PART 1.

REVIEW ON COMMON ABBREVIATIONS AND TERMINOLOGIES Abbreviations Abbreviations are widely used in writing directions for administration of medications and to perform activities. Standard abbreviations should be used. However, sometimes non-standard abbreviations are used and, as it is w/ any doctors order, it is the nurses responsibility to interpret correctly. Clarify an order if there is any question ABBREVIATIONS: medications administration route, time, medication dosage form, other abb.

Quiz 1. crosswise yellow paper. Write the abbreviation for each definition. 1. After meals ______ 2. As desired _______ 3. As needed _______ 4. At bedtime _______ 5. Before meals _____ 6. By mouth ______ 7. Every ____ 8. Everday _______ 9. Every hour ______ 10. Every other day ___ 11. Four times a day ___ 12. If necessary _______ 13. Immediately _______ 14. Three times a day ___ 15. Twice a day ______

(cont) Write the meaning for each abbreviation. 1. cc _______ 2. cm ______ 3. dr _______ 4. Gm, g, gm ____ 5. gr _______ 6. gtt ______ 7. kg ______ 8. L ________ 9. mg ______ 10. mEq _____ 11. ml _______ 12. oz _______ 13. T, tbsp ____ 14. t, tsp _____ 15. ss __________

MEDICAL TERMINOLOGIES - language of the health care industry - derived from Greek & Latin words - roots, prefixes, & suffixes Root foundation of a medical term
ex. arthro = joint cardio = heart derm or dermato = skin gastro = stomach

cyano = bluish eosino = rosy erythro = red leuko = white melano = black xantho = yellow Prefixes word element or part that is added to the beginning of the word root ex. ante = before; forward hemi = half multi = many neo = new sub = under/below

Suffix word element or part that is added to the end of the word root - indicate whether the medical term is a noun or adjective ex. ac; -al; -ar; -ary = pertaining to; like -ic; -iac = pertaining to -oid = like; resembling -ectomy = surgical removal; excision -itis = inflammation of -megaly enlargement -pathy = disease

Quiz 1. Write the meaning of the listed word elements Part 1 1. arthro _____ 2. gastro _____ 3. ante ______ 4. multi _______ 5. -oid _______ 6. -ic _____ 7. -megaly _____ 8. -pathy _______

Combining Roots, Prefixes, & Suffixes - basic way to create medical terms 1. cardiogastric pertaining to the heart & stomach 2. gastromegaly enlargement of the stomach 3. gastrectomy surgical removal of the stomach 4. gastroenterology study of the stomach & intestines

Singular & Plural Words -a -ae papilla pappillae -en -ina lumen lumina -ex; -ix -ices apex apices -is -es diagnosis diagnoses -is -ides epididymis epididymides -nx -nges larynx larynges -on -a ganglion ganglia -us -i bronchus bronchi -us -era viscus viscera -us -ora corpus corpora

Quiz 1. Part II. Correctly combine each root with the suffix to form a medical term. You must decide whether or not to use the combining form Example: ROOT SUFFIX TERM arthro -megaly arthromegaly ROOT SUFFIX TERM 1. arthro -itis ________________ 2. arthro -ectomy ________________ 3. arthro -pathy ________________ 4. dermato -itis ________________ 5. dermato -pathy ________________ 6. gastro -ic ________________ 7. gastro -ectomy ________________

Quiz 1. Part III. Write the plural form for the ff singular terms: 1. ampulla 2. fornix 3. foramen 4. ovum 5. phalanx 6. testis 7. thrombus

Working with Roots, Prefixes, & Suffixes

ROOT arthro cardio gastro hepato osteo MEANING PREFIX MEANING joint epiabove, upon heart hemihalf stomach hypobelow;deficient liver periaround bone polymany

SUFFIX -algia -itis -megaly -pathy -plasty

MEANING pain inflammation enlarged disease repair

Example: ROOT: PREFIX: SUFFIX: DEFINITION:

hemigastrectomy gastro hemi = half ectomy = surgical removal surgical removal of half the stomach

Building Medical Terms Example: DEFINITION: inflammation of joints BODY PART: joints ROOT: arthr/o SUFFIX: -itis PREFIX: none MEDICAL TERM: arthritis

Exercise:
DEFINITION: BODY PART: ROOT: SUFFIX: PREFIX: MEDICAL TERM: disease of the heart

PART II. REVIEW ON MEASUREMENTS & CONVERSIONS Metric System -common system of drug measurement -Liter, ml, or cc for liquid volume -cc is a common measurement of vol. that is equivalent to 1 ml of fluid -metric wt of a drug is stated in terms of kilograms (kg), grams, mg, or mcg -based on the decimal system

-units of measure are the gram (weight), the liter (volume), & the meter (length or ht.) -based on units of 10 by dividing or multiplying

Ex. To change mg to gm, or ml to L, divide the number by 1,000: 250 mg = x g (move decimal pt 3 places to the left) x = 0.25 g or 500 ml = x L = 0.5 L To convert gm to mg or L to ml, multiply the number by 1,000: 0.005 g = x mg (move dp 3 places to the right) x = 5mg or 0.725 L = x ml x = 725 ml

Apothecary & Household Systems -originated in England is based on the wt of 1 gr of wheat -older systems of measurement -uses the minim (size of a drop of water), fl. dr, fl. oz, pint, qt, & gal as the basic unit of liquid measure & the gr, lb, oz, dr as the basic unit of solid measure -this system is much harder to use than the metric system & is rarely seen in most clinical settings -uses Roman numeral; ex. 15 grains gr xv

Household System -least accurate of 3 systems -this system uses the teaspoon as the basic unit of fluid measure, others: gtt, tsp, tbsp, cup & glass -pound as the basic unit of solid measure - in this system, 1 lb is equal to 16 ounces -household units for liquids are tsp & tbsp - accurate medical dosing devices: calibrated oral dosing

Avoirdupois System -another older system that was very popular when pharmacists routinely had to compound medications on their own -uses ounces & grains, but measures differenlty than those of the apothecary & household systems -seldom used by prescribers but may be used for bulk medications that come directly from the manufacturer

Other units: unit reflects the biological activity of the drug in 1 mL of soln mEq used to measure electrolytes (K, Na, Cl, Ca, Fl) - refers to the ionic activity of the drug in question International units (IU) sometimes used to measure certain vitamins or enzymes - is unique because cannot be converted to another measuring form

PART III-1. INTRODUCTION TO NURSING PHARMACOLOGY INTRODUCTION TO DRUGS Drugs are chemicals that are introduced into the body to cause some sort of change. The nurse is in a unique position regarding drug therapy, because nursing responsibilities include the ff: Administering drug Assessing drug effects Intervening to make the drug regimen more tolerable Provide patient teaching about drugs and the drug regimen

Pharmacology derived from 2 Greek words, pharmakon, w/c means medicine,drug, and logos, w/c means study.
- is the study of the biological effects of chemicals (WHO) Drug is any substance or product that is used or intended to be used to modify or explore physiological system or pathological states for the benefit of the recipient.

Nurses deal with pharmacotherapeutics, or clinical pharmacology, the branch of pharmacology that uses drugs to treat, prevent, and diagnose disease Clinical pharmacology addresses 2 key concerns: the drugs effects on the body and the bodys response to the drug Because a drug can have many effects, the nurse must know which ones may occur when a particular drug is administered. Some drug effects are therapeutic or helpful but others are undesirable or potentially dangerous. These negative effects are called adverse effects

Pharmacotherapeutics science of drug used

to treat various illnesses and the responses of the individual. Factors that prevent drug actions and the need to alter drug dosage will be studied latter. Clinical Pharmacology helps generate data for optimum use of drugs. It includes pharmacodynamic and pharmacokinetic study of drugs in healthy volunteers and in patients to evaluate the efficacy and safety of a given drug in comparison with other forms of treatment and its adverse effects.

Pharmacy science of compounding and

dispensing drugs and preparing suitable dosage forms for administration. It includes identification, collection, isolation, purification, synthesis, quality control and standardization of medicinal substances.

Pharmaceutics technological science of drug

manufacture in large scale

Chemotherapy is treatment of systemic

infections, and malignancy by use of specific chemical agents (chemotherapeutic agents) that have selective toxicity for the infecting organism or malignant cells with minimal adverse effect or no effect on the host cells. Drugs having only pharacodynamic effects on the recipient are designated as pharmacodynamic agents

Pharmacopoeia- an official code

containing selected list of established drugs and preparations with a description of their physical properties, purity, and potency. It defines standards that these preparations must meet and their average doses for an adult.

Toxicology study of adverse effects of both

chemotherapeutic agents and pharmacodynamic agents, since the same agent could be a drug or poison depending on dosage used. It also includes the study of poisonous effects of drugs and other chemicals with an emphasis on prevention, detection, and treatment of poisoning.

*The following formulations of drugs should not be crushed or chewed Enteric-coated tablets, w/c are designed to dissolve in intestine instead of stomach. Sustained-release forms w/ abbreviations such as Dur (duration), SR (sustainedrelease), CR (controlled or continuous release), SA (sustained action), LA (long acting), and Contin (Continuous-release). Trade names with twice daily abbreviation (bid). Ex. Theobid or Cardabid

Liquid-containing capsules meant for oral use. Scored tablets may be broken along the scored line but should not be crushed or chewed.

FORMS OF DRUG PREPARATIONS

SOURCES OF DRUGS Natural Sources Minerals: kaolin, magnesium trisilicate, magnesium sulfate, and liquid paraffin. Plant products: alkaloids, oils, glycosides, resins, gums, tannins, and antibacterial substances (ex. Chitosan): Ex. Reserpine, digitalis, digoxin, quinine, atropine, and morphine Animal products: used to replace human chemicals that are not produced because of disease or genetic problems : thyroid extracts, heparin, gonadotrophins, and insulin for treating diabetes was obtained from cow and pig

Products of Genetic Engineering - the process of altering DNA-permits science to produce human insulin by altering Escherichia coli bacteria, making insulin a better product without some of the impurities that come with animal products

Drugs by recombinant DNA technology are vaccines for viral hepatitis and rabies, hormones such as human insulin, human growth hormones, etc.

Inorganic Compounds salts of various elements have therapeutic effects in the human body
: aluminum, flouride, iron, gold Al antacid, hyperphosphatemia, prevention of the formation of phosphate urinary stones Fl prevention of dental cavities & osteoporosos Au tx of RA Fe tx of IDA - discovered accidentally when a cause-effect relationship was observed

Microorganisms: penicillin and other antibiotics Synthetic made artificially by chemical synthesis, esp. so as to resemble a natural product

Most of the drugs in present use are synthetic, e.g., corticosteroids, sulfonamides, aspirin, etc.

Drug evaluation

FDA ensure the safety and reliability of any

drug approved in this country. For every 100,000 chemicals that are identified as being potential drugs, only about 5 end up being marketed

Phases of Drug Development 1. Preclinical Trials chemicals that may have therapeutic value are tested on laboratory animals for 2 main purposes: - to determine whether they have the presumed effects in living tissue - evaluate any adverse effects - at the end of trial, some chemicals are discarded for the ff reasons: The chemical lacks therapeutic activity Too toxic Highly teratogenic Safety margins are small , not useful in clinical testing

2. Phase 1 studies use human volunteers to test the drugs - more tightly controlled and are performed by specially trained clinical investigators - volunteers are fully informed of possible risks and may be padi for their participation - chemicals are dropped from the process for the ff reasons: they lack therapeutic effect in humans Cause an unacceptable adverse effects Highly teratogenic Too toxic

3. Phase II studies allow clinical investigators to try the drug in patients who have the disease that the drug is meant to treat. - performed at various sites across the country in hospitals, clinics, & doctors offices and are monitored by representatives of the pharmaceutical company studying the drug - at the end of phase II, may be removed from further investigation for the ff reasons:

Less effective than anticipated Too toxic when used with patients Produces unacceptable adverse effects Low benefit-to-risk ratio, meaning that the therapeutic benefit it provides does not outweigh the risk of potential adverse effects that it causes Is no more effective than other drugs already on the market, making the cost of continuedresearch and productionless attractive to the drug company

4. Phase III Studies involve use of the drug in a vast clinical market - prescribers are informed of all the known reactions to the drug and precautions required for its safe use Food and Drug Administration Approval - drugs that finished phase III studies are evaluated by the FDA - drug that receive FDA committee approval may be marketed - the entire devt and approval process can take 5-6 yrs. Resulting in a so-called drug lag in US

5. Phase IV Study - After a drug is approved, it enters a phase of continual evaluation - Approved drug is given a brand name, generic, and chemical names DRUG NAMES: Drugs in general have 3 categories or nomenclatures: Chemical name is the one that describes the drug chemically. ex. L-thyroxine, T4

Generic name is the non-proprietary

name that is accepted by a competent scientific body. The generic name of newer drugs all over the world are uniform by an agreement through WHO

also called as approved name or official name.

Brand name (Proprietary name) is the name

adopted by the particular manufacturing company. That means a given drug can have many propriety names. ex. Crocin in India, Tylenol in USA Eltroxin, Levothyroid, Synthroid

ex. levothyroxine sodium

Pregnancy Categories As part of the standards for testing and safety, the FDA requires that each new drug be assigned to a pregnancy category. Category A: Adequate studies in pregnant women have not demonstrated a risk to the fetus in the first trimester of pregnancy, and there is no evidence of risk in later trimesters

Category B: Animal studies have not demonstrated a risk to the fetus but there are no adequate studies in pregnant women, or animal studies have shown an adverse effect, but adequate studies in pregnant women have not demonstrated a risk to the fetus during the first trimester of pregnancy, and there is no evidence of risk in later trimesters

Category C: animal studies have shown an adverse effect on the fetus but there are no adequate studies in humans; the benefits from the use of the drug in pregnant women may be acceptable despite its potential risks, or there are no animal reproduction studies and no adequate studies in humans Category D: There is evidence of human fetal risk, but the potential benefits from the use of the drug in pregnant women may be acceptable despite its potential risks

Category X: Studies in animals or humans demonstrate fetal abnormalities or adverse reaction; reports indicate evidence of fetal risk. The risk of use in pregnant women clearly outweighs any possible benefit *Regardless of the designated pregnancy category or presumed safety, no drug should be administered during pregnancy unless it is clearly needed

Controlled Substances controlled substances drugs with abuse potential eg., heroin, marijuana, LSD, narcotics, amphetamines, barbiturates FDA studies the drugs and determines their abuse potential PDEA enforces their control Generic Drugs - are chemicals that are produced by companies that just manufacture drugs *why cheap? Because they do not have the research, the advertising, or sometimes, the quality control departments that pharmaceutical companies have

*the difference? Bioavailability of the drug - some prescribers however, specify that a drug prescription be dispensed as written (DAW) that is, the brand-name product be used - the prescriber ensures the quality control and bioavailability expected with that drug - may be most important in drugs that have narrow safety margins such as Digoxin (Lanoxin), a heart drug and Warfarin (Coumadin), an anticoagulant - the initial cost may be higher but some prescribers believe that, in the long run, the cost to the patient will be less

Orphan Drugs -are drugs that have been discovered but are not financially viable and therefore have not been adopted by any drug company OTC Drugs -are products that are available without prescription for self-treatment of a variety of complaints Disadvantages: Could mask the s/s underlying dse, making dx difficult Taking these drugs with prescription medications could result in drug interactions & interfere with drug therapy Serious overdoses

Sources of Drug Information Drug doses Therapeutic and adverse effects Nursing-related implications Package Inserts chemical & study info Reference books

PDR is a compilation of the package insert info from drugs Drug Facts & Comparisons - provides a wide range of info AMA Drug Evaluations contain detailed monographs

 Lippincotts Nursing Drug Guide (LNDG) has drug monographs Journals Medical Letter monthly review of new drugs, drug classes, & specific tx protocols Internet Information

PART III A. DRUGS AND THE BODY

Pharmacodynamics therapeutic effect or action (physiologic and biochemical effects) of drugs and their mechanism of action at molecular, cellular, and organ system levels. A drug can bring about physical or chemical change in the cell environment. Ex. 1. stool softeners that act by altering surface tension, and osmotic diuretics that alter osmosis.

