Pharmacology Bullet Review

Pharmacology Bullet Review
Nursing Board 2005
Drug classification
Pharmacodynamic s
Pharmacokinetics
Nursing process applied to pharmacology
Diuretics Comparison
Diuretic class 1. Carbonic anhydrase inhibitor 2. Thiazide and thiazide like 3. Loop diuretics 4. Potassium sparing 5. Osmotic diuretic Major site of action Proximal tubule Special Side effect (s) Acidosis
Proximal tubule Loop of Henle Distal tubule Glomerulus
Hyperuricemia Hypokalemia Hypokalemia Ototoxicity Hyperkalemia Hypovolemia & hypotension
Diuretics Comparison
Diuretic class
1. Carbonic anhydrase inhibitor
Special Uses Mountain sickness Menieres disease

Nephrolithiasis due to calcium stones Hypocalcemia Hypercalcemia
2. Thiazide and thiazide like 3. Loop diuretics 4. Potassium sparing 5. Osmotic diuretic
CHF taking digoxin Increased ICP LITHIUM TOXICITY
Thiazides
Prototype: Hydrochlorothiazide Hydrochlorothiazide

1. Bendroflumethiazide Bendroflumethiazide 2. Benthiazide Benthiazide 3. Chlorothiazide (Diuril) Chlorothiazide 4. Hydroflumethiazide Hydroflumethiazide 5. Methylclothiazide Methylclothiazide 6. Trichlormethiazide Trichlormethiazide
ThiazideThiazide-like

1. Indapamide 2. Quinethazone 3. Metolazone 4. Chlorthalidone
Thiazides
Pharmacodynamics These drugs BLOCK the chloride pump This will keep the Chloride and Sodium in the distal tubule to be excreted into the urine Potassium is also flushed out!!
Thiazide

Special Pharmacodynamics: Side effects

Hypokalemia DECREASED calcium excretion hypercalcemia DECREASED uric acid secretion hyperuricemia Hyperglycemia

Loop Diuretics
Prototype: Furosemide

1. Bumetanide 2. Ethacrynic acid 3. Torsemide
Loop Diuretics
Pharmacodynamics High-ceiling diuretics High BLOCK the chloride pump in the ascending loop of Henle SODIUM and CHLORIDE reabsorption is prevented Potassium is also excreted together with Na and Cl
Loop Diuretics
Loop Diuretics

Special Pharmacodynamics: side-effects sideHypokalemia Bicarbonate is lost in the urine INCREASED calcium excretion Hypocalcemia Ototoxicity- due to the electrolyte imbalances Ototoxicity
Potassium sparing diuretics

Prototype: Spironolactone

1. Amiloride 2. Triamterene

Pharmacodynamics Spironolactone is an ALDOSTERONE antagonist Triamterene and Amiloride BLOCK the potassium secretion in the distal tubule Diuretic effect is achieved by the sodium loss to offset potassium retention

Pharmacokinetics: Side effects

HYPERkalemia! Avoid high potassium foods:

Bananas Potatoes Spinach Broccoli Nuts Prunes Tomatoes Oranges Peaches
Osmotic Diuretics
Prototype: Mannitol

1. Glycerin 2. Isosorbide 3. Urea
Osmotic Diuretics
Pharmacodynamics Mannitol is a sugar not well absorbed in the nephron osmotic pull of water diuresis
Osmotic Diuretics
Pharmacokinetics: side effects

Sudden hypovolemia
Important for the nurse to warm the solution to allow the crystals to DISSOLVE in the bottle!
Carbonic Anhydrase Inhibitors

Prototype: Acetazolamide

1. Methazolamide

Pharmacodynamics Carbonic Anhydrase forms sodium bicarbonate BLOCK of the enzyme results to slow movement of hydrogen and bicarbonate into the tubules plus sodium is lost in the urine

Pharmacokinetics: side effects
Metabolic ACIDOSIS happens when bicarbonate is lost Hypokalemia

The Nursing Process and the diuretics

ASSESSMENT Assess the REASON why the drug is given: ______ ______ ______ ______

ASSESSMENT The nurse must elicit history of allergy to the drugs

Allergy to sulfonamides may contraindicate the use of thiazides

Assess fluid and electrolyte balance Assess other conditions like gout, diabetes, pregnancy and lactation

ASSESSMENT Physical assessment
Vital signs Special electrolyte and laboratory examination

Assess symptom of body weakness which may indicate hypokalemia

Nursing Diagnosis
Fluid volume deficit related to diuretic effect Alteration in urinary pattern Potential for injury (ototoxocity, hypotension) Knowledge deficit


IMPLEMENTATION Administer IV drug slowly Safety precaution for dizziness/hypotension Provide potassium RICH foods for most diuretics, with the exception of spironolactone Provide skin care, oral care and urinary care

IMPLEMENTATION Monitor DAILY WEIGHT- to evaluate the WEIGHTeffectiveness of the therapy Monitor urine output, cardiac rhythm. Serum electrolytes ADMINISTER in the MORNING! Administer with FOOD!

EVALUATION: for effectiveness of therapy Weight loss Increased urine output Resolution of edema Decreased congestion Normal BP
The ANXIOLYTICS AND HYPNOTICS

These drugs are used to change the individuals responses to the environment.

The medications that can prevent the feelings of tension and fear are called ANXIOLYTICS.
Anti-anxiety drugs Anti-

The drugs that can calm individuals making them unaware of the environment are called SEDATIVES.

The drugs that can induce sleep are called HYPNOTICS.

The drugs in this class are the
BENZODIAZEPINES BARBITURATES
Use of The Drugs

Clinical indications for the use of the anxiolytics, sedatives and hypnotics 1. Prevention of anxiety 2. Formation of sedative state 3. Induction of sleep
The BENZODIAZEPINES
The benzodiazepines are the most frequently used anxiolytic drugs. These agents prevent anxiety states without causing much sedation, with less physical dependence than other agents.
The BENZODIAZEPINES
The following are the benzodiazepines Alprazolam (Xanax) Chlordiazepoxide (Librium) (Librium) clonazepam clorazepate Diazepam (Valium) estazolam flurazepam lorazepam midazolam oxazepam quazepam temazepam triazolam
The BENZODIAZEPINES Special uses

Diazepam (Valium) Status epilepticus
Chlordiazepoxide Alcohol withdrawal (Librium) Alprazolam (Xanax) Panic attack
The BENZODIAZEPINES
The Mechanism of Action of the Benzodiazepines
These agents act on the Limbic system and the RAS (reticular activating system) to make the GABA ( GammaGammaaminobutyric acid) more effective causing interference with neuron firing.
The BENZODIAZEPINES
The Mechanism of Action of the Benzodiazepines
The GABA is an inhibitory neurotransmitter. This will result to an anxiolytic effect at lower doses than required for sedation/hypnosis.
The BENZODIAZEPINES
These agents are indicated for the treatment of 1. anxiety disorders 2. alcohol withdrawal 3. hyperexcitability, and agitation 4. pre-operative relief of anxiety and pretension and in induction of balanced anesthesia.
The BENZODIAZEPINES
Pharmacodynamics: The adverse effects CNS effects= sedation, drowsiness, depression, lethargy, blurred vision GIT= dry mouth, constipation, nausea, constipation, vomiting CVS= Hypotension or hypertension, arrhythmias, palpitations, and respiratory difficulties. Hematologic= blood dyscrasias and anemia GU= urinary retention, hesitancy, loss of libido and sexual functions changes.
The BENZODIAZEPINES
Nursing Considerations: Maintain patients on bed for at least 3 hours after drug administration. Instruct to avoid hazardous activities like driving and machine operation. Instruct to avoid consuming ALCOHOL while taking the drug. drug.
The BENZODIAZEPINES
Nursing Considerations: Provide comfort measures to help patients tolerate drug effectseffects instruct to urinate before taking drug give high fiber foods use side-rails and assistance with sideambulation.
Have available FLUMAZENIL as an antidote for benzodiazepine overdose.
The BARBITURATES
These are also anxiolytics and hypnotics with a greater likelihood of producing sedation, with increase risk of addiction and dependence.
The BARBITURATES
The following are the barbiturates
amobarbital aprobarbital butabarbital mephobarbital pentobarbital Phenobarbital secobarbital
The BARBITURATES
The Mechanism of Action of the Barbiturates They depress the motor output from the brain. The results of their MOA are sedation, hypnosis and anesthesia, and if extreme, coma.
The BARBITURATES
Clinical indications of the Barbiturates 1. Relief of anxiety manifestations 2. For sedation 3. For patients with insomnia 4. For pre-anesthesia pre5. seizures/epilepsy 6. The rapid acting barbiturates are also used for the treatment of acute manic reactions and status epilepticus
The BARBITURATES
Pharmacodynamics: The Adverse effects CNS= CNS depression, somnolence, depression, somnolence, vertigo, lethargy, ataxia, paradoxical excitement, anxiety and hallucinations. GIT= nausea, vomiting, constipation/diarrhea and epigastric pain CVS= bradycardia, Hypotension and syncope. Respi= serious hypoventilation, respiratory depression and laryngospasms Others= hypersensitivity and StevensStevensJohnson syndrome.
The BARBITURATES
Nursing Considerations Provide stand-by life support facilities standin cases of severe respiratory depression or hypersensitivity reaction. Taper the drug gradually after longlongterm therapy to avoid withdrawal syndrome. Provide comfort measures including small frequent meals, access to bathroom facilities, high-fiber foods, highenvironmental control, safety precaution and skin care.
The CNS stimulants

