pharma

Nursing Pharmacology/Drug Classifications/Ray Andrew S. del Rosario, RN 1

CHEMOTHERAPEUTIC AGENTS Anti-infectives

1. action: interfere with essential metabolic actions of microbial cells

2. examples a. silver sulfadiazine (Silvadene) b. silver nitrate 0.1%-0.5%

solution c. sulfonamides

1. sulfadiazine 2. sulfisoxazole

(Gantrisin) - STD 3. sulfasalazine

(Azulfidine) – ulcerative colitis, crohn’s disease

4. cotrimoxazole (Bactrim) – otitis media, bronchitis, PCP

5. succinylsulfathiazole (Sulfasuxidine)

3. uses a. ophthalmic solutions: treat

ophthalmic infections b. bladder and urethra irrigations c. sulfonamides: UTI

4. adverse effects a. silver sulfadiazine: skin irritation b. silver nitrate

1. electrolyte imbalance 2. brownish black

discoloration produced

on contact c. sulfonamides

1. blood dyscrasias 2. GI upset/irritation 3. Hypersensitivity 4. Crystalluria 5. Headache 6. photosensitivity

5. nursing interventions a. monitor client's condition during

treatment b. for eyes, use only silver nitrate

in ophthalmic solution c. handle silver nitrate with care:

solutions stain skin and clothing

d. silver sulfadiazine: use aseptic technique when applying

Antibiotics

1. Action: destroys or inhibits bacteria 2. Examples

i. penicillins, broad spectrum

ampicillin (Omnipen)

penicillin V (V-cillin)

penicillin G procaine ii. cephalosporins, broad spectrum

First-genration: I. cefazolin sodium (Ancef)

II. cephalexin monohydrate (Keflex)

Second-generation I. cefaclor (Ceclor)

II. cefamandole (Mandol)

Third-generation I. cefotaxime sodium (Claforam)

II. ceftriaxone (Rocephine)

Fourth-generation I. cefditoren (Spectracef)

II. cefepime ( Maxipime) iii. macrolides

erythromycin (E-mycin)

azithromycin (Zithromax)

clindamycin HCl (Cleocin)

Lincomycin HCl (Lincocin) iv. tetracyclines, broad spectrum

doxycycline (Vibramycin)

oxytetracycline (Terramycin) v. aminoglycosides, broad spectrum

gentamicin sulfate (Garamycin)

kanamycin sulfate (Kantrex)

Neomycin sulfate (Mycifradin)

Tobramycin sulfate (Nebcin)

streptomycin sulfate (Strycin) vi. fluoroquinolones

ciprofloxacin (Cipro)

levofloxacin (Levaquin) vii. polymyxin: polymyxin B sulfate

(Aerosporin) viii. chloramphenicol (Chloromycetin)

3. Use: treat bacterial infection 4. Adverse effects

a. gastric disturbances: nausea / vomiting, poor appetite,

diarrhea b. allergic reactions c. superinfection d. loss of water-soluble vitamins and

minerals e. tetracyclines: hepatotoxicity,

phototoxicity, hyperuricemia, tooth enamel hypoplasia, and bone defects in children under eight years of age

f. fluoroquinolones- photosensitivity g. aminoglycosides: ototoxicity, leukopenia,

thrombocytopenia, headache, confusion, peripheral neuropathy, optic neuritis,

nephrotoxicity h. chloramphenicol: blood dyscrasias,

fever, rash, jaundice 5. Contraindications:

a. hypersensitivity b. pregnancy- tetracyclines,

fluoroquinolones, aminoglycosides

c. fluoroquinolones- children <18 years of age

6. Nursing interventions a. culture and sensitivity test to

determine the appropriate drug to be used

b. monitor client for allergies

c. monitor client's response to treatment


d. teach client i. take all of prescribed

medication (to help prevent emergence of resistant strains)

ii. symptoms of allergic response

iii. if taking a liquid (suspension), shake it first

iv. take medication before meals

e. tetracyclines i. not for young children

or in last half of pregnancy

ii. possible oral anticoagulant effect

iii. avoid dairy products, antacids or iron preparations (reduce effectiveness)

f. fluoroquinolones: avoid hazardous machinery, avoid sunlight

g. macrolides: given as prophylaxis for endocarditis before dental procedure to client with valvular heart problems and also for acne

h. cephalosporins i. advise not to take

alcohol 72 hours after

course of therapy to prevent disulfiram-like reactions.

ii. False positive urine glucose results with Clinitest and Fehling’s and Benedicts solutions

i. aminoglycosides and polymyxins: May potentiate neuromuscular blocking agents, general anesthesia or magnesium effects; monitor for all three potentiation effects

j. chloramphenicol i. assess blood work

during therapy ii. assess for potentiation

of phenytoin, oral antidiabetic agents or coumadin anticoagulant effects

Antivirals

1. Action: interfere with DNA synthesis needed for viral replication

2. Examples a. acyclovir sodium (Zovirax) -

herpes b. amantadine HCL (Symmetrel) c. oseltamivir (Tamiflu)

3. Use: viral infections such as herpes, viral encephalitis

4. AIDS and HIV

a. Protease inhibitors b. Nucleosides c. Fusion inhibitors d. Reverse transcriptase inhibitors

5. Respiratory infections: a. amantadine – Parkinson’s,

treatment and prevention of respiratory infections

b. rivabirin – hepatitis C, influenza A, RSV and herpes

c. rimantadine – influenza A d. cidofovir – CMV

6. Adverse effects a. orthostatic hypotension b. dizziness c. GI disturbances d. nephrotoxicity e. blood dyscrasias

7. Contraindications: a. hypersensitivity b. immunosuppression

8. Nursing interventions a. monitor vital signs during antiviral

therapy b. monitor effect of therapy c. increased fluid intake d. monitor for signs of

superinfection: sore throat, fever, fatigue

e. protease inhibitors: advise client not to take herbal medication such as St. Jonh’s Wort

(increases renal excretion of drug)

Antifungals

1. Action: destroys fungal cells or inhibits their reproduction

2. Examples a. amphotericin B (Fungizone) b. griseofulvin (Grisactin) c. nystatin (Mycostatin) d. fluconazole (Diflucon) e. ketoconazole (Nizoral) - topical

3. Use - treat local and systematic fungal infections such as histoplasmosis, candidiasis, tinea

4. Adverse effects a. gastric irritability: nausea,

vomiting b. headache c. fever, chills d. paresthesia e. renal impairment

5. Contraindications a. severe bone marrow depression b. hypersensitivity

6. Nursing interventions a. monitor vital signs and I and O

during therapy b. with amphotericin B

i. protect IV solution from light

ii. monitor blood work


iii. use infusion device for IV administration

c. with griseofulvin: instruct client to avoid sunlight

Antiparasitics

1. Action: interferes with parasite metabolism and reproduction

2. Examples a. anthelmintics: mebendazole

(Vermox), piperazine (Vermizine) , praziquantel (Biltricide)

b. amebicides: chloroquine HCL (Aralen), metronidazole (Flagyl)

c. antimalarials: chloroquine HCL (Aralen), quinine sulfate (Quinamm), primaquine, hydroxychloroquine (Plaquenil)

3. Use: kills parasites, helminths (pinworm and tapeworm), protozoa (amebiasis and malaria)

a. chloroquine HCL – malaria b. praziquantel – schistosomiasis

4. Adverse effects a. anthelmintics: GI upset, CNS

disturbances, skin rash, headache

b. amebicides: GI upset, blood dyscrasias, skin rash, CNS disturbances

c. antimalarials: GI upset, blood

dyscrasia, visual disturbances, cinchonism (nausea and vomiting, tinnitus and vertigo)

5. Nursing interventions a. administer medication with food b. monitor vital signs, blood work

during therapy c. use safety precautions if CNS

disturbances manifested d. teach client to prevent further

infection e. with antimalarials: frequent visual

examinations, urine may turn rust colored

f. advise women of reproductive age

with the use of barrier contraceptives esp. if taking quinine

Antineoplastics (Cytotoxic, Antiproliferative Agents)

A. Action 1. Highly toxic agents that attack all rapidly

dividing cells, both normal and malignant 2. Represents a systemic approach that

bases its action on disruption of the cell life cycle

3. Most agents modify or interfere with DNA synthesis

B. Examples 1. Alkalyting agents: mechlorethamine HCl

(Nitrogen Mustard), cyclophosphamide (Cytoxan), cisplatin (Platinol), chlorambucil (Leukeran): produce breaks

in DNA molecule and cross-linking of strands thus interfering with DNA replication; most effective in hematologic malignancies; cell cycle nonspecific

2. Antitumor antibiotics: doxorubicin (Adriamycin), Biomycin; bind directly with DNA changing its configuration and inhibiting replication; cell cycle specific

3. Antimetabolites: methotrexate, 5-fluorouracil, floxuridine, cytosine arabinoside, 6-mercaptopurine, 6-thioguanine: inhibit DNA synthesis; most effective against rapidly growing tumors enzymes necessary for cell function and replication; cell cycle nonspecific

4. Plant alkaloids (Mitotic inhibitors): Vinblastine, Vincristine, Etoposide: Bind to substances needed to form mitotic spindle, thus preventing cell division ; cell cycle specific

5. Hormones and hormone inhibitors: Tamoxifen alters the endocrine environment to make it less conducive to cell growth; used in cancers of the breast, prostate, and other reproductive organs

C. Routes of administration 1. Intravenous (peripheral or central venous

access) 2. Oral 3. Intraarterial 4. Intraperitoneal

5. Intrapleural 6. Intrathecal 7. Via ventricular reservoir

D. Use 1. To cure, control or palliate results of

neoplasm 2. May be used as an adjunct to surgery

and radiation E. Adverse effects: result from the damage to normal

cells 1. Nausea/ vomiting, stomatitis, alterations

in taste, anorexia 2. Diarrhea, constipation 3. Alopecia, dermatitis, pruritus,

paresthesia, rash, bruising

4. Hemorrhagic cystitis 5. Cardiomyopathy 6. Fatigue, dyspnea, fever, chills 7. Sterility, amenorrhea 8. Depression, anxiety 9. Myelosuppression

F. Nursing interventions 1. Monitor lab studies as ordered 2. Monitor IV administration site for

extravasation a. Administer antidotes (either per

IV or if needle was removed, use tubercular syringe and give SC)

3. Maintain strict asepsis 4. Administer antiemetic agents as ordered

and prophylactically before chemotherapy.


5. Give antihistamines as ordered 6. Withhold food and fluids for four to six

hours before treatment 7. Between treatments, give small,

frequent, bland meals 8. Give antidiarrheals as ordered 9. Monitor for signs of dehydration and

encourage fluids as tolerated 10. Provide frequent oral hygiene, lubricate

lips as indicated 11. For stomatitis, use topical anesthetics

before eating and as indicated 12. Apply lotion to skin as indicated; avoid

harsh, drying soaps 13. Provide a restful environment, emotional

support and anxiolytics as ordered 14. Teach client

a. medications and side effects b. alopecia is temporary c. avoid bruising, aspirin products,

and persons with infections d. conserve energy e. recognize signs of bleeding;

anemia, infection f. use a soft-bristle toothbrush g. avoid use of razors

G. Special nursing considerations 1. Exposure to chemotherapeutic agents

can lead to adverse reactions a. contact dermatitis b. nausea and vomiting c. diarrhea

2. Exposure during pregnancy can lead to a. increased risk of fetal

abnormalities b. ectopic pregnancies c. spontaneous abortions

3. Guidlines for reducing risks when handling cytotoxic antineoplastic drugs

a. wear a mask to avoid inhaling powder when handling a powder form of a drug.

b. do not prepare drugs in eating places Wear gloves, eye protectors and protective clothing when in contact with injectable solutions.

c. dispose of contaminated materials in puncture-proof containers labeled as hazardous material.

d. wear gloves when handling linens contaminated with drugs for at least 48 hours after contamination.

e. wash hands thoroughly before and after exposure to drugs.

f. follow organizational procedure to clean-up after chemical spill.