Cell functions and process may be altered by drug interaction with drug receptors. Ex. Glucose transfer into cell is facilitated by insulin.

Agonist - Drug binding to receptor

that brings about pharmacological action Antagonist prohibits pharmacological action

Drug Mode of Action Certain drugs work by interacting with receptors, special sites on the surface of body cells. Drugs may bind to a specific receptor, possibly preventing naturally occurring chemicals from binding to the receptor. In so doing, if a drug enhances cell activity, it is called an agonist; if it blocks cell activity, it is called an antagonist. Microsoft Encarta 2009. 1993-2008 Microsoft Corporation. All rights reserved.

Local & systemic (ex. Xylocaine plus

epinephrine given SC) an agent given for its local effect but produces a systemic effect also. Drug effect could be local (ex. Topical application of acyclovir for herpes simplex viral infection) that acts at the site of application Systemic affects more than one part of the body (ex. Novalgin given IM for pain at a distant place

Herpes Simplex Blisters Around Mouth Region One strain of the herpes simplex virus causes cold sores (also known as fever blisters) in and around the mouth, lips, pharynx, nose, face, and ears. The causative agent remains in the cell bodies of facial nerves, causing repeated attacks of the blisters. No established therapy, beyond topical lotions for pain relief, has been developed. Encarta Encyclopedia John Watney/Science Source/Photo Researchers, Inc. Microsoft Encarta 2009. 1993-2008

Pharmacokinetics study of how drugs are Absorbed, Distributed, Metabolized and excreted (ADME) from the body.

Absorption refer to what happens to a drug from the time it is introduced to the body until it reaches the circulating fluids & tissues

Ex. Digoxin is absorbed orally to an extent of 80%, transported through the blood where 25% of it is bound to plasma proteins, distributed widely into all tissues with its effect localized in the heart muscle, only a small fraction is metabolized to its inactive form in the liver, most of it is excreted by kidney in unchanged form, and it has plasma half time (t ) of about 40 hrs.

ROUTES OF ADMINISTRATION There are many ways to administer drugs, and each method depends on the drug formulation, the expected action of the drug, and other clinically determined criteria. The most common methods of drug administration are oral and parenteral, w/c includes subcutaneous, intramuscular, and intravenous injections. Other methods include topical application to the skin or mucous membrane, inhalation into the respiratory tract, intra-articular injection into a joint activity, and intrathecal injection into the spinal column. Some drugs are also administered by rectum, by vagina, in the buccal pouch, and under the tongue

ORAL ADMINISTRATION -most commonly used route -convenient and simple, easy, safe, economical -sometimes crushed or dispensed in liquid form -may be swallowed or given by nasogastric or gastrostomy tube - (-) slow absorption, may be destroyed by digestive juices

Buccal -absorbed relatively slowly from the mucous membranes of the mouth -placed in the cheek next to the molars in either the upper or the lower jaw -troches and lozenges are forms -intended use is usually for local rather than systemic effect

Sublingual -small tablets that dissolve quickly under the tongue; absorbed through the mucous membranes of the mouth -are not to be chewed or swallowed and must be allowed to dissolve completely before the patient eats or drinks ex. NTG, Felpin (anti-hpn drug)

Rectal -inserted into the rectum -slow, irregular absorption Nasogastric -delivered through a tube placed through the nose & into the stomach -slow absorption; may be destroyed by digestive juices

PARENTERAL ADMINISTRATION -any route of drug administration that bypasses the gastrointestinal tract Intramuscular -made into a muscle tissue -most frequently used sites: large muscle masses such as vastus lateralis in the anterior thigh, gluteus maximus & gluteus medius in the buttocks & hip, & the deltoid in the upper arm -drugs are readily and rapidly absorbed from IM sites because muscles have a good blood supply ex. Antibiotics Sites: ventrogluteal, dorsogluteal, vastus lateralis, rectus femoris, deltoid site

Subcutaneuos Injection -made into the subcutaneous tissue or the fatty layer of the skin, just below the dermis -common sites are the outer aspect of the upper arm, the anterior thigh, & the abdomen -absorbed more slowly from these sites than from IM sites because they contain a lesser blood supply -ex. Insulin, hormones, local anesthetic Sites: Outer aspect of outer arm, Anterionr aspect of the thigh, abdomen, and scapular areas, Ventrogluteal areas, Dorsogluteal areas

Intravenous Injection -injected directly into a vein -action of drugs is very rapid, usually within minutes -ex. Antibiotics, blood
Intradermal -injection into the dermis of the skin -ex. Vaccinations, tuberculosis & allergy tests

Transdermal -through the skin; continuous administration via patch or disk -hormones, NTG patch Inhalation -applied topically but are absorbed for a systemic effect -taken into the nose or mouth; inhaled through face masks, nasal catheters, nebulizers, & positivepressure breathing machines; absorbed into the bloodstream through the lungs -ex. Asthma & anesthesia meds

TOPICAL ADMINISTRATION -used primarily for a local effect but because the medication is applied to the skin or mucous membrane, the drug may be absorbed and have a systemic effect. -may be in the form of creams, foams, gels, pastes, ointments, solutions, sprays & suppositories to the skin or to the mucous membranes lining the respiratory tract, vagina, rectum, or urethra -eyedrops & eardrops are drugs given topically by the ophthalmic and ottic routes

INTRA-ARTICULAR ADMINISTRATION -directly injected into a joint, usually by a physician -common ex: injection of the antiinflammatory agent cortisone into a knee or shoulder joint INTRATHECAL ADMINISTRATION -only specially trained nurses, such as nurse anesthetists & physicians administer drugs by this route directly into the spinal column -some drugs are injected into the subarachnoid space (w/c contains the CSF) & others are injected into epidural space of the spinal cord.

Forms of Medications Distribution involves the movement of a drug to the bodys tissues Factors that affect distribution:

tissues perfusion Hot/cold environment Drugs lipid solubility Protein-binding BBB Placenta & breast milk

Metabolism (biotransformation)

Liver Enzyme Systems for detoxification; hepatic cells are lined w/ enzymes - increased activity in an enzyme system speeds the metabolism of the drug
Excretion removal of a drug from the body kidneys (), saliva, lungs, feces glomerular filtration passage of water & water-soluble components from the plasma into the renal tubule considerations: kidney function & urine acidity

Half-Life - is the time it takes for the amount of drug in the body to decrease to of the peak level it previously achieved

Ex. If a pt. takes 20 mg of a drug w/ a half-life of 2 hrs., 10 mg of the drug will remain 2 hrs. after administration. 2 hrs. later, 5 mg will be left; in 2 more hrs., only 2.5 mg will remain Consideration: absorption rate, distribution to the tissues, speed of biotransformation, excretion of drug

Factors Influencing Drug Effects When administering a drug to a pt., the nurse must be aware that the human factor has a tremendous influence on what actually happens to a drug when it enters the body. Factors Affecting the Bodys Response to a Drug Weight 150 lb. Age children imature systems & older adults fewer plasma proteins & less efficient perfusion, altered biotransformation or metabolism because of liver changes w/ age, & less

 Gender men more vascular muscles - women more fat cells, poss. of pregnancy Physiological factors diurnal rhthym, electrolyte balance, acid-base balance, hydration Pathological factors dse, hepatic dysfunction, renal dysfunction, GI dysfunction, vascular disorders, low bp Genetic lack enzyme systems necessary for metabolizing a drug - overactive enzyme systems, breaking down drugs very quickly - differing metabolisms & enzymatic makeup

 Immunologic factors allergy after exposure to its proteins, can develop antibodies to a drug Psychological factors placebo effect, health beliefs, compliance - pts attitude about a drug has been shown to have a real effect on how that drug works Environmental factors temperature. Light, noise - some drug effects are helped by a quiet, cool, nonstimulating environment

 Drug tolerance because of increased biotransformation of the drug, increased resistance to its effects, or other pharmacokinetic factors - ex. Morphine Cumulative effects drug is taken in successive doses at intervals that are shorter than recommended or body not able to eliminate drug properly Drug-Drug interactions: At the site of absorption one drug prevents or accelerates absorption of the other drug - ex. Antibiotic tetracycline is not absorbed from the GI if there is a presence of Ca products

 During distribution one drug competes for the potein binding site of another drug, so the 2nd drug cannot be transported to the reactive tissue - ex. ASA competes with the drug methotrexate (Rheumatrex) for protein binding sites because ASA is more competitive for the sites, methotexate is bumped off resulting to increased toxicity to tissues During biotransformation one drug stimulates or blocks the metabolism of the other drug - Warfarin (coumadin) is biotransformed more quickly if it is taken at the same time as barbiturates, rifampin, etc. therefore higher doses will be needed

 During excretion one drug competes for excretion w/ the other drug, leading to accumulation & toxic effects of one of the drugs - ex. Digoxin (lanoxin) & quinidine (quinaglute) At the site of action one drug may be an antagonist of the other drug or may cause effects opposite of the other drug, leading to no therapeutic effect - ex. Anti-HPN drug taken w/ allergy drug that increases BP Drug-Food interactions ex. Antibiotic tetracycline cannot be taken w/ iron & Ca products

 Drug-Laboraroy test interactions some drugs may alter test results

- ex. Dalteparin (fragmin) may cause increased enzyme AST & ALT with no ijury to liver cells or hepatitis Hx, PA,

PART III-B. TOXIC EFFECTS OF DRUGS Adverse effects undesired effects - occur for many reasons: drug may have other effects on the body besides the therapeutic effect pt. sensitivity to drug drugs action on the body causes other responses that are undesirable too much or too little taking

Drug Allergy occurs when the body forms antibodies to a particular drug, causing an immune response when the person is re-exposed to the drug

4 classifications of drug allergy: Anaphylactic reaction Cytotoxic reaction Serum-sickness reaction Delayed allergic reaction

Drug-Induced tissue & organ damage Dermatologic reactions Assessment: hives, rash, severe: exfoliative dermatitis rash, scaling fever, enlarged lymph nodes, enlarged liver, potentially fatal erythema multiforme exudativum (StevensJohnson Syndrome) char. by dark red papules on extremities often in rings or disk-shaped patches Intervention: provide skin care, avoid rubbing, or tight rough clothing, harsh soaps, perfumed lotions, administer antihistamines. Topical corticosteroids, emollients as ordered

 Stomatitis ex. Fluorouracil (Adrucil) antineoplastic agent causes mouth sores Assessment: gingivitis, glossitis, dysphagia, bad breath, pain in mouth & throat Intervention: provide mouth care w/ nonirritating solution, tolerated diet, antifungals, local anesthetics as ordered

 Superinfections caused by the usually controlled organisms Assessment: fever, diarrhea, black or hairy tongue, glossitis, mucous membrane lesions, vaginal discharge w/ or w/o itching Intervention: frequent mouth care, skin care, small frequent meals, antifungal therapy, disc. Drug

 Blood dyscrasia bone marrow suppression caused by drug effects - occurs when drug that can cause cell death (antineoplastics, antibiotics) are used Assessment: fever, chills, sore throat, malaise, back pain, dark urine, dec. hct, (anemia), low platelet ct. (thrombocytopenia), low WBC ct. (leukopenia), pancytopenia Intervention: monitor bld. counts, provide rest, protect from infection,

 Toxicity - Liver injury Assessment: fever, malaise, n/v, jaundice, change in color of urine or stools, abd. pain or colic, inc. liver enzymes, changes in clotting factors (ex. PTT) Intervention: disc. Drug, notify physician, supportive measures (small frequent meal, skin care, cool envt, rest - Renal injury Gentamycin cuses renal tox A: elevated BUN, creatinine, dec. hct, electrolyte imbalances, fatigue, malaise, edema, irritability, skin rash

measures (diet, fluid restrictions, positioning, skin care, electrolyte therapy, rest, controlled envt)
- Poisoning occurs when an overdose of a drug damages multiple body systems
Alterations in glucose metabolism - Hypoglycemia Glipizide (glucotrol), glyburide (diabeta)

I: notify, disc. Drug, supportive

A: fatigue, drowsiness, hunger,

anxiety, h/a, cold clammy skin, shaking, lack of coordination, inc HR, BP, numbness, tingling of mouth, tongue, lips, confusion, rapid shallow respirations, seizure, coma I: restore glucose, skin care, envt control, rest

- Hyperglycemia ex. Ephedrine drug bronchodilator & antiasthma to relieve nasal congestion A: fatigue, polyuria, polydypsia, deep respirations (Kussmauls resp.), restessness, polyphagia, nausea, hot or flushed skin, fruity odor of breath I: insulin therapy controlled environment, mouth care

 Electrolyte imbalances - Hypokalemia loop diuretics A: serum K conc <3.5 mEq/L, weakness, numbness & tingling in the extremities, muscle cramps, NVD, dec bowel sounds, irregular pulse, weal pulse, orthostatic hpn, disorientation. In severe cases, paralytic ileus (absent bowel sounds, abd. Distention, & acute abdomen) may occur I: replace serum K, monitor serum levels, safety precautions

- Hyperkalemia K sparing diuretics, antineoplastic agents A: serum K level >5.0 mEq/L, malaise, muscle cramps, diarrhea, numbness & tingling, slow HR, low BP, dec urine output, DOB I: Na polystyrene sulfonate, safety measures, monitor cardiac effects,

 Sensory effects - Ocular toxicity drugs are deposited into tiny arteriesinflammation & tissue damage - chlorquine (aralen) x rheumatoid dseretinal damage/blindness
A: blurring of vision, color vision
changes, corneal damage, blindness I: monitor pts vision for known oculotoxic drugs, consult w/ physician, disc. drug, monitor exposure to lights

- Auditory damage ex. ASA A: dizziness, tinnitus, loss of balance, loss of hearing I: monitor perceptual losses or changes, provide protective measures, consult w/ physician, supportive measures

Neurological Effects - General CNS Effects Protection: BBB

- beta-blockers x hpn/angina cause feelings of anxiety, insomnia & nightmares A: confusion, delirium, insomnia, drowsiness, hyperreflexia/hyporreflexia, bizarre dreams, hallucinations I: provide safety measures, avoid dangerous situations (driving, operating dangerous machinery), orient, provide support, consult physician

