28896523-Pharmacology-Bullet-Review

28896523-Pharmacology-Bullet-Review - Pharmacology Bullet...

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Unformatted text preview: Pharmacology Bullet Review Nursing Board 2005 Drug classification Pharmacodynamic s Pharmacokinetics Nursing process applied to pharmacology Diuretic class 1. Carbonic anhydrase inhibitor 2. Thiazide and thiazide like 3. Loop diuretics 4. Potassium sparing 5. Osmotic diuretic Diuretics Comparison Major site of action Proximal tubule Acidosis Special Side effect (s) Proximal tubule Hyperuricemia Hypokalemia Loop of Henle Distal tubule Glomerulus Hypokalemia Ototoxicity Hyperkalemia Hypovolemia & hypotension Diuretics Comparison Diuretic class 1. Carbonic anhydrase inhibitor Special Uses Mountain sickness Meniere's disease Nephrolithiasis due to calcium stones Hypocalcemia Hypercalcemia 2. Thiazide and thiazide like 3. Loop diuretics 4. Potassium sparing 5. Osmotic CHF taking digoxin Increased ICP Thiazides Prototype: Hydrochlorothiazide 1. Bendroflumethiazide 2. Benthiazide 3. Chlorothiazide (Diuril) 4. Hydroflumethiazide 5. Methylclothiazide 6. Trichlormethiazide Thiazide-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 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: sideeffects Hypokalemia Bicarbonate is lost in the urine INCREASED calcium excretion Hypocalcemia Ototoxicity- due to the electrolyte imbalances Potassium sparing diuretics Prototype: Spironolactone 1. Amiloride 2. Triamterene Potassium sparing diuretics 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 Potassium sparing diuretics Potassium sparing diuretics 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 Carbonic Anhydrase Inhibitors 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 Carbonic Anhydrase Inhibitors 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: ______ ______ ______ ______ The Nursing Process and the diuretics 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 The Nursing Process and the diuretics ASSESSMENT Physical assessment Vital signs Special electrolyte and laboratory examination Assess symptom of body weakness which may indicate hypokalemia The Nursing Process and the diuretics Nursing Diagnosis Fluid volume deficit related to diuretic effect Alteration in urinary pattern Potential for injury (ototoxocity, hypotension) Knowledge deficit The Nursing Process and the diuretics 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 The Nursing Process and the diuretics IMPLEMENTATION Monitor DAILY WEIGHT- to evaluate the effectiveness of the therapy Monitor urine output, cardiac rhythm. Serum electrolytes ADMINISTER in the MORNING! Administer with FOOD! The Nursing Process and the diuretics 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 individual's responses to the environment. The ANXIOLYTICS AND HYPNOTICS The medications that can prevent the feelings of tension and fear are called ANXIOLYTICS. Anti-anxiety drugs The ANXIOLYTICS AND HYPNOTICS The drugs that can calm individuals making them unaware of the environment are called SEDATIVES. The ANXIOLYTICS AND HYPNOTICS The drugs that can induce sleep are called HYPNOTICS. The ANXIOLYTICS AND 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) 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 ( Gammaaminobutyric 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 tension 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, 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. The BENZODIAZEPINES Nursing Considerations: Provide comfort measures to help patients tolerate drug effects instruct to urinate before taking drug give high fiber foods use side-rails and assistance with ambulation. 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 5. seizures/epilepsy 6. The rapid acting barbiturates are also used for the treatment of acute manic reactions and status epilepticus Pharmacodynamics: The Adverse effects CNS= CNS 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 StevensJohnson syndrome. The BARBITURATES The BARBITURATES Nursing Considerations Provide stand-by life support facilities in cases of severe respiratory depression or hypersensitivity reaction. Taper the drug gradually after long-term therapy to avoid withdrawal syndrome. Provide comfort measures including small frequent meals, access to bathroom facilities, high-fiber foods, environmental control, safety precaution and skin care. The CNS stimulants These are drugs used to treat certain disorders 1. exogenous obesity 2. attention-deficit hyperactivity disorders (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 neurons. 