DRUGS ACTING ON THE IMMUNE SYSTEM

Anti-inflammatory Salicylates & Nonsteroidal antinflammatory drugs (NSAIDS)

1. action: interferes with prostaglandin synthesis a. first generation (COX-1 inhibitor) -

salicylates (aspirin - Bayer, Ecotrin), ibuprofen(Motrin, Advil), naproxen (Naprosyn)

b. second generation (COX-2 inhibitor)- celecoxib (Celebrex)

c. diclofenac (Voltaren), indomethacin (Indocin), ketorolac (Toradol)

d. mefenamic acid 2. use: rheumatoid arthritis, osteoarthritis,

dysmenorrhea, antipyretic and analgesic a. aspirin: reduction of risk of MI and TIA or

stroke 3. adverse effects

a. gastric disturbances- lessened with administration of COX-2 inhibitors

b. skin rash c. blood dyscrasias/bleeding d. CNS disturbances e. nephrotoxicity

4. contraindications a. hypersensitivity b. asthma c. renal disease d. liver disease

5. nursing interventions a. administer one hour before or two hours

after meals b. administer with food if GI upset is severe c. monitor blood work, vital signs d. monitor response to medication

Acetaminophen (Tylenol)

a. use: moderate to mild pain and fever b. directly acts on the thermoregulatory cells in the

hypothalamus to cause sweating and vasodilation c. contraindications: allergy and hepatic failure d. antidote to toxicity: acetylcesteine (Mucomyst)

Gold Compounds (Crysotherapy)

a. use: for rheumatic antiflammatory conditions b. absorbed by macrophages, which rsults in

inhibition of phagocytosis c. examples

1. auronofin (Ridaura) - long term, oral agent 2. aurothioglucose (Solganal) – injectable, given

early in the disease 3. gold sodium thiomalate (Aurolate) – injectable

d. contraindications: allergy to gold, diabetes, CHF, renal or liver impairment, pregnancy and lactation e. adverse effects:

1. GIT irritation and inflammation 2. Bone marrow depression 3. Allergic reactions

f. Nursing interventions: 1. Not to be combined with penicillamine,

antimalarials, cytotoxic drugs or immunosuppressive agents (causes severe toxicity)


Immunosuppressants 1. action: inhibit immune responses 2. example: cyclosporine (Sandimmune) 3. use

a. prevent organ rejection in transplant patient b. treat autoimmune disorders (such as rheumatoid

arthritis, systemic lupus erythematosus) 4. adverse effects

a. nephrotoxicity (poisons kidneys) b. infection c. hypertension d. tremor e. hirsutism

5. contraindications a. hypersensitivity b. nursing interventions

monitor BUN and creatinine; liver function tests teach client

1. report early signs of infection (such as fever, sore throat)

2. medication may be taken with meals 3. take medication same time each day 4. hirsutism is reversible when treatment

stops

DRUGS ACTING ON THE RESPIRATORY SYSTEM 1. Bronchodilators

a. action: 1. dilate air passages in the lungs, specific action

dependent on type of drug. 2. increase heart rate 3. act on the autonomic nervous system

b. examples 1. beta-adrenergic: albuterol (Proventil, Ventolin),

metaproterenol (Alupent) 2. xanthines: aminophylline, theophylline (Theo-

Dur) acts on bronchial smooth muscle 3. epinephrine HCL (Adrenalin) - increases the

rate and strength of cardiac contraction through the sympathetic nervous system

4. isoproterenol HCL (Isuprel) - increases the heart rate by stimulating the beta-adrenergic blocking agent of the sympathetic nervous system

c. use 1. bronchospasms 2. asthma

d. adverse effects 1. dizziness 2. tremors 3. anxiety 4. palpitations 5. gastric disturbances 6. headache 7. tachycardia 8. dysrhythmias

e. contraindications 1. hypersensitivity 2. narrow angle glaucoma 3. tachydysrhythmias 4. severe cardiac disease

f. nursing interventions 1. monitor theophylline levels (normal ten to 20

mcg/dl) 2. monitor intake and output, and vital signs 3. monitor EKG, vital signs during therapy 4. teach clients

take medication as prescribed only

report adverse effects

stop smoking during therapy

take with meals

avoid OTC drugs 2. Mucolytics/expectorants

a. action 1. mucolytics: disrupt molecular bonds and

thins mucus 2. expectorants: stimulate a gastric mucosal

reflex to increase production of lung mucous b. examples

1. mucolytic: acetylcysteine (Mucomyst) 2. expectorant: guaifenesin (Robitussin)

c. uses 1. asthma 2. acute or chronic bronchopulmonary disease 3. cystic fibrosis

4. Acetlycesteine (Mucomyst): acetaminophen toxicity (antidote)

d. adverse side effects


1. oropharyngeal irritation 2. bronchospasm 3. gastric effects

e. contraindications 1. increased intracranial pressure 2. status asthmaticus

f. nursing interventions 1. monitor respiratory status 2. teach client

take no fluids directly after oral administration

do take plenty of fluids

encourage coughing and deep breathing, especially before treatment

3. Antitussives a. action: to supress coughs through medullary cough

center or indirect action on sensory nerves b. examples

1. narcotic: codeine, hydrocodone bitartrate (Hycoda)

2. nonnarcotic - dextromethorphan (Robitussin)

c. use: colds, respiratory congestion, pneumonia, bronchitis, TB, cystic fibrosis, emphysema

d. adverse effects 1. drowsiness 2. nausea 3. dry mouth 4. dizziness

e. contraindications 1. hypothyroidism 2. iodine sensitivity

f. nursing interventions 1. monitor blood counts with long term

therapy 2. increase fluid intake 3. humidify client's room 4. teach client

increase fluid intake if not contraindicated

do not to take fluids immediately after medication

avoid driving and other hazardous activity especially if taking narcotic type

antitussives add to the effects of alcohol

4. Antituberculosis agents a. action: appears to inhibit RNA synthesis, so stops

tubercle bacilli from multiplying (first line) or functioning (second line)

b. examples 1. first line

isoniazid (INH) - suppresses mycobacterial cell-wall synthesis

paraaminosalysicylic acid – interefere with mycobacterial folic acid synthesis

streptomycin sulfate: inhibits mycobacterial folic acid synthesis

rifampicin, rifampin

ethambutol (Myambutol) decreases mycobacterial RNA synthesis - some books 2nd line

2. second line

capreomycin (Capastat) – some book 3rd line

pyrazinamide (PZA) c. adverse effects

1. gastric irritation 2. CNS disturbances 3. liver disturbances 4. blood dyscrasias 5. streptomycin - ototoxicity 6. ethambutol - visual disturbances 7. isoniazid - suppressed absorption of fat and

vitamin B complex , peripheral neuritis d. contraindications

1. severe renal disease 2. hypersensitivity

e. nursing interventions 1. monitor client response to therapy

2. monitor blood work during therapy 3. if CNS disturbances are evident, take safety

precautions 4. teach client

to take medication as ordered

take medications in the morning before meal but if GI upset is severe take it with meals

to eat foods rich in B-complex vitamins; B6 for isoniazid

avoid use of alcohol

report if become pregnant

ethambutol: report eye problems, have regular eye exams

rifampin: body fluids may appear red – orange

considered to be not contagious after 2 – 3 negative sputum test

5. Antihistamines a. action: blocks histamine at receptor sites b. examples

1. promethazine HCL (Phenergan) 2. chlorpheniramine maleate (Chlor-Trimeton) 3. diphenhydramine (Benadryl)

c. uses 1. relieves symptoms of allergies, colds, pruritus 2. prevents problems in blood transfusion and

drug reactions

d. adverse effects 1. drowsiness 2. gastric effects 3. dry mouth 4. headache 5. thickening of bronchial secretions

e. contraindications 1. acute asthma 2. lower respiratory heart disease 3. narrow angle glaucoma

f. nursing interventions 1. discontinue four days before skin testing for

allergies 2. avoid interaction with CNS depressants 3. teach client

avoid driving and hazardous activities

take antihistamines with food


additive effect with alcohol, other CNS depressants

6. Antiinflammatories a. action: stabilizes mast cells so chemical mediators

are not released as easily; decreases bronchial hyperreactivity; decreases airway inflammation

b. example: 1. cromolyn sodium (Intal) 2. leukotriene receptor antagonists-zafirlukast

(Accolate), montelukast (Singulair) 3. glucocorticoids- beclamethasone (Vanceril),

triamcinolone (Azmacort) c. use: to prevent asthma attacks, exercise-induced

bronchospasms d. adverse effects

1. cough 2. CNS disturbances 3. burning, stinging eyes 4. throat irritation 5. headache

e. contraindications 1. status asthmaticus 2. hypersensitivity

f. nursing interventions 1. monitor eosinophil count 2. monitor respiratory status 3. store in tightly closed light-resistant

container; keep cool 4. teach client

how to use the inhaler

rinse mouth after using steroid inhaler

when to call health care provider if medications are not effective

that therapeutic effect may take up to four weeks

Metered Dose Inhaler Device

- allows a canister containing the drug to be inserted into a metered dose device that will deliver a specific amount of th drug when the patient presses the canister

- has a mouthpiece and may also have a spacer - patient should deep breathe once before activating the

inhaler then continue breathing - teach client:

o Shake the canister, exhale and then place the

spacer in his mouth, (if spacer is not used, not be put in mouth but held about 2 fingerwidths or 1 inch in front of open mouth)

o Compress canister while inhaling, hold his breath for 10 -1 5 seconds before breathing out slowly through a pursed lip.

o If second dose is needed, wait 1 – 2 minutes before taking another dose.

o If two different drug is to be taken, take first the bronchodilator, then wait for 5 minutes following steroids

o Rinse mouth and wash spacer

DRUGS ACTING ON THE CARDIOVASCULAR SYSTEM Cardiac Glycosides (Cardiotonic Agents)

a. action: makes heart beat slower but stronger 1. improves pumping ability of heart 2. (+) inotropic – increases force of heart's

contraction 3. (-) chronotropic – decreases rate of contraction 4. increases cardiac output 5. (-) dromotropic – decrease automaticity of the SA

node and AV nodal conduction b. examples

1. digitoxin (Crystodigin) 2. digoxin (Lanoxin)

c. use 1. congestive heart failure 2. atrial flutter 3. atrial fibrillation

d. contraindications 1. ventricular tachycardia 2. ventricular fibrillation 3. second and third degree heart block

e. adverse side effects 1. gastrointestinal effects such as nausea and

vomiting, diarrhea, and anorexia 2. bradycardia 3. xanthopsia (yellow vision) 4. muscle weakness 5. dysrhythmia

f. nursing interventions 1. before giving glycoside, check apical pulse and

heart rhythm. Report if < 60 bpm

2. establish baseline data such as vital signs, electrolytes, clinical symptoms, creatinine clearance test

3. monitor for drug toxicity

in children - cardiac arrhythmias

in adults - visual disturbances, nausea and vomiting, anorexia

older clients more prone to toxicity

earliest signs of toxicity: Vomiting, Anorexia, Nausea, Diarrhea, Abdominal Cramps (VANDA)

monitor for signs of hypokalemia (Skeletal muscle weaness, U wave [ECG], Constipation/Ileus, Toxicity of digoxin,

Irregular heart rate, Orthostatic hypotension and Numbness or Tingling sensation [SUCTION].