- Atropine-like (Cholinergic) Effects - Donepezil (Aricept) x Alzheimers dse, also cold & antihistamine drugs A: dry mouth, altered taste perception, dysphagia, heartburn, constipation, bloating, paralytic ileus, urinary hesitancy & retention, impotence, blurred vision, cycloplegia (loss of movement in eye muscles), photophobia, h/a, mental confusion, nasal congestion, palpitations, decreased sweating, dry

to avoid dryness, have pt void before taking drug, safety measures, avoid hot envt, take protective measures from falling & dehydration
- Parkinson-like Syndrome antipsychotic & neuroleptic drugs A: lack of activity, akinesia, muscular tremors, drooling, changes in gait, rigidity, extreme restlessness or jitters (akathisia), spasms (dyskinesia)

I: provide sugarless lozenges, mouth care

I: disc. Drug, small frequent meals,

safety measures
- Neuroleptic Malignant Syndrome generalized syndrome that includes high fever; eg. general anesthetics A: EPS sx (tardive dyskenisia, akinesia,akathesia, acute dystonia) I: disc. drug, provide supportive care, safety precautions

 Teratogenecity drugsdeveloping tissues/embryo->death/congenital defects I: advise not to self-medicate, provide emotional & physical support

PART III-C. NURSING MANAGEMENT Introduction Nursing is a unique and complex science as well as a nurturing and caring art - deals with the whole person including physical, emotional, intellectual, social, & spiritual aspects - nurse needs to consider how a person responds to treatment, disease, and the changes in lifestyle that may be required

- nurse key health care provider who is in the position to: Assess the whole pt. Administer therapy as well as medications Teach pt. to cope w/ the therapy Ensure favorable outcome of therapy Evaluate effectiveness of therapy

The Nursing Process Assessment gathering information Nursing diagnosis analyzing the information gathered to arrive at some conclusions Interventions actions undertaken to meet the pts needs, such as administration of drugs, education, & comfort measures Evaluation determining the effects of the interventions that were performed

In general, the nursing process - provides an effective method for handling all of the scientific & technical information as well as the unique emotional, social, & physical factors that each pt. brings to a given situation - ensures that the pt. receives the best, most efficient, scientifically based, holistic care

Assessment systematic,

organized collection of data about the pt. - include information about physical, intellectual, emotional, social, & environmental factors - particular information that is needed varies w/ each drug, but the concepts involved are similar - 2 key areas that need to be assessed: pts history & physical

conditions

 Past History Chronic conditions the presence of certain conditions (eg, renal dse, heart dse, diabetes, chronic lung dse) may be contraindications the use of a drug. Or, these conditions may require that caution be used when administering a gertain drug or that the drug dosage be adjusted Drug use prescription drugs, OTC drugs, street drugs, alcohol, nicotine, alternative therapies, & caffeine may have an impact on a drugs effect.

 Allergies past exposure to a drug or other allergens can provoke a future reaction or provide a caution for the use of a drug, food, or animal product - it is impt to describe the particular allergic reaction when noting a drug allergy. In some cases, the reaction is not an allergic response but

 Level of education helps the nurse determine the level of explanation required & provides a basis for developing pt. education programs Level of understaning of dse & therapy this information also helps the devt of educational information Social supports available support at home, also involves referral to appropriate community resources

 Financial supports the high cost of health care in general, & of medications in particular, should be considered when initiating drug therapy Pattern of health care knowing how a pt. seeks health care gives the nurse valuable information to include in the educational plan - does this pt. seek ff. up care or does wait for emergency situation?

- does this pt. self-treat his complaints, or is brought to a health care provider? Physical Assessment Weight helps determine whether recommended drug dosage is appropriate. - Because the recommended dosage typically is based on a 150-lb adult male, pts who are lighter or much heavier need a dosage adjustment

 Age children & older adults require dosage adjustments based on the functional level of the liver & kidneys & the responsiveness of other organs Physical parameters or known drug effects provides baseline level -Depends on dse process being treated & on the expected therapeutic & adverse effects of the drug therapy

Ex. If a pt. is being treated for chronic pulmonary dse, the respiratory status & reserve need to be assessed, especially if a drug is being given that has known effects on the respiratory tract

Nursing Diagnosis a statement of the pts status from the nursing perspective - directs appropiate nursing interventions - shows actual or potential alterations in pt. function based on the assessment of the clinical situation - Ex. Imbalanced Nutrition: Less or More Than Body Requirements Impaired Physical Mobility Disturbed Body Image

Nursing Interventions - 3 types of interventions are frequently involved in drug therapy: drug administration, provision of comfort measures, and pt./family education Proper drug administration - there are 7 pts. to consider in the safe & effective administration of a drug: 1. Drug 2. Storage refrigeration, protection from light

3. Route check proper method of administering by that route 4. Dosage based on available drug form, the pts body wt. or surface area, or the pts kidney fxn 5. Preparation know specific preparation before administering any drug - Ex. Oral drugs may need to be shaken or crushed; - Parenteral drugs may need to be reconstituted or diluted w/ specific solutions

- Topical drugs may require specific handling, such as use of gloves during administration or shaving of a body area before application 6. Timing administration of one drug may require coordination w/ the administration of other drugs, foods, or physical parameters - educate pt. to do this on his own 7. Recording document in accordance w/ the local requirements for

 Comfort Measures - nurses are in a unique position to help the pt. cope w/ the effects of drug therapy Placebo effect anticipation that a drug will be helpful has been proven to have tremendous impact on the actual success of drug therapy - back rub, a kind word, positive approach may be as beneficial as the drug itself

 Managing Adverse Effects decrease anticipated adverse effects & promoting pt. safety environmental control (temp., light), safety measures (avoid driving, avoid sun, using side rails), & physical comfort (skin care, laxatives, frequent meals) Lifestyle adjustment ex. Pt. taking diuretics may have to rearrange their day so as to be near toilet facilities when the drug works

- pt. taking Monoamine oxidase inhibitors (MAOIs) must adjust their diet to prevent serious adverse effects from interaction of the drug w/ certain foods (tyramine-rich foods); eg.aged cheese, avocado, bean curd, bologna, chocolate, canned fish, dried & salted fish, pickled herring, caffeine, etc) - in some cases, change in lifestyle can affect coping & compliance w/ the medical regimen

 Patient and Family Education - written information - key elements that must be included in any drug education program are the ff: 1. Name, dose & action of drug to ensure safe & effective drug therapy & avoiding drug-drug interactions 2. Timing of administration teach pts. When to take the drug w/ respect to frequency, other drugs, & meals

3. Special storage & preparation instructions some drugs require particular handling procedures; inform pts. to carry out these requirements 4. Specific OTC drugs or alternative therapies to avoid causes unwanted & even dangerous drug-drug interactions - prevent by explaining w/c drugs or therapies should be avoided

5. Special comfort or safety measures - teach pts. How to cope w/ anticipated adverse effects to ease anxiety & avoid noncompliance w/ drug therapy - also educate pts. about the importance of ff-up tests or evaluation 6. Safety measures instruct all pts to keep drugs out of the reach of

- remind all pts to inform any health care provider they see about the drugs they are taking this can prevent drug- drug interactions & misdiagnoses based on drug effects 7. Specific pts. about drug toxicity give pts. a list of warning signs of drug toxicity - advise to notify their health care provider if any of these effects occur

8. Specific warnings about drug discontinuation some drugs w/ a small margin of safety & drugs w/ particular systemic effects cannot be stopped abruptly - alert pts to inform their hcp immediately if they cannot do their medication for any reason (illness, financial constraints)

Evaluation part of the continual process of pt care that leads to changes in assessment, diagnosis, & intervention - nsg intervention & education program

PART III D. DOSAGE CALCULATIONS Review on conversions b/w systems of measurement Converting b/w systems ratio & proportion Calculating dosage oral: solids, oral/parenteral liquids, IV solns Pediatric Considerations Frieds, Youngs & Clarks rule Quiz 3

Formula for Computation of Dosage Oral Medications: Solid desired dose ---------------- = quantity of drug stock dose (D/S=Q)

1.

2. Oral/Parenteral Medications: Liquid desired dose ---------------- x dilution = quantity stock dose of drug (D/S x Dil. = Q)

3. IV Fluid Rate a. gtts/min = vol. in cc x gtt factor no. of hrs x 60 mins. b. cc/hr = vol. in cc no. of hrs OR gtts/min x 4 c. duration in hrs = vol in cc cc/hr 4. Conversion of Temperature a. C to F = (C x 1.8) + 32 (Note: 1.8 = 9/5) b. F to C = (F 32) 1.8

5. Pediatric Dosages a. Clarks Rule wt. in lbs. x ave. adult dose = childs dose 150 lbs. b. Frieds Rule age in mos. x ave. adult dose = c.d. (age 150 mos. <1 yr.) c. Youngs Rule age in yrs. x ave. adult dose = c.d. (age 1age in yrs. + 12 12 yrs.) d. Surface Area Calculation surface area in sq. m. x ave. adult dose = 1.73 childs dose

Introduction to Cell Physiology To understand the actions & the adverse effects caused by chemotherapeutic agents, it is important to understand the basic functioning of the cell.

Chemotherapeutic drugs are used to destroy both organisms that invade the body (b,v,p,p,i) & abnormal cells within the body (neoplasms or cancers). By keeping in mind the various properties of the cell, & cell processes, nurses may help determine interventions that increase the therapeutic effectiveness of a drug & limit the undesired adverse effects.

The Cell - basic structural unit of the body

Cell Nucleus - contains all the genetic material that is necessary for cell reproduction & for regulation of cellular production of proteins - programmed by the genes for the production of specific proteins that allow the cell to carry out its function, maintain cell homeostasis or stability, & promote

cell division

- encapsulated by its own membrane - contains nucleolus & ribosomes, the site of protein synthesis in the cell - responsible for the formation of mRNA &

tRNA

 Cell

Membrane - a thin barrier surrounding the cell, w/c separates ICF from the ECF - essential for cellular integrity & is equipped w/ many mechanisms for maintaining cell homeostasis - contains:

 Lipoproteins - a structure in the cell membrane w/c consists lipids (phospholipids, glycolipids, cholesterol) & proteins - keeps cytoplasm w/n the cell & regulating what can enter the cell - the freely moving nature of the membrane allows it to adjust to the changing shape of the cell

 Receptor Sites - series of peripheral lipoproteins w/ several functions embedded in the lipoprotein membrane - reacts w/ specific chemicals outside the cell to stimulate a reaction w/n a cell ex. Receptor sitereacts w/ hormone insulincauses activation of ATP w/n the cellalters cells permeability to glucose - very impt in the functioning of neurons, muscle cells, endocrine glands, & other cell types

 Identifying Markers - are surface antigens, or genetically determined identifying markers - provide the histocompatibility antigens or HLAs identifies a cell as a self-cell & destroy non-self cells - can be changed in several ways: cell injury, viral invasion, age - if altered, the bodys immune system reacts to the change & can ignore it, allowing neoplasms to grow & develop; immune system may also attack the cell, leading to autoimmune disorders &

chronic inflammatory conditions

 Channels - pores w/n the cell membrane made by proteins in the cell wall that allow passage of small substances in or out of the cell (Na, K, Ca, Cl, HCO3, H2O) - ex. Ca channel blockers prevent the movement of Ca into a cell through Ca channels

 Cytoplasm - lies w/n the cell membrane, contains many organelles, is the site of activities of cellular metabolism & special cellular functions - inlcudes mitochondria, endoplasmic reticulum, free ribosomes, Golgi apparatus, &

lysosomes

 Mitochondria - rod-shaped power plants w/n each cell that produce energy in the form of ATP, w/c allows the cell to function - plentiful in very active cells (muscle cells) - uses ATP to maintain homeostasis, produce proteins, & carry out specific

functions

- if oxygen unavailable, lactic acid builds up as a byproduct of cellular respiration - LA leaves the cell & is transported to the liver for conversion to glycogen & CO2

 Endoplasmic Reticulum - fine network of channels that are interconnected - undulating surface provides large surface for chemical reactions w/n the cell - contains granules w/ enzymes & ribosomes w/c produce protein - production of proteins, nonproteins, hormones, & other substances & breakdown of toxic substances

 Free Ribosomes - not bound to the surface of the endoplasmic ret.; free floating - produce proteins that are impt to the structure of the cell & some of the enzymes that are necessary for cellular activity

 Golgi Apparatus - a series of flattened sacs - prepare hormones or other substances for secretion - may produce lysosomes & store other synthesized proteins & enzymes until they are needed Lysosomes - membrane-covered organelles that contain specific digestive enzymes that can break down proteins, nucleic acids, carbohydrates, & lipids - responsible for digesting worn or damaged sections of a cell

Cell Properties Endocytosis pinocytosis allow cells to absorb nutrients, enzymes, & other materials

Phagocytosis
Exocytosis allows a substance to move in & out of the cell (eg, hormones, neurotransmitters, enzymes, other subs.

 Homeostasis

- main goal of a cell, means keeping the cytoplasm stable w/n the cell membrane - uses active & passive transport systems to achieve homeostasis - disposes waste products that could be toxic

Passive Transport - happens w/o using energy, occurs across any semipermeable membrane 3 types: Diffusion - movement of a substance from a region of higher concentration to lower concentration - the difference b/w the concentration of the substance in these regions is called concentration gradient - the greater the conc. gradient, the faster the substance moves

- substances w/ negative charge move more freely than substances w/ a positive charge - includes Na, K, Ca, Carbonate, O2, HCO3, & H2O Osmosis - movement of water across a semipermeable membrane from an area that is low in dissolved solutes to one that is high in dissolved solutes - the diffusion of water across cell membrane from an area of high concentration to low concentration creates pressure on the cell membrane, called

osmotic pressure

Osmosis The experiment shown above demonstrates the process of osmosis. Water flows through a semipermeable membrane into a sugar solution, diluting the solution. The sugar molecules cannot pass through the membrane, so the water outside remains pure.

- the greater the concentration of solutes in the soln to w/c the water is flowing, the higher the osmotic pressure - a fluid that contains the same concentration of solutes as human plasma is called isotonic soln - a fluid that contains a higher concentration of solutes than human plasma is a hypertonic soln, & draws water from cells - a fluid that contains a lower concentration of solutes than human plasma does is hypotonic, loses water to cells

 Facilitated Diffusion - sometimes a substance cannot move freely on its own in or out of a cell - such substance may attach to another molecule, called carrier, to be diffused, is known as facilitated diffusion does not require energy, just the presence of carrier - carriers may be in the form of hormone, enzyme, or protein

 Active Transport - sometimes a cell requires a substance in greater concentration & must move substances against the concentration gradient, requiring them to use energy

- eg, sodium-potassium pump - cells use active transport to maintain high level of K, & low level of Na,

- allowing the cell to maintain an electrical charge on the cell membrane w/c gives cells the electrical properties of excitation & conduction - eg, cells in the kidney uses active transport to excrete drugs from the body as well as to maintain electrolyte & acid-base balances

Cell Cycle G0 Phase (resting phase) G1 Phase extends from stimulation to the formation of DNA; synthesizes the subs. That are needed fr DNA formation S Phase actual synthesis of DNA G2 Phase subs. production for manufacture of mitotic spindles M Phase cell splits to form 2 identical daughter cells (mitosis)

ANTI-INFECTIVE AGENTS - are drugs that are designed to act selectively on foreign organisms that have invaded & infected the body of a human host Bacitracin Chloramphenicol Meropenem Polymyxin B Spectinomycin Vancomycin

Mechanism of Action - Goal: interference w/ the normal function of the invading organism to prevent it from reproducing & to cause cell death w/o affecting host cells Some interfere w/ biosynthesis of the bacterial cell wall Prevent the cells of the invading organism from using substances essential for their growth & devt leading to inability to divide & eventually cell death (eg, sulfonamides, antimycobacterial, trimethoprim drugs

Interfere w/ the steps involved in protein synthesis, a necessary function to maintain the cell & allow for cell division (eg, aminoglycosides, macrolides, & chloramphen.

