Pharmacology
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Transcript of Pharmacology
PART 1. REVIEW ON COMMON ABBREVIATIONS AND TERMINOLOGIES
AbbreviationsAbbreviations are widely used in writing
directions for administration of medications and to perform activities. Standard abbreviations should be used. However, sometimes non-standard abbreviations are used and, as it is w/ any doctor’s order, it is the nurse’s responsibility to interpret correctly. Clarify an order if there is any question
ABBREVIATIONS: medications administration route, time, medication dosage form, other abb.
Quiz 1. ½ crosswise yellow paper.Write the abbreviation for each definition.1. After meals ______2. As desired _______3. As needed _______4. At bedtime _______5. Before meals _____6. By mouth ______7. Every ____8. Everday _______9. Every hour ______10.Every other day ___11.Four times a day ___12.If necessary _______13.Immediately _______14.Three times a day ___15.Twice a day ______
(con’t)Write the meaning for each abbreviation.1. cc _______2. cm ______3. dr _______4. Gm, g, gm ____5. gr _______6. gtt ______7. kg ______8. L ________9. mg ______10.mEq _____11.ml _______12.oz _______13.T, tbsp ____14.t, tsp _____15.ss __________
MEDICAL TERMINOLOGIES- language of the health care industry- derived from Greek & Latin words- roots, prefixes, & suffixes
Root – foundation of a medical termex. arthro = joint
cardio = heart derm or dermato = skin gastro = stomach
cyano = bluish eosino = rosy erythro = red leuko = white melano = black xantho = yellow
Prefixes – word element or part that is added to the beginning of the word rootex. ante = before; forward
hemi = halfmulti = manyneo = newsub = under/below
Suffix – word element or part that is added to the end of the word root
- indicate whether the medical term is a noun or adjectiveex. –ac; -al; -ar; -ary = pertaining to; like
-ic; -iac = pertaining to-oid = like; resembling-ectomy = surgical removal; excision-itis = inflammation of-megaly – enlargement-pathy = disease
Quiz 1. Write the meaning of the listed word elements
Part 11.arthro _____2.gastro _____3.ante ______4.multi _______5.-oid _______6.-ic _____7.-megaly _____8.-pathy _______
Combining Roots, Prefixes, & Suffixes- basic way to create medical terms
1.cardiogastric – pertaining to the heart & stomach
2.gastromegaly – enlargement of the stomach3.gastrectomy – surgical removal of the
stomach4.gastroenterology – study of the stomach &
intestines
Singular & Plural Words -a -ae papilla pappillae -en -ina lumen lumina -ex; -ix -ices apex apices -is -es diagnosis diagnoses -is -ides epididymis
epididymides -nx -nges larynx
larynges -on -a ganglion ganglia -us -i bronchus bronchi -us -era viscus viscera -us -ora corpus corpora
Quiz 1. Part II.Correctly combine each root with the suffix to form a medical term. You must decide whether or not to use the combining form
Example: ROOT SUFFIX TERM arthro -megaly arthromegaly
ROOT SUFFIX TERM 1. arthro -itis ________________ 2. arthro -ectomy ________________ 3. arthro -pathy ________________ 4. dermato-itis ________________ 5. dermato -pathy ________________ 6. gastro -ic ________________ 7. gastro -ectomy ________________ 8. gastro -megaly ________________ 9. cardio -megaly ________________ 10. cardio -pathy ________________
Quiz 1. Part III.Write the plural form for the ff singular terms:
1. ampulla2. fornix3. foramen4. ovum5. phalanx6. testis7. thrombus
Working with Roots, Prefixes, & Suffixes
ROOT MEANINGPREFIX MEANINGarthro joint epi- above, uponcardio heart hemi- halfgastro stomach hypo- below;deficienthepato liver peri- aroundosteo bone poly- many
SUFFIX MEANING-algia pain-itis inflammation-megaly enlarged-pathy disease-plasty repair
Example: hemigastrectomyROOT: gastroPREFIX: hemi = halfSUFFIX: ectomy = surgical removalDEFINITION: surgical removal of half the
stomach
Building Medical Terms
Example:DEFINITION: inflammation of jointsBODY PART: jointsROOT: arthr/oSUFFIX: -itisPREFIX: noneMEDICAL TERM: arthritis
Exercise:
DEFINITION: disease of the heartBODY PART:ROOT:SUFFIX:PREFIX:MEDICAL TERM:
PART II. REVIEW ON MEASUREMENTS & CONVERSIONS
•Metric System-common system of drug
measurement-Liter, ml, or cc– for liquid volume-cc is a common measurement of vol.
that is equivalent to 1 ml of fluid-metric wt of a drug is stated in terms
of kilograms (kg), grams, mg, or mcg
-based on the decimal system
-units of measure are the gram (weight), the liter (volume), & the meter (length or ht.)
-based on units of 10 by dividing or multiplying
Ex. To change mg to gm, or ml to L, divide the number by 1,000:
250 mg = x g(move decimal pt 3 places to the left)
x = 0.25 g or 500 ml = x L= 0.5 L
To convert gm to mg or L to ml, multiply the number by 1,000:
0.005 g = x mg(move dp 3 places to the right)x = 5mg or0.725 L = x mlx = 725 ml
Apothecary & Household Systems-originated in England is based on the
wt of 1 gr of wheat-older systems of measurement-uses the minim (size of a drop of
water), fl. dr, fl. oz, pint, qt, & gal as the basic unit of liquid measure & the gr, lb, oz, dr as the basic unit of solid measure
-this system is much harder to use than the metric system & is rarely seen in most clinical settings
-uses Roman numeral; ex. 15 grains – gr xv
Household System-least accurate of 3 systems-this system uses the teaspoon as the
basic unit of fluid measure, others: gtt, tsp, tbsp, cup & glass
-pound as the basic unit of solid measure- in this system, 1 lb is equal to 16
ounces-household units for liquids are tsp &
tbsp- accurate medical dosing devices:
calibrated oral dosing syringes, oral droppers, cylindrical spoons, medication cups
Avoirdupois System-another older system that was very
popular when pharmacists routinely had to compound medications on their own
-uses ounces & grains, but measures differenlty than those of the apothecary & household systems
-seldom used by prescribers but may be used for bulk medications that come directly from the manufacturer
Other units:unit – reflects the biological activity of the drug in 1 mL of sol’nmEq – used to measure electrolytes (K,
Na, Cl, Ca, Fl)- refers to the ionic activity of the
drug in questionInternational units (IU) – sometimes used to measure certain vitamins or enzymes
- is unique because cannot be converted to another
measuring form
PART III-1. INTRODUCTION TO NURSING PHARMACOLOGY
INTRODUCTION TO DRUGSDrugs – are chemicals that are introduced into the body to cause some sort of change. The nurse is in a unique position regarding
drug therapy, because nursing responsibilities include the ff:
Administering drug Assessing drug effects Intervening to make the drug regimen more
tolerable Provide patient teaching about drugs and the
drug regimen
Pharmacology derived from 2 Greek words, pharmakon, w/c means “medicine,drug,” and logos, w/c means “study.” - is the study of the biological effects of chemicals(WHO) – “ Drug is any substance or product that is used or intended to be used to modify or explore physiological system or pathological states for the benefit of the recipient.”