4. monitor drug levels

therapeutic range 0.5 to 2.0 ng/ml

toxic range > two ng/ml

diuretics may increase chance of toxicity esp. for a potassium wasting diuretics such as loop and thiazides.

g. monitor intake and output h. client teaching

1. take medication as prescribed 2. teach client how to take and record pulse daily 3. identify and report signs of toxicity

for atrial fibrillation: take pulse and report if below 60 or above 100 or changes in rhythm

daily weights: report two pound increase

antidote: Digoxin Immune Fab (Digibind)


Antihypertensives

a. action: dilates peripheral blood vessels b. examples

1. hydralazine HCL (Apresoline) 2. enalapril maleate (Vasotec) 3. reserpine (Serpasil) 4. prazosin HCL (Minipress) 5. methyldopa (Aldomet) 6. clonidine (Catapres)

Many hypertensives have trade names that contain –vas- -pres- -pas-

c. use: hypertension d. contraindications

1. heart block 2. children

e. adverse side effects 1. orthostatic hypotension 2. dizziness 3. bradycardia 4. tachycardia 5. sexual dysfunction 6. deterioration in renal function 7. agranulosis

f. nursing interventions 1. monitor vital signs and blood pressure, sitting

and standing 2. monitor for hearing changes, renal functioning 3. if hypotension, closely monitor client 4. encourage intake of foods high in vitamin B 5. teach client

low sodium diet

change positions slowly

take medication as instructed

avoid hazardous activities

protect medication from heat and light Four Categories of Antihypertensives

1. Angiotensin-Converting Enzyme (ACE) inhibitors a. Work by blocking a critical enzyme system

responsible for the production of angiotensin II (a potent vasoconstrictor)

b. By blocking angiotensin converting enzyme, ACE inhibitors prevent vasoconstriction caused by angiotensin II

c. Prevent aldosterone secretion and therefore sodium and water resorption

d. Prevent bradykinin (a potent vasodilator) from being broken down by angiotensin II

e. Examples include: Captopril (Capoten), Enalapril (Vasotec), lisinopril (Zestril) Action: Inhibits the action of angiotensin I converting enzymes Side Effects: a. A persistent dry or tickling, nonproductive cough b. Postural hypotension Implementation a. Monitor for the first dose phenomenon of profound hypotension b. Instruct client to change position slowly c. Monitor for cough – may be given nebulizer

d. Educate client to take the medication as prescribed; monitor blood pressure at home

2. Diuretics

a. Decrease the plasma and extracellular fluid volumes which results in decreased preload that leads to a decrease in cardiac output and total peripheral resistance (which decrease the workload of the heart

b. Used to increased urine output, which reduces hypovolemia, decreases preoload and afterload

c. Interferes with sodium reabsorption in the kidney d. Examples:

i. Carbonic Anhydrase Inhibitors [Acetazolamide (Diamox)]

ii. Loop Diuretics [Ethacrynic acid (Edecrin), Furosemide (Lasix) – interfere with active transport of sodium ions in loop of Henle and inhibit sodium chloride and water reabsoprtion at proximal tubule sites

iii. Osmotic diuretics [Mannitol (Osmitrol)] – induce diuresis mainly by increasing the osmotic pressure of the glomerular filtrate, which in turns inhibits the tubular resorption of water and solutes, producing a rapid diuresis

iv. Potassium-sparing Diuretics [Spironolactone (Aldactone), Triamterine (Dyrenium), Amiloride (Midamor)] – interefere with aldosterone-induced reabsorption of sodium ions at distal nephron sites to increase sodium chloride excretion and decrease potassium ions loss

v. Thiazides [Chlorothiazide (Diuril), Chlorthalidone

(Hygroton), Hydrochlorothiazide (HydroDIURIL), Methylclothiazide (Enduron) - interfere with sodium ion transport at loop of Henle and inhibit carbonic anhydrase activity at distal tubule sites

Major Side Effects: 1. GI irritation (local effect) 2. Hyponatremia (inhibition of sodium

reabsorption at the kidney tubule) 3. Orthostatic hypotension (reduced blood

volume) 4. Hyperuricemia (partial blockage of uric acid

excretion) 5. Dehydration (excessive sodium and water

loss)

6. All diuretics except potassium sparers: hypokalemia, increased urinary excreation of magnesium and zinc

7. Potassium-sparers: hyperkalemia, hypomagnesemia and increased urinary excretion of calcium

8. Furosemide competes with aspirin for renal excretion sites and can cause aspirin toxicity

Nursing Care: 1. Maintain intake and output records 2. Weigh daily (same time, same scale, same

clothing) 3. Administer the drug in the morning so that

the maximal effect will occur during the waking hours


4. Encourage the intake of foods high in calcium, magnesium, zinc and potassium (except for K-sparer)

5. Thiazide and Loop diuretics: monitor blood sugar in diabetics; may cause hyperglycemia

6. Be alert for signs of hypokalemia except for K-sparer such as muscle weakness and cramps

3. Adrenergics (Sympathomimetics)

a. Stimulate the sympathetic nervous system or mimic the effects of the SNS neurotransmitters norepinephrine, epinephrine and domapine

b. Increase the force of contraction (positive inotropic), increased heart rate (positive chronotropic), and positive dromotropic effect

c. Reduce intraocular pressure and dilate pupils (mydriasis) [open-angle glaucoma]

d. Examples i. anorexiants (adjuncts to diet on the short term

management of obesity) ii. bronchodilators (albuterol, ephedrine, terbutaline,

isoproterenol, epinephrine) iii. nasal decongestants (phenylpropanolamine,

tetrahydrozoline) iv. opthalmics v. vasoactive sympathomimetics, pressors,

inotropes or cardioselective sympathomimetics (used to support the heart during cardiac failure or shock) [dobutamine, dopamine, epinephrine etc)

4. Calcium Channel Blockers

a. used to treat angina, dysryhthmias and hypertension

b. relieve high blood pressure by causing smooth muscle relaxation and dilation of blood vessels

Major Side Effects of Antihypertensive

1. Orthostatic hypotension (loss of compensatory vasoconstriction with position change)

2. Dizziness 3. Cardiac rate alteration

a. Bradycardia (sympatholytics) [decreases SNS stimulation to the heart]

b. Tachycardia (direct relaxers) [reflex reaction to severe hypotension]

4. Sexual disturbances (failure of erection or ejaculation due

to loss of vascular tone) 5. Blood dyscrasias 6. Drowsiness

Nursing Care

1. Monitor blood pressure in standing and supine positions 2. Instruct client to: (Diet, Medication and Exercise)

a. Follow a low-sodium diet b. Change position slowly c. Continue to take medication as prescribed;

therapy is usually for life d. Report occurrence of any side effects to physician e. Avoid engaging in hazardous activities when

initially placed on antihypertensive 3. Reserpine (Serpasil): assess for mental depression;

implement suicide precautions

4. Nitroprusside (Nipride); protect IV solution from light; discard unused portions according to manufacturers schedule

5. Encourage intake of foods high in B- complex vitamins Thrombolytics

a. action: binds with plasminogen to dissolve thrombi (clots) in coronary arteries within four to six hours of myocardial infarction. Activates conversion of plasminogen to plasmin. Plasmin is able to break down clots (fibrin).

b. examples 1. streptokinase (Streptase) 2. urokinase (Abbokinase)

c. uses 1. myocardial infarction 2. deep venous thrombosis 3. pulmonary emboli

d. contraindications 1. active bleeding 2. cerebral embolism/thrombosis/hemorrhage 3. recent intraarterial diagnostic procedure or

surgery 4. recent major surgery 5. neoplasms of the CNS 6. severe hypertension

e. adverse side effects 1. bleeding 2. allergic reactions:urticaria, itching, flushing,

headache f. nursing interventions

1. monitor for bleeding 2. monitor coagulation studies

3. monitor for allergic reactions 4. keep available: aminocaproic acid (Amicar) -

(fibrinolysis inhibitor) -antidote Lipid-lowering agents (antilipemic)

a. action and use: lower LDL levels by reducing the synthesis of cholesterol and/or triglycerides. Use: primary hypercholesterolemia

b. examples 1. cholestyramine (Questran) 2. atorvastatin (Lipitor) 3. colestipol (Colestid) 4. nicotinic acid (Niacin)

c. contraindications: 1. hypersensitivity

2. pregnancy/lactation 3. active liver disease

d. adverse side effects 1. skin flushing 2. gastric upset 3. niacin: temporary, intense flushing of face,

neck and ears 4. reduced absorption of fat-soluble vitamins 5. disruption of liver function 6. muscle tenderness or weakness

(rhabdomyolysis) e. nursing interventions

1. monitor cholesterol levels 2. monitor liver function tests 3. teach client

blood work and eye exams will be necessary during treatment


to report blurred vision, severe GI symptoms, or headache

about low-cholesterol high-fiber diet

to report muscle weakness or tenderness

4. with cholestyramine, colestipol: Give other medications (e.g., such as thiazide diuretics, digoxin, warfarin, and certain antibiotics) one hour before or four hours after administration of cholestryramine and colestipol, so that they will not react with bile-acid-binding resins

Antianginals Nitrates

a. examples: nitroglycerin, isosorbide dinitrate (Isordil) b. action: dilate arterioles which lowers peripheral vascular

resistance (afterload) c. uses: treatment and prevention of acute chest pain

caused by myocardial ischemia d. adverse effects: postural hypotension, headache,

flushing, dizziness e. contraindications

hypersensitivity

severe anemia

hypotension

hypovolemia f. nursing Interventions

monitor for orthostatic hypotension

monitor for tolerance with long term use

administer every five minutes but not more than three tablets in 15 minutes

if pain not relieved after 15 minutes and three tablets, notify physician immediately

instruct client o take pulse before taking medication o take oral preparations without food o when to seek medical attention o not to chew or swallow sublingual tabs o make position changes slowly o carry drug so that it is always within reach but

avoid exposure to body heat and light o replace drug approximately every six months o avoid alcohol ingestion

Beta-adrenergic blocking agents

a. examples: propranolol (Inderal), metoprolol (Lopressor) b. action: inhibit sympathetic stimulation of beta receptors

in the heart decreases heart rate and force of myocardial contraction thus decreasing myocardial oxygen consumption

c. uses: reduces frequency and severity of acute anginal attacks, dysrhythmias

d. side effects: blood dyscrasias, hypotension, GI disturbances, flushing of the skin

e. contraindications

hypersensitivity

cardiogenic shock

cardiac failure f. nursing interventions

weigh daily. Report weight gain of five pounds or

greater

monitor ECG if using for dysrhythmia

administer on an empty stomach

protect injectable solution from light

instruct client o take pulse before taking drug o not to discontinue medication abruptly o avoid hazardous activities if drowsiness occurs o make position changes slowly o take drug at same time each day

Calcium channel blockers

a. examples: verapamil (Isoptin), nifedipine (Adalat), diltiazem (Cardizem)

b. action: prevent the movement of extracellular calcium into the cell resulting in coronary and peripheral artery dilation

c. uses: stable angina, dysrhythmias, hypertension d. side effects: headache, drowsiness, dizziness, GI

disturbances, flushing of the skin e. contraindications: hypersensitivity

f. nursing interventions

monitor chest pain

monitor ECG if used for dysrhythmia

administer with food

instruct client o increase fluids to counteract constipation o take pulse before taking drug o avoid hazardous activities until stabilized on

drug o limit caffeine consumption o avoid alcohol o change position slowly

Drugs for Hypotension and Shock a. natural and synthetic catecholamines b. examples: epinephrine, dopamine (Intropin), dobutamine