 Interfere w/ DNA synthesis in the cell, leading to inability to divide & cell death (eg, fluoroquinolones) Alter the permeability of the cell membrane to allow essential cellular components to leak out, causing cell death (eg, antibiotics, antifungals, & antiprotozoals

Anti-infective activity narrow (Spectinomycin Trobicin) & broad spectrum activity Bactericidal anti-infective that is so active against the infective MO that they actually cause the death of the cells they affect

 Bacteriostatic anti-infectives that are not as aggressive against invading MO; they interfere w/ the ability to reproduce or divide Depends on the concentration of the drug that is present Many of the adverse effects noted are associated w/ the aggressive properties of the drugs & their effect on the cells of the host as well as those of the pathogen

Human Immune Response - Goal: reduction of the population of the invading organism Immune response involves a complex interaction among chemical mediators, leukocytes, lymphocytes, antibodies, & released enzymes & chemicals If functional, could eliminate pathogenic organisms If immunocompromised for any reason (eg, malnutrition, age, AIDS, use of immunosuppressant drugs) incapable of dealing effectively w/ the invading org.

Resistance - ability of bacteria to adapt to an antibiotic & produce cells that are no longer affected by a particular drug Eg, Vancomycin (Vancocin, Vancoled) given to pts. who are intolerant/allergic to penicillin/cephalosporins & pts. w/ staphylococcal infection that no longer respond to these drugs Can be used orally or IV; for bacterial endocarditits Highly toxic, reserved for very

 Can cause renal failure, ototoxicity, superinfections, red man syndrome char. by sudden & severe hypotension, fever, chills, paresthesias, erythema of neck & back
Acquiring Resistance - MO develop resistance in a number of ways:

 Producing

an enzyme that deactivates the antimicrobial drug. Ex., some strains of bacteria that were once controlled by penicillin now produce an enzyme called penicillinase, w/c inactivates penicillin before it can affect the bacteria. This occurrence led to the development of new drugs that are resistant to penicillinase

 Changing cellular permeability to prevent the drug from entering the cell, or altering transport systems to exclude the drug from active transport into the cell Altering binding sites on the membranes or ribosomes, w/c then no longer accept the drug Producing a chemical that acts as an antagonist to the drug

Preventing Resistance Its impt to limit the use of antimicrobial agents to the tx of specific pathogens known to be sensitive to the drug being used Maintain a constant therapeutic level to prevent the emergence of resistant microbes during times of low concentration

 Timing of doses & length of time of therapy

Prescribing anti-infectives w/o knowing the causative organism promotes resistance

Treatment of Systemic Infections Several factors should be considered before beginning chemotherapeutic regimen Include identification of the correct pathogen & selection of a drug that is most likely to 1) cause the least cxs for that particular pt. & 2) be most effective against the pathogen involved

Identification of the Pathogen Culture of a tissue sample from the infected area, performed in the laboratory, where a swab of infected tissue is allowed to grow on an algar plate

Straining techniques & microscopic exam to identify organism

 For parasitic sources of infection, stool exam for ova & parasites Microscopic exam is also used to detect fungal & protozoal infections
Correct identification of CA is an impt 1st step in determining w/c anti-infective drug should be used

Sensitivity of the Pathogen Sensitivity testing shows w/c drugs are capable of controlling the particular MO that have known resistant strains

Combination Therapy - may be effective in interfering with cellular structure in different areas or developmental phases; my be used for several reasons:

 Uses a smaller dosage of each drug leading to fewer adverse effects

Some drugs are synergistic, w/c means they are more powerful when given in combination

 Many microbial infections are cause by more than one MO, & each pathogen may react to a different anti-infective agent
Delay the emergence of resistant strains, eg, tx of TB, malaria, & some bacterial infections

Adverse Reactions to Anti-infective Therapy

Kidney Damage - occurs more frequently w/ drugs that are metabolized by the kidney & then eliminated in the urine (eg, aminoglycosides) - to prevent accumulation in the kidney, pts. should be well hydrated throughout the course

 GI Toxicity - many have direct toxic effects on the cells lining the GIT, causing nausea, vomiting, stomach upset or diarrhea - death of MO releases chemical/toxins in the body, stimulate CTZ in medulla, induces n/v

- some are toxic to the liver, causes hepatitis or liver failure (eg, cephalosporins)

- ex. Meropenem inhibits bacterial cell wall synthesis; used to treat intra-abd. Infections & meningitis

 Neurotoxicity - Aminoglycoside collect in the 8th cranial nerve, that cause dizziness, vertigo, loss

of hearing - Chloroquine, used to treat

malaria & some rheumatoid d/o accumulate in the retina & optic nerve can cause blindness

- others can cause dizziness, drowsiness, lethargy, changes in reflexes, & even hallucinations when they irritate specific nerve tissues

- ex. Polymyxin B (generic), an older antibiotic, uses a surfactant-like reaction to enter the cell membrane & disrupt it, leading to cell death in susceptible gram (-) bacteria - can be toxic to the human host, leading to nephrotoxicity, neurotoxicity (facial flushing, dizziness, ataxia, paresthesias, & drowsiness), & drug fever & rashes

 Hypersensitivity

Reactions - it is impt to determine what the allergic reaction was & when the pt. experienced it (after 1st use of drug, after yrs. of use) - allergic reaction vs. adverse effect

 Superinfections

- destruction of the normal flora opportunistic pathogens cause infections superinfections - include vaginal or GI yeast infections by Proteus & pseudomonas

ANTIBIOTICS - are chemicals that inhibit bacteria - bacteriostatic prevents the growth of bacteria &
- bactericidal those that kill bacteria directly

- can be both, depends upon drug concentration

- made in 3 ways: by living microorganisms, synthetic manufacture, & in some cases, genetic engineering

Major Classes of Antibiotics: 1. Aminoglycosides, 2. Cephalosporins 3. Fluoroquinolones 4. Lincosamides 5. Macrolides 6. Monobactams 7. Penicillin 8. Penicillinase-resistant 9. Sulfonamides 10. Tetracycline 11. Disease-specific antimicrobacterials anti- TB, & leprostatic drug

Bacteria & Antibiotics

Invasion (routes)body becomes the host multiply/reproduceactivated immune responses/s (eg, fever, lethargy, signs of inflammation)

 Goal of therapy: decrease the population of bacteria interferes w/ specific proteins & enzyme systems C&S to know w/c antibiotic the MO is most sensitive

 Gram-positive bacteria are those whose cell wall retains a stain, known as grams stain, or resists decolorization w/ alcohol during C&S testing
- commonly associated w/ infections of the respiratory tract & soft tissues - ex. Streptococcus pneumoniae

 Gram-negative bacteria are those whose cell walls lose a stain or are decolorized by alcohol - frequently ass. w/ infections of GU or GI tract - ex. Escherichia coli, a common cause of cystitis

 Aerobic bacteria depend on oxygen for survival, anaerobic bacteria (ass. w/ gangrene) do not use O2 Broad spectrum antibiotics antibiotics that interfere w/ a biochemical reaction common to many organisms - has wide range of effects, therefore freq. ass. w/ adverse effects

Clinicians use drug w/ selective toxicity ability to strike foreign cells w/ little or no effect on human cells Consider contraindications like immunocompromised, have severe GI dse, debilitated

 Antibiotics are given in combination to promote synergy Bacteria & Resistance to Antibiotics
Aminoglycosides - group of powerful antibiotics used to treat serious infections caused by gram (-) aerobic bacilli; bactericidal

Aminoglycosides
amikacin (amikin), (P) gentamicin (garamycin), kanamycin (kantrex), neomycin (mycifradin), netilmicin (netromycin), streptomycin (generic), tobramycin (nebcin, tobrex)

Aminoglycosides - disrupts cell membrane - for tx of serious infections susceptible to penicillin when penicillin is contraindicated - can be used for C&S - rapidly absorbed via IM

Aminoglycosides
- crosses placenta & enters breast milk, use w/ caution esp. during pregnancy & lactation Contraindications: Known allergy Renal or hepatic dse Pre-existing hearing loss

Aminoglycosides
Active

infection w/ herpes or mycobacterial infections Myasthenia Gravis or parkinsonism Lactating mothers

Aminoglycosides Adverse Effects CNS: ototoxicity leading to irreversible deafness, vestibular paralysis, confusion, depression, disorientation, numbness, tingling, weakness

 Renal Bone

leading to immune suppression superinfections, fever GI: nvd, wt. loss, stomatitis, hepatic toxicity Cardiac: palpitations, hypotension, HPN, hypersensitive reactions

marrow depression

toxicity glomerulus

Drug-Drug Interactions Diuretic the incidence of ototoxicity, nephrotoxicity, & neurotoxicity inc.

Anesthetics, neuromuscular blockers, succinylcholine, citrate anticoagulated blood = inc. neuromuscular blockade w/ paralysis is possible

Nursing Consideration
1. Check C&S reports ensure that this is the DOC for this pt. 2. Ensure that pt. receives full course of aminoglycosides as px to inc. effectiveness & dec. risk for devt of resistant strains of bacteria

3. Monitor site of infection & presenting s/s (fever, lethargy) throughout the drug therapy failure of this s/s to resolve may indicate the need to reculture the site. Arrange to continue drug therapy for at least 2 days after all s/s resolve

4. Monitor regularly for signs of nephrotoxicity, neurotoxicity, & BMS for disc. of drug or dec. dosage 5. Provide for safety measures to protect from CNS effects, such as confusion, disorientation, or numbness & tingling, occur

6. Provide small, frequent, meals, offer frequent mouth care, & offer ice chips or sugarless candy to suck to provide relief from stomatitis, etc, maintain nutrition, provide fluid 7. Ensure hydration to minimize renal toxicity

8. Ensure that the pt. is instructed about the appropriate dosage regimen & possible adverse effects to enhance pt. knowledge about drug therapy & promote compliance

Cephalosporins - (P) Cefaclor, cefadroxil, cefazolin, cefotaxime, ceftazidime, ceftriaxone, cefuroxime, cephalexin, etc. 1st 4th generation 1st effective against gram (+) bacteria & gram (-) bacteria PEcK

 2nd

- 1st gen + HEN = HENPEck; less effective against gram (+) bacteria 3rd more potent against gram (-) bacillias well as Serratia marcescens (HENPEcKS) 4th active against gram (+) & (-) organisms including cephalosporin-resistant staphylococci & P. aeruginosa

Indication - both bactericidal & bacteriostatic - cause bacteria to build weak cell walls when dividing - well absorbed from GI, IM , & IV administration - for UTI, respi, skin, GU, bone infections

Contraindications - allergies, RF
Adverse Effect - GI: NVD, anorexia, abd. Pain, flatulence (common) - CNS: h/a, dizziness, lethargy, paresthesias - nephrotoxicity, superinfections, phlebitis

Drug-Drug Interactions - cepha w/ amino = inc. nephrotoxicity - oral anticoagulants = inc. bleeding - alcohol for 72 hrs disc. Of the drug = disulfiram-like reactions (h/a, n/v, chest pain, vertigo, etc.)

Nursing Considerations: (same as amino)

1.
2.

3.
4. 5.

Check C&S report Monitor RFT Ensure pt. receives full course Monitor site of infection & presenting s/s Provide small, frequent meals; mouth care

6. Monitor for signs of superinfection 7. Monitor injection sites regularly 8. Initiate safety measures 9. Instruct pt.

Fluoroquinolones - (P) ciprofloxacin, gatifloxacin, levofloxacin, lomefloxacin, moxifloxacin, norfloxacin, ofloxacin, sparfloxacin, trovafloxacin - Cipro effective against a wide spectrum of gramnegative bacteria (eg. E. coli, K. pneumoniae, N. gonrrheae)

 enter the bacterial cellinterferes w/ the DNA actioncell death - not recommended for use in children <18y/o - can cross the placenta, enter breast milk

Contraindications & Cautions w/ allergy, pregnant, & lactating women w/ renal dysfxn, seizures Adverse Effects CNS: h/a, dizziness, insomnia, depression GI: NVD, dry mouth,

 IS: BMD Others: fever, rash, photosensitivity, skin reactions avoid sun & UV light exposure, use sunscreen, protective clothing

Clinically Impt Drug-Drug Interactions - when used w/ iron salts, sucralfate, mineral supplements, or antacids, effect is decreased - if taken w/ drugs that inc. the QTc interval or cause torsades de pointes (quinidine, procainamide, amiodarone, sotalol, bepridil, erythromycin, terfenadine, astemizole, cisapride, pentamidine, tricyclics, phenothiazines), severe ot fatal cardiac reactions are possible

- Combined w/ theophylline, leads to inc. levels of theophylline - if combined w/ NSAIDS, inc. risk of CNS stimulation. If used, monitor closely esp. those w/ hx of seizures or CNS problems
- Nursing

Considerations (Same as above)

Macrolides
Interfere w/ protein synthesis in susceptible bacteria Azithromycin (zithromax), clarithromycin (biaxin), dirithromycin (dynabac), (P) erythromycin (E-Mycin, ERYC, etc.)

DOC x Legionnaires dse, infections caused by Corynebacterium diphtheriae, ureaplasma, syphillis, & other STIs

Indications Bactericidal/bacteriostatic binds to bacterial cell membrane & change protein fxnprevent cell division/cell death

 Indicated for acute infections caused by susceptible strains of S. pneumoniae, Mycoplasma pneumoniae, Listeria monocytogenes, & Legionella Pneumophila; group A B-hemolytic streptococci; PIDs; URTI; etc.

 May bre used for endocarditis before dental procedures in pts. w/ valvular heart dse who are allergic to penicillin Topical macrolides tx of ocular infection, acne vulgaris, minor skin abrasions, etc.