Nurses deal with pharmacotherapeutics, or clinical pharmacology, the branch of pharmacology that uses drugs to treat, prevent, and diagnose disease
Clinical pharmacology addresses 2 key concerns: the drug’s effects on the body and the body’s response to the drug
Because a drug can have many effects, the nurse must know which ones may occur when a particular drug is administered.
Some drug effects are therapeutic or helpful but others are undesirable or potentially dangerous. These negative effects are called adverse effects
Pharmacotherapeutics – science of drug used to treat various illnesses and the responses of the individual. Factors that prevent drug actions and the need to alter drug dosage will be studied latter.
Clinical Pharmacology – helps generate data for optimum use of drugs. It includes pharmacodynamic and pharmacokinetic study of drugs in healthy volunteers and in patients to evaluate the efficacy and safety of a given drug in comparison with other forms of treatment and its adverse effects.
Pharmacy – science of compounding and dispensing drugs and preparing suitable dosage forms for administration. It includes identification, collection, isolation, purification, synthesis, quality control and standardization of medicinal substances.
Pharmaceutics – technological science of drug manufacture in large scale
Chemotherapy – is treatment of systemic infections, and malignancy by use of specific chemical agents (chemotherapeutic agents) that have selective toxicity for the infecting organism or malignant cells with minimal adverse effect or no effect on the host cells.
Drugs having only pharacodynamic effects on the recipient are designated as pharmacodynamic agents
Pharmacopoeia- an official code containing selected list of established drugs and preparations with a description of their physical properties, purity, and potency. It defines standards that these preparations must meet and their average doses for an adult.
Toxicology – study of adverse effects of both chemotherapeutic agents and pharmacodynamic agents, since the same agent could be a drug or poison depending on dosage used. It also includes the study of poisonous effects of drugs and other chemicals with an emphasis on prevention, detection, and treatment of poisoning.
*The following formulations of drugs should not be crushed or chewed
Enteric-coated tablets, w/c are designed to dissolve in intestine instead of stomach.
Sustained-release forms w/ abbreviations such as Dur (duration), SR (sustained-release), CR (controlled or continuous release), SA (sustained action), LA (long acting), and Contin (Continuous-release).
Trade names with ‘twice daily’ abbreviation (bid). Ex. Theobid or Cardabid
Liquid-containing capsules meant for oral use.
Scored tablets may be broken along the scored line but should not be crushed or chewed.
FORMS OF DRUG PREPARATIONS
SOURCES OF DRUGSNatural Sources
Minerals: kaolin, magnesium trisilicate, magnesium sulfate, and liquid paraffin.
Plant products: alkaloids, oils, glycosides, resins, gums, tannins, and antibacterial substances (ex. Chitosan): Ex. Reserpine, digitalis, digoxin, quinine, atropine, and morphine
Animal products: used to replace human chemicals that are not produced because of disease or genetic problems: thyroid extracts, heparin, gonadotrophins, and insulin for treating diabetes was obtained from cow and pig pancreas tissue
Products of Genetic Engineering- the process of altering DNA-permits
science to produce human insulin by altering Escherichia coli bacteria, making insulin a better product without some of the impurities that come with animal products
Drugs by recombinant DNA technology are vaccines for viral hepatitis and rabies, hormones such as human insulin, human growth hormones, etc.
Inorganic Compounds – salts of various elements have therapeutic effects in the human body
: aluminum, flouride, iron, goldAl – antacid, hyperphosphatemia, prevention of the formation of phosphate urinary stonesFl – prevention of dental cavities & osteoporososAu – tx of RAFe – tx of IDA - discovered accidentally when a cause-effect relationship was observed
Microorganisms: penicillin and other antibiotics
Synthetic – made artificially by chemical synthesis, esp. so as to resemble a natural product
Most of the drugs in present use aresynthetic, e.g., corticosteroids,sulfonamides, aspirin, etc.
Drug evaluation
FDA – ensure the safety and reliability of any drug approved in this country. For every 100,000 chemicals that are identified as being potential drugs, only about 5 end up being marketed
Phases of Drug Development1.Preclinical Trials – chemicals that may
have therapeutic value are tested on laboratory animals for 2 main purposes:- to determine whether they have the presumed effects in living tissue- evaluate any adverse effects- at the end of trial, some chemicals are discarded for the ff reasons:
The chemical lacks therapeutic activity Too toxic Highly teratogenic Safety margins are small , not useful in
clinical testing
2. Phase 1 studies – use human volunteers to test the drugs- more tightly controlled and are performed by specially trained clinical investigators- volunteers are fully informed of possible risks and may be padi for their participation- chemicals are dropped from the process for the ff reasons:
they lack therapeutic effect in humans Cause an unacceptable adverse effects Highly teratogenic Too toxic
3. Phase II studies – allow clinical investigators to try the drug in patients who have the disease that the drug is meant to treat.- performed at various sites across the country – in hospitals, clinics, & doctors’ offices – and are monitored by representatives of the pharmaceutical company studying the drug- at the end of phase II, may be removed from further investigation for the ff reasons:
Less effective than anticipated Too toxic when used with patients Produces unacceptable adverse effects Low benefit-to-risk ratio, meaning that the
therapeutic benefit it provides does not outweigh the risk of potential adverse effects that it causes
Is no more effective than other drugs already on the market, making the cost of continuedresearch and productionless attractive to the drug company
4. Phase III Studies – involve use of the drug in a vast clinical market- prescribers are informed of all the known reactions to the drug and precautions required for its safe use
Food and Drug Administration Approval- drugs that finished phase III studies are evaluated by the FDA- drug that receive FDA committee approval may be marketed- the entire dev’t and approval process can take 5-6 yrs. Resulting in a so-called drug lag in US
5. Phase IV Study- After a drug is approved, it enters a
phase of continual evaluation- Approved drug is given a brand
name, generic, and chemical namesDRUG NAMES:
Drugs in general have 3 categories or nomenclatures:
Chemical name is the one that describes the drug chemically.ex. L-thyroxine, T4
• Generic name is the non-proprietary name that is accepted by a competent scientific body. The generic name of newer drugs all over the world are uniform by an agreement through WHO
◦ also called as approved name or official name.
ex. levothyroxine sodium Brand name (Proprietary name) is
the name adopted by the particular manufacturing company. That means a given drug can have many propriety names.ex. Crocin in India, Tylenol in USA
Eltroxin, Levothyroid, Synthroid
Pregnancy CategoriesAs part of the standards for testing
and safety, the FDA requires that each new drug be assigned to a pregnancy category.