(Dobutrex) c. actions: increase cardiac output, (+) inotrope, (+)

chronotrope d. uses: dopamine and dobutamine: hypovolemic and

cardiogenic shock, epinephrine: anaphylactic shock e. adverse effects: dysrhythmias, hypotension, tissue

necrosis if extravasation occurs. Tremors, anxiety, dizziness with epinephrine

f. contraindications 1. hypersensitivity 2. ventricular fibrillation 3. tachydysrhythmias 4. safety in children not known

g. nursing interventions 1. correct hypokalemia before administering 2. monitor vital signs frequently 3. monitor ECG continuously during administration 4. administer with infusion pump 5. start drug slowly and increase according to health

care provider's orders 6. monitor injection site for extravasation 7. protect solution from light 8. do not use discolored solution 9. stop the drug gradually

Anticoagulants

a. action: disrupt the blood coagulation process, thereby suppressing the production of fibrin

b. examples 1. heparin: parenteral administration 2. coumadin (Warfarin): oral administration


c. use 1. pulmonary embolism 2. deep vein thrombosis 3. myocardial infarction 4. atrial fibrillation

d. adverse side effects 1. allergic responses such as chills, fever and urticaria 2. use cautiously if client tends to bleed (hemophilia,

peptic ulcer) 3. GI disturbances- nausea and vomiting, diarrhea,

abdominal cramps e. contraindications

1. hemophilia 2. leukemia 3. peptic ulcer 4. blood dyscrasias

f. nursing interventions 1. heparin: monitor APTT (activated partial

thromboplastin time)

normal 40 seconds

at therapeutic levels, APTT increases by a factor of 1.5 to 2

can be given to pregnant and lactating mothers (doesn’t cross the placenta and breast milk)

2. coumadin - monitor PT (prothrombin time)

normal 12 seconds

INR (International normalized ratio) two to three

Teratogenic (not to be given to pregnant and lactating women)

3. do baseline blood studies before therapy 4. have antidote ready

heparin: protamine sulfate

coumadin: vitamin K 5. monitor client for symptoms of hemorrhage such as

increased pulse, decreased BP 6. avoid salicylates (such as aspirin) 7. avoid IM injections 8. teach client

take medication at same time every day

wear medical alert jewelry: wearer takes anticoagulants

use a soft toothbrush

do not use a straight razor; use an electric razor

avoid alcohol and smoking

report any signs of bleeding, red or black bowel movements, headaches, rashes, red or pink-tinged urine, sputum

avoid trauma

blood levels of the anticoagulant may be monitored

do not take over-the-counter (OTC) medications without health care provider's approval

avoid excessive intake of green leafy vegetables and sudden shift or change in diet

Antidysrhythmics a. action

1. prevent abnormal heart rhythms 2. action depends on type of antidysrhythmics drug

b. examples 1. class I: sodium channel blockers - quinidine

(Quinidex), lidocaine; decreases myocardial excitability and contractility

2. class II: beta blockers -propranolol (Inderal); stabilizes cell membrane

3. class III: conduction delayers- bretylium (Bretylol); decreases conduction and excitability of myocardial cells

4. class IV: calcium channel blockers - verapamil (Isoptin);inhibits influx of calcium ions across cell membrane during cardiac contraction; reduces cardiac excitability and dilates main coronary arteries

5. others - digoxin (Lanoxin), adenosine (Adenocard); slows heart rate, improves pumping ability of the heart

c. use: to treat abnormalities in cardiac rate and rhythm d. adverse effects

1. hypotension 2. nausea and vomiting 3. blood dyscrasias 4. toxicity such as CNS disturbances due to

neurotoxicity, and diarrhea due to GI irritation e. nursing interventions

1. monitor cardiac rhythm 2. monitor blood levels and for blood dyscrasias 3. administer oral preparations with meals 4. monitor EKGs and use infusion-control devices for IV

administration 5. teach client to report changes in heart rate and/or

rhythm and report any side effects

Managing hematological conditions a. Hematopoietic growth agent

1. action: stimulates production, growth, maturation, and differentiation of bone marrow stem cells

2. example i. filgrastim (Neupogen)- stimulates

production of white blood cells ii. epoetin alfa (Epogen)- stimulates

production of red blood cells 3. use: chronic renal failure, HIV-infected clients,

reduce bone marrow recovery after transplantation, stimulate bone marrow production after chemotherapy

4. adverse effects

i. filgrastim: bone pain ii. epoetin alfa: hypertension, headache,

joint pain 5. contraindications

i. hypersensitivity to proteins of E. Coli 6. nursing interventions

i. take baseline CBC and diff (complete blood count and differential count) prior to treatment

ii. monitor lab results until target reached Iron supplements

1. action: iron transported as transferrin to bone marrow and incorporated into hemoglobin

2. examples i. ferrous sulfate (Feosol) ii. ferrous fumarte (Feco-T) iii. ferrous gluconate (Fergon)

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3. use: correct simple iron deficiency anemia 4. adverse effects

i. gastric disturbances ii. with massive overdose - lethargy,

drowsiness, leading to metabolic acidosis, shock and cardiovascular collapse

5. contraindications: i. hypersensitivity ii. ulcerative colitis iii. peptic ulcer disease iv. hemolytic anemia v. cirrhosis

6. nursing interventions i. monitor hemoglobin level ii. have antidote ready: deferoxamine

(Desferal) – iron-chelating agent iii. teach client

take on empty stomach

best taken with Vitamin C rich juice or fruits (e.g. orange) for best absoprtion

liquid preparation - take with a straw to prevent tooth discoloration

protect from moisture and heat

may cause dark or greenish stools

DRUGS ACTING ON THE CNS AND PNS 1. Anticonvulsants

a. action - modifies bioelectric activity at subcortical and cortical areas

b. examples 1. diazepam (Valium) 2. magnesium sulfate 3. phenytoin (Dilantin) 4. phenobarbital (Luminal)

c. use: prevents seizures d. adverse effects

1. blood dyscrasias 2. gastric effects - nausea, vomiting 3. CNS depression - dizziness, drowsiness 4. phenytoin: ataxia, hirsutism, hypotension

e. contraindications 1. hypersensitivity

f. nursing interventions 1. give medication with food 2. wiith phenytoin: monitor condition of oral

mucosa, don't mix with other IV fluids, monitor blood lab results, monitor urine

3. renal, liver, and blood studies 4. teach clients

avoid alcohol

notify physician of unusual symptoms

carry medical alert information

take medication on schedule; do not discontinue

avoid driving and other potentially hazardous activities

phenytoin: good oral hygiene, frequent dental visits

2. Antiparkinson agents a. action

1. anticholinergics: block or compete at central acetylcholine receptors

2. dopamine agonists: activation of dopamine receptors

3. reinforce client education

do not stop taking antiparkinsonian meds suddenly: may precipitate parkinsonian crisis

continue medical supervision

avoid alcohol while on therapy

take with meals

caution with hazardous activities

to change position slowly to prevent orthostatic hypotension

levodopa o minimize Vitamin B6 in diet,

because it hinders drug's effectiveness

o do not take OTC medications without health care provider's approval

o sweat and urine may be dark colored

o toxicity: personality changes, increased twitching, grimacing, tongue protrusion


3. Cholinesterase inhibitors

a. action 1. prevents breakdown of acetylcholine at nerve

endings 2. facilitates transmission of impulses across

myoneural junction 3. strengthens muscle contractions including

respiratory muscles b. examples

1. edrophonium chloride (Tensilon) for diagnostic purposes

2. neostigmine bromide (Prostigmin) 3. ambenonium chloride (Mytelase)

c. use: treat myasthenia gravis d. adverse effects

1. gastric irritation: nausea, vomiting, diarrhea 2. hypersalivation 3. CNS disturbances

4. orthostatic hypotension 5. toxicity: pulmonary edema, respiratory failure,

bronchospasm e. contraindications

1. intestinal obstruction, renal obstruction 2. peritonitis

f. nursing interventions 1. monitor client response to medication; may

need to adjust dosage 2. monitor vital signs during period of dosage

adjustment 3. keep atropine sulfate available for overdosage 4. administer medication with food 5. administer medication as per schedule 6. teach client

wear medic alert jewelry and ID

change position cautiously; sit at first feeling of faintness.

4. Antidepressants a. action: increase norephinephrine at subcortical

neuroeffector sites b. examples

1. norepinephrine blockers (tricyclic, TCAs): amitriptyline (Elavil), imipramine (Tofranil)

2. monoamine oxidase inhibitors (MAOIs): isocarboxazid (Marplan), phenelzine sulfate (Nardil)

3. selective serotonin reuptake inhibitors: fluoxetine (Prozac), sertraline (Zoloft)

c. use: treat melancholia, depression d. adverse effects

1. norepinephrine blockers

potentiate anticholinergics and CNS depressants

orthostatic hypotension

drowsiness, dizziness, confusion

CNS stimulation 2. MAOIs

potentiate alcohol, barbiturates, antihistamines

hypertensive crisis with ingestion of foods high in tyramine (pickled herring, beer, wine, cheese, chocolate)

orthostatic hypotension 3. selective serotonin reuptake inhibitors

may interact with tryptophan

insomnia

headache

sexual dysfunction

gastric irritation e. contraindications

1. acute schizophrenia 2. mixed mania and depression 3. suicidal tendencies 4. narrow angle glaucoma

f. nursing interventions 1. monitor effect of medication 2. maintain suicide precautions especially as

depression lifts 3. give SSRIs in morning; TCAs at bedtime 4. teach client

do not take OTC medication without physician approval

avoid hazardous activities

effect of medication may take up to four weeks

MAOIs: teach client to avoid food containing tyramine; monitor client for hypertensive crisis

SSRIs and MAOIs should not be given concurrently or close together

5. Antimanic agents a. action: reduces adrenergic neurotransmitter

levels in cerebral tissue b. examples

1. antimanic agents: lithium carbonate (Lithane)

2. alternative antimanic agents: carbamazepine (Tegretol), clonazepam (Klonopin)


c. use: control of manic phase of mood disorders; bipolar disorder

d. adverse effects 1. metallic taste 2. hand tremors 3. excess voiding and extreme thirst 4. slurred speech 5. disorientation 6. cogwheel rigidity 7. renal failure 8. respiratory depression

e. nursing interventions 1. monitor blood levels 2. avoid concurrent administration of

adrenergic drugs 3. evaluate client's response to medication 4. teach client

effect of medication may take several weeks

high intake of fluids and normal sodium

toxicity signs: diarrhea, vomiting, weak muscles, confusion etc.

take medication with meals 6. Antipsychotics

a. action blocks dopamine hydrochloride receptors in the CNS and sympathetic nervous system

b. examples phenothiazines: chlorpromazine

(Thorazine), thioridazine (Mellaril) benzisoxazole: risperidone (Risperdal) thioxanthenes: chlorprothixene