These are drugs used to treat certain disorders 1. exogenous obesity 2. attention-deficit hyperactivity attentiondisorders (ADHD) 3. narcolepsy
The CNS stimulants

What is unusual is the ability of the CNS stimulants to CALM hyperactive children, which allows them to focus on one activity for a longer period.
The CNS stimulants

The following are the CNS stimulants: 1. Methylphenidate (Ritalin)= most commonly used for ADHD 2. Dextroamphetamine= a CNS stimulant that is used for short tem therapy for obesity. 3. Modafinil= used for narcolepsy 4. Pemoline= used for ADHD
The CNS stimulants

The Mechanism of Action These agents act as to stimulate the cortical and reticular activating system (RAS) of the brain. This is by releasing neurotransmitters from the nerve cells leading to increased stimulation of the post-synaptic postneurons.
The CNS stimulants

The paradoxical effect of calming hyperexcitability through CNS stimulation seen in ADHD is believed to be related to the increased stimulation of an IMMATURE Reticular Activating System leading to the ability to be more selective in response to incoming stimuli.
The CNS stimulants

Pharmacodynamics: Adverse effects of the CNS stimulants CNS= nervousness, insomnia, dizziness, insomnia, headache, and blurred vision GIT= anorexia, nausea and weight loss anorexia, CVS= hypertension, tachycardia arrhythmias, and angina Others= rashes, physical/psychological dependence.
The CNS stimulants

Implementation The nurse must ensure that the drug is only given to the indicated conditions Administer the drug before 6 pm to reduce the effect of insomnia BEST given AFTER meals to prevent the effect of anorexia Consult with school personnel to monitor the patient under therapy Provide safety measures such as side-rails and sideassisted ambulation
The CNS stimulants

Evaluation Evaluate the effectiveness of the drug: 1. Calming effect in the patient with ADHD 2. Alertness for patients with narcolepsy
The Anti-epileptics AntiThese agents, also called anticonvulsants, are used to treat epileptic conditions. Hydantoins, Barbiturates, benzodiazepines, Succinimides and many others are given to a specific type of seizure.
AntiAnti-epileptics
Agents for treating TONIC-CLONIC SEIZURES TONIC1. Hydantoins
Phenytoin Ethotoin Fosphenytoin Mephenytoin
2. Benzodiazepines
Diazepam Clonazepam Clorazepate
3. Barbiturates
Phenobarbital
AntiAnti-epileptics
Agents for treating ABSENCE SEIZURES 1. Succinimides a. Ethosuximide b. Methsuximide c. Phensuximide 2. Valproic Acid 3. Zosinamide
AntiAnti-epileptics
Agents for treating Partial FOCAL SEIZURES 1. Carbamazepine 2. Gabapentin 3.Lamotrigine 4. Tiagabine 5. Topiramate
The hydantoins
These agents are utilized for general seizures because they can depress the central nervous system. They affect the entire brain and reduce the chance of sudden electrical outburst that causes seizures. These agents generally are less sedating than other anti-epileptics. anti-epileptics.
The hydantoins
Mechanism of Action of the Hydantoins These agents STABILIZE the nerve cell membrane throughout the brain reducing and limiting the excitability and conduction through nerve pathways.
The hydantoins
Clinical Indications of the hydantoins 1. Tonic-clonic seizures Tonic2. Status epilepticus 3. For the prevention of seizures in neurosurgery 4. For muscle relaxation.
The hydantoins
Contraindications and Precautions Hydantoins are NOT given to pregnant patient because it can cause fetal hydantoin syndrome. syndrome.
The hydantoins
Pharmacodynamics: Adverse effects of the Hydantoins CNS effects- depression, confusion, effectsdrowsiness, lethargy, fatigue GITGIT- GI upset, constipation, dry mouth, mouth, GINGIVAL HYPERPLASIA , severe liver toxicity which are all related to cellular toxicity. SKINSKIN- hirsutism and coarsening of the facial skin Bone Marrow depression
The hydantoins
Implementation Administer the drug with food to alleviate GI irritation Discontinue the drug at any sign of hypersensitivity reaction, severe liver dysfunction and severe skin rashes. Provide meticulous mouth oral care Rule out pregnancy and advise women to use contraceptive measures to prevent pregnancy.
Drugs affecting GI secretions

There are five types of drugs that affect gastric acid secretions and are useful for the treatment of peptic ulcer. 1. Histamine (H2) receptor antagonist/blockers 2. Antacids 3. Proton pump inhibitors 4. Mucosal protectants 5. Prostaglandin analogs
Drugs affecting secretions: anti ulcer

Anti-ulcer drugs Prototype Cimetidine
Histamine (H2) receptor antagonist/blockers Antacids Proton pump inhibitors Mucosal protectants Prostaglandin analog
AlOH and MgOH Omeprazole Sucralfate Misoprostol
General indication of the drugs affecting gastric acid secretion

Peptic ulcer Gastritis Patient on NPO to prevent stress ulcer
General time of administration of the drugs affecting gastric acid secretion

Anti-ulcer drugs Prototype Best time to give With FOOD or ONE hour after ANTACID Usually after meals BEFORE MEALS BEFORE MEALS WITH MEALS Histamine (H2) Cimetidine receptor antagonist/blockers Antacids Proton pump inhibitors Mucosal protectants Prostaglandin analog AlOH and MgOH Omeprazole Sucralfate Misoprostol
Pharmacology of Anti-ulcer Antidrugs

Drug Mechanism of Action AntacidsAntacids- AlOH, MgOH Neutralize Gastric ACIDITY
H2-BlockersH2-Blockers- tidine Cimetidine, Cimetidine, Ranitidine
Block Histamine receptor causing decreased secretion and acidity Inhibit Proton Pump in parietal cell decreasing secretion and acidity
Proton pump inhibitorsinhibitorsPrazoles Omeprazole, pantoprazole
Pharmacology of Anti-ulcer drugs AntiDrug Mechanism of Action
Anti-cholinergicAnti-cholinergic- Prophanteline Bromide Sucralfate (Carafate)
Blocks VAGUS nerve, decreases secretion Coats the mucosal lining
Misoprostol (Cytotec)
Prostaglandin Analogue, causes secretion of MUCUS
Pharmacodynamics
Histamine (H2) receptor blockers These drugs BLOCK the release of hydrochloric acid in the stomach in response to gastrin

Antacids These drugs interact with the gastric acids at the chemical level to neutralize them

Proton pump inhibitors These drugs suppress the secretion of hydrochloric acid into the lumen of the stomach

Mucosal protectants These are agents that coat any injured area in the stomach to prevent further injury from acid