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, headache, and blurred vision GIT= anorexia, nausea and weight loss 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 assisted 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 These 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. Anti-epileptics Agents for treating TONIC-CLONIC SEIZURES 1. Hydantoins Phenytoin Ethotoin Fosphenytoin Mephenytoin Diazepam Clonazepam Clorazepate 2. Benzodiazepines 3. Barbiturates Phenobarbital Anti-epileptics Agents for treating ABSENCE SEIZURES 1. Succinimides a. Ethosuximide b. Methsuximide c. Phensuximide 2. Valproic Acid 3. Zosinamide Anti-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. 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 2. 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. The hydantoins Pharmacodynamics: Adverse effects of the Hydantoins CNS effects- depression, confusion, drowsiness, lethargy, fatigue GIT- GI upset, constipation, dry mouth, GINGIVAL HYPERPLASIA , severe liver toxicity which are all related to cellular toxicity. SKIN- 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 AlOH and MgOH Omeprazole Mucosal protectants Sucralfate Prostaglandin analogMisoprostol Pharmacology of Antiulcer drugs Drug Mechanism of Action Antacids- AlOH, MgOH Neutralize Gastric ACIDITY H2-Blockers- "tidine" Cimetidine, Ranitidine Block Histamine receptor causing decreased secretion and acidity Inhibit Proton Pump in parietal cell decreasing secretion and acidity Proton pump inhibitors"Prazoles" Omeprazole, pantoprazole Pharmacology of Anti-ulcer drugs Drug Mechanism of Action Anti-cholinergicProphanteline 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 Drugs affecting GI secretions Antacids These drugs interact with the gastric acids at the chemical level to neutralize them Drugs affecting GI secretions Proton pump inhibitors These drugs suppress the secretion of hydrochloric acid into the lumen of the stomach Drugs affecting GI secretions Mucosal protectants These are agents that coat any injured area in the stomach to prevent further injury from acid Drugs affecting GI secretions 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" Prototype: Cimetidine 1. Ranitidine 2. Famotidine 3. Nizatidine The H2 Blockers- "tidines" Pharmacodynamics: 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" Therapeutic use of the H2 blockers Short-term treatment of active duodenal ulcer or benign gastric ulcer Treatment of hypersecretory conditions like the Zollinger-Ellison syndrome Prevention of stress-induced ulcers and acute GI bleeding Treatment of erosive GERD (reflux disease) Relief of Symptoms of heart burn and acid indigestion The H2 Blockers- "tidines" Precautions 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" Pharmocodynamics- 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" Drug-drug Interactions Cimetidine, Famotidine, Ranitidine are metabolized in the liver- they can cause slowing of excretion of other drugs leading to their increased concentration. The H2 Blockers- "tidines" Drug-drug Interactions These drugs can interact with CIMETIDINE anticoagulants, phenytoin, alcohol, antidepressants. The H2 Blockers- "tidines" Nursing 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" Nursing 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" Nursing 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" Nursing considerations: Provide health teaching as to the dose, frequency, comfort measures to initiate when side-effects are intolerable Evaluate 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 absorption 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 acid-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 the 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 Lanisoprazole Esomeprazole 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 Short-term treatment of active duodenal ulcers, GERD, erosive esophagitis and benign gastric ulcer. Long-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, headache, asthenia (loss of strength), vertigo, insomnia, apathy GIT- diarrhea, abdominal pain, nausea, vomiting, dry mouth and tongue atrophy Respi- 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 are NOT resolved after 4-8 weeks of therapy. 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 duodenal 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 aluminum may occur if used with aluminum containing products. The Mucosal Protectant Pharmacodynamics: Side-effects & adverse reactions Primarily GIT= CONSTIPATION, occasionally diarrhea, nausea, indigestion, gastric discomfort, and dry mouth may also occur CNS= dizziness, drowsiness, vertigo Others= rash and back pain The Mucosal Protectant Drug-drug interactions If used with aluminum salts= high risk of accumulation of aluminum and toxicity. If used with phenytoin, fluoroquinolones and penicillaminesdecreased levels of these drugs when taken with sucralfate The Mucosal Protectant Nursing Considerations Administer drug ON AN EMPTY stomach, 1 hour before meals , or 2 hour after meals and at BEDTIME Monitor for side-effects like constipation and GI upset Encourage intake of high-fiber foods and increased fluid intake Administer antacids BETWEEN doses of