(Taractan) butyrophenones: haloperidol (Haldol)

c. use: treatment of psychotic symptoms in schizophrenia, psychosis, Tourette's syndrome, bipolar disorder

d. adverse effects excessive sedation jaundice orthostatic hypotension urinary retention anorexia dry mouth hypersensitivity reactions (such as

photoallergic reaction, impotence, cardiac toxicity)

blood dyscrasias - agranulocytosis extrapyramidal side effects: dystonia,

pseudoparkinsonism, akathisia, akinesia, tardive dyskinesia

neuroleptic malignant syndrome: fever, muscle rigidity, agitation, confusion, deliruim, respiratory failure

e. nursing interventions assess client's response to therapy monitor for signs of infection, liver

toxicity, extrapyramidal symptoms monitor blood work if long-term therapy monitor vital signs give medication at bedtime

teach client o avoid alcohol use

o avoid driving or other hazardous activities

o avoid exposure to direct sunlight o good oral hygiene o report extrapyramidal symptoms or

signs of infection to physician o drink plenty of water

7. Hypnotics a. action: depress CNS b. examples

1. barbiturates: pentobarbital (Nembutal), secobarbital (Seconal): physical dependency may result with long term use

2. acetylinic alcohol: ethchlorvynol (Placidyl) 3. chloral derivatives: chloral hydrate (Noctec)

c. uses: insomnia, sedation d. adverse reaftions

1. respiratory depression 2. hypotension 3. barbiturate toxicity: hypotension, pulmonary

constriction, cold and clammy skin, cyanosis of lips, insomnia, hallucinations, delirium

e. contraindications 1. hypersensitivity 2. pregnancy

f. nursing interventions 1. monitor client response to medication 2. teach client

take medication exactly as prescribed

avoid alcohol and other depressant use

avoid driving and other hazardous activities while under the influence

8. Antianxiety (Anxiolytic) a. action: depress CNS b. examples

1. benzodiazepines: alprazolam (Xanax), chlordiazepoxide (Librium):physical dependency and withdrawal after long term use

2. azapirones: buspirone (Buspar) c. uses: anxiety, sleep disorders, alcohol withdrawal d. adverse reactions

1. CNS disturbances: dizziness drowsiness, lethargy, orthostatic hypotension

2. skin rash 3. blood dyscrasias

e. contraindications 1. hypersensitivity 2. acute narrow angle glaucoma 3. liver disease

f. nursing interventions 1. notify health care provider if systolic BP drops

20mm Hg 2. administer with food or milk 3. teach client

take medication as prescribed

do not take OTC medication without health care provider's approval

use caution when driving or hazardous activities

action potentiated with alcohol or sedatives

never abruptly stop taking benodiazepine


with chlordiazepoxide- avoid excessive sunlight

9. General anesthetics a. action: depresses the CNS through a

progressive sequence b. examples

1. inhalation anesthetics: cyclopropane, enflurane (Ethrane), ether, nitrous oxide

2. IV barbiturates: thiopental sodium (Pentothal), methohexital sodium (Brevital)

3. IV and IM nonbarbiturates: midazolam HCL (Versed), ketamine HCL (Ketaject)

c. use: used in combination for surgical anesthesia d. adverse effects

1. inhalation anesthetics: excitement and restlessness, nausea and vomiting, respiratory distress

2. IV barbiturates: respiratory depression, hypotension, tachycardia, laryngospasm

3. IV and IM nonbarbiturates: respiratory failure, hyper/hypotension, rigidity, psychiatric disturbances

e. contraindications 1. CVA 2. increased intracranial pressure 3. severe hypertension 4. cardiac decompensation

f. nursing interventions 1. have oxygen and emergency treatment

available 2. monitor vital signs

3. use precautions if agent flammable 4. use safety precautions when client

induced 10. Local anesthetics

a. action: decreases nerve membrane permeability to sodium ion influx

b. examples 1. topical: benzocaine, cocaine, lidocaine

HCL (Xylocaine) 2. spinal: dibucaine (Nupercaine), procaine

HCL (Novocaine) 3. nerve block: bupivacaine HCL (Marcaine),

mepivacaine HCL (Carbocaine) c. use: pain control while client is conscious d. adverse effects

1. allergic reactions 2. respiratory arrest 3. arrhythmias, cardiac arrest 4. convulsions 5. hypotension

e. nursing interventions 1. have oxygen and emergency equipment

available 2. monitor vital signs during local anesthesia 3. if spinal anesthesia, keep client flat for 6-

12 hours to prevent headaches

11. Skeletal muscle relaxants a. use: relax muscles, treat spasm disorders

Selected Neurotransmitters Altered by Pscyhotrophic Drugs

Dopamine Serotonin

Norepinephrine

GABA Acetycholine

Primarily affected antipsychotics Primarily affected by antidepressants and antipsychotics Affected by mood-stabilizing agents, antidepressants, antipsychotics and pyschostimulants Primarily affected by antianxiety agents Affected by anticholinesterase agents, antipsychotics and antidepresssants

Benzodiazepine Tricyclic Antidepressants

(first line of treatment)

a. alprazolam (Xanax) b. chlordiazepoxide (Librium) c. diazepam (Valium) d. lorazepam (Ativan) e. midazolam (Versed)

Increases brain amine levels a. imipramine (Tofranil) b. amitryptiline HCL (Elavil) c. nortriptyline (Aventyl)) d. desipramine HCl (Pertofrane, Norpramin)

Selective Serotonin Reuptake Inhibitors (SSRI)

Antipsychotic Agents

a. fluoxetine (Prozac) b. paroxetine (Paxil) c. sertraline (Zoloft) d. fluvoxamine (Luvox)

Phenothiazine a. chlorpromazine (Thorazine) b. fluphenazine (Prolixin) c. trifluperazine (Stelazine) d. perphenazine (Trilafon) Thioxanthenes a. Thiothixine (Navane) Butyrophenones a. Haloperidol (Haldol Dihydroindolones a. Molindone (Moban) Dibenzoxazepines a. Loxapine (Loxitane) Atypical Antipyschotics a. clozapine (Clozaril) b. risperidone (Risperdal) c. olanzapine (Zyprexa)

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DRUGS ACTING ON THE GASTROINTESTINAL SYSTEM Antiemetics

1. action - prevent expulsion of stomach contents by decreasing stimulation of either the chemoreceptor trigger zone (CTZ), near the medulla, or the vomiting center in the medulla

2. examples a. antihistamines: dimenhydrinate

(Dramamine), promethazine (Phenergan) b. anticholinergic: scopolamine (Transderm-

Scop) c. phenothiazines;chlorprimazine (Thorazine),

prochlorperazine (Compazine) d. serotonin (5-HT3) receptor antagonist;

granisetron (Kytril), odansetron (Zofran) 3. use: prevent nausea and vomiting; cause must be

identified to prevent masking a serious problem 4. adverse reactions

a. tachycardia, hypotension b. dry mouth and eyes, blurred vision,

constipation c. sedation, drowsiness

5. contraindications a. narrow-angle glaucoma b. liver disease c. intestinal obstrucion d. depression

6. nursing interventions a. use nonpharmacologic measures first (tea,

crackers, dry toast) b. monitor vital signs

c. monitor for signs and symptoms of shock if vomiting severe

d. monitor bowel sounds e. provide mouth care after vomiting f. teach client

store drug in tight, light resistant container

avoid OTC drugs

avoid alcohol because of cumulative sedative effects

avoid during first trimester of pregnancy

Antacids

1. action a. neutralizes gastric acid b. coats stomach lining

2. examples a. aluminum hydroxide gel (Amphojel) b. aluminum and magnesium hydroxides (Maalox) c. magaldrate (Riopan)

3. use: peptic ulcers, reflux esophagitis, hiatal hernia 4. adverse reactions

a. aluminum compounds - constipation, intestinal obstruction

b. magnesium compounds - diarrhea c. reduced absorption of calcium and iron

5. nursing interventions a. shake oral suspension well b. monitor client's response to treatment c. administer with 8 oz glass of water

Monoamine Oxidase Inhibitors Tetracylclic Antidepressants

Increase concentration of neurotransmitters a. tranycypromine sulfate (Parnate) b. phenelzine sulfate (Nardil) c. isocarboxazid (Marplan)

a. amoxapine (Asendin) b. maprotiline

Antimanic Agents Other Antidepressants

a. lithium (Eskalith, Lithane, Cibalith-S, Lithonate) Anticholinesterase a. donezepil (Aricept) b. galantamine (Reminyl) c. rivastigmine (Exelon) d. tacrine (Cognex) Pschostimulants a. dextroamphetamine (Dexedrine) b. methylpenidate (Ritalin, Concerta, Adderal) c. pemoline (Cylert) Non-psychostimulants a. atomoxetine (Strattera)

a. venlafaxine (Effexor) b. nefazodone (Serzone) c. buproprion (Wellbutrin)


d. teach client

avoid overuse of antacids

dietary restrictions for ulcers

need for diet high in calcium and iron

for clients on low sodium diets: antacids contain sodium

may color stools whitish Antiulcers

1. actions a. decrease acetylcholine release b. decrease HCl production/secretion c. block release of histamines d. inhibit secretion of pepsin e. inhibit proton pump

2. examples

a. anticholinergics; belladonna tincture, chlorodiazepoxide (Librax)

b. h2 blockers - cimetidine (Tagamat), ranitidine (Zantac)

c. pepsin inhibitor - sucralfate (Carafate) d. proton pump inhibitor - lansoprazole (Prevacid),

omeprazole (Prilosec) 3. uses: management of peptic ulcer disease,

gastroesophageal reflux disease(GERD), protects gastric mucosa from hydrochloric acid production

4. adverse reactions a. dry mouth, decreased secretions, constipation,

tachycardia, & urinary retention b. headaches, dizziness, constipation, skin reash,

pruritis, impotence

c. sucralfate is nonabsorbable, occasional constipation

5. contraindications a. anticholinergics - narrow- angle glaucoma b. renal failure c. liver disease

6. nursing interventions a. administer on empty stomach b. avoid antacids within 30 minutes of sucralfate c. avoid antacids within one to two hours of other

antiulcer drugs d. administer other drugs one to two hours after

sucralfate e. teach clients

avoid alcohol, spicy food, and caffeinated beverages

eliminate smoking

increase fluid intake

medication can take up to two weeks for full effect

report increasing abdominal pain, vomiting of blood, or passage of bloody stools

Anti-diarrheal

1. action: forms the stool; mechanism depends on type of medication

2. examples a. fluid absorbents - decrease fluid content; kaolin

and pectin (Kaopectate) b. motility suppressants - decrease motility of GI

tract; diphenoxylate HCL (Lomotil), loperamide HCL (Imodium)

c. enteric bacterium - replacements help intestine turn carbohydrates into lactic acid; lactobacillus acidophilus (Bacid)

3. use: treat diarrhea 4. adverse reactions

a. fluid absorbents: gastric disturbances, CNS toxicity

b. enteric bacterium replacements: excessive flatulence, abdominal cramps

c. motility suppressants: urinary retention, tachycardia, sedation, paralytic ileus, respiratory depression

5. contraindications: a. ulcerative colitis

6. nursing interventions a. monitor effect of medication b. assess for fluid and electrolyte imbalance c. assess for cause of diarrhea d. motility suppressants may cause physical

dependence, may impair ability to perform hazardous activities

Laxatives

1. action: moves stool; mechanism dependent on type of laxative

2. examples a. lubricants moisten stool; mineral oil b. stool softeners allow water to penetrate stool;

dioctyl sodium sulfosuccinate (Colace) c. bulk forming: increase bulk in intestine; psyllium

hydrophilic mucilloid (Metamucil) d. colon irritant stimulates peristalsis; bisacodyl

(Dulcolax) e. saline cathartics increase osmotic pressure

thereby absorbing fluid from bowel wall; milk of magnesia

3. use: to treat constipation 4. adverse reactions

a. gastric effects: nausea, cramping, diarrhea b. dependence with long-term use c. intestinal lubricants inhibit absorption of fat-

soluble vitamins d. saline cathartics: dehydration, hypernatremia

5. contraindications: a. GI obstruction b. suspected appendicitis c. megacolon

d. abdominal pain e. nausea

6. nursing interventions a. monitor effects of medication b. teach client

dietary considerations (increased fiber and fluid intake)

maintain/increase activity level

caution regarding overuse of laxatives

mix bulk-forming laxatives with a glass of water and follow with another glass of water

Pancreatic enzymes

1. action: replacement for natural pancreatic enzymes 2. examples

a. pancreatin (Dizymes) b. pancrelipase (Cotazym)


3. use: aid in digestion; cystic fibrosis 4. adverse reactions, with large doses

a. diarrhea b. nausea c. hypersensitivity reaction: sneezing, skin rashes

5. contraindications a. hypersensitivity to pork b. chronic pancreatic disease

6. nursing interventions a. monitor for symptoms of diabetes mellitus (such

as polyuria, thirst, hunger) b. monitor weight, intake and output c. administer with meals d. do not crush enteric coated medications e. determine client's response to therapy

Total Parenteral Nutrition (TPN)

1. A form of specialized nutritional support in which nutrients are provided by the intravenous route

2. Purpose: to sustain clients nutritionally. Solutions consist of water, amino acids, glucose, minerals, vitamins and lipid emulsions, and trace elements which are calculated for each client individually.