Prostaglandin analogs These are agents that inhibit the secretion of gastrin and increase the secretion of mucus lining of the stomach, providing a buffer.
The H2 Blockers- tidines BlockersPrototype: Cimetidine 1. Ranitidine 2. Famotidine 3. Nizatidine
The H2 Blockers- tidines BlockersPharmacodynamics: Drug Action The H2 blockers are antagonists at the receptors in the parietal cells of the stomach. The blockage results to inhibition of the hormone gastrin. There will be decreased production of gastric acid from the parietal cells. Also, the chief cells will secrete less pepsinogen.
The H2 Blockers- tidines BlockersTherapeutic use of the H2 blockers ShortShort-term treatment of active duodenal ulcer or benign gastric ulcer Treatment of hypersecretory conditions like the ZollingerZollinger-Ellison syndrome Prevention of stress-induced ulcers and acute GI stressbleeding Treatment of erosive GERD (reflux disease) Relief of Symptoms of heart burn and acid indigestion
The H2 Blockers- tidines BlockersPrecautions and Contraindications Any known allergy is a clear contraindication to the use of the agents. Conditions such as pregnancy, lactation, renal dysfunction and hepatic dysfunction should warrant cautious use. Nizatidine can be used in hepatic dysfunction.
The H2 Blockers- tidines BlockersPharmocodynamicsPharmocodynamics- Side effects and adverse effects GIT= diarrhea or constipation CNS= Dizziness, headache, drowsiness, confusion and hallucinations Cardio= arrhythmias, HYPOTENSION (related to H2 receptor blockage in the heart) Cimetidine= TREMORS, Gynecomastia and impotence in males
The H2 Blockers- tidines BlockersDrugDrug-drug Interactions Cimetidine, Famotidine, Ranitidine are metabolized in the liver- they can livercause slowing of excretion of other drugs leading to their increased concentration.
The H2 Blockers- tidines BlockersDrugDrug-drug Interactions These drugs can interact with CIMETIDINE anticoagulants, phenytoin, alcohol, antidepressants.
The H2 Blockers- tidines BlockersNursing considerations: Administer the drug WITH meals at BEDTIME to ensure therapeutic level One hour after Antacids Stress the importance of the continued use for the length of time prescribed
The H2 Blockers- tidines BlockersNursing considerations: Monitor the cardiovascular status especially if the drugs are given IV Warn patient of the potential problems of increased drug concentration if the H2 blockers are used with other drugs or OTC drugs. Advise consultation first!
The H2 Blockers- tidines BlockersNursing considerations: Provide comfort measures like analgesics for headache, assistance with ambulation and safety measures Warn the patients taking cimetidine that drowsiness may pose a hazard if driving or operating delicate machines.
The H2 Blockers- tidines BlockersNursing considerations: Provide health teaching as to the dose, frequency, comfort measures to initiate when side-effects are intolerable sideEvaluate the effectiveness: Relief of symptoms of ulcer, heart burn and GERD
The Antacids
These are drugs or inorganic chemicals that have been used for years to neutralize acid in the stomach. The following are the common antacids that can be bought OTC: Aluminum salts (hydroxide) Calcium salts (carbonate) Magnesium salts (milk of magnesia) Sodium bicarbonate Magaldrate (aluminum and magnesium combination)
The Antacids
Pharmacodynamics: drug action These agents act to neutralize the acidic pH in the stomach. They do not affect the rate of gastric acid secretion.
The Antacids
Pharmacodynamics: drug action The administration of antacid may cause an acid rebound. Neutralizing the stomach content to an alkaline level stimulates gastrin production to cause an increase in acid production and return the stomach to its normal acidic state.
The Antacids
Therapeutic Indications Symptomatic relief of upset stomach associated with hyperacidity Hyperacidic conditions like peptic ulcer, gastritis, esophagitis and hiatal hernia Special use of AMPHOGEL (aluminum hydroxide): to BIND phosphate
The Antacids
Precautions of Antacid Use Known allergy is a clear contraindication. Caution should be instituted if used in electrolyte imbalances, GI obstruction and renal dysfunction. Sodium bicarbonate is rarely used because of potential systemic absorption
The Antacids
Pharmacokinetics These agents are taken orally and act locally in the stomach
The Antacids
Pharmacodynamics: Effects of drugs 1. GIT= rebound acidity; alkalosis may occur. Calcium salts may lead to hypercalcemia Magnesium salts can cause DIARRHEA Aluminum salts may cause CONSTIPATION and hypophosphatemia by binding with phosphates in the GIT. 2. Fluid retention due to the high sodium content of the antacids.
Nursing Considerations: Administer the antacids apart from any other medications by ONE hour before or TWO hours after- to ensure adequate afterabsorption of the other medications Tell the patient to CHEW the tablet thoroughly before swallowing. Follow it with one glass of water Regularly monitor for manifestations of acidacid-base imbalances as well as electrolyte imbalances
The Antacids
The Antacids
Nursing Considerations: Provide comfort measures to alleviate constipation associated with aluminum and diarrhea associated with magnesium salts. Monitor for the side-effects, effectiveness of sidethe comfort measures, patient s response to the medication and the effectiveness of the health teachings
The Antacids
Nursing Considerations: Evaluate for effectiveness: Decreased symptoms of ulcer and pyrosis Decreased Phosphate level (amphogel)
The PPI
These are the newer agents for ulcer treatment The prazoles Prototype: Omeprazole Omeprazole Lanisoprazole Lanisoprazole Esomeprazole Esomeprazole Pantoprazole Pantoprazole
The PPI
Pharmacodynamics: drug action They act at specific secretory surface receptors to prevent the final step of acid production and thus decrease the level of acid in the stomach. The pump in the parietal cell is the H-K ATPase enzyme system on the secretory surface of the gastric parietal cells
The PPI
Clinical use of the PPIs ShortShort-term treatment of active duodenal ulcers, GERD, erosive esophagitis and benign gastric ulcer. Long-termLong-term- maintenance therapy for healing of erosive disorders.
The PPI
Clinical use of the PPIs. Precautions with the use of the PPIs Known allergy is a clear contraindication. Caution if patient is pregnant
The PPI
Pharmacodynamics: Adverse effects CNS- dizziness, CNS- dizziness, headache, asthenia (loss of strength), vertigo, insomnia, apathy vertigo, GITGIT- diarrhea, abdominal pain, nausea, vomiting, dry mouth and tongue atrophy RespiRespi- cough, stuffy nose, hoarseness and epistaxis.
The PPI
Nursing considerations: Administer the drug BEFORE meals. Ensure that patient does not open, chew or crush the drug. Provide safety measures if CNS dysfunction happens. Arrange for a medical follow-up if symptoms followare NOT resolved after 4-8 weeks of 4therapy.
The PPI
Nursing considerations: Provide health teaching as to drug name, dosages and frequency, safety measures to handle common problems. Monitor patient response to the drug, the effectiveness of the teaching plan and the measures to employ
The PPI
Nursing considerations: Evaluate for effectiveness of the drug Healing of peptic ulcer Decreased symptoms of ulcer
The Mucosal Protectant

Sucralfate This is given to protect the eroded ulcer sites in the GIT from further damage by acid and digestive enzymes
Sucralfate
Pharmacodynamics: Action of drug It forms an ulcer-adherent complex at ulcerduodenal ulcer sites, protecting the sites against acid, pepsin and bile. This action prevents further breakdown of proteins in the area and promotes healing.
Sucralfate
Clinical use of sucralfate Short and long term management of duodenal ulcer. NSAIDs induced gastritis Prevention of stress ulcer Treatment of oral and esophageal ulcers due to radiation, chemotherapy or sclerotherapy.
Sucralfate
Precautions on the use of Sucralfate This agent should NOT be given to any person with known allergy to the drug, and to those patients with renal failure/dialysis because of build-up of buildaluminum may occur if used with aluminum containing products.

Pharmacodynamics: Side-effects & adverse Sidereactions Primarily GIT= CONSTIPATION, occasionally diarrhea, nausea, indigestion, gastric discomfort, and dry mouth may also occur CNS= dizziness, drowsiness, vertigo Others= rash and back pain

DrugDrug-drug interactions If used with aluminum salts= high risk of accumulation of aluminum and toxicity. toxicity. If used with phenytoin, fluoroquinolones and penicillamines- decreased levels of penicillaminesthese drugs when taken with sucralfate

Nursing Considerations Administer drug ON AN EMPTY stomach, 1 stomach, hour before meals , or 2 hour after meals and at BEDTIME Monitor for side-effects like constipation and GI sideupset Encourage intake of high-fiber foods and highincreased fluid intake Administer antacids BETWEEN doses of sucralfate, NOT WITHIN 30 minutes of sucralfate dose

Nursing Considerations Provide comfort measures if CNS effects occur Provide health teaching as to drug name, dosages and frequency, safety measures to handle common problems. Monitor patient response to the drug, the effectiveness of the teaching plan and the measures employed

Nursing Considerations Evaluate effectiveness of therapy Healing of ulcer No formation of ulcer
Prostaglandin analogue
Misoprostol This agent is a synthetic prostaglandin E1 analog that is employed to protect the lining of the mucosa of the stomach
Misoprostol: Pharmacodynamics Being a prostaglandin analog, it inhibits gastric acid secretion to some degree It INCREASES mucus production in the stomach lining.
Misoprostol: Clinical use NSAIDsNSAIDs-induced gastric ulcers Duodenal ulcers unresponsive to H2 antagonists.
Precautions of Misoprostol Use This drug is CONTRAINDICATED during pregnancy because it is an abortifacient. Women should be advised to have a negative pregnancy test within 2 weeks of beginning therapy and should begin the drug on the second or third day of the next menstrual cycle. They should be instructed in the use of contraceptives during therapy.
Pharmacodynamic effects: drug reactions GIT= Nausea, diarrhea, abdominal pain, flatulence, vomiting, dyspepsia GU effects= miscarriages, excessive uterine CRAMPING and bleeding, bleeding, spotting, hypermenorrhea and menstrual disorders.
Nursing Considerations Administer to patients at risk for NSAIDs-induced NSAIDsulcers during the full course of NSAIDs therapy Administer four times daily with meals and at bedtime Obtain pregnancy test within 2 weeks of beginning therapy. Begin the therapy on second or third day of menstrual period to ensure that the woman is not pregnant
Nursing Considerations Provide patient with both written and oral information regarding the associated risks of pregnancy Provide health teaching as to drug name, dosages and frequency, safety measures to handle common problems. Monitor patient response to the drug, the effectiveness of the teaching plan and the measures to employ
Laxatives
Type Prototype Action Chemical stimulants Bisacodyl (Dulcolax)
Direct stimulation of the GIT nerves Irritant laxatives Increased fluid content of the fecal material causing stimulation of the local reflex Lubricating the intestinal material to promote passage through the GIT
Mechanical (bulk) Lactulose stimulants
Lubricants
Docusate
Laxatives
Generally used to INCREASE the passage of the colonic contents The general classifications is as follows: 1. Chemical stimulants 2. Mechanical stimulants 3. Lubricants
Therapeutic Indications of the Laxatives

SHORT term relief of Constipation Prevention of straining in conditions like CHF, post-MI, post partum, post-op postpostPreparation for diagnostic examination Removal of poison or toxins Adjunct in anti-helminthic therapy anti-
Contraindications in Laxative use

ACUTE abdominal disorders
Appendicitis Diverticulitis Ulcerative colitis
Chemical Stimulant Cathartics

Prototype: Bisacodyl Irritant laxatives: 1. Castor oil 2. Senna 3. Cascara 4. Phenolphthalein
Chemical Stimulant Cathartics

Pharmacodynamics These agents DIRECTLY stimulate the nerve plexus in the intestinal wall The result is INCREASED movement or motility of the colon
Mechanical Stimulant Cathartics

Prototype: LACTULOSE (Cephulac) BulkBulk-forming laxatives 1. Magnesium (citrate, hydroxide, sulfate) 2. Psyllium 3. Polycarbophil
Mechanical Stimulant Cathartics