Category A: Adequate studies in pregnant women have not demonstrated a risk to the fetus in the first trimester of pregnancy, and there is no evidence of risk in later trimesters
Category B: Animal studies have not demonstrated a risk to the fetus but there are no adequate studies in pregnant women, or animal studies have shown an adverse effect, but adequate studies in pregnant women have not demonstrated a risk to the fetus during the first trimester of pregnancy, and there is no evidence of risk in later trimesters
Category C: animal studies have shown an adverse effect on the fetus but there are no adequate studies in humans; the benefits from the use of the drug in pregnant women may be acceptable despite its potential risks, or there are no animal reproduction studies and no adequate studies in humans
Category D: There is evidence of human fetal risk, but the potential benefits from the use of the drug in pregnant women may be acceptable despite its potential risks
Category X: Studies in animals or humans demonstrate fetal abnormalities or adverse reaction; reports indicate evidence of fetal risk. The risk of use in pregnant women clearly outweighs any possible benefit
*Regardless of the designated pregnancy category or presumed safety, no drug should be administered during pregnancy unless it is clearly needed
Controlled Substances controlled substances – drugs with abuse
potential eg., heroin, marijuana, LSD, narcotics, amphetamines, barbiturates
FDA studies the drugs and determines their abuse potential
PDEA enforces their controlGeneric Drugs
- are chemicals that are produced by companies that just manufacture drugs*why cheap? Because they do not have the research, the advertising, or sometimes, the quality control departments that pharmaceutical companies have
*the difference? Bioavailability of the drug- some prescribers however, specify that a drug prescription be “dispensed as written” (DAW) – that is, the brand-name product be used- the prescriber ensures the quality control and bioavailability expected with that drug- may be most important in drugs that have narrow safety margins such as Digoxin (Lanoxin), a heart drug and Warfarin (Coumadin), an anticoagulant- the initial cost may be higher but some prescribers believe that, in the long run, the cost to the patient will be less
Orphan Drugs-are drugs that have been discovered but
are not financially viable and therefore have not been “adopted” by any drug company
OTC Drugs-are products that are available without
prescription for self-treatment of a variety of complaintsDisadvantages:
Could mask the s/s underlying d’se, making dx difficult
Taking these drugs with prescription medications could result in drug interactions & interfere with drug therapy
Serious overdoses
Sources of Drug Information Drug doses Therapeutic and adverse effects Nursing-related implications
Package Inserts – chemical & study infoReference books • PDR is a compilation of the package insert info
from drugs• Drug Facts & Comparisons - provides a wide
range of info• AMA Drug Evaluations – contain detailed
monographs
• Lippincott’s Nursing Drug Guide (LNDG) – has drug monographs
Journals• Medical Letter – monthly review of new
drugs, drug classes, & specific tx protocolsInternet Information
PART III – A. DRUGS AND THE BODY
Pharmacodynamics – therapeutic effect or action (physiologic and biochemical effects) of drugs and their mechanism of action at molecular, cellular, and organ system levels.A drug can bring about physical or chemical change in the cell environment.Ex. 1. stool softeners that act by altering surface tension, and osmotic diuretics that alter osmosis.
Cell functions and process may be altered by drug interaction with drug receptors.Ex. Glucose transfer into cell is facilitated by insulin.
Agonist - Drug binding to receptor that brings about pharmacological action
Antagonist – prohibits pharmacological action
Drug Mode of Action Certain drugs work by interacting with
receptors, special sites on the surface of body cells. Drugs may bind to a specific receptor, possibly preventing naturally occurring chemicals from binding to the receptor. In so doing, if a drug enhances cell activity, it is called an agonist; if it blocks cell activity, it is called an antagonist.
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Local & systemic – (ex. Xylocaine plus epinephrine given SC) an agent given for its local effect but produces a systemic effect also.
Drug effect could be local (ex. Topical application of acyclovir for herpes simplex viral infection) that acts at the site of application
Systemic – affects more than one part of the body (ex. Novalgin given IM for pain at a distant place
Herpes Simplex Blisters Around Mouth Region One strain of the herpes simplex virus causes cold
sores (also known as fever blisters) in and around the mouth, lips, pharynx, nose, face, and ears. The causative agent remains in the cell bodies of facial nerves, causing repeated attacks of the blisters. No established therapy, beyond topical lotions for pain relief, has been developed.
Encarta Encyclopedia John Watney/Science Source/Photo Researchers, Inc. Microsoft ® Encarta ® 2009. © 1993-2008
Microsoft Corporation. All rights reserved.
Pharmacokinetics – study of how drugs are Absorbed, Distributed, Metabolized and excreted (ADME) from the body.•Absorption – refer to what happens to a drug from the time it is introduced to the body until it reaches the circulating fluids & tissues
Ex. Digoxin is absorbed orally to an extent of80%, transported through the blood where25% of it is bound to plasma proteins,distributed widely into all tissues with itseffect localized in the heart muscle, only asmall fraction is metabolized to its inactiveform in the liver, most of it is excreted bykidney in unchanged form, and it hasplasma half time (t ½) of about 40 hrs.
ROUTES OF ADMINISTRATIONThere are many ways to administer
drugs, and each method depends on the drug formulation, the expected action of the drug, and other clinically determined criteria. The most common methods of drug administration are oral and parenteral, w/c includes subcutaneous, intramuscular, and intravenous injections. Other methods include topical application to the skin or mucous membrane, inhalation into the respiratory tract, intra-articular injection into a joint activity, and intrathecal injection into the spinal column. Some drugs are also administered by rectum, by vagina, in the buccal pouch, and under the tongue (sublingual).