3. Used for clients who are unable to digest or absorb sufficient enteral nutrition

4. Complications a. Hypoglycemia b. Hyperglycemia c. Fluid overload d. Catheter - related sepsis e. Air embolism f. Central venous thrombosis

g. Catheter occlusion 5. Administration

a. Via peripheral administration - up to 10% glucose solutions

b. Via central administration - up to 35% glucose solutions

6. Nursing interventions a. Before administration of TPN

1. check label of solution with medical order 2. check rate of infusion with medical order 3. inspect TPN bottle for precipitates or

turbidity 4. administer via an infusion pump

b. During administration 1. monitor vital signs every four hours

2. observe for signs of air embolism, pneumothorax, or allergic responses (such as chills, increased temperature, urticaria etc.)

3. monitor client's weight daily 4. monitor laboratory values; if blood glucose

levels rise, may need to use sliding-scale insulin therapy

5. monitor client for fluid overload 6. monitor respiratory rate: tachypnea may

indicate excess carbohydrates are increasing carbon dioxide production

7. monitor insertion site for infection 8. monitor infusion rate

if rate too high, hyperosmolar diuresis and dehydration

if too slow, little benefit

do not overcorrect flow rate if too slow or fast accurately record intake and output

change insertion site dressing as per facility's policy


DRUGS ACTING ON THE ENDOCRINE SYSTEM Antidiabetic agents

1. action: provides insulin to promote transport of glucose; exact mechanism dependent on type of antidiabetic agent

2. examples a. oral hypoglycemics stimulate pancreatic beta

cells to produce insulin tolazamide (Tolinase), glipizide (Glucotrol), metformin (Glucophage), rosiglitazone (Avandia)

b. parenteral agents provide exogenous insulin 3. use: treat diabetes mellitus 4. adverse effects

a. hypoglycemia, irritability, confusion b. convulsions, tachycardia, tremor c. moist skin, headache, hunger d. nausea, bloating, diarrhea

5. contraindications: a. hypersensitivity

6. nursing interventions a. assess client for effect of medication b. monitor blood/urine glucose levels c. guidelines for administration of insulin

rotate sites

administered subcutaneously

only regular insulin is administered IV

when mixing insulin, regular insulin is withdrawn into the syringe first

d. instruct client

how to administer the medication

compliance with dietary restrictions

urine and blood testing

wear medic alert jewelry

how to cope with hypoglycemic reactions

signs of ketoacidosis

importance of weight loss if obese INSULIN THERAPY

Instructions: Storage: Opened/used vial: room temperature; Closed/extra:

refrigerator; away from direct sunlight Preparation: if regular insulin appears cloudy: discard; do not

shake to avoid inactivation; roll non – regular insulin gently between hands; draw regular insulin first when mixing it with other types of insulin.

1. Injection: rotate injection sites to prevent lipoatrophy/lipodystrophy; do not inject in an area that will be involved in exercise as it will increases the rate of absorption, onset and peak action

2. Monitor for signs of hypoglycemia: have candy or foods with simple carbohydrates available (crackers, candy or orange juice)

3. Avoid alcohol while taking insulin because it lowers blood glucose levels and can cause hypoglycemia

Hypothyroid agents

1. action: help regulate the metabolic rate of cells 2. examples

a. levothyroxine sodium (Synthroid) b. thyroglobulin (Proloid) c. thyroid (Thyrar)

3. use: replace thyroid hormones 4. adverse reactions

a. hyperactivity b. cardiac stimulation c. thyroid storm

5. contraindications a. adrenal insufficiency b. myocardial infarction c. thyrotoxicosis d. hypersensitivity to beef

6. nursing interventions a. monitor client's response to medication b. teach client

usually lifelong therapy

take medication same time each day

monitor pulse rate; report pulse rate over 100

report signs of toxicity (such as chest pain, palpitations, nervousness)

wear medic alert jewelry / ID

avoid OTC medications unless approved by health care provider

continue medical supervision Hyperthyroid agents

1. action: blocks synthesis of thyroid hormone 2. examples

a. iodine (Lugol's solution) b. methimazole (Tapazole) c. propylthiouracil (PTL)

3. use: treat hyperthyroidism 4. adverse effects

a. agranulocytosis b. skin disturbances

c. decreased metabolism d. gastric disturbances e. iodine: stains teeth, bitter taste

5. contraindications: a. hypersensitivity

6. nursing interventions a. administer iodine preparations through a straw b. monitor effects of medication

Category Agent Onset Peak Duration

Rapid Acting Humalog Rapid 30 – 60 min 3 – 4 hours

Regular 30 – 60 min

2 – 4 hours 5 – 7 hours

Regular IV 10 – 30

min

15 – 30 min 30 – 60 min

Fast Acting NPH/Regular (70/30)

30 min 4 – 8 hours 24 hours

Intermediate Acting

Lente 1 – 3 hours

8 – 12 hours

18 – 28 hours

NPH 1 – 4 hours

6 – 12 hours

18 – 28 hours

Long Acting Ultra-Lente 4 – 6 hours

18 – 24 hours

36 hours

Inject air in the vial of non – regular insulin and also to regular insulin; then withdraw regular

insulin first then non – regular insulin next

(N – R ; R – N)


c. instruct client

report side effects

avoid OTC drugs containing iodine

do not discontinue medication abruptly

carry medic alert jewelry Anterior pituitary: growth hormone

1. action: stimulates the growth of practically all organs and tissues

2. examples a. somatrem (Protropin) b. somatropin (Humatrope)

3. use: treat dwarfism 4. adverse effects

a. hyperglycemia b. hypothyroidism c. antibodies to growth hormone d. interaction with glucocorticoids

5. contraindications: a. hypersensitivity to benzyl alcohol b. closed epiphyses c. intracranial lesions

6. nursing interventions a. monitor diabetic client closely b. instruct client

record height measurements at regular intervals

report to physician if growth is less than expected

Antidiuretic hormone 1. action: helps distal renal tubules reabsorb water 2. examples

a. lypressin (Diapid) b. vasopressin (Pitressin)

3. use: treatment of diabetes insipidus 4. adverse effects

a. gastric disturbances b. hyponatremia c. water intoxication d. cardiac disturbances

5. nursing interventions a. monitor response to therapy: intake and

output, blood pressure b. assess for dehydration

DRUGS ACTING ON THE RENAL SYSTEM Diuretics

1. action: interferes with sodium reabsorption 2. examples

a. loop diuretics interrupt the transport of sodium ions in Loop of Henle

bumetanide (Bumex)

furosemide (Lasix) b. potassium sparers act on collecting tubules to

promote sodium and water excretion

spironolactone (Aldactone)

triamterene (Dyrenium) c. thiazides: inhibit reabsorption of Na+ and CL- in

early distal tubule

chlorothiazide (Diuril)

hydrochlorothiazide (Hydrodiuril) d. osmotic: increase osmotic pressure of

glomerular filtrate

mannitol

urea 3. use: treat hypertension, edema 4. adverse side effects

a. gastrointestinal irritation b. electrolyte imbalance: hyponatremia,

hypokalemia c. orthostatic hypotension d. dehydration

5. contraindications a. electrolyte imbalances b. dehydration c. anuria

6. nursing interventions a. monitor weight, intake and output, vital signs b. give medication in morning c. monitor client for fluid and electrolyte imbalance d. teach client

change positions slowly

report changes in hearing

diabetic clients: closely monitor glucose levels

Sulfonamides

1. action: substitutes a false metabolite for p-aminobenzoic acid, which is essential for the bacterial synthesis of folic acid

2. example a. succinylsulfathiazole (Sulfasuxidine) b. sulfisoxazole (Gantrisin) c. sulfamethoxazole and trimethoprim (Bactrim,

Septra) 3. use: urinary tract infections 4. adverse effects

a. gastric irritation: nausea and vomiting, stomatitis

b. rash c. malaise d. blood dyscrasias e. crystalluria f. photosensitivity

g. allergic response 5. contraindications

a. hypersensitivity b. infants < two months-old


c. pregnancy at term 6. nursing interventions

a. check if client has a history of allergies b. monitor client response to treatment c. monitor vital signs and blood work d. teach client

drink plenty of fluids


avoid OTC medications unless approved

by health care provider

avoid direct sunlight Immunosuppressants

1. action: inhibit immune responses 2. example: cyclosporine (Sandimmune) 3. use

a. prevent organ rejection in transplant patient

b. treat autoimmune disorders (such as rheumatoid arthritis, systemic lupus erythematosus)

4. adverse effects a. nephrotoxicity (poisons kidneys) b. infection c. hypertension d. tremor e. hirsutism

5. contraindications a. hypersensitivity b. nursing interventions

monitor BUN and creatinine; liver function tests

teach client

1. report early signs of infection (such as fever, sore throat)

2. medication may be taken with meals

3. take medication same time each day

4. hirsutism is reversible when treatment stops

Antinfective

1. action: interferes with several bacterial enzyme systems 2. example

a. nitrofurantoin (Furadantin) b. methenamine (Hiprex)

3. use: treat pyelonephritis, pyelitis, cystitis 4. adverse effects

a. anorexia b. nausea and vomiting c. methenamine - crystalluria, bladder irritation d. nitrofurantoin: exfoliative dermatitis, interstitial

nephritis, necrosis 5. contraindications

a. hypersensitivity b. anuria c. severe renal disease d. infants < 1 month-old

6. nursing interventions a. monitor intake and output b. teach client


drink plenty of fluids

take medication with food or milk

with nitrofurantoin:

1. do not crush pill because it stains teeth; dilute oral suspensions and

rinse mouth after taking

2. report changes in urinary pattern

3. report muscle weakness, tingling or numbness

4. urine may look brown or rust yellow

5. avoid alcohol


DRUGS ACTING ON THE FEMALE REPRODUCTIVE SYSTEM Estrogens

1. action: affect the release of pituitary FSH and LH; causes capillary dilatation, fluid retention, and protein anabolism and thin the cervical mucus; conserve calcium and phosphorus and encourage bone formation; inhibit ovulation; and prevent postpartum breast disconmfort

2. example: estradiol (Estrace), conjugated estrogens (Primarin), esterified estrogen (Estratab), estropipate (Ortho-Est, Ogen)

3. use: a. palliative

menopause

prostatic and mammary cancers b. hormonal replacement therapy c. treatment of hypogonadism

d. prevention of postpartum breast engorgement e. contraception f. retardation of osteoporosis in postmenopausal

4. adverse effects: a. bleeding b. menstrual irregularities c. dysmenorrhea; amenorrhea d. changes in libido e. systemic effects: fluid retention, electrolyte

disturbance f. GI effects

5. contraindications a. hypersensitivity b. idiopathic vaginal bleeding c. history of thromboembolic disorders

Estrogen Receptor Modulators

6. action: stimulate specific estrogen receptor sites so as to increase bone mineral density without stimulating the endometrium in women

7. example: raloxifene (Evista) 8. uses: treatment of postmenopausal osteoporosis 9. contraindication: hypersensitivity 10. adverse effect:

a. GI upset b. Changes in fluid balance c. Hot flashes, skin rash d. Edema e. Vaginal bleeding

11. nursing interventions: a. annual physical examination (Pelvic exam, Pap

smear and breast exam) b. monitor liver function c. provide analgesics for headache d. provide support and reassurance

Progestins

1. action: transform the proliferative endometrium into a secretory endometrium, inhibit the secretion of FSH and LH, prevent maturation and ovulation and inihibit uterine contractions.