Contraindications & Cautions Pts. w/ known allergy Ocular preps for viral, fungal, or mycobacterial infections of the eye exacerbated by loss of bacteria of the normal flora Pts. w/ hepatic dysfxn, renal dse, lactating women can cause diarrhea & superinfections to the infant, pregnant women teratogenic

Adverse Effects Few adverse effects Most frequent GI: abd. Cramping, anorexia, DV, & pseudomembranous colitis Neuro: confusion, uncontrollable emotions Hypersensitivity reactions ranging from rash to anaphylaxis, superinfections r/t loss of normal flora

Drug-Drug Interactions Inc. serum levels of digoxin Oral anticoagulants, theophyllines, carbamezipine, or corticosteroids may require reduced dosage & careful monitoring Cycloserine (antiTB/leprotic) inc. risk of renal toxicity

Astemizole may lead to cardiac arrhythmias

Drug-Food Interactions Given on empty stomach 1hr or at least 2-3 hrs. after meals Should be taken w/ full, 8oz. Glass of H2O

Lincosamides
(P)clindamycin), lincomycin Similar to Macrolides but more toxic Clindamycin: Reserved for severe infections caused by the same strains of bacteria that are susceptible to macrolides

 Rapidly absorbed from the GI tract or from IM injections Has a half-life of 2-3 hrs.; metabolized in the liver, excreted in the urine & feces Caution w/ hepatic or renal impairment Crosses placenta & enters breast milk Severe GI reactions

Available in parenteral, topical, vaginal form Lincomycin: indicated for severe infections If pen & macrolides cannot be used Rapidly absorbed from GI /IM injection Metabolized in the liver, excreted in the urine & feces

Half-life: 5 hrs. Caution w/ hepatic & renal impairment Crosses placenta, enters breast milk Severe GI reactions pseudomembranous colitis Careful monitoring of GI activity & fluid balance Stop drug at first sign of severe bloody diarrhea

Toxic effects: pain, skin infections, BMD

Monobactam antibiotics

Aztreonam only currently available for use Structure is unique among anitbiotics Little cross-resistance occurs

 Is efective against gram (-) enterobacteria & has no effect on gram (+)/anaerobic bacteria Alternative for those allergic to pen & cepha Absorbed well in IM Peak levels: 1-1.5 hrs Crosses placenta & enters breast milk

 Half-life: 1.5-2 & is excreted unchanged in the urine

Indications - disrupts bacterial cell wall synthesis, w/c promotes leakage of cellular contents & cell death in susceptible bacteria

- tx of UT, skin, intraabdominal, gynecological infections, septicemia caused by susceptible bacteria ( E. coli, Enterobacter, Serratia, Proteus, Salmonella,et) - available for IV & IM use only

Contraindications & Cautions

Allergy to Aztreonam Caution to pts. w/ hx of acute allergic reaction to Pen or Cepha w/ renal/hepatic dysfxn Pregnant & lactating women

Adverse Effects Local GI effects Hepatic enzyme elevations Inflammation, phlebitis, discomfort @ injection sites Potential allergic response (anaphylaxis)

Nursing Considerations 1. Hx of allergic reactios, liver/renal dse 2. Pregnancy & lactation status 3. PA 4. Obtain specimen for C & S 5. Monitor temp. 6. Abd. Exam & LFT & KFT to determine any needed alteration in dosage

Nursing Dx Acute pain r/t GI & local effects of drug Deficient knowledge regarding drug therapy Deficient fluid volume Implementation 1.Check C&S

2. Monitor hepatic & renal fxn tests 3. Ensure full course therapy 4. Monitor for signs of infection 5. Small, frequent meals as tolerated, mouth care, ice chips or sugarless candy 6. Adequate fluids

7. Ensure ready access to bathroom 8. Pt. Instruciton (route, S/E,)

Evaluation Monitor pt. response to the drug Monitor for AE orientation & affect, GI effects, local inflammation)

 Evaluate effectiveness of teaching plan (pt. can name the drug, dosage, poss. AE, & speciic measures to help avoid AE) Monitor effectiveness of comfort, safety measures, compliance

PENICILLINS and PENICILLANSERESISTANT ANTIBIOTICS First antibiotic introduced for clinical use Sir Alexander Fleming used Penicillin molds to produce the original penicillin in 1920s Developed to decrease AE & modifies to act on resistant bacteria

 With prolonged use, bacteria synthesized enzyme penicillinase counteract the effects of penicillins Led to the devt of group of drugs w/ a resistance to penicillinase C & S should always be performed

Indication Bactericidal effect Tx of streptococcal infections, inc. pharyngitis, tonsillitis, scarlet fever, & endocarditis; pneumococcal infections; staphylococcal infections; fusospirochetal; ratbite fever; diphtheria; anthrax; syphilis, uncx gonococcal infection

Pharmacokinetics Rapidly absorbed from GI, taken on empty stomach Excreted unchanged in the urine, Enters breast milk & cause diarrhea & adverse reactions to the baby

Contraindications & Cautions (same w/ other antibiotics)

Gi tract, superinfections, pain & inflammation @ injection site, hypersensitivity reactions, anaphylaxis

Important Drug-Drug Interactions Penicillin & penicillinaseresistant anitbiotics w/ tetracycline decrese effect of Pen w/ aminglycosides inactivation of Amino Nursing Considerations (same as other antibiotics)

Example of Penicillins
Penicillin G Benzathine (Bicillin, Permapen) Penicillin G Potassium (Pfizerpen) Penicillin G Procaine (Crysticillin-AS) Penicillin V (Beepen-VK)

Example of Extended Spectrum Penicillins Ampicillin (D-amp, omnipen) Amoxicillin (P) (amoxil, trimox) Carbenicillin (geocillin) Mezlocillin (Mezlin) Piperacillin (Pipracil) Ticarcillin (ticar)

Penicillinase-resistant Antibiotics
Cloxacillin (P) (Cloxapen, Tegapen) Dicloxacillin (dyapen, Dycill) Nafcillin (nafcil, nallpen) Oxacillin (bactocill, prostaphillin)

SULFONAMIDES (sulfa drugs) Are drugs that inhibit Folic Acid synthesis w/c is necessary for the synthesis of purine & pyramidines, a precursor of RNA & DNA Not used much anymore cause of emergence of new antibiotics & resistant bacterias

Remain as inexpensive & effective tx for UTI & trachoma

Example of Sulfa drugs Sulfadiazine for susceptible bacteria; absorbed from GI; peak levels: 3-6 hrs.

 Sulfisoxazole for broadspectruminfection (STDs, otitis media); absorbed from GI; PL: 2hrs., HL: 4-8hrs. Sulfasalazine (Azulfidine) a sullfapyridine carried by ASA; for ulcerative collitis, Crohns dse, RA; absorbed from GI; PL: 2-6hrs.; HL: 5-10hrs.

 Cotrimoxazole (septra, bactrim) combination drug containing sulfamethoxazole & trimethoprim; very effective for otitis media; absorbed from GI; PL: 2hrs.; HL: 712hrs.

Indications: Trachoma, nocardiosis (causes pneumonias, brain abscess, & inflammation), UTI & STDs Pharmacokinetics Absorbed form GIT, metabolized in the liver, excreted in the urine Teratogenic; distributed into the breastmilk

Contraindications Allergy to sulfonamide, sulfonylureas, thiazide diuretics Pregnant can cause birth defects (kernicterus) Lactation diarrhea, rash Renal dse or hx of kidney stone

Adverse Effects 1. Same w/ others + renal effects like crystalluria, hematuria, & proteinuria to nephrotic syndrome & poss. toxic nephrosis 2. CNS, BMD, dermatologic effects

Drug-Drug Interactions Antidiabetic agents (glyburide, glipizide); if needed, monitor pt. & dosage adjustment must be made Cyclosporine increased risk of nephrotoxicity

Nursing Considerations (same w/ others) 1. On empty stomach w/ water to promote adequate absorption of the drug 2. Discontinue if hypersensitivity occursmonitor CBC, U/A to check for adverse effects 3. Instruct pt.

TETRACYCLINES Inhibits protein synthesis of susceptible bacteria Available in oral & topical forms, including ophthalmic infections for tx of minor skin infections Demeclocycline, doxycycline, minocycline, oxytetracycline, (P) tetracycline

Indication Rickettsiae, M. pneumonia, H. influenza, H. ducreyi, etc. Uncx GU infections, some protozoal infections
Contraindications Allergy to tartrazine caution w/ children <8 yrs. of age

 Pts. Who have fungal, mycobacterial, or viral ocular infections esp. the ophthalmic preps. Adverse Effect Glossitis, dysphagia, damage to teeth & bones Anemia, intracranial HPN

Drug-Drug Interactions

If taken w/ pen G, pen G decreases If used, dosage of pen is increased Also w/ contraceptives Methoxyflurane inc. risk of nephrotoxicity Digoxin toxicity Dec. absorption w/ Ca salts, bismuth salts, Fe, urinary alkalinizers, & charcoal

Drug-Food Interaction Not absorbed effectively w/ food/dairy products 1 hr. before & 2-3 hrs. after a meal or other medcation
Nursing Consideration (same as sulfonamides)

ANTIMYCOBACTERIAL ANTIBIOTICS - cause TB & Leprosy - has the ability to hold a stain even in the presence of a destaining agent - because of this property, they are called acid-fast bacteria - takes several years before

Anti TB drugs - affects lungs, GUT, bones, & the meninges First line drugs: (P) Isoniazid (Nydrazid) affects the mycolic acid of the bacterium Rifampin (Rifadin, Rimactane) alters DNA & RNA activity in the bacterium

 Ethionamide (Trecator SC) prevents cell division Rifapentine (Priftin) - alters DNA & RNA activity, causing cell death *If the dse continues to progress because of the emergence of resistant strains 2nd line of drugs
Ethambutol (Myambutol) inhibits cellular metabolism

 Pyrazinamide (generic) both bactericidal & bacteriostatic 3rd line: Capreomycin (Capastar) idiopathic Cycloserine (Seromycin) inhibits cell wall synthesis & leads to cell death

Leprostatic Drugs (P) Dapsone Clofazimine (Lapmrene) Indication, Pharmacokinetics, & Contraindication/caution (same as w/ other antibiotics) *if needed during pregnancy, combination of INH, ehtambutol, & rifampin is considered safest

Adverse Effects CNS: neuritis, dizziness, h/a, malaise, drowsiness & hallucinations are often reported GI: same Discoloration of body fluids urine, sweat, tears

Drug-Drug Interactions Rifampin & INH toxic to liver Quinidine. Metoprolol, oral contraceptives inc. metabolism & dec. effectiveness of drugs

New Class of Antibiotics Ketolides RI, given OD; Telithromycin (Ketek) - for tx of CAP, acute bacterial exacerbations of chronic bronchitis & acute bacterial sinusitis - given 800-mg oral dose Ertapenem (Invanz) CAP, skin infections

ANTIVIRALS acyclovir amantadine didanosine foscarnet ganciclovir idoxuridine ribavirin trifluridine vidarabine zidovudine

General Information & Action - inhibit viral growth by inhibiting an enzyme within the viral cell, DNA polymerase - DNA synthesis is inhibited & the cell cannot replicate - Amantadine prevents virus from entering body cells

 Viruses warts, common cold flu, chicken pox & measles To carry on any metabolic processes, including replication, a virus must enter a cell Interferons tissue hormone that is released in response to viral invasion; blocks viral replication

Indication Effective for a single class of virus Acyclovir & Vidarabine used in the tx of severe virus infections Amantadine - prevention of Influenza A infections; Parkinsons dse because of its action on dopamine release in the EP tracts in the CNS

Ganciclovir & Foscarnet used to treat retinitis caused by CMV CMV common on patients whose natural immune process are depressed Didanosine & Zidovudine slow the progression of AIDS

Idoxuridine & Trifluridine currently used only for viral eye infections herpes simplex Ribavirin used in tx of RSV infections in infants & young children

Contraindications Hypersensitivity

 Zidovudine & Idoxuridine can appear in breast milk therefore Adverse Reactions & Side Effects
Vary greatly among the individual antiviral drugs Some have life-threatening reactions

 Lightheadedness, dizziness, insomnia, nausea, orthostatic hypotension, urinary retention NV, h/a, depression, rash, hair loss, Rash, inflammation, burning at site of injection & topical application

Nursing Precautions Patients w/ renal & hepatic dysfxns should be monitored carefully Safety among pregnant women & young children Ribavirin safety among adults

Because drug is given by continuous aerosol administration caution to pregnant nurses or of childbearing age avoid exposure to the drug

Interactions

Varies among the individual antiviral drugs

ANTIFUNGALS From annoying athletes foot to potentially fatal systemic infections Caused by fungus called Fungus has a rigid cell wall made up of chitin & various polysaccharides & a cell membrane that contains ergosterol

mycosis

Candida can cause thrush on GIT & vagina

Systemic Antifungals - can be toxic to the host - culture of fungus is impt Amphotericin B (Fungizone, Albecet, Amphotec, AmBisome) Flucytosine (Ancoban) Griseofulvin (Fulvicin, Grifulvin V, Grisactin, Gris-PEG)

 Nystatin (Mycostatin, Nilstat, Nystex) Azoles newer drug used to tx systemic fungal infections Ketoconazole (Nizoral), Fluconazole (Diflucan) Indications Acts on cell permeability of fungus leading to cell death & prevention of replication

Contraindications & Cautions w/ known allergy Pregnancy & lactation (exception to the terbinafine) w/ renal/liver dse Adverse Effects h/a, dizziness, fever, shaking, chills, malaise NVD, dyspepsia, anorexia Rash & pruritus

Drug-Drug Interactions Pts. Who receive Amphotericin B should take neither nephrotoxic drugs nor corticosteroids Cyclosporine, digoxin, oral hypoglycemics, & phenytoin = inc serum levels of azole family

azole + lovastatin, simvastatin, astemizole, cisapride, triazolam, & midazolam = potentially

severe CV events

Assessment: History & Patient Assessment - establishment of baseline data Hx of allergy Hx of liver/renal dysfxn Pregnant? Lactating? Culture of infected area orientation & reflexes Skin color & lesions RFT/LFT

Nursing Dx Acute pain r/t GI, CNS, local effects of drug Disturbed sensory perception r/t CNS effects Deficient knowledge regarding drug therapy

Implementation Arrange for appropriate C&S tests

 Administer entire course of the drug to get the full beneficial effects Monitor IV sites to ensure that phlebitis does not occur Monitor renal & hepatic fxn Provide comfort & safety if CNS effects occur Provide small, frequent meals Provide pt. instruction

The patient should: Follow appropriate dosage regimen Take safety precautions changing position slowly, avoiding driving & hazardous tasks if CNS effects occur Take oral drug w/ meals & try small, frequent meals if GI upset is a problem

 Report to a health care provider any of the ff: - sore throat - unusual bruising & bleeding - yellowing of eyes or skin - severe n/v - severe local irritation w/ local application, w/c could indicate a sensitivity reaction & worsening of the infection

Evaluation Monitor pt. response to the drug Monitor for adverse effects Evaluate effectiveness of the teaching plan Monitor effectiveness of comfort & safety measures & compliance w/ the regimen

TOPICAL ANTIFUNGALS Fungi that cause mycoses of the skin & mucos membranes are called dermatophytes Includes tinea infections & candida infections Fungizone, gentian violet, miconazole Too toxic but effective in tx of local fungal infections

Should not be used near open wounds Can cause serious local irritation, burning & pain. Stop if this conditions occur

ANTIPROTOZOAL AGENTS CA: amebiasis, gardiasis, &

Malaria p. falciparum, p. vivax, p. malariae, p. ovale Ex. of drugs: quinine & chloroquine Quinine may lead to severe diarrhea & a condition called cinchonism (n/v, tinnitus, vertigo)

trichomoniasis

Action/Indications Interrupt plasmodial reproduction of protein synthesis in the RBC stage of the life cycle Contraindications Known allergy Liver dse or alcoholism Lactation Caution w/ retinal dse

 Psoriasis or porphyria (metabolism) w/ damage to mucous membranes w/ prolonged QTc interval, if using halofantrine Adverse Effects CNS: h/a, dizziness, fever, shaking, chills, malaise

GI: n/v, dyspepsia, anorexia, liver toxicity Skin: rash, pruritus, loss of hair ass. w/ changes in protein synthesis Eye: possible blindness r/t retinal damage Ototoxicity r/t addl nerve damage Cinchonism

Drug-Drug Interactions Quinine + quinine derivatives =cardiac toxicity & convulsions Halofantrine increased risk for cardiac arrythmias & death if they take other drug that prolong the QTc interval Fansidar sulfadoxine +pyrimethamine tx of p. falciparum when chloroquine resistance is suspected

Nursing Considerations (same w/ antifungals) Other Protozoal Infections Amebiasis intestinal infection caused by entamoeba hystolytica, a.k.a. amebic dysentery Leishmaniasis (skin dse) passed from sand flies

Trypanosomiasis caused by

typanosoma causing acute CNS inflammation that result to lethargy, prolonged sleep, even death (African sleeping sickness) transmitted by tsetse fly Trichonomiasis caused by flagellated protozoans trichomonas vaginalis vaginits reddened, inflamed vaginal mucosa, itching, burning, &

yellowish-green discharge

 Gardiasis caused by giardia lamblia from contaminated food/water, cause diarrhea, rotten egg-smelling stool, pale, mucous-filled stool, epigastric distress, wt. loss, malnourishment Pneumocystis caranii pneumonia (PCP) if pt. is immunosuppressed due to AIDS or ARC, etc.