ORAL ADMINISTRATION-most commonly used route-convenient and simple, easy, safe,
economical-sometimes crushed or dispensed in
liquid form-may be swallowed or given by
nasogastric or gastrostomy tube - (-) slow absorption, may be
destroyed by digestive juices
Buccal-absorbed relatively slowly from the
mucous membranes of the mouth-placed in the cheek next to the
molars in either the upper or the lower jaw-troches and lozenges are forms-intended use is usually for local rather
than systemic effect
Sublingual-small tablets that dissolve quickly
under the tongue; absorbed through the mucous membranes of the mouth
-are not to be chewed or swallowed and must be allowed to dissolve completely before the patient eats or drinksex. NTG, Felpin (anti-hpn drug)
Rectal-inserted into the rectum-slow, irregular absorption
Nasogastric-delivered through a tube placed
through the nose & into the stomach-slow absorption; may be destroyed by
digestive juices
PARENTERAL ADMINISTRATION-any route of drug administration that
bypasses the gastrointestinal tractIntramuscular
-made into a muscle tissue-most frequently used sites: large
muscle masses such as vastus lateralis in the anterior thigh, gluteus maximus & gluteus medius in the buttocks & hip, & the deltoid in the upper arm
-drugs are readily and rapidly absorbed from IM sites because muscles have a good blood supply ex. AntibioticsSites: ventrogluteal, dorsogluteal, vastus lateralis, rectus femoris, deltoid site
Subcutaneuos Injection-made into the subcutaneous tissue or
the fatty layer of the skin, just below the dermis
-common sites are the outer aspect of the upper arm, the anterior thigh, & the abdomen
-absorbed more slowly from these sites than from IM sites because they contain a lesser blood supply
-ex. Insulin, hormones, local anestheticSites: Outer aspect of outer arm, Anterionr aspect of the thigh, abdomen, and scapular areas, Ventrogluteal areas, Dorsogluteal areas
Intravenous Injection-injected directly into a vein-action of drugs is very rapid, usually
within minutes-ex. Antibiotics, blood
Intradermal-injection into the dermis of the skin-ex. Vaccinations, tuberculosis &
allergy tests
Transdermal-through the skin; continuous
administration via patch or disk-hormones, NTG patch
Inhalation-applied topically but are absorbed
for a systemic effect-taken into the nose or mouth;
inhaled through face masks, nasal catheters, nebulizers, & positive-pressure breathing machines; absorbed into the bloodstream through the lungs
-ex. Asthma & anesthesia meds
TOPICAL ADMINISTRATION-used primarily for a local effect but
because the medication is applied to the skin or mucous membrane, the drug may be absorbed and have a systemic effect.
-may be in the form of creams, foams, gels, pastes, ointments, solutions, sprays & suppositories to the skin or to the mucous membranes lining the respiratory tract, vagina, rectum, or urethra
-eyedrops & eardrops are drugs given topically by the ophthalmic and ottic routes
INTRA-ARTICULAR ADMINISTRATION-directly injected into a joint, usually
by a physician-common ex: injection of the anti-
inflammatory agent cortisone into a knee or shoulder joint
INTRATHECAL ADMINISTRATION-only specially trained nurses, such
as nurse anesthetists & physicians administer drugs by this route directly into the spinal column
-some drugs are injected into the subarachnoid space (w/c contains the CSF) & others are injected into epidural space of the spinal cord.
Forms of Medications
• Distribution – involves the movement of a drug to the body’s tissuesFactors that affect distribution: tissues perfusion Hot/cold environment Drug’s lipid solubility Protein-binding BBB Placenta & breast milk
• Metabolism (biotransformation) – Liver Enzyme Systems – for
detoxification; hepatic cells are lined w/ enzymes
- increased activity in an enzyme system speeds the metabolism of the drug
Excretion – removal of a drug from the body
kidneys (), saliva, lungs, feces glomerular filtration – passage of water &
water-soluble components from the plasma into the renal tubule
considerations: kidney function & urine acidity
Half-Life - is the time it takes for the amount of
drug in the body to decrease to ½ of the peak level it previously achieved• Ex. If a pt. takes 20 mg of a drug w/ a half-life of 2 hrs., 10 mg of the drug will remain 2 hrs. after administration. 2 hrs. later, 5 mg will be left; in 2 more hrs., only 2.5 mg will remain• Consideration: absorption rate, distribution to the tissues, speed of biotransformation, excretion of drug
Factors Influencing Drug EffectsWhen administering a drug to a pt.,
the nurse must be aware that the human factor has a tremendous influence on what actually happens to a drug when it enters the body.
Factors Affecting the Body’s Response to a Drug•Weight – 150 lb.• Age – children – imature systems & older adults – fewer plasma proteins & less efficient perfusion, altered biotransformation or metabolism because of liver changes w/ age, & less effective excretion
• Gender – men – more vascular muscles- women – more fat cells, poss. of
pregnancy• Physiological factors – diurnal rhthym,
electrolyte balance, acid-base balance, hydration• Pathological factors – d’se, hepatic
dysfunction, renal dysfunction, GI dysfunction, vascular disorders, low bp• Genetic – lack enzyme systems necessary
for metabolizing a drug- overactive enzyme systems,
breaking down drugs very quickly- differing metabolisms &
enzymatic makeup
• Immunologic factors – allergy after exposure to its proteins, can develop antibodies to a drug
• Psychological factors – placebo effect, health beliefs, compliance
- pt’s attitude about a drug has been shown to have a real effect on how
that drug works• Environmental factors – temperature. Light,
noise- some drug effects are helped by a
quiet, cool, nonstimulating environment
Drug tolerance – because of increased biotransformation of the drug, increased resistance to its effects, or other pharmacokinetic factors
- ex. Morphine Cumulative effects – drug is taken in
successive doses at intervals that are shorter than recommended or body not able to eliminate drug properly
Drug-Drug interactions:• At the site of absorption – one drug
prevents or accelerates absorption of the other drug
- ex. Antibiotic tetracycline is not absorbed from the GI if there is a presence of Ca products
• During distribution – one drug competes for the potein binding site of another drug, so the 2nd drug cannot be transported to the reactive tissue
- ex. ASA competes with the drug methotrexate (Rheumatrex) for protein binding sites because ASA is more competitive for the sites, methotexate is bumped off resulting to increased toxicity to tissues
• During biotransformation – one drug stimulates or blocks the metabolism of the other drug
- Warfarin (coumadin) is biotransformed more quickly if it is taken at the same time as barbiturates, rifampin, etc. therefore higher doses will be needed
• During excretion – one drug competes for excretion w/ the other drug, leading to accumulation & toxic effects of one of the drugs
- ex. Digoxin (lanoxin) & quinidine (quinaglute)• At the site of action – one drug may be an
antagonist of the other drug or may cause effects opposite of the other drug, leading to no therapeutic effect
- ex. Anti-HPN drug taken w/ allergy drug that increases BP
• Drug-Food interactions – ex. Antibiotic tetracycline cannot be taken w/ iron & Ca products
• Drug-Laboraroy test interactions – some drugs may alter test results
- ex. Dalteparin (fragmin) may cause increased enzyme AST & ALT with no ijury to liver cells or hepatitis
Hx, PA,
PART III-B. TOXIC EFFECTS OF DRUGS• Adverse effects – undesired effects
- occur for many reasons: drug may have other effects on the
body besides the therapeutic effect pt. sensitivity to drug drug’s action on the body causes
other responses that are undesirable too much or too little taking