Pharmacodynamics These agents are rapid-acting laxatives that rapidINCREASE the GI motility by
Increasing the fluids in the colonic material Stimulating the local stretch receptors Activating local defection reflex
Lubricants
Prototype: Docusate 1. Glycerin 2. Mineral oil
Lubricants
Pharmacodynamics Docusate increases the admixture of fat and water producing a softer stool Glycerin Mineral oil forms a slippery coat on the colonic contents
Pharmacokinetics: Common Side-effects of the Laxatives SideDiarrhea Abdominal cramping Nausea Fluid and electrolyte imbalance Sympathetic reactions- sweating, reactionspalpitations, flushing and fainting CATHARTIC dependence
The Nursing Process and Laxative

ASSESSMENT Nursing History- elicit allergy to any Historylaxatives, elicit history of conditions like diverticulitis and ulcerative colitis Physical Examination- abdominal Examinationassessment Laboratory Test: fecalysis, electrolyte levels

NURSING DIAGNOSIS Alteration in bowel pattern Alteration in comfort: pain Knowledge deficit

IMPLEMENTATION 1. Emphasize that it is use on a SHORT term basis 2. Provide comfort and safety measures like ready access to the bathroom, side-rails side3. Administer with a full glass of water

IMPLEMENTATION 4. Encourage fluid intake, high fiber diet and daily exercise 5. DO NOT administer if acute abdominal condition like appendicitis is present 6. Advise to change position slowly an avoid hazardous activities because of potential dizziness

EVALUATION of drug effectiveness 1. Evaluate relief of GI symptoms, absence of staining and increased evacuation of GI tract 2. For Lactulose: decreased ammonia
The Anti-diarrheals AntiThese are agents used to calm the irritation of the GIT for the symptomatic relief of diarrhea General Classifications 1. Local anti-motility anti2. Local reflex inhibition 3. Central action on the CNS
The Anti-diarrheals AntiType Prototype Action Local reflex inhibitor Bismuth subsalicylate
Locally coats the lining of the GIT to soothe irritation that may stimulate the reflex Directly inhibits the intestinal muscle activity to SLOW peristalsis Stops GIT spasm by CNS action
Local anti-motility
Loperamide
Central acting agent
Opium derivatives (paregoric)
Clinical Indications of drug use

Relief of symptoms of acute and chronic diarrhea Reduction of fecal volume discharges from ileostomies Prevention and treatment of traveler's diarrhea
Contraindications of anti-diarrheal antiUse

Poisoning Drug allergy GI obstruction Acute abdominal conditions
Pharmacokinetics: Side effects

Constipation Nausea, vomiting Abdominal distention and discomfort TOXIC MEGACOLON
Nursing process and anti-diarrheals antiASSESSMENT Nursing History Elicit history of drug allergy, conditions like poisoning, GI obstruction and acute abdominal conditions Physical Examination- Abdominal Examinationexamination Laboratory test- electrolyte levels test-
Nursing process and anti-diarrheals antiNURSING DIAGNOSIS Alteration in bowel pattern Alteration in comfort: pain
Nursing process and anti-diarrheals antiIMPLEMENTATION 1. Monitor patient response within 48 hours. Discontinue drug use if no effect 2. Provide comfort measures for pain 3. Provide teaching
Nursing process and anti-diarrheals antiEVALUATION 1. Monitor effectiveness of drug- RELIEF of drugdiarrhea 2. Monitor adverse effects, effectiveness of pain measures and effectiveness of teaching plan
Emetics and Anti-emetics AntiEmetic Agent Syrup of Ipecac AntiAnti-emetics 1. Phenothiazines 2. Non-phenothiazines Non3. Anticholinergics/Antihistamines 4. Serotonin receptor Blockers 5. Miscellaneous
EMETIC
Prototype: Ipecac Syrup
EMETIC
Pharmacodynamics Ipecac syrup irritates the GI mucosa locally, resulting to stimulation of the vomiting center It acts within 20 minutes
EMETIC
Clinical Use of ipecac To induce vomiting as a treatment for drug overdose and certain poisonings
EMETIC
Contraindications of Ipecac use Ingestion of CORROSIVE chemicals Ingestion of petroleum products Unconscious and convulsing patient
EMETIC
Pharmacokinetics: side effects of Ipecac Nausea Diarrhea GI upset Mild CNS depression CARDIOTOXICITY if large amounts are absorbed in the body
Nursing process and the EMETIC

ASSESSMENT Nursing History- elicit the exact nature of Historypoisoning Physical Examination- CNS status and Examinationabdominal exam

IMPLEMENTATION 1. Administer to conscious patient only 2. Administer ipecac as soon as possible 3. Administer with a large amount of water 4. Vomiting should occur within 20 minutes of the first dose. Repeat the dose and expect vomiting to occur with 20 minutes

IMPLEMENTATION 5. Provide comfort measures like ready access to bathroom, assistance with ambulation 6. Offer support

EVALUATION 1. Evaluate patient response within 20 minutes of drug ingestion 2. Monitor for adverse effects 3. Evaluate effectiveness of comfort measures and teaching plan
ANTIANTI-EMETICS
These are agents used to manage nausea and vomiting They act either locally or centrally
ANTIEMETICS
Anti-emetic types Phenothiazines Non-phenothiazines Anticholinergics and Antihistaminics Serotonin Receptor blockers Miscellaneous Common examples Prochlorperazine, promethazine Metoclopramide Meclizine, buclizine setron- dolasetron Dronabinol, hydroxyzine
ANTIEMETICS
Types Phenothiazines Pharmacodynamics
Non-phenothiazine
Centrally block the vomiting center in the medulla Reduces the responsiveness of the nerve cell in the medulla Block the transmission of the impulses to the medulla Centrally and locally inhibits the serotonin receptors Act in the CNS , either in the medulla or in the cortex
Anticholinergics
Serotonin receptor blockers
Miscellaneous
ANTIEMETICS
Types Phenothiazines Clinical Use
Non-phenothiazine
N/V associated with anesthesia, intractable hiccups N/V associated with chemical stimulation N/V associated with motion sickness
N/V associated with chemotherapy N/V associated with chemotherapy
Anticholinergics
Serotonin-receptor Blockers Miscellaneous
ANTIEMETICS
Contraindications 1. Severe CNS depression 2. Severe liver dysfunction
ANTIEMETICS
Pharmacokinetics: Side-effects Side1. PHOTHOSENSITIVITY 2. Drowsiness, dizziness, weakness and tremors and DEHYDRATON 3. Phenothiazines= autonomic antianticholinergic effects like dry mouth, nasal congestion and urinary retention
Nursing Process and the ANTIEMETICS

ASSESSMENT Nursing History- elicit allergy, impaired Historyhepatic function and CNS depression Physical Examination- CNS status and Examinationabdominal examination Laboratory test- Liver function studies test-

NURSING DIAGNOSIS 1. Alteration in comfort: pain 2. High risk for injury 3. Knowledge deficit

IMPLEMENTATION 1. Assess patient s intake of other drugs that may cause dangerous drug interaction 2. Emphasize that this is given on a short term basis

IMPLEMENTATION 3. Provide comfort and safety measures
Advise to change position slowly Avoid hazardous activities Provide mouth care and ice chips Monitor for dehydration and offer fluids if it occurs

IMPLEMENTATION 4. Protect from sun exposure
Sunscreens Protective covering
5. Provide health teaching

EVALUATION 1. Monitor for the drug effectiveness
Relief of nausea and vomiting
2. Monitor for adverse effects 3. Evaluate effectiveness of comfort measures and teaching plan
Pharmacology of the Selected Endocrine Drugs

Nursing Review
Endocrine Medications
AntiAnti-diuretic hormones Enhance re-absorption of water in the rekidneys Used in DI 1. Desmopressin and Lypressin intranasally 2. Pitressin IM
Endocrine Medications
AntiAnti-diuretic hormones SIDESIDE-effects Flushing and headache Water intoxication
Thyroid Medications
Thyroid hormones These products are used to treat the manifestations of hypothyroidism Replace hormonal deficit in the treatment of HYPOTHYROIDSM
Thyroid Medications
Thyroid hormones Levothyroxine (Synthroid) Liothyroxine (Cytomel) Thyroid dessicated Liotrix (Thyrolar)
Thyroid Medications
Thyroid hormones: Actions Increase the metabolic rate Increase O2 consumption Increase HR, RR, BP
Thyroid Medications
Thyroid hormones SideSide-effects 1. Nausea and Vomiting 2. Signs of increased metabolism= tachycardia, hypertension, cardiac arrhythmias, anxiety, headache
Thyroid Medications
Thyroid hormones : Nursing responsibility
1. Monitor weight, VS 2. Instruct client to take daily medication the same time each morning WITHOUT FOOD Monitor blood tests to check the activity of thyroid
Thyroid Medications
Thyroid hormones: Nursing responsibility
3. Advise to report palpitation, tachycardia, and chest pain 4. Instruct to avoid foods that inhibit thyroid secretions like cabbage, spinach and radishes
ANTIANTI-Thyroid Medications
ANTI-THYROID medications ANTIThe thyroid becomes oversaturated with iodine and stop producing thyroid hormone
ANTI-THYROID medications ANTIDrugs used to BLOCK the thyroid hormones and treat hyperthyroidism Inhibit the synthesis of thyroid hormones
ANTI-THYROID medications ANTI1. Methimazole (Tapazole) 2. PTU (prophylthiouracil) 3. Iodine solution- SSKI and solutionLugols solution
ANTIANTI-THYROID medications SideSide-effects of thionamides
N/V, drowsiness, lethargy, bradycardia, skin rash GI complaints AGRANULOCYTOSIS

Most important to monitor
ANTIANTI-THYROID medications SideSide-effects of Iodine solutions
Most common adverse effects is HYPOTHYROIDISM Iodism= metallic taste, burning in the mouth, sore teeth and gums, diarrhea, stomach upset

ANTI-THYROID medications ANTINursing responsibilities 1. Monitor VS, T3 and T4, weight 2. The medications WITH MEALS to avoid gastric upset
ANTIANTI-THYROID medications Nursing responsibilities
3. Instruct to report SORE THROAT or unexplained FEVER 4. Monitor for signs of hypothyroidism.