Other Antiprotozoal Agents Metronidazole (Flagyl, MetroGel, Noritate)amebiasis, trichomoniasis, & gardiasis - crosses placenta & enters fetal circulation, passes into breastmilk Others: Pentamidine (Pentam 300, NebuPent); Atovaquone (Mepron)

Indication Inhibit DNA synthesis

Contraindications Allergy, hypersensitivity, pregnancy Caution w/ CNS dse because of possible exacerbation Hepatic dse Candidiasis superinfection Lactation

Adverse Effects CNS: h/a, dizziness, ataxia, loss of coordination peripheral neuropathy GI: NVD, unpleasant taste, cramps & changes in liver fxn Superinfections

ANTIHELMINTIC AGENTS - about 1 B people have worms in their GIT or other tissues - common in tropical areas - helminths that most commonly infect humans are of 2 types: nematodes / roundworms & platyhelminths/flatworms

Intestine-Invading Worms - Involves the prevention of reinfection or spread of an existing infection Nematodes or roundworms include pinworms, whipworms, threadworms, Ascaris, & hookworms Pinworm stay in the intestine, cause perianal itching, or occ. vag. itching

 Whipworms attach to the wall of the colon; cause colic & bloody diarrhea when they inc. in #; may result in prolapse of the intestinal wall & anemia r/t bld. Loss Threadworms more pervasive; after burrowing, lay eggs, hatch into larvae that invade lungs, liver, & heart

- may result to death from pneumonia or from lung or liver abscesses Ascaris most prevalent helminthic infection; hatch in the small intestine to the lungs, cause cough, fever, & other signs of pulmonary infiltrate - migrate back to the intestine, grow to adult size

- cause abdominal distention & pain - severe case: intestinal obstruction by masses of worms can occur Hookworms attach to the small intestine & suck bld. from it; cause damage to the intestinal wall, cause severe anemia w/ lethargy, weakness, & fatigue

- malabsorption may occur; tx for anemia & fluid & electrolyte disturbances is an impt part of therapy Platyhelminths: Cestodes Flatworms include cestodes (tapeworms) live in the human intestine & the flukes (schistosomes)

 Cestodes segmented flatworms, may experience some abdominal discomfort & distention, wt. loss - pts. Require psychological support when the worm comes out of their mouth, or nose w/c occur occasionally

Tissue-Invading Worm Infections Trichinosis ingestion of the encysted larvae of the roundworm, Trichinella spiralis, in undercooked pork - deposited in intestinal mucosa, pass into bloodstream, throughout the body - penetrate skeletal muscle, cause inflammatory reaction to cardiac muscle & brain

- can cause fatal pneumonia, heart failure, encephalitis Filariasis infection of the bld. & tissues; cause inflammation of lymphatic system lead to swelling of hands, feet, legs, arms, scrotum, breast elephantiasis

 Schistosomiasis - infection by fluke carried by snail; larvae attach to the skin, burrow into the bloodstream & lymphatics
-Move into the lungs & liver, migrate into intestine & urinary bladder -Lay eggs, expelled in feces & urine -Pruritic rash/swimmers itch

- after 1-2 mos., may experience fever, chills, h/a, abdominal pain, diarrhea, blockage of bld. Flow leading to hepatomegaly / spleenomegaly & signs of CNS & cardiac ischemia

ANTIHELMINTICS Mebendazole (Vermox) effective against pin, round, whip, & hookworms - available in chewable tablet, in typical 3-day course, can be repeated in 3 wks. If needed - few adverse effects

 Pyrantel (antiminth, pin-rid, pin-X, reeses pinworm - oral; effective against pin & roundworms; given as single dose Thiabendazole (mintezol) Albendazole (albenza) Ivermectin (stromectol

Indication - Interfere w/ metabolic processes in particular worms Contraindications Known allergy Lactation Pregnancy Caution w/ renal/hepatic dse, diarrhea, & malnourishment

Adverse Effects Abdominal discomfort, diarrhea, or pain h/a & dizziness Fever, shaking, chills, malaise Rash, pruritus, loss of hair Changes in protein synthesis to Steven-Johnson sydrome ass. w/ thiabendazole

Drug-Drug Interactions Theophylline + thiabendazole = increased levels of theophylline Albendazole + dexamethasone/praziquantel / cimetidine = increased toxicity of albendazole

Assessment Screen for hx of allergy hepatic or renal dysfxn Pregnancy, lactation Physical assessment Culture of stool for ova & parasite Examine reflexes & muscle strength Hepatic evaluation including

 Examine skin (lesion, color, temperature, & texture) & abdomen Nursing Dx Acute pain r/t GI, CNS, skin effects of drug Disturbed personal identity r/t diagnosis & treatment Deficient knowledge regarding drug therapy

Implementaiton C & S Administer complete course of drug; ensure chewable tabs are chewed Take w/ food, avoid high-fat meals Monitor hepatic & renal function before & periodically during tx

Provide comfort & safety measures if CNS effects occur Provide oral hygiene & ready access to bathroom facilities Small, frequent nutrition, monitor nutritional status Ensure pt. instruction

The pt. should: Take safety precaution changing position slowly, avoid driving & hazardous tasks

Take drug w/ meals & try small, frequent meal if GI upset occur Note importance of hand washing & hygiene measures Report fever & severe diarrhea, or aggravation of condition, w/c could indicate a resistant strain or noneffective therapy to a health care provider

Evaluation Monitor pt. response to the drug Monitor for adverse effects (nutritional state, orientation & effect, skin color & lesions, hepatic & renal fxn, abdominal discomfort & pain Evaluate effectiveness of teaching plan Monitor compliance, comfort, & safety measures

ANTINEOPLASTIC AGENTS - use components of immune system instead of destroying cells directly - 2nd leading cause of death n US - genetically different cells divide passed to daughter cells tumor/neoplasm - cancerous cells exhibit

anaplasia

- anaplasia loss of cellular differentiation & organization - metastasis Alkylating Agents

Busulfan, Carboplatin, Chlorambucil, Cisplatin, Cyclophosphamide, Ifosfamide, Mechlorethamine, Thiotepa

Antimetabolites Cytarabine, Fludarabine, Fluorouracil, Mercaptopurine, methotrexate Antitumor Anitbiotics Bleomycin, Dactinomycin, Daunorubicin, Doxorubicin

Hormonal Agents Diethylstilbestrol, Leuprolide, Megestrol, Tamoxifen, Testosterone Vinca Alkaloids Vinblastine, Vincristine Individual Agents Asparaginase, Procarbazine

General Information & Action Goal: Interruption or alteration of phase of the cell cycle Classified as cell cycle specific/nonspecific Cell cycle specific agents that affect the cell during 1 phase of the cell life cycle; have their greatest activity during the S phase, blocking DNA synthesis

Cell cycle nonspecific those that exert their effects during >1 phase Destroys normal cells as well as malignant cells Adverse reactions are most often a result of changes in normal cell growth Cancer cells rapidly dividing; drug affects them directly

Also affects other body cells that normally reproduce rapidly: cells of GIT, hair follicles, bone marrow

General Use For cure, control, or palliation (temporary relief of symptoms) of leukemias, lymphomas, solid tumors & preparation for BMT

 Some drugs (methotrexate) used to treat RA Often used in combination, to reduce risk drug of drug toxicity & increase therapeutic response Also used for surgery & radiation Adjuvant therapy drugs given after removal of all known cancer present

Contraindications Consumption of alcohol Hypersensitivity History of BMD

Adverse Reaction BMD (myelosuppression) Nausea, vomiting, anorexia, diarrhea Alopecia

 Amenorrhea Stomatitis, mucositis Pneumonitis skin eruptions Male impotency Heart failure & resp. changes Anaphylaxis Metabolic alterations, neurotoxicity Decreased kidney function Paralytic ileus Septic shock

Nursing Considerations 1.Accurate identification of kind of cell involved in the neoplasm 2.Proper evaluation of the pts condition ideally: no major infection, bleeding or other serious illness 3.Spills of chemo drugs should be cleaned up immediately by trained personnel

4. Follow special protective procedures for drug mixing, administration, disposal of equipment, unused drugs 5. Vesicant drugs that accidentally leak into surrounding tissues from IV site require immediate tx to prevent tissue damage 6. 24 hr. monitoring of reactions may be needed

NONNARCOTIC ANALGESICS/NONSTEROIDAL ANTI-INFLAMMATORY AGENTS Individual agents: acetaminophen, misoprostol, phenazopyridine NSAIDs: ibuprofen, indomethacin, naproxen, piroxicam, sulindac Salicylates: aspirin, choline magnesium trisalicylate, choline salicylate, salsalate

General Information & Action Salicylates, salicylate-like & NSAIDs inflammatory diseases (RA, DJD, lupus erythematosus, & scleroderma) NSAIDs have analgesic, anti-inflammatory, & antipyretic actions

 Analgesic/anti-inflammatory inhibition of prostaglandin synthesis Antipyretic inhibition of both prostaglandin synthesis & vasodilation Major Subgroups: Acetaminophen prostaglandin inhibition in CNS; peripheral & anti-inflammatory effects, minimal

 Misoprostol synthetic prostaglandin, marketed as antiulcer - Inhibit gastric acid secretion & thought to increase mucus production thereby protecting against adverse GI effects of prostaglandin inhibitors (ie. salicylates, NSAIDs); px concurrently w/ NSAID therapy

 NSAIDs anti-prostaglandin agents enhanced by inhibition of lysosomal enzyme release of substances causing inflammation Salicylates have antipyretic, analgesic, & antiinflammatory properties - cholin salicylate only liquid salicylate available

- salsalate converted to salicylate in the liver & has fewer GI adverse effects General Use To control mild to moderate pain, fever & inflammation (RA, OA) Acetaminophen has no antiinflammatory effect, useful only to reduce pain & fever

 Phenazopyridine (spasmolytic) used only for pain r/t urinary tract ASA, ibuprofen, & acetaminophen are popular nonprescription drugs for h/a, mild to moderate pain ASA & Aceta found in many OTC drug combinations

Contraindications Hypersensitivity - ASA Acetaminophen safe for use in pregnancy occasionally All salicylates are contraindicated in persons <21 y/o Reyes syndrome, a potentially fatal dse involving brain & liver dysfunction

Adverse Effects GI irritation & discomfort NVD, abdominal pain, flatulence, GI bleeding & ulceration Tinnitus, hearing loss, weakness, profuse sweating, slowed respiration & HR

Nursing Consideration 1. Patients w/ hx of bleeding should be monitored closely coz of prolonged bleeding time 2. Caution w/ severe CV, liver, or kidney dse 3. w/ pregnant women 4. w/ asthma or nasal polyps, allergy to ASA higher risk for hypersensitivity

Drug-Drug Interactions w/ narcotics additive analgesic effect w/ anticoagulants, some cephalosporins, plicamycin, thrombolytic agents, valproic acid prolonged bleeding time

 Diuretics & other antihypertensive drugs may be diminished fluid retention w/ zidovudine toxicity w/ acetaminophen Large doses of Acetaminophen can cause necrosis of liver w/ corticosteroid + salicylates = GI ulceration & bleeding

 w/ phenytoin, sulfonlyureas, & sulfonamides = toxicity & shortened duration of action

ANXIOLYTIC/SEDATIVE/HYPNO TIC/MINOR TRANQUILIZER

A. Benzodiazepine lam, pam Diazepam (P) Midazolam Hcl Clonazepam Alprazolam

Action - act in the limbic system & the RAS to make GABA more effective - for anxiety d/o, alcohol withdrawal, hyperexcitability & agitation Contraindication Allergy to any benzodiazepine

 Psychosis exacerbated by sedation Glaucoma, shock, coma, acute alcoholic intoxication Pregnancy cleft lip/palate, inguinal hernia, cardiac defects, microcephaly, or pyloric stenosis Lactation Caution w/ elderly/debilitated pts.