Drug Allergy – occurs when the body forms antibodies to a particular drug, causing an immune response when the person is re-exposed to the drug
4 classifications of drug allergy:•Anaphylactic reaction•Cytotoxic reaction•Serum-sickness reaction•Delayed allergic reaction
Drug-Induced tissue & organ damage• Dermatologic reactions
Assessment: hives, rash, severe: exfoliative dermatitis – rash, scaling fever, enlarged lymph nodes, enlarged liver, potentially fatal erythema multiforme exudativum (Stevens-Johnson Syndrome) char. by dark red papules on extremities often in rings or disk-shaped patches
Intervention: provide skin care, avoid rubbing, or tight rough clothing, harsh soaps, perfumed lotions, administer antihistamines. Topical corticosteroids, emollients as ordered
Stomatitisex. Fluorouracil (Adrucil)
antineoplastic agent causes mouth sores Assessment: gingivitis, glossitis, dysphagia, bad breath, pain in mouth & throat Intervention: provide mouth care w/ nonirritating solution, tolerated diet, antifungals, local anesthetics as ordered
•Superinfections – caused by the usually controlled organisms
Assessment: fever, diarrhea, black or hairy tongue, glossitis, mucous membrane lesions, vaginal discharge w/ or w/o itching
Intervention: frequent mouth care, skin care, small frequent meals, antifungal therapy, disc. Drug
•Blood dyscrasia – bone marrow suppression caused by drug effects
- occurs when drug that can cause cell death (antineoplastics, antibiotics) are used
Assessment: fever, chills, sore throat, malaise, back pain, dark urine, dec. hct, (anemia), low platelet ct. (thrombocytopenia), low WBC ct. (leukopenia), pancytopenia
Intervention: monitor bld. counts, provide rest, protect from infection, injury, bleeding, disc. drug
• Toxicity - Liver injuryAssessment: fever, malaise, n/v, jaundice, change in color of urine or stools, abd. pain or colic, inc. liver enzymes, changes in
clotting factors (ex. PTT)Intervention: disc. Drug, notify physician, supportive measures (small frequent meal, skin care, cool env’t, rest
- Renal injury – Gentamycin cuses renal tox
A: elevated BUN, creatinine, dec. hct, electrolyte imbalances, fatigue, malaise, edema, irritability, skin rash
I: notify, disc. Drug, supportive measures (diet, fluid restrictions, positioning, skin care, electrolyte therapy, rest, controlled env’t)
- Poisoning – occurs when an overdose of a drug damages multiple body systems
• Alterations in glucose metabolism- Hypoglycemia – Glipizide (glucotrol),
glyburide (diabeta)
A: fatigue, drowsiness, hunger, anxiety, h/a, cold clammy skin, shaking, lack of coordination, inc HR, BP, numbness, tingling of mouth, tongue, lips, confusion, rapid shallow respirations, seizure, coma
I: restore glucose, skin care, env’t control, rest
- Hyperglycemia – ex. Ephedrine drug – bronchodilator & antiasthma to
relieve nasal congestionA: fatigue, polyuria, polydypsia, deep respirations (Kussmaul’s resp.),
restessness, polyphagia, nausea, hot or flushed skin, fruity odor of breath
I: insulin therapy controlled environment, mouth care
• Electrolyte imbalances- Hypokalemia – loop diureticsA: serum K conc <3.5 mEq/L,
weakness, numbness & tingling in the extremities, muscle cramps, NVD, dec bowel sounds, irregular pulse, weal pulse, orthostatic hpn, disorientation. In severe cases, paralytic ileus (absent bowel sounds, abd. Distention, & acute abdomen) may occur
I: replace serum K, monitor serum levels, safety precautions
- Hyperkalemia – K sparing diuretics, antineoplastic agentsA: serum K level >5.0 mEq/L, malaise, muscle cramps, diarrhea, numbness & tingling, slow HR, low BP, dec urine
output, DOBI: Na polystyrene sulfonate, safety
measures, monitor cardiac effects,
•Sensory effects- Ocular toxicity – drugs are
deposited into tiny arteriesinflammation & tissue damage
- chlorquine (aralen) x rheumatoid d’seretinal damage/blindness
A: blurring of vision, color vision changes, corneal damage, blindness
I: monitor pt’s vision for known oculotoxic drugs, consult w/ physician, disc. drug, monitor exposure to lights
- Auditory damage – ex. ASAA: dizziness, tinnitus, loss of balance, loss of hearingI: monitor perceptual losses or
changes, provide protective measures, consult w/ physician, supportive measures
•Neurological Effects- General CNS Effects –
Protection: BBB
- beta-blockers x hpn/angina cause feelings of anxiety, insomnia & nightmares A: confusion, delirium, insomnia, drowsiness, hyperreflexia/hyporreflexia, bizarre dreams, hallucinationsI: provide safety measures, avoid dangerous situations (driving, operating dangerous machinery), orient, provide support, consult physician
- Atropine-like (Cholinergic) Effects- Donepezil (Aricept) x
Alzheimer’s d’se, also cold & antihistamine drugsA: dry mouth, altered taste perception, dysphagia, heartburn, constipation, bloating, paralytic ileus, urinary hesitancy & retention, impotence, blurred vision, cycloplegia (loss of movement in eye muscles), photophobia, h/a, mental confusion, nasal congestion, palpitations, decreased sweating, dry skin
I: provide sugarless lozenges, mouth care to avoid dryness, have pt void
before taking drug, safety measures, avoid hot env’t, take protective measures from falling & dehydration
- Parkinson-like Syndrome – antipsychotic & neuroleptic drugs
A: lack of activity, akinesia, muscular tremors, drooling, changes in gait,
rigidity, extreme restlessness or jitters (akathisia), spasms (dyskinesia)
I: disc. Drug, small frequent meals, safety measures
- Neuroleptic Malignant Syndrome
– generalized syndrome that includes high fever; eg. general anesthetics
A: EPS sx (tardive dyskenisia, akinesia,akathesia, acute dystonia)
I: disc. drug, provide supportive care, safety precautions
• Teratogenecitydrugsdeveloping
tissues/embryo-->death/congenital defects
I: advise not to self-medicate, provide emotional & physical support
PART III-C. NURSING MANAGEMENTIntroductionNursing is a unique and complex science as well as a nurturing and caring art
- deals with the whole person including physical, emotional, intellectual, social, & spiritual aspects
- nurse needs to consider how a person responds to treatment, disease, and the changes in lifestyle that may be required
- nurse – key health care provider who is in the position to:•Assess the whole pt.•Administer therapy as well as medications•Teach pt. to cope w/ the therapy•Ensure favorable outcome of therapy•Evaluate effectiveness of therapy
The Nursing Process
Assessment – gathering informationNursing diagnosis – analyzing the information gathered to arrive at some conclusions
Interventions – actions undertaken to meet the pt’s needs, such as administration of drugs, education, & comfort measures
Evaluation – determining the effects of the interventions that were performed
In general, the nursing process - provides an effective method for handling all of the scientific & technical information as well as the unique emotional, social, & physical factors that each pt. brings to a given situation
- ensures that the pt. receives the best, most efficient, scientifically based, holistic care
Assessment – systematic, organized collection of data about the pt.
- include information about physical, intellectual, emotional, social, & environmental factors
- particular information that is needed varies w/ each drug, but the concepts involved are similar
- 2 key areas that need to be assessed: pt’s history & physical conditions
•Past History Chronic conditions – the presence of certain conditions (eg, renal d’se, heart d’se, diabetes, chronic lung d’se) may be contraindications the use of a drug. Or, these conditions may require that caution be used when administering a gertain drug or that the drug dosage be adjusted
Drug use – prescription drugs, OTC drugs, street drugs, alcohol, nicotine, alternative therapies, & caffeine may have an impact on a drug’s effect.