Instruct not to stop abrupt medication
ANTIANTI-THYROID medications Lugols Solution Used to decrease the vascularity of the thyroid (in preparation for thyroid surgery) T3 and T4 production diminishes Given per orem, can be diluted with juice Use straw to decrease staining Monitor iodism (metallic taste, burning in mouth)
STEROIDS
Replaces the steroids in the body Interfere with the release of inflammatory factors and immune responses
STEROIDS
Cortisol, cortisone, betamethasone, and hydrocortisone Dexamethasone= long acting
STEROIDS
These drugs enter the cells and bind to receptors They inhibit the enzyme phospholipase
STEROIDS
Corticosteroids are used topically and locally to achieve the desired antianti-inflammatory effects at a particular site
STEROIDS
Steroid Dexamethasone Clinical use Use to induce the formation of lung surfactant Use for the treatment of immuneimmune-related diseases, control of asthma and allergic symptoms
Other steroids
STEROIDS
SideSide-effects HYPERglycemia Increased susceptibility to infection (immunosuppression) Hypokalemia Edema and Hypertension Peptic ulceration
STEROIDS
SideSide-effects If high doses- osteoporosis, dosesgrowth retardation, peptic ulcer, hypertension, cataract, cataract, mood changes, hirsutism, and fragile skin
STEROIDS
Nursing responsibilities 1. Monitor VS, electrolytes, glucose 2. Monitor weight edema and I/O. Encourage Potassium supplements
STEROIDS
Nursing responsibilities 3. Protect patient from infection 4. Handle patient gently 5. Instruct to take meds WITH MEALS to prevent gastric ulcer formation
STEROIDS
Nursing responsibilities 6. Caution the patient NOT to abruptly stop the drug 7. Drug is tapered to allow the adrenal gland to secrete endogenous hormones
STEROIDS
Evaluation: The drugs are effective if there is: 1. Relief of signs and symptoms of inflammation 2. Return of adrenal function to normal
The cardiac glycosides

are agents extracted from the foxglove plant. They are available in oral and parenteral preparations. The following are the cardiac glycosides: Digoxin (Lanoxin) Digitoxin (Crystodigin) Ouabain
These

Pharmacodynamics: the Mechanism of action They increase the level of CALCIUM inside the cell by inhibiting the Sodium-Potassium pump. Sodium More calcium will accumulate inside the cell during cellular depolarization.

Positive
inotropic Effect- the Effectmyocardium will contract forcefully

Increased cardiac output Increased blood flow to the body organs like the kidney and liver
Negative
chronotropic effect- the heart effectrate is slowed due to decreased rate of cellular repolarization
Bradycardia
Decreased
conduction velocity through the AV node

Clinical Use of the cardiac glycosides Treatment of congestive heart failure Treatment of dysrhythmias like atrial flutter, atrial fibrillation and paroxysmal atrial tachycardia

Contraindications and Precautions Contraindicated in the presence of allergy to any cardiac glycoside. They are NOT given to patients with ventricular dysrhythmias, heart block or sick sinus syndrome, aortic stenosis, acute MI, electrolyte imbalances (HYPOKALEMIA, HYPOMAGNESEMIA and HYPERCALCEMIA) and renal failure HYPERCALCEMIA) (may cause accumulation of drug)

Pharmacodynamics: the Adverse Effects of the Cardiac glycosides CNS- Headache, weakness , seizures and CNSdrowsiness CVS- arrhythmias CVS If digitalis toxicity is developing- the nurse must developingassess the following adverse effects: Anorexia, nausea and vomiting, visual changeschangesYELLOW halo around an object, and palpitations or very slow heart rate

Remember= NAVDA and hypokalemia

DrugDrug-Drug Interactions If taken with potassium-losing potassiumdiuretics like furosemide- can furosemideINCREASE the risk of toxicity and arrhythmias. Potassium replacement must be given.

Implementation Administer the initial rapid digitalization and loading dose as ordered intravenously Monitor the APICAL pulse rate for ONE full minute before administering the drug. Withhold the drug if
Less than 60 in adults Less than 90 in infants More than 110 in adults
Retake
pulse in one hour, if pulses remain abnormal, refer!

Implementation Check the spelling of the drug- DIGOXIN drugis different from DIGITOXIN! Check the dosage preparation and the level of digitalis in the blood. (Therapeutic (Therapeutic level is 0.5 to 2.0 nanograms/mL) nanograms/mL) Administer intravenous drug VERY slow IV over 5 minutes to avoid arrhythmias. Do NOT administer intramuscularly because it can cause severe pain

Implementation Administer the drug without food if possible to avoid delayed absorption. Weight patient absorption. daily to determine fluid retention Maintain emergency equipment and drugs= Potassium salts, Lidocaine for arrhythmias, phenytoin for seizures, atropine for bradycardia. Provide comfort measures- small, frequent measuresmeals, adequate lighting, comfortable position, rest periods and safety precautions

Implementation

Provide health teaching- drug name, action, teachingdosage and side effects. Advise the patient to report any of the following: Visual changes, rapid weight gain, unusually low heart rate, persistent nausea, vomiting and anorexia Monitor serum potassium level

Evaluation Evaluate effectiveness of the drug: Increased urine output Normal heart rate in arrhythmia
The Antianginal drugs

In
the treatment of angina, three agents are commonly employedemployedOrganic nitrates Beta-blockers and BetaCalciumCalcium-channel blockers.
The
benefits of the drugs lie in their different mode of action.

The nitrates can cause vasodilatation of the veins and to some extent, coronary artery

Beta-blockers Beta-
will decrease the heart
rate

Calcium-channel Calcium-
blockers will decrease force of contraction leading to a decreased myocardial workload and demand. They can also produce vasodilation
The Organic nitrates

agents are simple nitric and nitrous acid esters of alcohols. Being alcohol, they differ in their volatility. The following are the nitrates commonly used: Nitroglycerin- A moderately volatile Nitroglycerinnitrate Isosorbide Dinitrate (Isordil) or mononitrate Amyl nitrate- an extremely volatile nitrate nitrate These

Nitroglycerin This agent is supplied in oral, spray, transdermal and ointment preparations.

Pharmacodynamics: the mechanism of action Nitroglycerin relaxes the smooth muscles in the vascular system by its conversion to nitric oxide, a chemical mediator in the body that relaxes smooth muscles.

Administered nitrates Increased nitrates in the blood increased formation of nitric oxide increased cGMP formation increased dephosphorylation of myosin Vascular smooth muscle relaxation vasodilatation

PharmacokineticsPharmacokinetics- absorption to excretion It can be given orally, parenterally and topically. The onset of action of nitroglycerin is more than 1 hour. Because significant first-pass hepatic firsteffect, Nitroglycerin is given SUBLINGUALY.

Pharmacodynamics: Side effects and adverse effects HEADACHE is the most common effect of nitroglycerin. nitroglycerin. CVS- postural Hypotension, facial flushing, CVStachycardia TOLERANCE- the tolerance to the actions TOLERANCEof nitrates develop rapidly. This can be managed by providing a day of abstinence.
The Nitrates
Implementation Monitor vital signs, especially watchful for hypotensive episodes Advise patient to remain supine or sit on a chair when taking the nitroglycerin for the first time. Emphasize that he should change his position slowly or rise from bed slowly to avoid orthostatic Hypotension Offer sips of water before giving sublingual nitroglycerin because dryness may inhibit drug absorption
The Nitrates
Implementation Apply nitroglycerin ointment to the designated mark on paper. The nurse should remove any excess ointment on the skin from the previous dose. She should NEVER USE her bare fingers because the drug can be absorbed, utilize gloves or tongue blades instead.
The Nitrates
Implementation Apply nitroglycerin patch to an area with few hairs. Never touch the medication portion. The patch and the ointment should NOT be applied near the area for defibrillation because explosion and skin burns may result
The Nitrates
IMPLEMENTATION Emphasize that tolerance to the nitroglycerin can occur. If the medication cannot relieve the pain, report to the hospital immediately.
The Nitrates
IMPLEMENTATION Provide client health teaching- the sublingual teachingnitroglycerin tablet is USED if chest pain occurs The dose may be repeated if pain is unrelieved within 5 minutes. Repeat the medication administration if the pain has not yet subsided. subsided. DO NOT give more than 3 tablets!!! If tablets!!! chest pain persists for more than 15 minutes, hospital consult should be done immediately.
The Nitrates
IMPLEMENTATION Instruct the client to avoid alcohol while taking nitroglycerin to avoid potentiating the hypotensive effect of the medication If beta blockers and calcium-channel calciumblockers are given, instruct the patients to consult the physician before discontinuing the medication
The Nitrates
IMPLEMENTATION Other components of health teaching for home self-administration: selfIf taking Sublingual Nitroglycerin, the patient should be instructed to place the tablet under the tongue for quick absorption. A burning sensation/biting/stinging sensation may indicate that the tablet is FRESH! Store the tablet in a dark container, keep it container, away from heat and direct sunlight to avoid lessening the potency
The Nitrates
IMPLEMENTATION Other components of health teaching for home selfself-administration:
HEADACHES are common in the initial period of nitroglycerin therapy. Advise patient to take PARACETAMOL for relief The nitroglycerin patch is applied once a day, usually in the morning. The sites should be rotated, in the chest, arms and thighs avoiding hairy areas.
The Nitrates
IMPLEMENTATION Other components of health teaching for home self-administration: selfPosition supine with elevated legs to manage Hypotension. Nitroglycerin tablet can be taken prophylactically in situations where chest pain is anticipated- Sex, exercise, etc.. anticipatedIf patient is taking beta blockers, instruct how to obtain heart rate in a minute
Drugs for Shock