2. example: levonorgestrel (Norplant System), medroxyprogesterone (Provera), norethindrone (Aygestin), norgestrel (Ovrette) and progesterone (Progestasert)

3. use:

a. contraception b. treatment of primary and secondary

amenorrhea c. treatment for functional uterine bleeding

4. contraindications: a. hypersensitivity b. pregnancy/lactation c. hepatic dysfunction d. PID; STD e. Endometriosis or pelvic surgery

5. adverse effects: a. weight gain b. increased BP c. headache

6. nursing interventions a. follow same implementations as for estrogen

OXYTOCICS

1. action: stimulate contraction of the uterus; and its synthetic form stimulates let down reflex

2. example: ergonovine (Ergotrate), methylergonovine (Methergine), oxytocin (Pitocin, Syntocinon)

3. uses: treatment and prevention of uterine atony induction of labor; promotes uterine contraction lactation to stimulate milk ejection

4. contraindications: hypersensitivity cephalopelvic disproportions complete uterine atony

5. adverse effects: uterine hypertonicity and spasm; rupture postpartum hemorrhage ergotism (nausea, BP changes, weak pulse, dyspnea

etc) water intoxication (oxytocin)

6. nursing interventions: regulate oxytocin delivery between contractions if

given to stimulate labor monitor BP periodically; discontinue if BP rises

dramatically discontinue the drug at any sign of uterine

hypertonicity monitor fetal heart beat


DRUGS AFFECTING THE MALE REPRODUCTIVE SYSTEM Androgens

1. action: increase the retention of nitrogen, sodium, potassium and phosphorus and to decrease urinary excretion of calcium; responsible for growth and development of secondary sex characteristics

2. example: fluoxymesterone (Halostestin), testolactone (Teslac), testosterone (Duratest, Testoderm)

3. uses: a. hypogonadism b. breast cancer for postmenopausal women

4. adverse effects: a. edema b. hirsutism c. deepening of the voice d. antiestrogen effects (flushing, sweating,

vaginitis etc) 5. contraindications:

a. hypersensitivity b. pregnancy and lactation c. prostate or breast cancer in men

6. nursing interventions: a. monitor liver functions b. remove old dermal system before applying new

system to clean, dry, intact skin c. monitor blood tests

Drugs for Erectile Dysfunction:

1. action: relax vascular smooth muscle and promote blood flow into the corpus cavernosum, causing penile erection

2. examples: sildenafil (Viagra), tadalafil (Cialis), vardenafil

(Levitra), aprostadil (Caverject)

3. use: penile erectile dysfunction

4. contraindications: any anatomical obstruction that might predispose to

priapism penile implants women

5. adverse effects: headache, flushing dyspepsia UTI Diarrhea Dizziness Rash

6. nursing interventions: avoid the use of nitrates or alpha blockers avoid drinking grapefruit juice (decrease metabolism

thus increased toxicity) avoid taking the drug with or just a high-fat meal

(delay absorption) used once daily and works only during sexual

stimulation Viagra is usually taken about 1 hour before sexual

activity. However, it may be taken anywhere from 4 hours to ½ hour before sexual activity.

Take Cialis at least 30 minutes before sexual activity, as directed; may work for up to 36 hours after taking it

BLOOD TRANSFUSION 1. Use: restore blood volume or blood components 2. Nursing responsibilities and interventions

Verify that blood had been typed and cross matched Verify five factors:

client number

blood type

Rh factor

blood number

expiration date Pretransfusion assessment includes baseline vital

signs, lung sounds, level of consciousness, IV site, and prescence of pain

Verify informed consent Start infusion with blood administration set, filter,

and normal saline IV Watch for signs of hemolytic reaction; usually occurs

within the first 15 minutes (shivering, headache, lower back pain, oliguria, hypotension)

Watch for signs of febrile reaction; usually occurs within first 30 minutes (hematemesis, confusion, back pain, elevated temperature, headache, shaking)

Watch for allergic reaction (hives, wheezing, pruritus, joint pain)

Monitor vital signs If reaction occurs

stop blood immediately maintain IV with saline notify physician send blood and urine specimen to lab monitor client during transfusion monitor lab results - hemoglobin and

hematocrit


INTRAVENOUS THERAPY 1. Methods of IV administration

a. iv push A. use

a. for quick response b. replace IM injects for patient comfort c. to administer loading doses

B. nursing interventions a. first, check that medication, dose and route

are correct b. assess patency of IV line c. determine compatibility with infusing IV

liquids d. monitor how client reacts to medication

b. infusion control devices A. use to administer a fluid volume accurately B. nursing interventions

a. know how the device works b. double check the flow rate c. monitor client closely for complications such

as inflammation, infiltration or infection at insertion site

d. explain purpose of infusion device to client c. heparin lock

A. use - administer periodic IV medication without continuous IV therapy

B. nursing interventions a. monitor for inflammation, infection or

infiltration at insertion site b. follow your facility's policy to maintain

patency venous access devices

c. uses 1. long-term intravenous therapy

Intravenous therapy

Use - replace fluid, electrolytes and other nutrients for clients who cannot eat or drink adequately

Types of IV therapy solutions: o Isotonic: Osmotic pressure similar to that of plasma

examples: normal saline 0.9%; lactated Ringer's solution; 5% dextrose in water

o Hypotonic: exerts less osmotic pressure than plasma (cell swells)

examples: 2.5% dextrose in water; half strength normal saline 0.45%

o Hypertonic: exerts higher osmotic pressure than plasma (draws water out of the cells) (cell crenates/shrink)

examples: 5% dextrose in normal saline 0.9%; 5% dextrose in lactated Ringer's solution

THERAPEUTIC SERUM MEDICATION LEVELS

Medication Therapeutic Range

Acetaminophen (TYLENOL) 10 - 20 mcg/ml

Amikacin (AMIKIN) 25 - 30 mcg/ml

Amitriptyline (ELAVIL) 120 - 150 ng/ml

Carbamazepine (TEGRETOL) 5 - 12 mcg/ml

Chloramphenicol (CHLOROMYCETIN) 10 - 20 mcg/ml

Desipramine (NORPRAMIN) 150 - 300 ng/ml

Digtoxin (CYRSTODIGIN) 15 - 25 ng/ml

Digixon (LANOXIN) 0.5 - 2.0 ng/ml

Disopyramide (NORPASE) 2 - 5 mcg/ml

Ethosuximide (ZARONTIN) 40 - 100 mcg/ml

Gentamicin (GARAMYCIN) 5 - 10 mcg/ml

Imipramine (TOFRANIL) 150 - 300 ng/ml

Lidocaine (XYLOCAINE) 1.5 - 5.0 mcg/ml

Lithium (LITHOBID) .5 - 1.3 mEq/L

Magnesium Sulfate 4 - 7 mg/dl

Nortriptyline (AVENTYL) 50 - 150 ng/ml

Phenobarbital (LUMINAL) 10 - 30 mcg/ml

Phenytoin (DILANTIN) 10 -20 mcg/ml

Primidone (MYSOLINE) 5 - 20 mcg/ml

Procainamide (PRONESTYL) 4 - 10 mcg/ml

Propranolol (INDERAL) 50 - 100 ng/ml

Quinidine (QUINAGLUTE) 2 - 5 mcg/ml

(CARDIOQUIN)

Salicylate 100 - 250 mcg/ml

Theopylline (AMINOPHYLLINE) 10 - 20 mcg/ml

(THEO-DUR)

Tobramycin (NEBCIN) 5 - 10 mcg/ml

Valporic Acid (DEPAKENE) 50 - 100 mcg/ml

DRUGS WITH ANTIDOTE

Drugs in Generic Antidote

Acetaminophen Acetylcysteine (Mucomyst)

Benzodiazepine Flumazenil

Coumadin Vitamin K

Curare Endrophonium (Tensilon)

Cyanide poisoning Methylene blue

Digitalis Digibind

Enoxaparin (Lovenox)/ Heparin Protamine sulfate

Ethylene poisoning Fomepizole (Antizol)

Iron Deferoxamine mesylate (Desferal)

Lead Edetate disodium (EDTA) Dimercaprol (BAL) Succimer (Chemet) for kids

Magnesium sulfate Calcium gluconate

Morphine sulfate Naloxone HCl (Narcan)

Methotrexate Leucovorine

Neostigmine Pralidoxime chloride

Penicillin Epinephrine

Pyridostigmine (Mestinon) Atropine sulfate

tPA, streptokinase Aminocaproic acid


Normal Laboratory Values

APTT

Activated partial thromboplastin time For HEPARIN 20 – 30 seconds APTT: b/n 1.5 – 2.5 times the normal

PT

Prothrombin time For COUMADIN Within 2 seconds PT: 9.6 – 11.8 secs. MALE

9.5 – 11.3 secs FEMALE INR: 2.0 – 3.0 secs standard warfarin

therapy 3.0 – 4.5 secs high dose warfarin

therapy

Clotting Time 8-15 minutes

Fibrinogen Level

200-400 mg/dl Platelet Count

150,000 – 400,000 cells/ul Bleeding time (1 – 9 minutes) Eryhthrocyte Sedimentation Rate

ESR – eryrythrocyes settle out of anticoagulated blood in 1 hour

0 – 30 mm/hr Hemoglobin & Hematocrit

Hemoglobin Hematocrit

Male 14 – 16.5 g/dl 42% - 45%

Female 12 – 15 g/dl 35% - 47%

Serum Iron

Male 65 – 175 mcg/dl

Female 50 – 170 mcg/dl

Creatinine Kinase (CK)

26 – 174 units/L o CK-MB (heart) 0% - 5% of total o CK-MM (muscles) 95% - 100% of total o CK-BB (brain) 0%

Troponin Troponin I Normal: .6 ng/ml MI: 1.5 ng/ml

Troponin T MI: > .1 to .2 ng/ml

Lactate Dehydrogenase

LDH: 140 – 280 units/L LD FLIP LDH 1 > LDH2

Albumin 3.4 – 5 g/dl

Alkaline Phosphotase

4.5 – 13 king-armstrong units/dl Ammonia

not reliable indicator of hepatic coma 36 – 65 mcg/dl

Amylase

25 – 151 units/L Lipase

10 – 140 units/L Bilirubin

Total: < 1.5 mg/dl Indirect: 0.1 – 1.0 mg/dl Direct: 0 – 0.3 mg/dl

Lipids

Cholesterol: 140 – 199 mg/dl LDL: < 130 mg/dl HDL: 30 – 70 mg/dl Triglycerides: <200 mg/dl