 Renal/hepatic dysfunction Adverse Effects CNS: sedation, drowsiness, lethargy, blurred vision, h/a, apathy, lightheadedness, confusion GU: urinary retention, hesitancy, loss of libido, *do not stop abruptly

B. Barbiturates - general CNS depressant; relief of s/s of anxiety, insomnia, seizure

C. Non-Barbiturate, Nonbenzodiazepine Buspirone (Buspar), Nabilone (cesamet) *used for long term therapy; takes 3-6 wks. to take effect

ANTIDEPPRESSANT AGENTS - Obsessive-Compulsive disorder, Panic, PTSD, Premature Ejaculation

TCA

(Tricyclic Antideppressant)

Elavil (Amitriptyline) Tofranil (Imipramine Hcl) Anafranil (Clomipramine Hcl) Mellaril (Thioridazine Hcl)

SSRI

(Selective Serotonin Reuptake Inhibitor) Paxil (Paroxetine Hcl) Prozac (Fluoxetine Hcl) Zoloft (Sertraline Hcl) MAOI (Monoamine Oxidase Inhibitor) NO for tyrmaine Pamoate Nardil Marplan

Nursing Consideration Limit drug access if pt. is suicidal Maintain 4-8 wks. Initial dosage reduce dosage if minor S/E occurs

ANTIPSYCHOTIC/ MAJOR TRANQUILIZERS/NEUROLEPTIC S/DOPAMINE ANTAGONIST

A.Typical (old) zine

Chlorpromazine (P) Thorazine Haldol B. Atypical (new) after 1990 - <effect on EPS

 Resperidone (Resperdal) Clozapine (Clozaril); (P) Olanzapin (Zyprexia) Adverse Effect Agranulocytosis Photosensitivity Orthostatic hypotension Akathisia Tardive dyskenisia Dystonia

Antipsychotic Antimanic Lithium Oskalith, Carbolith, Lithobid CNS Stimulants - for tx of attention-deficit d/o; narcolepsy Dexymethylphenidate Dextroamphetamine Methylphenidate (Ritalin); (P)

ANTIEPILEPTIC AGENTS Tonic-clonic (Grand Mal) Seizure A. Hydantoins- Phenytoin (P) B. Barbiturates Phenobarbital (P) C. Benzodiazepines diazepam (P)

Absence (Petit Mal) Seizure A. Succinimides Ethosuximide (P) B. Other drugs Valproic acid (P); Acetazolamide
Partial (Focal) Seizure Carbamezipine (P)

ANTIPARKINSONISM A. Dopaminergic (DA Agonist) - Carbidopa (Sinemet) - Amantadine (Symmetrel) - Levodopa (Larodopa)

B. Anticholinergic - ABCs - A Atropine So4, Artane, Akineton - Benadryl - Cogentin (Benztropine Mesylate

Action - to achieve balance b/w acetlycholine & dopamine (DA) Contraindication Anticholinergic narrowangle glaucoma, tachycardia, thyrotoxicosis No for children <12 y/o Levodopa lactation

Adverse Reaction Changes in BP & cardiac arrythmias Levodopa - precipitates psychosis, melanoma, hemolytic anemia, Anticholinergic dry mouth, blurred vision, constipation, urinary retention

MUSCLE RELAXANTS Centrally Acting Baclofen, Carisoprodol, Cyclobenzaprine, Diazepam, Methocarbamol Direct-acting Agents dantrolene

Action - for muscle spasm, sprain, SCI, cerebral palsy

Contraindications Hypersensitivity to drug or tartrazine (yellow food color) pt. w/ glaucoma, gastric & intestinal obstruction, prostatic hypertrophy Adverse Reaction CNS depression drowsiness, ataxia Anticholinergic effects

 Blood leukopenia, thrombocytopenia, agranulocytosis Caution w/ seizure d/o hepatotoxicity

NARCOTIC ANALGESIC Narcotic codeine, hydrocodone, hydromorphone, meperidine, methadone, morphine, oxycodone, propoxyphene Mixed narcotic agonist/antagonist

Action - interferes w/ pain receptors in nerve endings, change pain perception, or change pain reaction through responses in the autonomic & skeletal muscle

Contraindication
Hypersensitivity

Narcotics head injury, respiratory depression & shock

Adverse Reaction CNS: euphoria or sedation, dizziness, resp. depression GI: vomiting (CTZ), constipation GU: urinary retention

Morphine: biliary colic CV: flushing, inc. HR, palpitations, hypotension, fainting

ALPHA-ADRENERGIC BLOCKING AGENTS (alpha blockers) block the effects of the catecholamines epinephrine & norepinephrine on alpha-adrenergic receptors in ANS Prevents vasoconstriction caused by catecholamines Primary site smooth muscle of bld. vessel wall

 Causes relaxation of bld. vessel wall, increasing bld. flow Inhibit effects of glands sweat & salivary Agents: phenoxybenzamine, phentolamine

Indication Blood vessel spasm Raynauds dse

 HPN, sweating adrenergic excess (pheochromocytoma, pt. taking MAOI, eats food w/ tyramine) Contraindication In any condition in w/c a sharp drop in BP is undesirable Hypersensitivity, pregnancy, lactation

Adverse Reaction Orthostatic hypotension, circulatory failure Dizziness, weakness, fainting Tachycardia esp. to pts. w/ heart dse GI irritation, NVD

Nursing Consideration Pts. w/ severe cerebral or coronary arteirosclerosis, gastritis, ulcer stimulate motility & contractility

Drug-Drug Interactions antiHPN, block effects of adrenergic drugs (phenylephrine, ephedrine) used as OTC decongestants

BETA-ADRENERGIC BLOCKING AGENTS Atenolol, metoprolol, nadolol, propranolol, timolol 2 types of beta-adrenergic receptors beta-1 & beta-2

Action Beta-1 increased contractility (+ inotropic effect), HR (+ chronotropic effect), & AV conduction (+ dromotropic effect) Beta-2 located in smooth muscle of bronchi, bld. vessel, & uterus cause bronchodilation, vasodilation, relaxation of uterus

 Blocks beta-1 & beta-2 receptor stimulation slows HR, dec. in myocardial contractility, CO, BP Indication For angina pectoris, HPN, tachyarrhythmias, pheochromocytoma, prevention of MI & migrane h/a

 Timolol used for glaucoma Useful for symptoms of hyperthyroidism Propranolol only betablocker for hypertrophic subaortic stenosis causes angina, palpitations, syncope; control tremors

Contraindication CHF, heart block, bradycardia caused by arrhthymias w/ asthma, COPD, any conidtion involving acute bronchospasm Adverse Reaction CV reactions Dizziness, fatigue, weakness, depression insomnia

 Raynauds phenomena *do not withdraw abruptly (sympathomimetic (adrenergic symptoms)

Drug-Drug Interaction w/ cardiac glycosides, Ca channel blockers, GA quinidine may exaggerate bradycardia & cardiac depression

 Antidiabetic drugs (insulin) prolonged hypoglycemia HPN drugs, phenothiazines, & nitrates Bronchodilators, catecholamines (epi, norepi, DA) Cimetidine, oral contraceptives, furosemide, or hydralzine Thyroid prep. dec. effect

CALCIUM CHANNEL BLOCKERS - Diltiazem, felodipine, nicardipine, nifedipine, verapamil Action Contraction of the heart muscle, & tone of blood vessels

 Decrease the ability of Ca to enter the cells of myocardium & smooth muscle of peripheral blood vessels Dilate coronary arteries & help prevent coronary artery spasm Decrease force of contraction, slows AV conduction, reduces HR

Indication Angina pectoris, HPN, coronary artery spasm Tx of menstrual cramps, premature labor Contraindication Hypersensitivity Bradycardia, 2nd & 3rd-degree heart block, or severe CHF (Diltiazem & Verapamil)

Adverse Reaction CV: Hypotension, changes in HR, cardiac arrhythmias GI: nausea, constipation CNS: dizziness, h/a CHF s/s: SOB, dyspnea, peripheral edema

Drug-Drug Interactions w/ B-adrenergic blockers, quinidine, carbamezipine Phenobarbital, phenytoin, cardiac glycoside

GENERAL & LOCAL ANESTHETIC AGENTS General are CNS depressants used to produce loss of pain sensation & consciousness Barbiturates:methohexital, thiopental (P)

 Non-barbiturate: droperidol, etomidate, ketamine, midazolam (P), propofol Gases: cyclopropane, ethylene, nitrous oxide (P) Volatile liquids: desflurane, enflurane, halothane (P)

Local Anesthetics used to cause loss of pain sensation & feeling in a designated part of a body without the systemic effects ass. w/ severe CNS depression Esters: benzocaine (P), butamben, procaine Amine: Bupivacaine, lidocaine(P)

NEUROMUSCULAR JUNCTION BLOCKING AGENTS

Non-depolarizing Neuromuscular blockers acts

as antagonists to Ach at the NMJ & prevent depolarization of muscle cells Atracurium, tubocurarine (P), vecoronium

Depolarizing neuromuscular blocker acts as ACH agonist

causing stimulation of the muscle cells & then preventing it from repolarizing succinylcholine *Both of these types cause

paralysis/loss of muscular function, for performance of

SP or facilitation of MV

Indication - adjunct to GA, facilitate mechanical intubation, facilitate ECT

ADRENERGIC AGENTS (Sypmathomimetic drugs)

Dobutamine, dopamine (P), epinephrine, norepinephrine, terbutaline, albuterol

Indication

shock, bronchospasm, asthma

increases HR, bronchodilation, vasoconstriction, glycogenolysis,

Contraindication pheochromocytoma, tachyarrhythmias, ventricular fibrillation, PVD,

Adverse Effect SNS: arrhythmia, HPN, palpitation, angina, dyspnea, N/V, h/a, sweating, piloerection

Drug-Drug Interactions Increased effects of TCAs & MAOI

CHOLINERGIC AGENTS Direct-Acting Cholinergic

Agonists

- Bethanecol (P), pilocarpine

Indirect-Acting Cholinergic

Agonists

- donepezil (P), edrophonium, neostigmine, pyridostigmine (P)

Are chemicals that act at the same site as the neurotransmitter acetylcholine (Ach) Found in PNS stimulation of these sites produces a response similar to what is seen when the PNS is activated Referred to as

parasympathomimetic drugs

Action slows HR, vasodilation, bronchoconstriction, inc. secretion from bronchial mucus, inc. GI activity, inc. bladder tone, pupil constriction

ADRENOCORTICAL AGENTS
Glucocorticoids antiinflammatory & immunosuppressive effect; affect K, NA, & h2o levels betamethasone, prednisolone (P)

Mineralocorticoids inc. NA reabsorption, inc. K & H excretion, renal insufficiency,hypotension hydrocortisone, fludrocortisone (P)

THYROID & PARATHYROID AGENTS

Thyroid Hormones hypothyroidism (myxedem coma); inc. metabolic rate, prevention of goiters, mngt. of thyroid Ca levothyroxine (P) (Synthroid)

Antithyroid Agents acute thyrotoxicosis; to block thyroid function in radiation emergencies propylthiouracil (PTU), radioactive idodide (I 131), K iodide Antihypocalcemic Agents calcitrol (P)

Antihypercalcemic - Pagets dse, osteoporosis (Biphosphonates) alendronate (P), calcitonins, gallium

ANTIDIABETIC AGENTS Parenteral Antidiabetic insulin Oral Antidiabetic Sulfonylureas: 1st generation Chlorpropamide (P) Talbutamide Sulfonylureas: 2nd generation Glipizide Glyburide (P)

Nonsulfonylureas acarbose (P) metformin, Glucose-elevating agent glucagon, diazoxide

DRUGS AFFECTING FEMALE REPRODUCTIVE SYSTEM

hormone progesterone Eg. Levonorgestrel (P); estradiol (P) Fertility drugs stimulate the female reproductive system Eg. Clomiphene

Progestins - Includes female

 Oxytocics stimulate uterine contractions & assist labor Eg. Oxytocin (P) Abortifacients used to induce abortion Eg. Dinoprostone (P); Carboprost

 Tocolytics used to relax gravid uterus to polong pregnancy Eg. Ritodrine (Yutopar) (P)

DRUGS AFFECTING THE MALE REPRODUCTIVE SYSTEM

ANDROGEN more anabolic effects rather than androgenic

(male sexual characteristic); improve penile dysfunction;

hypogonadism

(underdeveloped testes); tx of breast Ca Eg. Testosterone (P); Danazol

Anabolic steroids stanozolol

(P); oxymetholone

Drugs for treating Penile Dysfunction sildenafil (P);

alprostadil

DRUGS ACTING ON THE CARDIOVASCULAR SYSTEM Drugs affecting Blood Pressure Cardiotonic Agents Antiarrhthmic Agents Antianginal Agents Lipid-lowering Agents Drugs Affecting Blood Coagulation Drugs Used to Treat Anemias

Drugs Affecting BP (ABCD) A Angiotensin-Converting Enzyme Inhibitors (ACE) pril; stops the phase of RAS Benazepril, enalapril, capropril (P) A Angiotensin II Receptor

Blockers

Betablocker

Losartan (P), telmisartan

Ca Channel Blockers Diuretics Others: Vasodilators hydralazine; Nitroprusside

Ganglionic Blocker
mecamylamine

Antihypotensive agent
midodrine

Action - prevent conversion of AI to AII, a powerful vasoconstrictor & stimulator of aldosterone release - conjunction w/ digoxin & diuretics to tx CHF & left ventricle dysfunction

Contraindication Allergy to ACE inhibitors Impaired renal function Pregnancy & lactation Caution w/ CHF & salt/volume depletion

Adverse Effects Tachycardia, chest pain, CHF, cardiac arrhythmias

 GI irritation, ulcers, constipation, liver injury Proetinuria, RF Rash, alopecia, dermatitis, photosensitivity Drug-Drug Interaction w/ Allopurinol Drug-Food Empty stomach

CARDIOTONIC AGENTS Cardiac Glycoside Digoxin (P) (Lanoxin)

Phosphodiesterase Inhibtors Inamrinone (P)

Digoxin Antidote Digoxin Immune Fab

Action & Indication - increase intracellular Ca & allow more Ca to enter myocardial cells during depolarization causing: + inotropic effect (inc. force of myocardial contraction - Increased cardiac output& renal perfusion

- Slow HR owing to slowing of cellular repolarization (chronotropic effect) - Decreased conduction velocity through AV node Contraindication & Caution Vent. tach./vent. fib.

Allergy w/ digitalis preparation

Heart block; MI Pregnant & lactating

ANTIARRHYTHMIC AGENTS

membrane by binding to Na channels; Ventricular A.

quinidine (P); procainamide

Class Ia stabliize cell

Contraindication

Allergy bradycardia/heart block CHF; hypotension, shock

 lactation; electrolyte disturbances; renal/hepatic dysfunction; pregnancy Adverse Effects CNS: dizziness, drowsiness, fatigue, twitching, mouth numbness, slurred speech, vision changes, tremors GI: change in taste, n/v

cardiac arrest RS: resp. depression Others: rash, hypersensitivity, loss of hair, BMD

CV: hypotension, vasodialtion,

lidocaine (P)

Class Ib Antiarrhythmics Class Ic Antiarrhythmics

flecainide

 Class II Antiarrhythmics propranolol (P) Class III Antiarrhythmics amiodarone; bretyllium (P); sotalol Class IV Antiarrhythmics diltiazem (P); verapamil Other: adenosine; digoxin

ANTIANGINAL AGENTS

smooth muscle, reduces myocardial workload; for prevention & tx of angina pectoris
Isosorbide mononitrate

Nitrates direct relaxation of

Nitrogylcerin (NTG) (P)

Contraindication Allergy to nitrates Severe anemia Head trauma/cerebral hemorrhage Pregnancy/Lactation hepatic/renal dse Caution w/ hypotension, conditions limiting CO (eg. tamponade)

Adverse Effects

CNS: h/a, dizziness, weakness

GI: n/v, incontinence CV: hypotension, tachycardia, angina Skin: flushing, pallor, sweating, increased perspiration

B-blockers block Badrenergic receptors & vasoconstriction

metoprolol

Nadolol Propranolol

Ca-Channel Blockers prevent movement of Ca into cardiac & smooth muscle cell

 Amlodipine Bepridil Diltiazem (P)

LIPID-LOWERING AGENTS/ANTILIPEMICS

HMG-CoA Reducatse Inhibitors - block formation of cellular cholesterol, leading to decrease in serum cholesterol

Cholestyramine (P)

Bile acid sequestrant

 Lovastatin (Mevacor) (P) Simvastatin (Zocor) Other: clofibrate, niacin, HRT Contraindication Allergy w/ statins or fungal byproducts or compounds Active liver dse Pregnancy/lactation Impaired endocrine function

Adverse Effects GI: flatulence, abdominal pain, cramps, n/v, constipation, acute liver failure CNS: h/a, dizziness, blurred vision, insomnia, fatigue, cataract devt MS: Rhabdomyolysis ES: ARF