Dopamine This is a sympathomimetic drug often used to treat Hypotension in shock states that are not caused by Hypovolemia. This drug is an immediate precursor of nornor-epinephrine, occurs naturally in the CNS basal ganglia where it functions as a neurotransmitter.
Drugs for Shock

Dopamine Pharmacodynamics: It can activate the alpha and beta adrenergic receptor depending upon the concentration. It stimulates receptors to cause cardiac stimulation and renal vasodilation. vasodilation. The dose range is 1-20 micrograms/kg/min 1-
Drugs for Shock

Dopamine Pharmacokinetics: Dopamine is administered IV, excreted in the urine. At low dose (1-2 micrograms), micrograms), dopamine DILATES the renal and mesenteric blood vessels producing an increase output (dopaminergic effect)
Drugs for Shock

Dopamine At moderate dose of 2-10 micrograms, dopamine enhance cardiac output by increasing heart rate (beta 1-adrenergic (beta 1effect) and elevates blood pressure through peripheral vasoconstriction (alpha adrenergic effect)
Drugs for Shock

Dopamine At higher doses of more than 10 microgramsmicrograms- vasoconstriction of all vessels will predominate that can lead to diminished tissue perfusion
Drugs for Shock

Dopamine Dopamine is indicated to treat Hypotension, to increase heart rate and to increase urine output (given less than 5 mg/kg/min) The nurse typically prepares the dopamine dripdripdopamine (at a concentration of 400-800 mg) is 400mixed in 250 mL D5W and administered as drip via an infusion pump for precise dosage administration. Sodium bicarbonate will inactivate the dopamine
Drugs for Shock

Dopamine Pharmacodynamics: side effectseffectsTachycardia hypertension ectopic beats, angina, dysrhythmias, myocardial ischemia, nausea and vomiting.
Drugs for Shock

Dopamine: Nursing consideration
Check the IV site hourly for signs of drug infiltration of dopamine, which can cause tissue necrosis. Phentolamine should be infiltrated in multiple areas to reduce tissue damage. Drug is effective if Urine output is increased and BP is increased
Antihypertensive drugs
The Drugs employed to control hypertension can be classified as: Diuretics Beta-blockers Beta Alpha adrenergic blockers Calcium channel blockers Angiotensin-converting enzyme inhibitors Angiotensin Angiotensin II receptor blockers Peripheral vasodilators
Common Drugs in HPN

IN Evaluating the effectiveness of these drugs is simply to monitor the BP if it becomes NORMAL
AntiAnti-hypertensive drugs
Class Diuretics BetaBeta-blocker ACE Inhibitors Ca channel blockers Vasodilator Alpha blockers Prototype Furosemide Propranolol Captopril Nifedipine Nitroglycerin Prazozin MOA Decreases blood volume Blocks B1 receptor in the heart Prevents A1 to AII conversion Blocks Ca entry into cell Dilates veins and arteries Blocks alpha receptor in BV causing vasodilatation Stimulates CNS alpha 2 receptor Side effects Hypokalemia Bradycardia, hypoglycemia Headache, Cough, flushing Headache, flushing, reflex tachycardia HEADACHE Urination
Central alpha Clonidine agonist
Depression
Anticoagulants
HEPARIN Parenteral (SQ and IV)
Action is to enhance natural antianti-thrombin III in the blood
WARFARIN Oral
Action is to INHIBIT Vitamin-K Vitamindependent clotting factors (10,9,7,2)
Acts within minutes Monitor for aPTT
Acts within days Monitor for PT and INR
Large molecule, can be given to Small molecule CANNOT be pregnant given to pregnant
Antidote: Protamine sulfate SE: bleeding, decreased platelets
Antidote: Vit. K SE: Bleeding
The antianemics: Iron preparations and Epoetin

Iron preparations Iron is important for hemoglobin formation. The iron preparations are: Ferrous sulfate Ferrous fumarate Ferrous gluconate

SideSide-effects: GITGIT- constipation (usually), diarrhea, vomiting, epigastric pain, gastric ulceration and darkening of stools. Liquid preparation can stain the teeth, and injectable iron can cause tissue discoloration Other- dizziness Other-

DrugDrug-Drug interaction Tetracyclines combine with iron preparations and render the iron unabsorbable. Antacids and cimetidine- decrease iron cimetidineabsorption and effects Foods can impair iron absorption but they should be taken with iron to reduce GI discomfort. Milk containing foods, coffee, tea and eggs are NOT given with iron because they delay iron absorption.

Implementation Encourage the patient to eat iron-rich foods like liver, lean ironmeat, egg yolk, dried beans, green leafy vegetables. Administer iron preparations orally with foods to decrease GI discomfort. If increased absorption is necessary, administer IN BETWEEN meals with full glass of water or juice. It is best to offer citrus juices because the vitamin C content can increase iron absorption. Instruct the patient to swallow the whole tablet and remain upright for 30 minutes to prevent esophageal corrosion from reflux. DO NOT administer iron together with or within 1 hour of ingesting tetracyclines, antacids, milk and milk-containing milkproducts. Advise clients to increase fluid intake and consume fiber rich foods if constipation becomes a problem.

Implementation Emphasize that the therapeutic effect of iron therapy may not be apparent until several weeks. If injecting a parenteral iron preparation, inject ZDEEP IM utilizing the Z-track method to avoid leakage into the subcutaneous tissues and skin. skin. Offer straw if giving liquid iron preparation to avoid staining the teeth. To prevent undue alarm, instruct the patient that the stools may turn black or dark green. This is a harmless occurrence.

Evaluation The nurse evaluates the effectiveness of the drug therapy by determining that the client is not fatigued, with absence of pallor, and with hemoglobin results within desired range. range.
Erythropoietin
The mechanism of action of epoetin alfa (Epogen) This drug acts like the natural glycoprotein erythropoietin to stimulate the production of RBC in the bone marrow.
Erythropoietin
Clinical indications It is given SUBCUTANEOUSLY or INTRAVENOUSLY for the treatment of anemia associated with renal failure or for patients on dialysis. dialysis. It is also used in patients for blood transfusion to decrease the need for blood in surgical patients.
Erythropoietin
Pharmacodynamics: the adverse effects of epoetin alfa CNS- headache, fatigue, asthenia, CNSdizziness and seizures- these are due to seizuresthe cellular response to the glycoprotein. GIT- nausea, vomiting and diarrhea GIT CVS- hypertension, edema and chest pain CVSdue to increase RBC number
Erythropoietin
Implementation Administer the drug SC or IV usually 3 times per week. Monitor the IV access line if given IV. Do not mix with other solutions Determine periodically the level of hematocrit and iron stores during therapy. If patient does not respond to the drug, reevaluate the cause of anemia. Maintain seizure precaution on stand by as seizure can occur. Provide comfort measures like small frequent feedings and pain medications for headache. Provide thorough health teaching: need for lifetime injection
Erythropoietin
Evaluation Monitor patient response to the drug= increased hemoglobin
Psychotrophic drugs
Drugs that can: 1. Stimulate the release of neurotransmitters 2. Block the receptor/activity of the neurotransmitter= like dopamine 3. Stimulate the receptors in the CNS 4. Prevents the breakdown of the neurotransmitters or the re-uptake mechanism re-
AntiAnti-Psychotics/Neuroleptics
Drugs used to treat PSYCHOSES MAIN ACTION: Blockage of the DOPAMINE receptor in the CNS
Class Phenothiazines Prototype Chlorpromazine Others Thioridazine, Fluphenazine, Perphenazine droperidol thirothixene
Butyrophenones Thioxanthines Dibenzoxapine
Haloperidol Chlorprothixene Molindone
Diphenylbutlypiperidine Pimozide Atypical drugs Clozapine Risperidone Olanzapine quetiapine
1 2 3 4 5 6 Desired Effects Reduced hallucination and illusions CNS sedation and emotional slowing Decreased ambivalence, reduced delusion Reduced agitation resulting to calmness Relief of emotional turmoil Reduced flattening of affect
Common SE Anticholinergic effects Photosensitivity Postural hypotension Agranulocytosis Seizure Sedation
Nursing Interventions Sugarless gum, bed rest Sunglasses, sunscreen, avoid sun Change position slowly, lie prone for 1 hour after drug intake, monitor BP Instruct to report sore throat and fever, monitor WBC Monitor EEG Safety, no machine operation
ExtraExtra-Pyramidal Syndrome ParkinsonismParkinsonism-Tremor, rigidity, bradikinesia Nursing Intervention Avoid abrupt withdrawal, give antiantiEPS drugs like Cogentin
DystoniaDystonia- torticollis, contraction Remain with client, administer antiantiof face and tongue EPS Akathisia= motor restlessness Verbalize understanding of the condition, administer anti-EPS anti-
Tardive Dyskinesia= irreversible No treatment except discontinue drooling, tongue movement and drug shuffling gait Neuroleptic Malignant syndrome= elevated temp, treme muscle rigidity Notify physician, prepare to administer dantrolene
Review Outline