sucralfate, NOT WITHIN 30 minutes of sucralfate dose The Mucosal Protectant 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 The Mucosal Protectant 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 Prostaglandin analogue Misoprostol: Pharmacodynamics Being a prostaglandin analog, it inhibits gastric acid secretion to some degree It INCREASES mucus production in the stomach lining. Prostaglandin analogue Misoprostol: Clinical use NSAIDs-induced gastric ulcers Duodenal ulcers unresponsive to H2 antagonists. Prostaglandin analogue 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. Prostaglandin analogue Pharmacodynamic effects: drug reactions GIT= Nausea, diarrhea, abdominal pain, flatulence, vomiting, dyspepsia GU effects= miscarriages, excessive uterine CRAMPING and bleeding, spotting, hypermenorrhea and menstrual disorders. Prostaglandin analogue Nursing Considerations Administer to patients at risk for NSAIDsinduced ulcers 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 Prostaglandin analogue 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 Preparation for diagnostic examination Removal of poison or toxins Adjunct in anti-helminthic therapy 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) Bulk-forming laxatives 1. Magnesium (citrate, hydroxide, sulfate) 2. Psyllium 3. Polycarbophil Mechanical Stimulant Cathartics Pharmacodynamics These agents are rapid-acting laxatives that INCREASE the GI motility by Increasing the fluids in the colonic material Stimulating the local stretch receptors Activating local defection reflex Lubricants Prototype: 1. Docusate 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 Diarrhea Abdominal cramping Nausea Fluid and electrolyte imbalance Sympathetic reactions- sweating, palpitations, flushing and fainting CATHARTIC dependence The Nursing Process and Laxative ASSESSMENT Nursing History- elicit allergy to any laxatives, elicit history of conditions like diverticulitis and ulcerative colitis Physical Examination- abdominal assessment Laboratory Test: fecalysis, electrolyte levels The Nursing Process and Laxative NURSING DIAGNOSIS Alteration in bowel pattern Alteration in comfort: pain Knowledge deficit The Nursing Process and Laxative 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 3. Administer with a full glass of water The Nursing Process and Laxative 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 The Nursing Process and Laxative 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 These are agents used to calm the irritation of the GIT for the symptomatic relief of diarrhea General Classifications 1. Local anti-motility 2. Local reflex inhibition 3. Central action on the CNS The Anti-diarrheals Type 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 antidiarrheal Use Poisoning Drug allergy GI obstruction Acute abdominal conditions Pharmacokinetics: Side effects Constipation Nausea, vomiting Abdominal distention and discomfort TOXIC MEGACOLON Nursing process and antidiarrheals ASSESSMENT Nursing History Elicit history of drug allergy, conditions like poisoning, GI obstruction and acute abdominal conditions Physical Examination- Abdominal examination Laboratory test- electrolyte levels Nursing process and antidiarrheals NURSING DIAGNOSIS Alteration in bowel pattern Alteration in comfort: pain Nursing process and antidiarrheals IMPLEMENTATION 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 antidiarrheals EVALUATION 1. Monitor effectiveness of drugRELIEF of diarrhea 2. Monitor adverse effects, effectiveness of pain measures and effectiveness of teaching plan Emetics and Anti-emetics Emetic Agent Syrup of Ipecac Anti-emetics 1. Phenothiazines 2. Non-phenothiazines 3. 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 poisoning Physical Examination- CNS status and abdominal exam Nursing process and the EMETIC 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 Nursing process and the EMETIC IMPLEMENTATION 5. Provide comfort measures like ready access to bathroom, assistance with ambulation 6. Offer support Nursing process and the EMETIC 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 ANTI-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 (Reglan) Meclizine, buclizine "setron"- dolasetron Dronabinol, hydroxyzine ANTIEMETICS Types Phenothiazines Non-phenothiazine Pharmacodynamics 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 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 Non-phenothiazine Anticholinergics Serotonin-receptor Blockers Miscellaneous ANTIEMETICS Contraindications 1. Severe CNS depression 2. Severe liver dysfunction ANTIEMETICS Pharmacokinetics: Side-effects 1. PHOTHOSENSITIVITY 2. Drowsiness, dizziness, weakness and tremors and DEHYDRATON 3. Phenothiazines= autonomic anticholinergic effects like dry mouth, nasal congestion and urinary retention Nursing Process and the ANTIEMETICS ASSESSMENT Nursing History- elicit allergy, impaired hepatic