Allergies – past exposure to a drug or other allergens can provoke a future reaction or provide a caution for the use of a drug, food, or animal product- it is imp’t to describe the particular allergic reaction when noting a drug allergy. In some cases, the reaction is not an allergic response but an actual drug effect
Level of education – helps the nurse determine the level of explanation required & provides a basis for developing pt. education programs
Level of understaning of d’se & therapy – this information also helps the dev’t of educational information
Social supports – available support at home, also involves referral to appropriate community resources
Financial supports – the high cost of health care in general, & of medications in particular, should be considered when initiating drug therapy
Pattern of health care – knowing how a pt. seeks health care gives the nurse valuable information to include in the educational plan
- does this pt. seek ff. up care or does wait for emergency situation?
- does this pt. self-treat his complaints, or is brought to a health care provider?
Physical Assessment Weight – helps determine whether recommended drug dosage is appropriate.
- Because the recommended dosage typically is based on a 150-lb adult male, pts who are lighter or much heavier need a dosage adjustment
Age – children & older adults – require dosage adjustments based on the functional level of the liver & kidneys & the responsiveness of other organs
Physical parameters or known drug effects – provides baseline level
- Depends on d’se process being treated & on the expected therapeutic & adverse effects of the drug therapy
Ex. If a pt. is being treated for chronic pulmonary d’se, the respiratory status & reserve need to be assessed, especially if a drug is being given that has known effects on the respiratory tract
Nursing Diagnosis – a statement of the pt’s status from the nursing perspective
- directs appropiate nursing interventions
- shows actual or potential alterations in pt. function based on the assessment of the clinical situation
- Ex. Imbalanced Nutrition: Less or More Than Body Requirements
Impaired Physical Mobility Disturbed Body Image
Nursing Interventions- 3 types of interventions are
frequently involved in drug therapy: drug administration, provision of comfort measures, and pt./family education•Proper drug administration- there are 7 pts. to consider in the safe & effective administration of a drug:1. Drug2. Storage – refrigeration, protection from light
3. Route – check proper method of administering by that route4. Dosage – based on available drug form, the pt’s body wt. or surface area, or the pt’s kidney fxn
5. Preparation – know specific preparation before administering any drug - Ex. Oral drugs may need to
be shaken or crushed; - Parenteral drugs may need
to be reconstituted or diluted w/ specific solutions
- Topical drugs may require specific handling, such as use of gloves during administration or shaving of a body area before application
6. Timing – administration of one drug may require coordination w/ the administration of other drugs, foods, or physical parameters
- educate pt. to do this on his own7. Recording – document in accordance w/ the local requirements for recording medication administration
•Comfort Measures- nurses are in a unique position to help the pt. cope w/ the effects of drug therapy
Placebo effect – anticipation that a drug will be helpful has been proven to have tremendous impact on the actual success of drug therapy
- back rub, a kind word, positive approach may be as beneficial as the drug itself
•Managing Adverse Effects – decrease anticipated
adverse effects & promoting pt. safety – environmental control (temp., light), safety measures (avoid driving, avoid sun, using side rails), & physical comfort (skin care, laxatives, frequent meals) Lifestyle adjustment – ex. Pt. taking diuretics may have to rearrange their day so as to be near toilet facilities when the drug works
- pt. taking Monoamine oxidase inhibitors (MAOIs) must adjust their diet to prevent serious adverse effects from interaction of the drug w/ certain foods (tyramine-rich foods); eg.aged cheese, avocado, bean curd, bologna, chocolate, canned fish, dried & salted fish, pickled herring, caffeine, etc)
- in some cases, change in lifestyle can affect coping & compliance w/ the medical regimen
•Patient and Family Education - written information
- key elements that must be included in any drug education program are the ff:1. Name, dose & action of drug – to ensure safe & effective drug therapy & avoiding drug-drug interactions2. Timing of administration – teach pts. When to take the drug w/ respect to frequency, other drugs, & meals
3. Special storage & preparation instructions – some drugs
require particular handling procedures; inform pts. to carry out these requirements
4. Specific OTC drugs or alternative therapies to
avoid – causes unwanted & even dangerous drug-drug
interactions - prevent by explaining w/c
drugs or therapies should be avoided
5. Special comfort or safety measures
- teach pts. How to cope w/ anticipated adverse effects to ease anxiety & avoid noncompliance w/ drug therapy
- also educate pts. about the importance of ff-up tests or evaluation6. Safety measures – instruct all pts
to keep drugs out of the reach of children
- remind all pts to inform any health care provider they see about the drugs they are taking – this can prevent drug-drug interactions & misdiagnoses based on drug effects
7. Specific pts. about drug toxicity – give pts. a list of warning signs of drug toxicity
- advise to notify their health care provider if any of these effects occur
8. Specific warnings about drug discontinuation – some drugs w/ a small margin of safety & drugs w/ particular systemic effects cannot be stopped abruptly
- alert pts to inform their hcp immediately if they cannot do their medication for any reason (illness, financial constraints)
Evaluation– part of the continual
process of pt care that leads to changes in assessment, diagnosis, & intervention
- nsg intervention & education program
PART III – D. DOSAGE CALCULATIONS Review on conversions b/w systems of
measurement Converting b/w systems – ratio & proportion Calculating dosage – oral: solids,
oral/parenteral liquids, IV sol’ns Pediatric Considerations – Fried’s, Young’s &
Clark’s rule Quiz 3
Formula for Computation of Dosage
1.Oral Medications: Soliddesired dose
---------------- = quantity of drug stock dose
(D/S=Q)
2. Oral/Parenteral Medications: Liquiddesired dose
---------------- x dilution = quantity stock dose of drug
(D/S x Dil. = Q)
3. IV Fluid Ratea. gtts/min = vol. in cc x gtt factor
no. of hrs x 60 mins.b. cc/hr = vol. in cc
no. of hrs ORgtts/min x 4
c. duration in hrs = vol in cc cc/hr
4. Conversion of Temperaturea. C to F = (C x 1.8) + 32 (Note: 1.8 = 9/5)b. F to C = (F – 32)
1.8
5. Pediatric Dosagesa. Clark’s Rule
wt. in lbs. x ave. adult dose = child’s dose150 lbs.
b. Fried’s Ruleage in mos. x ave. adult dose = c.d. (age150 mos. <1 yr.)
c. Young’s Ruleage in yrs. x ave. adult dose = c.d. (age 1-age in yrs. + 12 12
yrs.)d. Surface Area Calculation
surface area in sq. m. x ave. adult dose = 1.73 child’s dose
Introduction to Cell Physiology
To understand the actions & the adverse effects caused by chemotherapeutic agents, it is important to understand the basic functioning of the cell.