CHON

6.0 – 8.0 g/dl Uric Acid

Male 4.5 – 8 mg/dl

Female 2.5 – 6.2 mg/dl

Glucose:

Glucose fasting: 70 – 110 mg/dl Glucose monitoring: 60 – 110 mg/dl

o Baseline fasting: 70 – 110 mg/dl o 30 mins fasting: 110 – 170 mg/dl o 60 mins fasting: 120 – 170 mg/dl o 90 mins fasting: 100 – 140 mg/dl o 120 mins fasting: 70 – 120 mg/dl

Glucose 2 hour postprandial 140 mg/dl

Serum Creatinine .6 – 1.3 mg/dl

BUN

8 – 25 mg/dl Calcium 8.6 – 10 mg/dl

Magnesium

1.6 – 2.6 mg/dl

Phosphorus 2.7 – 4.5 mg/dl

Thyroid

TSH: .2 – 5.4 microunits/ml T4: 5.0 – 12.0 mcg/dl Thyroxine, free .8 – 2.4 ng/dl T3: 80 – 230 ng/dl


WBC

4,000 – 11,000 cells Hepatitis

Hepatits A o HBcAg (core) o HBeAg (envelope) o HBsAg (surface)

Hepatitis C o (+) antibodies of hepC

Hepatitis E

o IgM + IgG to HepE HIV

(+) ELISA (+) Western Blot / Immunofluorescence assay (IFA)

CD4 T Cell Count

b/n 500 – 1600 cells / uL Immune System Healthy

CD4T is > 500 cells Immune System Problem

CD4T is 200 – 499 cells/uL Severe Immune System

CD4T – 200 cells/uL

DRUGS THAT CHANGE URINE COLOR:

amitriptyline (blue-green) Iron salts (black) levodopa (dark) methylene blue (blue-green) metronidazole (dark/brownish) Oral anticoagulants (orange) Phenothiazines (dark) phenytoin (red to reddish brown or pink) rifampin (red-orange) cotrimoxazole (reddish) doxorubucin (reddish) rifabutin (red-orange) methocarbamol (brown, black or greenish) rifampicin (red-orange) sulfasalazine (orange yellow)

DRUGS THAT CAUSE PROTEINURIA

Aminoglycosides amphotericin B bacitracin Cephalosporins cisplatin NSAIDs Sulfonamides

DRUGS THAT CAUSE TRUE GLYCOSURIA

ammonium chloride carbamazipine Corticosteroids Estrogens

lithium bicarbonate phenytoin Thiazide diuretics

DRUGS THAT INCREASE WHITE BLOOD CELL COUNT

allopurinol ampicillin aspirin (toxicity) methicillin

DRUGS THAT CAUSE TRUE KETONURIA

insulin (excessive doses) isoniazid (intoxication)

DRUGS THAT CAUSES HEMATURIA

amphotericin B aspirin bacitracin caffeine Coumarin derivatives Indomethacin Methicillin Sulfonamides

DRUGS BEST TAKEN WITH MEALS

allopurinol (Zyloprim) hydralazine(Apresoline) phenytoin (Dilantin)

sulfasalazine (Azulfidine) aspirin (Aspilet, COr) metronidazole (Flagyl) probenecid (Benemid) chlorothiazide (Diuril) pancreatin (Creon) paracetamol (Tylenol) cimetidine (Tagamet) propranolol (Inderal) morphine

DRUGS BEST TAKEN BEFORE MEALS

atropine sulfate diazepam (Valium)

insulin co-trimoxazole (Bactrim) flurazepam (Dalmane) pyridostigmine (Mestinon)

DRUGS BEST TAKEN AFTER MEALS

amitryptylline (Elavil) imipramine (Tofranil) prednisone (Delatsone) phenazopyridine (Pyridium) benztropine mesylate (Cogentin) lithium (Lithotabs) streptomycin

MAOI trihexyphenidyl (Artane) haloperidol (Haldol) chlorpromazine (Thorazine)


methyphenidate (Ritalin) clozapine (Clozaril) phenelzine (Nardil)

DRUGS BEST TAKEN ON AN EMPTY STOMACH

ampicillin (Ampicin) eryhtromycin (Eryhtrocin) isoniazid penicillin chloramphenicol Ferrous sulfate Isordil Rifampicin

DRUGS NEED TO BA TAKEN IN THE MORNING

aminophylline

cyclophosphamide isotretinoin (Accutane)

tamoxifen (Tamofen) acetazolamide (Diamox) doxurubicin (Adrriamycin) levothyroxine (Synthroid) theophylline chlorpropamide (Diabenase) epinephrine mannitol pseudoephedrine

THE 25 MOST IMPORTANT MUST-KNOW DRUGS FOR NCLEX

The best way to study for medications for NCLEX is to study it by classifications or body system use methods. Do not study medications at random and do not study it like a Pharmacy student would. ANALGESICS:

(1) Aspirin: Do not give together with other anticoagulants. Stop taking Aspirin some days before surgery. Do not give to children with viral infection(Reye syndrome)

(2) NSAID’s e.g. Ibuprofen—Take with food; contraindicated for people with GI ulcers

(3) Morphine: A respiratory depressant. It should be withheld if the respirations are below 10

ANTI-CONVULSANTS:

(4) Dilantin: Causes gum hyperplasia. Advice client to visit dentist frequently

ANTIINFLAMMATORY/STEROIDS

(5) Prednisone: Causes Cushing like symptoms. Common side effects are immunosupression (monitor client for infection), hyperglycemia

ANTI-COAGULANTS

(6) Heparin: Monitor pt’s lab work-APTT. Antidote is protamine sulfate

(7) Coumadin: Monitor pt’s lab work—PT. Antidote is Vitamin K ANTI-PARKINSONIAN (8 )Cogentin: Used to treat EPS (9)Sinemet: Drug is effective when tremors are not observed

RESPIRATORY (10)Theophylline/Aminophylline: Side effects--Tachycardia CARDIOVASCULAR (11)Digoxin (Lanoxin): Signs of toxicity: Pt will complaint of visual change in colors. They would also complain of loss of appetite. ANTIHYPERTENSIVE (PRE-ECLAMPSIA) (12)Magnesium Sulfate: Monitor for deep tendon reflex and respiratory depression DIURETICS (13)Hydrochlothiazide: Monitor potassium levels (14)Lasix: Monitor potassium levels (15)Aldactone: Potassium sparing PSYCHOTROPICS (16) Lithium Carbonate: Know therapeutic range (0.8 to 1.2mEq). Also know symptoms of toxicity. Adequate fluid and salt intake is important. (17) MAOI inhibitors: Have dangerous food-drug interactions. Food with Tyramine should be avoided. For example: aged cheese, wine etc. (18) Disulfiram (Antabuse): Used for alcohol aversion therapy. Clients started on Disulfiram must avoid any form of alcohol or they would develop a severe reaction. Teach pt to avoid some over-the-counter cough preparations, mouthwash etc. MATERNITY (18) Oxytocin: Assess uterus frequently for tetanic contraction. ANTIDOTES (19) Narcan: Reverses the effects of narcotics (20)Calcium Gluconate: Antidote for magnesium sulfate (21)Vitamin K: Antidote for Coumadin Questions have been asked on NCLEX recently about the following drugs: (22Tegretol: side effects. (23)Atropine: What checks do you do before giving this drug (BP.) (24)Epogen: Used in treating anemia because it increases RBC production. (25) Acyclovir: anti-viral medication used in treating shingles. UPDATES:

tadalafil (Cialis); sildenafil (Viagra): don’t take with

nitrates; taken once daily 30 minutes or 1 hour before sexual activity

alandronate (Fosamax): treatment of Pagets disease, postmenopausal osteoporosis treatment and prevention; stay upright for at least 30 minutes after taking this medication

clopidogrel (Plavix): antiplatelet; patients at risk for ischemic events and history of MI, PAD or ischemic stroke

ticlopidine (Ticlid): antiplatelet; use for clients who are intolerant to aspirin

Botox injection: works by blocking nerve impulses to the muscles or sweat glands, temporarily paralyzing the muscle or gland

Flu vaccine: assess for allergy to eggs or chicken egg

protein


EXTRA NOTES: (A) When a client is on antibiotics, teach the client to continue

taking the medication even though they feel better (B) Monitor client taking antibiotics such as vancomycin for

ototoxicity. Pt will complain of tinnitus, room spinning (vertigo) and nausea.

(C) Clients taking vasodilators e.g. verapamil would complain of headache

SOME POINTS TO REMEMBER WHEN TAKING EXAMS:

1. You have to know and understand your basics in order to answer exam questions. If you don't know how the heart works, it will be difficult to answer questions relating to the heart.

2. You don't have to memorize every single drug out there - there are 60,000+ drugs. Break down the drug name and look for something that jumps out at you. If it's a cardiac drug - look for the cardiac answer. 2 cardiac answers...look for the one that doesn't harm, kill or delay treatment to your patient.

3. Trust your instinct. Do not sit there and try and talk yourself out of an answer because you don't know why you know it. If it feels right to you - it more than likely is right and pick the answer. Your mind stores a huge amount of information and it's buried deep down in there somewhere and it comes out when you least expect it.

4. If you can do something first without drugs...that is more often a better choice than drugging up the patient.

5. This is not the real world - repeat that over and over and over when you take the test. Do not rely on the information you have seen or done in the real world. This is a "perfect world"

test. 6. You aren't supposed to know all the answers. What they do

want to know is that you are safe in your practice and you won't do things that will kill or harm patient.

7. If you have never heard of it, no one else has either. Don't pick that answer.

8. You are a nurse, not a doctor or a surgeon, so don't pick the answer that makes you do things that are outside your practice. You can call the doctor and ask for pains meds, but you can't order them. You also can't trache a person or crack a chest open or insert a chest tube.

9. You aren't there to make the doctor happy; you are there to keep your patient alive. If the answer says to question an order....DO NOT think...I can't call and question the doctor...he might yell at me. Who cares...this is an

exam...you are there to keep your patient alive. 10. If there is anything that you can do that will not harm, kill or

delay treatment to your patient, pick that answer before you call the doctor.

11. Do not pick answers that delay treatment. If your patient is unstable, don't pick the answer that says to reassess in 15 mins. because your patient might just be dead in 15 mins. Look for another answer that doesn't delay treatment and calling the dr. just might be the ONLY thing you can do.

12. Always pick the answer that allows your patient to speak. The patient has 100% right to their healthcare. Do not pick the answers that make the family speak or answers that make the family happy. You are only talking about your patient here.

13. When you see assessment or evaluation in the stem of the question....start thinking S/S.

14. Try to narrow it down to 2 answers and then pick the answer that is the most threatening to the patient.

15. It's all about ABC's for the test. If your patient doesn't have an airway - he doesn't have anything else for that matter.

16. Don't pick answers that will cause long term consequences to your patient.

17. Eliminate answers that have "always, never, etc..." because in the nursing profession - nothing is that certain. They will be tempting to pick too because they look so good....but nursing IS NOT certain and those words make it certain.

18. Tell yourself over and over during the test, you can pass it and you will pass it. Self talk goes a long way during a test like this.

19. Read all over again, browse the net, share and PRAY.

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