function and CNS depression Physical Examination- CNS status and abdominal examination Laboratory test- Liver function studies Nursing Process and the ANTIEMETICS NURSING DIAGNOSIS 1. Alteration in comfort: pain 2. High risk for injury 3. Knowledge deficit Nursing Process and the ANTIEMETICS 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 Nursing Process and the ANTIEMETICS 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 Nursing Process and the ANTIEMETICS IMPLEMENTATION 4. Protect from sun exposure Sunscreens Protective covering 5. Provide health teaching Nursing Process and the ANTIEMETICS 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 Anti-diuretic hormones Enhance re-absorption of water in the kidneys Used in DI 1. Desmopressin and Lypressin intranasally 2. Pitressin IM Endocrine Medications Anti-diuretic hormones SIDE-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 Side-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 ANTI-Thyroid Medications ANTI-THYROID medications The thyroid becomes oversaturated with iodine and stop producing thyroid hormone ANTI-Thyroid Medications ANTI-THYROID medications Drugs used to BLOCK the thyroid hormones and treat hyperthyroidism Inhibit the synthesis of thyroid hormones ANTI-Thyroid Medications ANTI-THYROID medications 1. Methimazole (Tapazole) 2. PTU (prophylthiouracil) 3. Iodine solution- SSKI and Lugol's solution ANTI-Thyroid Medications ANTI-THYROID medications Side-effects of thionamides N/V, drowsiness, lethargy, bradycardia, skin rash GI complaints AGRANULOCYTOSIS Most important to monitor ANTI-Thyroid Medications ANTI-THYROID medications Side-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 ANTI-THYROID medications Nursing responsibilities 1. Monitor VS, T3 and T4, weight 2. The medications WITH MEALS to avoid gastric upset ANTI-Thyroid Medications ANTI-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 ANTI-Thyroid Medications ANTI-THYROID medications Lugol's 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 anti-inflammatory effects at a particular site STEROIDS Steroid Dexamethasone Clinical use Use to induce the formation of lung surfactant Use for the treatment of immune-related diseases, control of asthma and allergic symptoms Other steroids STEROIDS Side-effects HYPERglycemia Increased susceptibility to infection (immunosuppression) Hypokalemia Edema and Hypertension Peptic ulceration STEROIDS Side-effects If high doses- osteoporosis, growth retardation, peptic ulcer, hypertension, 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 These 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 The cardiac glycosides Pharmacodynamics: the Mechanism of action They increase the level of CALCIUM inside the cell by inhibiting the Sodium-Potassium pump. More calcium will accumulate inside the cell during cellular depolarization. The cardiac glycosides Positive inotropic Effect- the myocardium will contract forcefully Increased cardiac output Increased blood flow to the body organs like the kidney and liver Negative chronotropic effect- the heart rate is slowed due to decreased rate of cellular repolarization Bradycardia Decreased conduction velocity through the AV node The cardiac glycosides Clinical Use of the cardiac glycosides Treatment of congestive heart failure Treatment of dysrhythmias like atrial flutter, atrial fibrillation and paroxysmal atrial tachycardia The cardiac glycosides 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 (may cause accumulation of drug) The cardiac glycosides Pharmacodynamics: the Adverse Effects of the Cardiac glycosides CNS- Headache, weakness , seizures and drowsiness CVS- arrhythmias If digitalis toxicity is developing- the nurse must assess the following adverse effects: Anorexia, nausea and vomiting, visual changes- YELLOW halo around an object, and palpitations or very slow heart rate The cardiac glycosides Remember= NAVDA and hypokalemia The cardiac glycosides Drug-Drug Interactions If taken with potassium-losing diuretics like furosemide- can INCREASE the risk of toxicity and arrhythmias. Potassium replacement must be given. The cardiac glycosides 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 is different from DIGITOXIN! Check the dosage preparation and the level of digitalis in the blood. (Therapeutic level is 0.5 to 2.0 nanograms/mL) Administer intravenous drug VERY slow IV over 5 minutes to avoid arrhythmias. Do NOT administer intramuscularly because it can cause severe pain The cardiac glycosides The cardiac glycosides Implementation Administer the drug without food if possible to avoid delayed absorption. Weight patient 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 meals, adequate lighting, comfortable position, rest periods and safety precautions The cardiac glycosides Implementation Provide health teaching- drug name, action, dosage 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 The cardiac