Adrenergic Agonists Adrenergic Antagonists Cholinergic Agonists Cholinergic Antagonists
Comparison of the Sympathetic and Parasympathetic Nervous system

Characteristics CNS origin Sympathetic Parasympathetic Thoraco-lumbar spinal Cranio-Sacral spinal cord cord Long axon Acetylcholine Near target organ Short axon Acetylcholine AcetylcholineESTERASE Rest and Digest Acetylcholine Next to spinal cord Long axon Epi and NE MAO, COMT Fight or flight
Pre-ganglionic neuron Short axon Pre-ganglionic NTA Ganglia location Post-ganglionic neuron Post-ganglionic NTA Enzyme for NTA General response
The autonomic drugs

Pharmacologic use depends on their EFFECTS on the body They can STIMULATE= agonists OR mimetics They can DECREASE THE RESPONSE= antagonists OR blockers
The autonomic drugs

They can STIMULATE= agonists OR mimetics DIRECT STIMULATION by binding with receptors INDIRECT STIMULATION by blocking the enzymes that degrade the neurotransmitters or increasing the release of neurotransmitters
The autonomic drugs

They can DECREASE THE RESPONSE= antagonists OR blockers DIRECT blockage by removing the neurotransmitter or competing with the neurotransmitter Binding with the receptor and NO RESPONSE will happen
They can be The autonomic drugs NON-SELECTIVE when they stimulate or block many receptors SELECTIVE when they stimulate or block specific receptors SPECIFIC when only ONE type of receptor is stimulated or blocked
The autonomic drugs: Pharmacologic use depends on their EFFECTS on the body
Effect on the body Therapeutic use
Increases BP
Used for SHOCK where there is LOW BP Used for HYPERTENSION and Tachycardia
Decreases BP and heart rate
The Adrenergic AGONISTS

Also called SYMPATHOMIMETIC agents These drugs MIMIC the effects of the sympathetic nervous system

They usually stimulate DIRECTLY the receptors of the adrenergic system

Alpha and Beta agonists (non-selective)

Prototype: Epinephrine
Alpha Agonists (Selective)

Prototype: Phenylephrine
Beta Agonists (Selective)

Prototype: Isoproterenol

Alpha and Beta agonists (non-selective) Pharmacodynamics: These agents stimulate ALL types of adrenergic receptors in the body by direct interaction or by releasing neurotransmitters from the nerve cells

Alpha and Beta agonists

Prototype: Epinephrine
1. Ephedrine 2. Epinephrine 3. Metaraminol 4. Norepinephrine 5. Dobutamine (sometimes a B1 specific) 6. Dopamine

Alpha and Beta agonists: Clinical Use 1. Dopamine- used in shock 2. Epinephrine- drug of choice of anaphylaxis, Status asthmaticus 3. Norepinephrine- used in shock 4. Dobutamine- used in CHF 5. Ephedrine- used in shock, asthma and rhinitis

Alpha and Beta agonists: Desirable effects

Increased myocardial contractility Bronchial DILATATION Vasoconstriction Increased blood pressure Decreased intraocular pressure Pupillary dilatation

Alpha and Beta agonists: Contraindications

Pheochromocytoma Tachyarrhythmias With halogenated anesthesia- increased sensitivity to adrenergic drugs

Alpha and Beta agonists: Adverse effects

Sympathetic stimulation effects
CVS- hypertension, tachycardia, palpitations Respi- tachypnea GI- nausea, vomiting Others- sweating, headache, piloerection

Alpha and Beta agonists: Nursing considerations 1. Monitor patient response to the drug 2. Emphasize to avoid the use with MAOIs and TCA 3. Maintain phentolamine (alpha blocker) to manage extravasation of IV drug 4. Usually given IV

Alpha and Beta agonists: Nursing considerations Determine effectiveness of the drug: Increased BP in shock Relief of anaphylaxis and asthma attack Relief of nasal congestion

Alpha Agonists (selective) Prototype: phenylephrine clonidine (alpha-2 specific)

Alpha Agonists Pharmacodynamics: These agents bind primarily to the alpha receptors in the body Clonidine Stimulating the ALPHA-2 receptor causes decreased sympathetic outflow from the CNS/ decreased release of NE

Alpha Agonists: Clinical use
1.
2.
Phenylephrine- vasoconstricting drug, used topically to decrease the symptoms of rhinitis Clonidine- for hypertension

Alpha Agonists: Contraindication 1. Allergy to drug 2. Caution in the following conditions:

Hyperthyroidism-aggravation of symptoms Diabetes- increased glucose levels Tachyarrhythmias- possible additive effect

Alpha Agonists: Adverse effects CNS- anxiety, depression, fatigue CVS- palpitations GI- nausea, vomiting and anorexia GU- oliguria, dysuria

Alpha Agonists: Nursing considerations 1. DO NOT discontinue drug abruptly to prevent rebound effect 2. Maintain phentolamine if giving IV drug 3. Provide comfort measures- rest, quiet environment, analgesics

Alpha Agonists: Nursing considerations Evaluate effectiveness: Decreased BP Decreased Nasal congestion

Beta Agonists (Selective): ANTI-ASTHMA DRUGS Prototype: isoproterenol (B1 and B2) salbutamol (Ventolin)= B2 specific 1. Ritodrine (B2 specific) 2. terol- albuterol, salmeterol, bitolterol 3. Terbutaline (B2)

Beta Agonists Pharmacodynamics These agents bind to the BETA receptors causing the sympathetic manifestations and effects

Beta Agonists Clinical use 1. Asthma- due to the bronchodilation! 2. Preterm labor- ritodrine is given to relax the uterine muscles 3. Shock= To increase BP

Beta Agonists Adverse effects CNS- restlessness, headache, anxiety , tremors CVS- tachycardia, angina, palpitations GI- nausea, vomiting and anorexia Others- pupilary dilation, rash, sweating, pulmonary edema

Beta Agonists Nursing considerations 1. Monitor VS when giving the drug 2. Remind mothers to lie on the left side during ritodrine administration 3. Maintain a beta blocker on stand by 4. Provide comfort- quiet environment, rest, analgesics. 5. Prevent over-hydration to avoid pulmonary edema

Beta Agonists Nursing considerations These are given usually inhalational for asthma attack Instruct on how to use inhalers and nebulizers Evaluate effectiveness: Normal RR Clear breath sounds
The Adrenergic ANTAGONISTS

These are called adrenergic blockers They can be Alpha Blockers (selective) Beta Blockers (selective) Both Alpha & Beta Blockers (non-selective)

The alpha blockers (selective) Prototype: Phentolamine Phenoxybenzamine zosin- prazosin, doxazosin, terazosin- these are alpha 1 blockers

The alpha blockers: Pharmacodynamics These agents have affinity for the ALPHA receptors Blocking the alpha receptors will cause: Vasodilation Sphincter relaxation in the bladder

The alpha blockers: Clinical use 1. Phenoxybenzamine- used in pheochromocytoma 2. Phentolamine- also used in pheochomocytoma 3. zosin drugs- are used to decrease blood pressure and to relax the urinary sphincter in BPH!

The alpha blockers: Contraindications
1. 2.
Myocardial infarction Allergy

The alpha blockers: Adverse Effects CVS- hypotension, reflex tachycardia, flushing CNS- dizziness, weakness, fatigue, drowsiness Others- nasal congestion, reddened eyes, priapism

The alpha blockers: nursing consideration 1. Monitor heart rate and BP 2. Caution to change position slowly 3. Advise to avoid hazardous activities 4. Provide supportive measures like quiet environment, rest and analgesics 5. Monitor response to the drugimprovement of blood pressure readings and urination

The Beta blockers These are agents used to treat cardiovascular problems- Hypertension, CHF, angina Blocking beta receptor will cause decreased heart rate decreased BP

The Beta blocker or The olols They can be beta 1 blockers, beta 2 blockers or Both Prototype of non-selective: propranOLOL (beta 1 and 2) carteOLOL nadOLOL penbutOLOL sotaLOL

The Beta blocker or The olols They can be beta 1 blockers, beta 2 blockers or Both Prototype of B1 selective: atenOLOL acebutOLOL betaxOLOL esmOLOL metoprOLOL

The Beta blockers: pharmacodynamics These agents block the beta receptors of the sympathetic system. The selective B1 antagonists block the B1 receptors, especially in the heart and the kidney

The Beta blockers: Clinical use 1. Hypertension 2. Angina and MI 3. Cardiac arrhythmias 4. Migraine headache 5. HYPERTHYROIDISM

The Beta blockers: Clinical use
Hypertension Angina and MI
Cardiac tachyarrhythmias
to decrease BP to decrease cardiac workload to terminate arrhythmias to cause vasoconstriction in the cranial vessels to decrease the tachycardia
Migraine headache HYPERTHYROIDISM