Chemotherapeutic drugs are used to destroy both organisms that invade the body (b,v,p,p,i) & abnormal cells within the body (neoplasms or cancers). By keeping in mind the various properties of the cell, & cell processes, nurses may help determine interventions that increase the therapeutic effectiveness of a drug & limit the undesired adverse effects.
The Cell
- basic structural unit of the body
Cell Nucleus- contains all the genetic material that
is necessary for cell reproduction & for regulation of cellular production of proteins
- “programmed” by the genes for the production of specific proteins that allow the cell to carry out its function, maintain cell homeostasis or stability, & promote cell division
- encapsulated by its own membrane- contains nucleolus & ribosomes, the site of protein synthesis in the cell- responsible for the formation of mRNA & tRNA
Cell Membrane- a thin barrier surrounding the cell, w/c separates ICF from the ECF- essential for cellular integrity & is equipped w/ many mechanisms for maintaining cell homeostasis- contains:
Lipoproteins - a structure in the cell
membrane w/c consists lipids (phospholipids, glycolipids, cholesterol) & proteins - keeps cytoplasm w/n the cell & regulating what can enter the cell - the freely moving nature of the membrane allows it to adjust to the changing shape of the cell
Receptor Sites - series of peripheral
lipoproteins w/ several functions embedded in the lipoprotein membrane
- reacts w/ specific chemicals outside the cell to stimulate a reaction w/n a cell
ex. Receptor sitereacts w/ hormone insulincauses activation of ATP w/n the cellalters cell’s permeability to glucose
- very imp’t in the functioning of neurons, muscle cells, endocrine glands, & other cell types
Identifying Markers- are surface antigens, or genetically determined identifying markers- provide the histocompatibility antigens or HLAs – identifies a cell as a “self-cell” & destroy non-self cells- can be changed in several ways: cell injury, viral invasion, age- if altered, the body’s immune system reacts to the change & can ignore it, allowing neoplasms to grow & develop; immune system may also attack the cell, leading to autoimmune disorders & chronic inflammatory conditions
Channels - pores w/n the cell
membrane made by proteins in the cell wall that allow passage of small substances in or out of the cell (Na, K, Ca, Cl, HCO3, H2O) - ex. Ca channel blockers prevent the movement of Ca into a cell through Ca channels
Cytoplasm- lies w/n the cell membrane, contains many organelles, is the site of activities of cellular metabolism & special cellular functions- inlcudes mitochondria, endoplasmic reticulum, free ribosomes, Golgi apparatus, & lysosomes
Mitochondria - rod-shaped power plants w/n
each cell that produce energy in the form of ATP, w/c allows the cell to function
- plentiful in very active cells (muscle cells)
- uses ATP to maintain homeostasis, produce proteins, & carry out specific functions
- if oxygen unavailable, lactic acid builds up as a byproduct of cellular respiration
- LA leaves the cell & is transported to the liver for conversion to glycogen & CO2
Endoplasmic Reticulum - fine network of channels that
are interconnected - undulating surface provides
large surface for chemical reactions w/n the cell
- contains granules w/ enzymes & ribosomes w/c produce protein
- production of proteins, non-proteins, hormones, & other substances & breakdown of toxic substances
Free Ribosomes - not bound to the surface of the endoplasmic ret.; free floating - produce proteins that are imp’t to the structure of the cell & some of the enzymes that are necessary for cellular activity
Golgi Apparatus - a series of flattened sacs - prepare hormones or other
substances for secretion - may produce lysosomes & store
other synthesized proteins & enzymes until they are needed
Lysosomes - membrane-covered organelles
that contain specific digestive enzymes that can break down proteins, nucleic acids, carbohydrates, & lipids
- responsible for digesting worn or damaged sections of a cell
Cell Properties
Endocytosis – pinocytosis – allow cells to absorb nutrients, enzymes, & other materials
Phagocytosis
Exocytosis – allows a substance to move in & out of the cell (eg, hormones, neurotransmitters, enzymes, other subs.
Homeostasis - main goal of a cell, means keeping the cytoplasm stable w/n the cell membrane - uses active & passive transport systems to achieve homeostasis - disposes waste products that could be toxic
Passive Transport- happens w/o using energy, occurs
across any semipermeable membrane3 types: Diffusion
- movement of a substance from a region of higher concentration to lower concentration
- the difference b/w the concentration of the substance in these regions is called concentration gradient
- the greater the conc. gradient, the faster the substance moves
- substances w/ negative charge move more freely than substances w/ a positive charge
- includes Na, K, Ca, Carbonate, O2, HCO3, & H2O Osmosis
- movement of water across a semi-permeable membrane from an area that is low in dissolved solutes to one that is high in dissolved solutes
- the diffusion of water across cell membrane from an area of high concentration to low concentration creates pressure on the cell membrane, called osmotic pressure
Osmosis The experiment shown above demonstrates the process of osmosis. Water flows through a semipermeable membrane into a sugar solution, diluting the solution. The sugar molecules cannot pass through the membrane, so the water outside remains pure.
- the greater the concentration of solutes in the sol’n to w/c the water is flowing, the higher the osmotic pressure
- a fluid that contains the same concentration of solutes as human plasma is called isotonic sol’n
- a fluid that contains a higher concentration of solutes than human plasma is a hypertonic sol’n, & draws water from cells
- a fluid that contains a lower concentration of solutes than human plasma does is hypotonic, loses water to cells
Facilitated Diffusion - sometimes a substance
cannot move freely on its own in or out of a cell
- such substance may attach to another molecule, called carrier, to be diffused, is known as facilitated diffusion does not require energy, just the presence of carrier
- carriers may be in the form of hormone, enzyme, or protein
Active Transport - sometimes a cell requires a
substance in greater concentration & must move substances against the concentration gradient, requiring them to use energy
- eg, sodium-potassium pump- cells use active transport to
maintain high level of K, & low level of Na,
- allowing the cell to maintain an electrical charge on the cell membrane w/c gives cells the electrical properties of excitation & conduction
- eg, cells in the kidney uses active transport to excrete drugs from the body as well as to maintain electrolyte & acid-base balances
Cell Cycle G0 Phase (resting phase) G1 Phase – extends from stimulation to the formation of DNA; synthesizes the subs. That are needed fr DNA formation
S Phase – actual synthesis of DNA G2 Phase – subs. production for manufacture of mitotic spindles
M Phase – cell splits to form 2 identical daughter cells (mitosis)
ANTI-INFECTIVE AGENTS- are drugs that are designed to act selectively on foreign organisms that have invaded & infected the body of a human host
BacitracinChloramphenicolMeropenemPolymyxin BSpectinomycinVancomycin
Mechanism of Action- Goal: interference w/ the normal function of the invading organism to prevent it from reproducing & to cause cell death w/o affecting host cells• Some interfere w/ biosynthesis of the bacterial cell wall • Prevent the cells of the invading organism from using substances essential for their growth & dev’t leading to inability to divide & eventually cell death (eg, sulfonamides, antimycobacterial, trimethoprim drugs
• Interfere w/ the steps involved in protein synthesis, a necessary function to maintain the cell & allow for cell division (eg, aminoglycosides, macrolides, & chloramphen.