glycosides 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 employed Organic nitrates Beta-blockers and Calcium-channel blockers. The benefits of the drugs lie in their different mode of action. The Antianginal drugs The nitrates can cause vasodilatation of the veins and to some extent, coronary artery The Antianginal drugs Beta-blockers heart rate will decrease the The Antianginal drugs Calcium-channel blockers will decrease force of contraction leading to a decreased myocardial workload and demand. They can also produce vasodilation The Organic nitrates These 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 nitrate Isosorbide Dinitrate (Isordil) or mononitrate Amyl nitrate- an extremely volatile nitrate The Organic nitrates Nitroglycerin This agent is supplied in oral, spray, transdermal and ointment preparations. The Organic nitrates 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. The Organic nitrates Administered nitrates Increased nitrates in the blood increased formation of nitric oxide increased cGMP formation increased dephosphorylation of myosin Vascular smooth muscle relaxation vasodilatation The Organic nitrates Pharmacokinetics- 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 effect, Nitroglycerin is given SUBLINGUALY . Pharmacodynamics: Side effects and adverse effects HEADACHE is the most common effect of nitroglycerin. CVS- postural Hypotension, facial flushing, tachycardia TOLERANCE- the tolerance to the actions of nitrates develop rapidly. This can be managed by providing a day of abstinence. The Organic nitrates 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 nitroglycerin 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. DO NOT give more than 3 tablets!!! If 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 blockers 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: If 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 away from heat and direct sunlight to avoid lessening the potency The Nitrates IMPLEMENTATION Other components of health teaching for home self-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: Position supine with elevated legs to manage Hypotension. Nitroglycerin tablet can be taken prophylactically in situations where chest pain is anticipated- Sex, exercise, etc.. If 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 nor-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. The dose range is 1-20 micrograms/kg/min Drugs for Shock Dopamine Pharmacokinetics: Dopamine is administered IV, excreted in the urine. At low dose (1-2 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 effect) and elevates blood pressure through peripheral vasoconstriction (alpha adrenergic effect) Drugs for Shock Dopamine At higher doses of more than 10 micrograms- 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 dripdopamine (at a concentration of 400-800 mg) is mixed 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 effectsTachycardia 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 Alpha adrenergic blockers Calcium channel blockers Angiotensin-converting enzyme inhibitors 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 Class Anti-hypertensive drugs Prototype MOA Side effects Furosemide Decreases blood volume Hypokalemia Blocks B1 receptor Bradycardia, in the heart hypoglycemia Prevents A1 to AII Headache, Cough, conversion flushing Blocks Ca entry into cell Headache, flushing, reflex tachycardia Diuretics Beta-blocker Propranolol ACE Inhibitors Ca channel blockers Vasodilator Alpha blockers Captopril Nifedipine Nitroglycerin Dilates veins and HEADACHE arteries Prazozin Blocks alpha receptor in BV causing vasodilatation Stimulates CNS Urination Central alpha Clonidine Depression Anticoagulants HEPARIN Parenteral (SQ and IV) WARFARIN Oral Action is to enhance natural Action is to INHIBIT Vitamin-K anti-thrombin III in the blood dependent 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 Small molecule CANNOT be to pregnant given to pregnant Antidote: Protamine Antidote: Vit. K sulfate SE: bleeding, decreased SE: Bleeding platelets The antianemics: Iron preparations and Epoetin Iron preparations Iron is important for hemoglobin formation. The iron preparations are: Ferrous sulfate Ferrous fumarate Ferrous gluconate The antianemics: Iron preparations and Epoetin Side-effects: GIT- 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 The antianemics: Iron preparations and Epoetin Drug-Drug interaction Tetracyclines combine with iron preparations and render the iron unabsorbable. Antacids and cimetidine- decrease iron absorption 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. The antianemics: Iron preparations and Epoetin Implementation Encourage the patient to eat iron-rich foods like liver, lean meat, 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 products. Advise clients to increase fluid intake and consume fiber rich foods if constipation becomes a problem. The antianemics: Iron preparations and Epoetin Implementation Emphasize that the therapeutic effect of iron therapy may not be apparent until several weeks. If injecting a parenteral iron preparation, inject DEEP IM utilizing the Z-track method to avoid leakage into the subcutaneous tissues and 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. The antianemics: Iron preparations and Epoetin 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. 