamol (Robaxin), baclofen (Lioresal), dantrolene

(Dantrium), metaxalone (Skelaxin), orphanedrine (Norgesic), chlorzoxazone

Mechanism of actions: - depress CNS - inhibit calcium ion release in the muscle - enhance the inhibitory action of GABA (gamma-amino butyric acid) Indications : - for acute musculoskeletal pain - for muscle spasticity associated with multiple sclerosis, cerebral palsy, CVA, and spinal cord injury. Adverse effects : - hypotonia, ataxia, hypotension, drowsiness - blurred vision, bradycardia, depression, urine retention Nursing considerations : 1. Caution clients that mental alertness may be impaired. 2. Monitor neuromuscular status, bowel and bladder functions. 3. Inform clients that maximum benefit of baclofen is attained for 1-2 months. 4. Reduce baclofen dosage gradually because of associated withdrawal symptoms : Confusion, hallucinations, paranoia & rebound spasticity. ANTICONVULSANTS Prototype : a. Hydantoins - phenytoin (Dilantin) b. Barbiturates - phenobarbital ( Luminal) c. Miscellaneous - carbamazepine (Tegretol), diazepam, clorazepate (Tranxene), valproic acid (Dapakene), ethosuximide (Zarontin). Mechanism of action : treat seizures by depressing abnormal neuronal activity in motor

cortex.

Adverse effects : - sedation & drowsiness, gingival hyperplasia - diplopia, nystagmus, vertigo, dizziness - thrombocytopenia, aplastic anemia Nursing considerations: 1. Advise female clients to use contraceptives. 2. Inform clients taking phenytoin that harmless urine discoloration is common. 3. Warn clients with diabetes that hydantoins may increase blood sugar level and that valproic acid may produce a false positive result in urine ketone test. 4. Teach clients receiving carbamazepine to identify symptoms of bone marrow depressions. 5. Reassure that barbiturates are not addictive at a low dosage. 6. Avoid taking alcohol with barbiturates. 7. Administer IV phenytoin slowly to avoid cardiotoxicity. 8. Avoid mixing other drugs in same syringe with phenytoin.

ANTIPARKINSONIAN AGENTS Prototype : a. Anticholinergic agents - trihexyphenidyl (Artane), benztropine (Congentin) b. Dopaminergic agents - Levodopa, carbidopa-levodopa (Sinemet), amantidine (Symmetrel), pergolide (Permax), selegiline (Eldepryl), bromocriptine. Mechanism of actions : a. anticholinergic agents - inhibit cerebral motor centers. b. dopaminergic agents - increasing dopamine concentrations or

enhancing neurotransmitter functioning. Adverse effects of dopaminergic agents: a. levodopa nausea, vomiting, anorexia, orthostatic hypotension, dark-colored urine and sweat b. amantidine ankle edema, constipation c. bromocriptine palpitations, tachycardia Nursing considerations : 1. Give dopaminergic agents after meals to reduce GI symptoms. 2. Reassure client that levodopa may cause harmless darkening of urine and sweat. 3. Avoid taking Vit B6 (pyridoxine) with levodopa because it speed up metabolism. 4. Educate clients to minimize orthostatic hypotension. 5. Elevate leg to reduce ankle edema.

CENTRAL NERVOUS SYSTEM STIMULANTS Prototype : - amphetamines, methylphenidate (Ritalin) Mechanism of actions : - increase excitatory CNS neurotransmitter activity and blocks inhibitory impulses. Indications : - for obesity (amphetamines) - attention deficit hyperactivity disorders - narcolepsy - drug-induced respiratory depressions. Adverse effects : - nervousness, insomnia, restlessness - hypertension, tachycardia, headache anorexia, dry mouth.

Nursing considerations : 1. Should be given at morning. 2. Dont stop amphetamine abruptly to avoid withdrawal symptoms. 3. Monitor blood pressure and pulse. 4. Ice chips or sugarless gum for dry mouth. 5. Watch out for growth retardation in children taking methylphenidate.

DRUGS AFFECTING MENTAL FUNCTIONING Sedatives, Hypnotics, and Anxiolytics Prototype : a. Benzodiazepines - diazepam (Valium), lorazipam (Ativan), alprazolam (Xanax), flurazepam (Dalmane) b. Barbiturates - amobarbital, phenobarbital, secobarbital c. Miscellaneous - chloral hydrate (Noctec), buspirone (Buspar), paraldehyde (Paral) Mechanism of actions : a. Benzodiazepines - increase the effect of inhibitory neuro transmitter GABA (gamma-amino butyric acid) b. Barbiturates and Miscellaneous agents - depress CNS Indications : - induce sleep, sedate and calm clients Adverse effects : - hangover-effect, dizziness, CNS depression - respiratory depression, drug-dependence

Nursing considerations : 1. Warn clients of injuries and falls. 2. Brief period of confusion and excitement upon waking up is common with benzodiazepines. 3. Warn clients not to discontinue medications abruptly without consulting a physician. 4. Avoid alcohol while taking these drugs. 6. Rotate and dont shake the ampules of barbiturates. Dont mix with other drugs. 7. Warn female clients that diazepam is associated with cleft lip.