DRUGS AFFECTING BLOOD COAGULATION

Antiplatelet drugs inhibit platelet adhesion & aggregation by blocking receptor sites on platelet membrane
Aspirin (P)

Clopidogrel (Plavix)

Contraindication Allergy to specific drug Pregnancy, lactation Presence of known bleeding disorder Recent surgery Closed head injuries

Adverse effects Bleeding Skin rash

Anticoagulants interferes clotting process; tx of thromboembolic disorders (eg. atrial fib., MI, pulmonary embolus, stroke)
Antithrombin Heparin (P) Warfarin

Low-Molecular-Weight Heparins inhibit thrombus & clot formation by blocking clotting factors Enoxaparin (P)
Anticoagulant Adjunctive Therapy Protamine sulfate Vitamin K

Contraindication Known allergy to drugs w/ hemorrhagic disorders Recent trauma, spinal punture GI ulcers recent sx Caution w/ CHF, thyrotoxicosis, psychosis

Hemorheologic agent Pentoxifylline

Thrombolytic agents breaks down fibrin threads & dissolves clot

Alteplase

Reteplase Streptokinase(P) Urokinase

Drugs used to control bleeding replacement factors that are genetically missing; prevent blood loss, treat bleeding episodes Antihemophilic agent Antihemophilic factor(P) Factor IX complex

Contraindication Allergy to mouse proteins Liver dse factor IX Lactation/pregnancy Adverse Effects Risk w/ use of blood products h/a, flushing, chills, fever, lethargy

n/v, stinging, itching, burning at site of injection

Systemic

Hemostatic Agents Aminocapoic acid (P) Aprotinin hemostatic agent Absorbable gelatin (P) Microfibrillar collagen

Topical

DRUGS USED TO TREAT ANEMIAS

Erythropoietin Darbopoetin alfa Epoetin alfa Indication & Action Acts like the natural glycoprotein erythropoietin to stimulate the production of RBCs in the bone marrow

 Tx of anemia in RF & for pts. on dialysis To decrease need of BT Tx of anemia associated w/ AIDS therapy Tx for anemia associated w/ cancer chemotherapy

Contraindication & Caution Uncontrolled HPN

 w/ allergy to mammalian-cell derived product/human albumin lactation

Adverse Effects CNS effects asthenia, potential for seizure GI sx CV: HPN, edema, possible chest pain

 Possible clotting of access line r/t direct cellular effects of the drug

Iron preparations Ferrous fumarate Ferrous gluconate Ferrous sulfate (P) Iron dextran

Indications Elevate serum iron concentration Tx of IDA Adjunctive therapy for pt. receiving epoetin alfa Contraindication & Caution w/ known allergy

 Hemochromatosis (excessive iron) Hemolytic anemias

Peptic ulcer, colitis, regional enteritis

Adverse Effects
CNS toxic

GI irritation/upset: + dark stools constipation

Parenteral Iron: anaphylactic

reaction, local irritation, staining of the tissues, phlebitis

Folic acid (P)

Folic acid derivatives

Leucovorin

Indication & Action Essential for cell growth & division Production of strong stoma in RBCs Necessary for maintenance of myelin sheath in nerve tissue Dietary deficiencies Pregnancy & lactation

Contraindication & Caution

w/ caution to pregnant & lactating patients

Adverse effects

Pain & discomfort at injection sites

Nasal irritation w/ the use of nasal spray

Vitamin b12 Cyanocobalamin Hydroxocobalamin (P)

DRUGS ACTING ON THE RENAL SYSTEM

DIURETIC AGENTS

Thiazide Diuretics (DCT) Hydrochlorothiazide (P)

Thiazide-Like Diuretics Chlorthalidone (P)

Loop Diuretics (LoH) Furosemide (P)

Carbonic Anhydrase Inhibitors (PT) Acetazolamide (P) Potassium-Sparing Diuretics (DT & collecting duct) Spironolactone (P)

Osmotic Diuretic (glomerulus, tubule) Mannitol (P) Isosorbide

General Action & Indication Prevents reabsorption of excessive proportion of sodium ions in glomerular filtrate

 Cause increased intravascular volume & hydrostatic pressure, w/c could result in leaking of fluids at capillary level For tx of edema (CHF) Acute pulmonary edema Liver/renal disease Tx of HPN

 Decrease fluid pressure in the eye (intraocular pressure; glaucoma) Tx of hyperkalemia

Contraindication & Caution

Allergy

w/ fluid & electrolyte imbalance severe renal dse

 Systemic lupus erythematosus (SLE) DM (glucose-elevating effects) Gout (abnormality in renal tubule reabsorption & secretion) Liver dse Pregnancy & lactation

Adverse Effects GI upset Fluid & electrolyte imbalances Hypotension Electrolyte disturbances

DRUGS AFFECTING THE URINARY TRACT & THE BLADDER

Methylene blue

Urinary Tract Anti-Infectives

Nalidixic acid Norfloxacin

Oxybutynin
Urinary

Urinary Tract Antispasmodics

Tract Analgesic Phenazopyridine

Bladder Protectant protect from irritation r/t solutes in the urine; has anticoagulant & fibrinolytic effects Pentosan Polysulfate Sodium

Drug Used to Treat BPH (aused to block dilation of arterioles in bladder & urinary tract Doxazosin (P) Finasteride terazosin

adrenergic blocking agent)

DRUGS ACTING ON THE RESPIRATORY SYSTEM

DRUGS ACTING ON THE UPPER RESPIRATORY TRACT

Antitussive Codeine Dextromethorphan Hydrocodone

Topical Nasal Decongestants

Oral Decongestants
Ephedrine (P) Phenylephrine

Decongestants

Topical Nasal Steroid Decongestants

Pseudoephedrine (P)

Beclomethasone Dexamethasone flunisolide

Antihistamines Azatadine Brompheniramine Cetirizine Desloratadine Diphenhydramine (P)

Expectorants Guaifenesin Terpin hydrate

Mucolytics Acetlycysteine (P) Domase alfa

DRUGS USED TO TREAT OBSTRUCTIVE PULMONARY DISORDERS Asthma COPD; emphysema; RDS
Bronchodilators/Antiasthmatic

s, Xanthines Aminophylline

Theophylline (P)

Action & Indication Directly affects smooth muscle of RT both in bronchi & blood vessels Increase vital capacity that has been impaired by bronchospasm or air trapping

Contraindication w/ GI problems coronary dse, respiratory dysfunction Renal/hepatic dse,alcoholism Hyperthyroidism Adverse Effects

Normal level: 10-20 mcg/ml

GI upset, irritability,

 Seizure, brain damage, death

Sympathomimetics Terbutaline Ephedrine Epinephrine (P)

Indication Bronchospasm in reversible obstructive airway dse

Contraindication Cardiac/vascular dse, arrhythmias Diabetes. Hyperthyroidism Pregnancy, lactation Adverse Effects CNS stimulation GI upset Cardiac arrhythmias, HPN

Bronchospasm, sweating Pallor, flushing

Anticholinergics Ipratropium

Inhaled Steroids (P) flunisolide Action & Indication Used to decrease inflammatory response in airway Increase airflow & facilitate respiration

Promotes B-adrenergic receptor activity w/c may promote smooth muscle relaxation & inhibit bronchoconstriction Prevention & tx of asthma

Contraindications Not for use during acute asthma attack/status asthmaticus

Pregnancy/lactation w/ active infection of Resp. sys.

Adverse Effects Sore throat, hoarseness, coughing, dry mouth Pharyngeal/laryngeal fungal infection

Leukotriene Receptor Antagonists Zafirlukast (P) Montelukast

Indication Blocks s/s of asthma (eg. neutrophil & eosinophil migration, smooth muscle contraction)

 For prophylaxis & chronic tx of bronchial asthma in adults & <12y/o Not indicated for acute asthmatic attacks

Contraindications w/ hepatic/renal impairment Pregnancy & lactation

Adverse Effects h/a, dizziness, myalgia Nvd, abd. Pain, elevated liver enzymes Generalized pain, fever

Lung Surfactants Beractant (P) Calfactant

Indication Reduces surface tension w/n the alveoli allowing expansion & gas exchange Prophylactic tx for those at risk for RDS Adverse Effects Patent ductus arteriosus, hypotension

 Intraventricular hemorrhage, pneumothorax Hyperbilirubinemia, sepsis

Mast Cell Stabilizers (P) Cromolyn Nedocromil

Action/Indication Prevent release of inflammatory & bronchoconstricting substances Prevents allergic asthmatic response Tx of chronic bronchial asthma, exercise-induced asthma, allergic rhinitis

Contraindication Known allergy to drug Cannot be used during an acute attack Cromolyn not recommended for <2y/o children Nedocromil not recommended for >12y/o

Adverse Effects Swollen eyes, h/a, dizziness, fatigue dry mucosa, nausea, cough Should not be discontinued abruptly

DRUGS ACTING ON THE GI SYSTEM

Drugs Affecting GI secretions 5 types of drugs used to treat ulcers: 1. Histamine-2 (H2) antagonists block the release of HCL acid in response to

gastrin

 Cimetidine (P) Famotidine Ranitidine

Action/Indication Block histamine-2 receptor sites w/c leads to reduction in gastric acid secretion & reduction in overall pepsin production H2 receptor sites heart cardiac arrhythmias Short-term tx of active doudenal ulcer or benign gastric ulcer

 Tx of pathological hypersecretory conditions (Zollinger-Ellison syndrome) Prophylaxis of stress-induced ulcers, acute upper GI bleeding Tx of erosive GER Relief of symptoms of heartburn, acid indigestion, & sour stomach (OTC prep.)

Contraindications/Cautions Known allergy Caution w/ pregnancy/lactation Hepatic/renal dysfunction Adverse Effects Diarrhea/constipation Dizziness, h/a, somnolence, confusion, hallucination

 Cardiac arrhythmias, hypotension

Gynecomastia (w/ long-term use w/ cimetidine), impotence 2. Antacids interact w/ acids at the chemical level to neutralize them

 Aluminum Sodium bicarbonate (P) Magnesium/Ca salts Magaldrate Action/Indication Symptomatic relief of upset stomach associated w/ hyperacidity (w/ peptic ulcer, gastritis, peptic esophagitis, hiatal hernia)

hernia of upper stomach: a hernia in which the part of the stomach around the esophagus entrance is forced up into the chest cavity through the normal opening in the diaphragm for the esophagus. Hiatal hernia is associated with heartburn and can usually be corrected by surgery. Microsoft Encarta 2009. 1993-2008 Microsoft Corporation. All rights reserved.

Contraindication/Caution Known allergy Caution w/ electrolyte imbalance, GI obstruction Adverse Effects Rebound acidity

Alkalosis w/ resultant metabolic changes (n/v, neuromuscular changes, h/a, irritability, muscle twitching, coma)

Hypercalcemia & milk-alkali syndrome (seen as

alkalosis, renal Ca deposits, severe electrolyte disorders) Constipation/diarrhea Hypophosphatmeia (due to Al salts) Fluid retention, CHF (Na HCO3)

3. Proton Pump Inhibitors (PPI) suppress the secretion of HCL acid into the lumen of the stomach Omeprazole (P) lansoprazole Indication/Action Act at specific secretory surface receptors to prevent final step of acid production

 For short-term tx of active doudenal ulcers, GERD, erosive esophagitis, benign active gastric ulcer Long-term tx of pathological hypersecretory conditions As maintenance therapy for healing of erosive esophagitis & ulcers

Contraindications/Cautions w/ known allergy Pregnant/lactating women Adverse Effects Dizziness, h/a asthenia (loss of strength), vertigo, insomnia, apathy Diarrhea, abd. pain, n/v, dry mouth, tongue atrophy

 Cough, stuffy nose, hoarseness, epistaxis Rash, pruritus 4. Antipeptic Agents coat any injured area in the stomach to prevent further injury from acid Sucralfate

Action/Indication Protect sites against acid, pepsin, & bile salts prevents furhter beakdown of the area & promotes ulcer healing Inhibits pepsin activity in gastric juices Short-term tx of doudenal ulcers

5. Prostaglandins inhibit the secretion of gastrin & increase the secretion of mucus lining of the stomach, providing a buffer Misoprostol Action/Indication Prevent NSAID-induced gastric ulcers

Contraindication Abortifacient

Adverse Effects Nvd, dyspepsia Miscarriages, excessive bleeding, spotting, cramping, hypermenorrhea, dysmenorrhea

6. Digestive Enzymes suffered strokes, salivary gland disorders, surgery of head/neck, cystic fibrosis, pancreatic dysfunction Pancrelipase Pancreatin (P) Saliva substitute

Action/Indication Contains electrolytes & carboxymethylcellulose to act as thickening agent in dry mouth conditions Help digestion & absorption of fats, proteins, & CHO Replacement therapy in pts. w/ cystic fibrosis, chronic pancreatitis, ductal obstruction,

pancreatic insuffciency, steatorrhea, malabsorption syndrome, after pancreatectomy, gastrectomy

Contraindication/Caution Known allergy to parabens or any component of the drug w/ pt. w/ CHF, HPN, RF Known allergy to the product or to pork products

Adverse Effects Cx from abnormal electrolyte absorption (eg. increased level of Mg, Na, or K GI irritation

LAXATIVE & ANTIDARRHEAL AGENTS Speed up or improve movement of intestinal contents along GIT Increase tone of GIT & to stimulate motility throughout the system

Used to decrease movt along GIT when rapid movt decreases the time for absorption of nutrients, leading to loss of H2O & nutrient

LAXATIVES Chemical stimulants Bisacodyl

 Cascara Castor oil (P)

Bulk Laxatives Lactulose Mg citrate (P) Mg hydroxide

Lubricants Mineral oil (P)

GI Stimulants Metoclopramide (P) Dexpanthenol Antidiarrheal Agents Bismuth subsalicylate Loperamide (P) Opium

EMETIC & ANTIEMETIC AGENTS Emetic Agent Ipecac syrup (P)

Indication/Action In cases of overdose or poisoning Gastric lavage

Irritates GI mucosa w/c stimulates CTZ

Contraindication/Caution Ingestion of caustic alkali or corrosive mineral acids potential for upper GI & airway serious damage When volatile petroleum distillate (kerosene) have been swallowed - aspiration

 Comatose/semi-comatose pt.; s/s of convulsion Adverse Effects GI upset, mild CNS depression Cardiotoxicity

Antiemetic decrease or prevent nausea or vomiting Reduces hyperactivity of the vomiting reflex either decrease local response to stimuli or block CTZ Phenothiazine Chlorpromazine Prochlorperazine (P) Promethazine

 Nonphenothiazines Metoclopramide

Anticholinergics/Antihistami

nes

Meclizine (P) Cyclizine Buclizine

Ondansetron Dolasetron

5-HT3 receptor blockers

Miscellaneous Dronabinol Hydroxyzine trimethobenzamide

Contraindication/Caution w/ coma/severe CNS depression Brain damage/injury Hypo/hypertension Severe liver dysfxn/renal Active eptic ulcer Prenancy/lactation

Adverse Effect interference w/ normal CNS response Cardiac arrhythmias Autonomic effects dry mouth, anorexia, pallor, photosensitivity