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. 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, dizziness and seizures- these are due to the cellular response to the glycoprotein. GIT- nausea, vomiting and diarrhea CVS- hypertension, edema and chest pain due 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 1. 2. 3. 4. Drugs that can: Stimulate the release of neurotransmitters Block the receptor/activity of the neurotransmitter= like dopamine Stimulate the receptors in the CNS Prevents the breakdown of the neurotransmitters or the re-uptake mechanism AntiPsychotics/Neuroleptics Drugs used to treat PSYCHOSES MAIN ACTION: Blockage of the DOPAMINE receptor in the CNS AntiPsychotics/Neuroleptics Class Phenothiazines Prototype Chlorpromazine Others Thioridazine, Fluphenazine, Perphenazine droperidol thirothixene Butyrophenones Thioxanthines Dibenzoxapine Haloperidol Chlorprothixene Molindone Diphenylbutlypiperi Pimozide dine Atypical drugs Clozapine Risperidone Olanzapine quetiapine AntiPsychotics/Neuroleptics 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 AntiPsychotics/Neuroleptics Common SE Anticholinergic effects Photosensitivity Postural hypotension Agranulocytosis 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 AntiPsychotics/Neuroleptics Extra-Pyramidal Syndrome Parkinsonism-Tremor, rigidity, bradikinesia Dystonia- torticollis, contraction of face and tongue Akathisia= motor restlessness Tardive Dyskinesia= irreversible drooling, tongue movement and Nursing Intervention Avoid abrupt withdrawal, give anti-EPS drugs like Cogentin Remain with client, administer anti-EPS Verbalize understanding of the condition, administer anti-EPS No treatment except discontinue drug Review Outline Adrenergic Agonists Adrenergic Antagonists Cholinergic Agonists Cholinergic Antagonists Characteristics CNS origin Comparison of the Sympathetic and Parasympathetic Nervous system 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 Pre-ganglionic neuron Short axon Pre-ganglionic NTA Ganglia location Post-ganglionic neuron Long axon Post-ganglionic NTA Enzyme for NTA General response Epi and NE MAO, COMT Fight or flight 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 Decreases BP and heart rate Used for HYPERTENSION and Tachycardia The Adrenergic AGONISTS Also called SYMPATHOMIMETIC agents These drugs MIMIC the effects of the sympathetic nervous system The Adrenergic AGONISTS They usually stimulate DIRECTLY the receptors of the adrenergic system The Adrenergic AGONISTS Alpha and Beta agonists (non-selective) Prototype: Epinephrine Alpha Agonists (Selective) Prototype: Phenylephrine Beta Agonists (Selective) Prototype: Isoproterenol The Adrenergic AGONISTS 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 The Adrenergic AGONISTS Alpha and Beta agonists Prototype: Epinephrine 1. Ephedrine 2. Epinephrine 3. Metaraminol 4. Norepinephrine 5. Dobutamine (sometimes a B1 specific) 6. Dopamine The Adrenergic AGONISTS 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 The Adrenergic AGONISTS Alpha and Beta agonists: Desirable effects Increased myocardial contractility Bronchial DILATATION Vasoconstriction Increased blood pressure Decreased intraocular pressure Pupillary dilatation The Adrenergic AGONISTS Alpha and Beta agonists: Contraindications Pheochromocytoma Tachyarrhythmias With halogenated anesthesia- increased sensitivity to adrenergic drugs The Adrenergic AGONISTS Alpha and Beta agonists: Adverse effects Sympathetic stimulation effects CVS- hypertension, tachycardia, palpitations Respi- tachypnea GI- nausea, vomiting Others- sweating, headache, piloerection The Adrenergic AGONISTS 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 The Adrenergic AGONISTS 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 The Adrenergic AGONISTS Alpha Agonists (selective) Prototype: phenylephrine clonidine (alpha-2 specific) The Adrenergic AGONISTS 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 The Adrenergic AGONISTS Alpha Agonists: Clinical use 1. 