ANTIDEPRESSANTS AND MOOD DISORDER DRUGS Prototype : a. Tricyclic antidepressants - amitriptyline (Elavil), protriptyline (Vivactil), - imipramine (Tofranil), desipramine b. MAO (monoamine oxidase inhibitors ) - isocarboxazid (Marplan), phenelzine (Nardil), tranylcypromine (Pernate) c. Second-generation antidepressants - fluoxetine (Prozac), trazodone (Desyrel) d. Lithium Mechanism of actions : a. Tricyclic antidepressants - increase receptor sensitivity to serotonin and/or norepinephrine. b. MAO inhibitors - inhibit the enzyme MAO that metabolize the neurotransmitters norepinephrine and serotonin. c. Second generation antidepressants

- inhibits the reuptake of serotonin. d. Lithium - increase serotonin & norepinephrine uptake Adverse effects : - dry mouth, blurred vision, urine retention, constipation (anticholinergic effects) - orthostatic hypotension, insomnia - hypertensive crisis (MAO) - dehydration (Lithium). Nursing considerations : 1. Caution client to rise slowly to reduce the effects of orthostatic hypotension. 2. Take antidepressant with food to enhance absorption 3. Explain to client that full response may take several weeks (2 weeks). 4. Assess client for constipation resulting from tricyclic antidepressant use. 5. Client taking MAO inhibitors should avoid tyramine-rich foods to avoid hypertensive crisis. - aged cheese, sour cream, yogurt, beer, wine, chocolate, soy sauce and yeast - pentholamine (Regintine) is the drug of choice for hypertensive crisis. 6. Inform physician and withhold fluoxetine if client develop rashes. 7. Take lithium with food to reduce GI effects - > 1.5 mEq/L blood level may cause toxicity manifested by: confusion, lethargy, seizures,hyperreflexia. - maintain salt and adequate fluid intake - tremors may occur but it is temporary - monitor white blood cell count (increase).

ANTIPSYCHOTIC DRUGS (NEUROLEPTICS) Prototype : a. Phenothiazines - chlorpromazine (Thorazine), - trifluoperazine (Stelazine), - thioridazine (Mellaril) b. Other Agents - clozapine (Clozaril), haloperidol (Haldol) Mechanism of action : block dopamine receptor in the limbic system, hypothalamus, and

other regions of the brain. Adverse effects : and an irreversible tardive dyskinesia as manifested by : a. lip smacking b. fine wormlike tongue movement c. involuntary movements of arms and leg. - Neuroleptic malignant syndrome a. fever, tachycardia, tachypnea, diaphoresis, cardiovascular collapse b. muscle rigidity, seizures. - orthostatic hypotension Nursing considerations : 1. Teach family members the signs of EPS and NMS, and report to physician immediately. 2. Normalization of symptoms may not occur for several weeks after beginning of therapy . 3. Avoid administering haloperidol intravenously 4. Watch out of neutropenia with clozapine. 5. Watch out for orthostatic hypotension and photosensitivity with Extra pyramidal symptoms such as dystonia, pseudoparkinsonism,

phenothiazine. 6. Be sure that oral doses are swallowed, and not hoarded.

DRUGS USED IN PAIN MANAGEMENT General Anesthetics Prototype : a. Inhalation anesthetics - enflurane (Ethrane), halothane - isoflurane (Forane), nitrous oxide b. Injection anesthetics - fentanyl (Sublimaze), ketamine (Ketalar), thiopental Na (Penthotal), etomidate (Amidate) Mechanism of actions : - cause CNS depression, by producing loss of consciousness, unresponsiveness to pain stimuli, and muscle relaxation. Nursing considerations : 1. Instruct client NPO for 8 hours before administration. 2. Monitor cardio pulmonary depression and hypotension. 3. Monitor urinary retention. 4. Monitor body temperature - malignant hyperthermic crisis : dantrolene (antidote) 5. Avoid alcohol or CNS depressants for 24 hours after anesthesia. 6. In patient who received halothane, monitor signs of hepatic fatal side effects : - rash, fever, nausea, vomiting - jaundice and altered liver function

LOCAL AND TOPICAL ANESTHETIC

Prototype : local : bupivacaine, lidocaine, tetracaine, procaine, mepivacaine, prilocaine topical : benzocaine, butacaine, dibucaine,lignocaine Mechanism of action : - block transmission of impulses across nerve cell membrane. Adverse effects : - cardiac dysrhythmias Nursing considerations : - lignocaine + prilocaine (EMLA cream) should be applied topically 60 minutes before procedure. - administer cautiously to the areas of large broken skin. - observe for fetal bradycardia in pregnant clients. ANALGESICS Prototype : a. Narcotic analgesics - codeine, meperidine (Demerol) morphine, butorphanol (Stadol) nalbuphine (Nubain) b. Non narcotic analgesic NSAIDs aspirin (aminosalicylic acid), mefenamic acid (Ponstan), ibuprofen (Motrin), naproxen, ketoprofen (Orudis), ketorolac. paracetamol and acetaminophen (Tylenol) Mechanism of actions : a. Narcotic analgesics - alter pain perception by binding to opiod receptors in CNS. b. Non- narcotic analgesic - relieves pain and fever by inhibiting the prostaglandin pathway.

Nursing considerations : 1. Monitor respiratory depression & hypotension in clients taking narcotic analgesic. 2. Injury and accident precautions in clients taking narcotic analgesic. 3. Warn clients about possibility of dependency,and do not discontinue narcotics abruptly in the narcotic-dependent clients. 4. Naloxone is antidote for narcotic overdose. 5. Advice clients to take NSAIDs with food and monitor bleeding complications. 6. Aspirin is contraindicated in clients below 18 years old with flu-like symptoms. 7. Monitor hearing loss in clients taking aspirin. 8. Monitor liver function in clients taking acetaminophen. 9. N-acetylcysteine is antidote for paracetamol overdose.