The Beta blockers: contraindications 1. Allergy 2. Heart blocks 3. Bradycardia 4. COPD 5. Precaution in DM

The Beta blockers: Adverse effects CVS- bradycardia, hypotension, heart block CNS- fatigue, dizziness, depression Respi- bronchospasm, pulmonary edema GI- nausea, vomiting, diarrhea, hypoglycemia GU- decreased libido, impotence, dysuria

The Beta blockers: nursing considerations 1. Emphasize NOT to stop abruptly the drug intake 2. Give with FOODS to improve absorption 3. Provide comfort measures

Adequate rest periods Avoidance of hazardous activities Change position slowly

The Beta blockers: nursing considerations Evaluate effectiveness: Decreased BP in hypertension Decreased HR in hyperthyroidism Decreased PAIN angina
The Cholinergic Agonists

These are also called parasympathomimetic agents Their action mimics the parasympathetic nervous system

These agents INCREASE the activity of acetylcholine in the acetylcholine receptors DIRECTLY by occupying the receptor INDIRECTLY by blocking the enzyme that degrades the acetylcholine, preventing it from breakdown - the enzyme: acetylcholinESTERASE

Direct acting cholinergic agonists Prototype: BetaneCHOL CarbaCHOL Pilocarpine Indirect acting cholinergics
Prototype: Pyridostigmine
Neostigmine Endrophonium (Tensilon)

Direct acting cholinergic agonists Pharmacodynamics They are similar to acetylcholine and directly act on the acetylcholine receptors

Direct acting cholinergic agonists Parasympathetic stimulation will cause: DUMBELS urination miosis (pupil constriction)

Direct acting cholinergic agonists: Clinical use 1. Post operative and post partum urinary retention and to treat neurogenic bladder 2. Relief of increased intraocular pressure of glaucoma by inducing miosis

Direct acting cholinergic agonists: Clinical use 1. The drugs INCREASE the bladder tone, RELAX the GI and urinary sphincters 2. The topical agent (pilocarpine) topically causes pupilary constriction to reduce IOP

Direct acting cholinergic agonists: Contraindications 1. Bradycardia 2. Hypotension 3. Asthma

Direct acting cholinergic agonists: Adverse effects (DUMBELS) CVS- bradycardia, heart block, hypotension GIT- nausea, vomiting, diarrhea, increased salivation, lacrimation GUT- sense of urgency, sphincter relaxation Others- increased sweating, headache, miosis

Direct acting cholinergic agonists: nursing considerations 1. Assure proper administration of ophthalmic preparations 2. Administer on EMPTY stomach 3. Provide safety precautions- because of poor visual acuity 4. Promote cool environment, maintain access to the bathroom (urination)
The Cholinergic Agonists: evaluate effectiveness

Drug effectiveness
Pilocarpine
Decreased IOP in glaucoma Urination/ relief of bladder distention
Betanechol/Carbachol

Indirect acting cholinergic agonists Pharmacodynamics These agents DO NOT react directly with the receptors but REACT chemically with the enzyme= acetylcholinesterase

Indirect acting cholinergic agonists Pharmacodynamics The acetylcholine breakdown is prevented so that the effect of acetylcholine is prolonged!= increased muscle contraction They are used IN myasthenia gravis

Indirect acting cholinergic agonists Clinical use 1. Myasthenia gravis

Physostigmine, pyridostigmine, Neostigmine, and endrophonium Tacrine and Donepezil
2. Alzheimer's disease


Indirect acting cholinergic agonists Adverse effects GI- nausea, vomiting, cramps, diarrhea, increased salivation, involuntary defection CVS- bradycardia, heart block, hypotension GU- urinary urgency Others- blurred vision, miosis, headache, dizziness

Indirect acting cholinergic agonists Nursing considerations 1. Administer IV drug slowly 2. Administer with foods BUT better BEFORE meals 3. Maintain atropine sulfate as antidote 4. Discontinue the drug if excessive salivation, diarrhea, vomiting become problematic

Indirect acting cholinergic agonists Nursing considerations Evaluate effectiveness Decreased muscle weakness Decreased dysphagia, ptosis Increased muscular activity
The ANTI-cholinergics
These are drugs that BLOCK the effect of acetylcholine They are also called parasympatholytic agents In effect, the sympathetic system becomes unopposed!!!
Anticholinergics: Prototype: Atropine dicyclomine glycopyrrolate propantheline scopolamine
Anticholinergics: pharmacodynamics These agents work by BLOCKING or COMPETING with acetylcholine for the acetylcholine receptors BEST taken BEFORE MEALS
Atropine
Depresses salivation Decreases bronchial secretions Mydriasis Cyclopedia Inhibits vagal response in the heart Reverses cholinergic toxicity
Atropine
effects Clinical use
Depresses salivation Decreases bronchial secretions Mydriasis Cyclopledia
Used as pre-op med Used as pre-op med Used in cataract surgery Used in cataract surgery
Inhibits vagal response in Used in BRADYCARDIA the heart and heart block Used in partly to control diarrhea Constipation
(in Lomotil)
Reverses cholinergic toxicity
Used in Cholinergic and Organophosphate poisoning
Scopolamine
Decreases nausea and vomiting associated with motion sickness
Anticholinergic
Contraindications of anticholinergic
1. 2. 3.
Known allergy Glaucoma Bladder obstruction (like PBH)
Anticholinergic
Adverse effects: anticholinergic effects CNS- blurred vision, pupil DILATION, photophobia, cycloplegia and increased Intraocular pressure GI- dry mouth, constipation, bloatedness CVS- tachycardia, palpitations GU- urinary retention Others- decreased sweating, flushing
Anticholinergic
Nursing considerations 1. Provide comfort measures

Frequent mouth care Provide increased fluids Protect eyes form lights Advise to avoid hazardous activities Provide high-fiber diet and laxative Avoid extremes of temperature Instruct to void before administering the drug
Anticholinergic
Nursing considerations 2. Monitor for toxicity: 3. Ensure adequate hydration to prevent hyperpyrexia Evaluate effectiveness of drug: Increased HR in heart block Decreased secretions in pre-op patients Relief of motion sickness (scopolamine)

Pharmacology Bullet Review

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Pharmacology Bullet Review

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Pharmacology Bullet Review

Nursing Board 2005

Nursing process applied to pharmacology

Proximal tubule Loop of Henle Distal tubule Glomerulus

Hyperuricemia Hypokalemia Hypokalemia Ototoxicity Hyperkalemia Hypovolemia & hypotension

Special Uses Mountain sickness Menieres disease

CHF taking digoxin Increased ICP LITHIUM TOXICITY

1. Indapamide 2. Quinethazone 3. Metolazone 4. Chlorthalidone

Special Pharmacodynamics: Side effects

1. Bumetanide 2. Ethacrynic acid 3. Torsemide

Potassium sparing diuretics

Potassium sparing diuretics

Potassium sparing diuretics

Potassium sparing diuretics

HYPERkalemia! Avoid high potassium foods:

Bananas Potatoes Spinach Broccoli Nuts Prunes Tomatoes Oranges Peaches

1. Glycerin 2. Isosorbide 3. Urea

Carbonic Anhydrase Inhibitors

Carbonic Anhydrase Inhibitors

Carbonic Anhydrase Inhibitors

The Nursing Process and the diuretics

The Nursing Process and the diuretics

Allergy to sulfonamides may contraindicate the use of thiazides

The Nursing Process and the diuretics

Assess symptom of body weakness which may indicate hypokalemia

The Nursing Process and the diuretics

The Nursing Process and the diuretics

The Nursing Process and the diuretics

The Nursing Process and the diuretics

The ANXIOLYTICS AND HYPNOTICS

The ANXIOLYTICS AND HYPNOTICS

The ANXIOLYTICS AND HYPNOTICS

The ANXIOLYTICS AND HYPNOTICS

The ANXIOLYTICS AND HYPNOTICS

Use of The Drugs

The BENZODIAZEPINES Special uses

Chlordiazepoxide Alcohol withdrawal (Librium) Alprazolam (Xanax) Panic attack

Have available FLUMAZENIL as an antidote for benzodiazepine overdose.

amobarbital aprobarbital butabarbital mephobarbital pentobarbital Phenobarbital secobarbital

The CNS stimulants

The CNS stimulants

The CNS stimulants

The CNS stimulants

The CNS stimulants

The CNS stimulants

The CNS stimulants

The CNS stimulants

Drugs affecting GI secretions

Drugs affecting secretions: anti ulcer

AlOH and MgOH Omeprazole Sucralfate Misoprostol

General indication of the drugs affecting gastric acid secretion

General time of administration of the drugs affecting gastric acid secretion

Pharmacology of Anti-ulcer Antidrugs

H2-BlockersH2-Blockers- tidine Cimetidine, Cimetidine, Ranitidine

Proton pump inhibitorsinhibitorsPrazoles Omeprazole, pantoprazole

Pharmacology of Anti-ulcer drugs AntiDrug Mechanism of Action

Anti-cholinergicAnti-cholinergic- Prophanteline Bromide Sucralfate (Carafate)

Blocks VAGUS nerve, decreases secretion Coats the mucosal lining

Prostaglandin Analogue, causes secretion of MUCUS

Drugs affecting GI secretions

Drugs affecting GI secretions

Drugs affecting GI secretions

Drugs affecting GI secretions