2. Phenylephrine- vasoconstricting drug, used topically to decrease the symptoms of rhinitis Clonidine- for hypertension The Adrenergic AGONISTS 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 The Adrenergic AGONISTS Alpha Agonists: Adverse effects CNS- anxiety, depression, fatigue CVS- palpitations GI- nausea, vomiting and anorexia GU- oliguria, dysuria The Adrenergic AGONISTS 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 The Adrenergic AGONISTS Alpha Agonists: Nursing considerations Evaluate effectiveness: Decreased BP Decreased Nasal congestion The Adrenergic AGONISTS 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) The Adrenergic AGONISTS Beta Agonists Pharmacodynamics These agents bind to the BETA receptors causing the sympathetic manifestations and effects The Adrenergic AGONISTS 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 The Adrenergic AGONISTS 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 The Adrenergic AGONISTS 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 The Adrenergic AGONISTS 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 Adrenergic ANTAGONISTS The alpha blockers (selective) Prototype: Phentolamine Phenoxybenzamine "zosin"- prazosin, doxazosin, terazosin- these are alpha 1 blockers The Adrenergic ANTAGONISTS 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 Adrenergic ANTAGONISTS 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 Adrenergic ANTAGONISTS The alpha blockers: Contraindications 1. 2. Myocardial infarction Allergy The Adrenergic ANTAGONISTS The alpha blockers: Adverse Effects CVS- hypotension, reflex tachycardia, flushing CNS- dizziness, weakness, fatigue, drowsiness Others- nasal congestion, reddened eyes, priapism The Adrenergic ANTAGONISTS 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 drug- improvement of blood pressure readings and urination The Adrenergic ANTAGONISTS 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 Adrenergic ANTAGONISTS The Beta blocker or The "olol"s 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 Adrenergic ANTAGONISTS The Beta blocker or The "olol"s They can be beta 1 blockers, beta 2 blockers or Both Prototype of B1 selective: atenOLOL acebutOLOL betaxOLOL esmOLOL metoprOLOL The Adrenergic ANTAGONISTS 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 Adrenergic ANTAGONISTS The Beta blockers: Clinical use 1. Hypertension 2. Angina and MI 3. Cardiac arrhythmias 4. Migraine headache 5. HYPERTHYROIDISM The Adrenergic ANTAGONISTS 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 Adrenergic ANTAGONISTS The Beta blockers: contraindications 1. Allergy 2. Heart blocks 3. Bradycardia 4. COPD 5. Precaution in DM The Adrenergic ANTAGONISTS 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 Adrenergic ANTAGONISTS 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 Adrenergic ANTAGONISTS 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 The Cholinergic Agonists 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 The Cholinergic Agonists Direct acting cholinergic agonists Prototype: BetaneCHOL CarbaCHOL Pilocarpine Indirect acting cholinergics Prototype: Pyridostigmine Neostigmine Endrophonium (Tensilon) The Cholinergic Agonists Direct acting cholinergic agonists Pharmacodynamics They are similar to acetylcholine and directly act on the acetylcholine receptors The Cholinergic Agonists Direct acting cholinergic agonists Parasympathetic stimulation will cause: DUMBELS urination miosis (pupil constriction) The Cholinergic Agonists 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 The Cholinergic Agonists 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 The Cholinergic Agonists Direct acting cholinergic agonists: Contraindications 1. Bradycardia 2. Hypotension 3. Asthma The Cholinergic Agonists 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 The Cholinergic Agonists 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 Betanechol/Carbachol Urination/ relief of bladder distention The Cholinergic Agonists Indirect acting cholinergic agonists Pharmacodynamics These agents DO NOT react directly with the receptors but REACT chemically with the enzyme= acetylcholinesterase The Cholinergic Agonists 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 The Cholinergic Agonists Indirect acting cholinergic agonists Clinical use 1. Myasthenia gravis Physostigmine, pyridostigmine, Neostigmine, and endrophonium Tacrine and Donepezil 2. Alzheimer's disease The Cholinergic Agonists 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 The Cholinergic Agonists 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 The Cholinergic Agonists 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!!! The ANTI-cholinergics Anticholinergics: Prototype: Atropine dicyclomine glycopyrrolate propantheline scopolamine The ANTI-cholinergics 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 effects Atropine 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 Constipation Reverses cholinergic toxicity Used in partly to control diarrhea (in Lomotil) Used in Cholinergic and Organophosphate poisoning Scopolamine Decreases nausea and vomiting associated with motion sickness Anticholinergic Contraindications of anticholinergic Known allergy Glaucoma Bladder obstruction (like PBH) 1. 2. 3. 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) ...
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