• Interfere w/ DNA synthesis in the cell, leading to inability to divide & cell death (eg, fluoroquinolones)•Alter the permeability of the cell membrane to allow essential cellular components to leak out, causing cell death (eg, antibiotics, antifungals, & antiprotozoals
Anti-infective activity narrow (Spectinomycin – Trobicin) & broad spectrum activity
Bactericidal – anti-infective that is so active against the infective MO that they actually cause the death of the cells they affect
•Bacteriostatic – anti-infectives that are not as aggressive against invading MO; they interfere w/ the ability to reproduce or divide•Depends on the concentration of the drug that is present•Many of the adverse effects noted are associated w/ the aggressive properties of the drugs & their effect on the cells of the host as well as those of the pathogen
Human Immune Response- Goal: reduction of the population of the invading organism• Immune response – involves a complex interaction among chemical mediators, leukocytes, lymphocytes, antibodies, & released enzymes & chemicals• If functional, could eliminate pathogenic organisms• If immunocompromised for any reason (eg, malnutrition, age, AIDS, use of immunosuppressant drugs) – incapable of dealing effectively w/ the invading org.
Resistance- ability of bacteria to adapt to an antibiotic & produce cells that are no longer affected by a particular drug• Eg, Vancomycin (Vancocin, Vancoled) – given to pts. who are intolerant/allergic to penicillin/cephalosporins & pts. w/ staphylococcal infection that no longer respond to these drugs• Can be used orally or IV; for bacterial endocarditits•Highly toxic, reserved for very special situations
Can cause renal failure, ototoxicity, superinfections, “red man syndrome” char. by sudden & severe hypotension, fever, chills, paresthesias, erythema of neck & back
Acquiring Resistance- MO develop resistance in a
number of ways:
Producing an enzyme that deactivates the antimicrobial drug. Ex., some strains of bacteria that were once controlled by penicillin now produce an enzyme called penicillinase, w/c inactivates penicillin before it can affect the bacteria. This occurrence led to the development of new drugs that are resistant to penicillinase
• Changing cellular permeability to prevent the drug from entering the cell, or altering transport systems to exclude the drug from active transport into the cell
• Altering binding sites on the membranes or ribosomes, w/c then no longer accept the drug
• Producing a chemical that acts as an antagonist to the drug
Preventing Resistance• It’s imp’t to limit the use of
antimicrobial agents to the tx of specific pathogens known to be sensitive to the drug being used• Maintain a constant therapeutic
level to prevent the emergence of resistant microbes during times of low concentration
• Timing of doses & length of time of therapy
• Prescribing anti-infectives w/o knowing the causative organism promotes resistance
Treatment of Systemic Infections• Several factors should be
considered before beginning chemotherapeutic regimen
• Include identification of the correct pathogen & selection of a drug that is most likely to 1) cause the least cxs for that particular pt. &
• 2) be most effective against the pathogen involved
Identification of the Pathogen
•Culture of a tissue sample from the infected area, performed in the laboratory, where a swab of infected tissue is allowed to grow on an algar plate
•Straining techniques & microscopic exam to identify organism
•For parasitic sources of infection, stool exam for ova & parasites
•Microscopic exam is also used to detect fungal & protozoal infections
•Correct identification of CA is an imp’t 1st step in determining w/c anti-infective drug should be used
Sensitivity of the Pathogen• Sensitivity testing shows w/c drugs are capable of controlling the particular MO that have known resistant strains
Combination Therapy- may be effective in interfering with cellular structure in different areas or developmental phases; my be used for several reasons:
•Uses a smaller dosage of each drug leading to fewer adverse effects
•Some drugs are synergistic, w/c means they are more powerful when given in combination
•Many microbial infections are cause by more than one MO, & each pathogen may react to a different anti-infective agent
•Delay the emergence of resistant strains, eg, tx of TB, malaria, & some bacterial infections
Adverse Reactions to Anti-infective Therapy
•Kidney Damage- occurs more frequently w/
drugs that are metabolized by the kidney & then eliminated in the urine (eg, aminoglycosides)
- to prevent accumulation in the kidney, pts. should be well hydrated throughout the course
•GI Toxicity- many have direct toxic
effects on the cells lining the GIT, causing nausea, vomiting, stomach upset or diarrhea
- death of MO releases chemical/toxins in the body, stimulate CTZ in medulla, induces n/v
- some are toxic to the liver, causes hepatitis or liver failure (eg, cephalosporins)
- ex. Meropenem – inhibits bacterial cell wall synthesis; used to treat intra-abd. Infections & meningitis
•Neurotoxicity- Aminoglycoside collect in the
8th cranial nerve, that cause dizziness, vertigo, loss of hearing
- Chloroquine, used to treat malaria & some rheumatoid d/o accumulate in the retina & optic nerve can cause blindness
- others can cause dizziness, drowsiness, lethargy, changes in reflexes, & even hallucinations when they irritate specific nerve tissues
- ex. Polymyxin B (generic), an older antibiotic, uses a surfactant-like reaction to enter the cell membrane & disrupt it, leading to cell death in susceptible gram (-) bacteria
- can be toxic to the human host, leading to nephrotoxicity, neurotoxicity (facial flushing, dizziness, ataxia, paresthesias, & drowsiness), & drug fever & rashes
Hypersensitivity Reactions- it is imp’t to determine
what the allergic reaction was & when the pt. experienced it (after 1st use of drug, after yrs. of use)
- allergic reaction vs. adverse effect
Superinfections- destruction of the normal
flora opportunistic pathogens cause infections superinfections
- include vaginal or GI yeast infections by Proteus & pseudomonas
ANTIBIOTICS- are chemicals that inhibit bacteria
- bacteriostatic – prevents the growth of bacteria &
- bactericidal – those that kill bacteria directly
- can be both, depends upon drug concentration
- made in 3 ways: by living microorganisms, synthetic manufacture, & in some cases, genetic engineering
Major Classes of Antibiotics:1. Aminoglycosides, 2. Cephalosporins3. Fluoroquinolones4. Lincosamides5. Macrolides6. Monobactams7. Penicillin8. Penicillinase-resistant9. Sulfonamides10. Tetracycline11. Disease-specific antimicrobacterials –
anti- TB, & leprostatic drug
Bacteria & Antibiotics
• Invasion (routes)body becomes the host multiply/reproduceactivated immune responses/s (eg, fever, lethargy, signs of inflammation)
•Goal of therapy: decrease the population of bacteria – interferes w/ specific proteins & enzyme systems
•C&S to know w/c antibiotic the MO is most sensitive
◦Gram-positive bacteria – are those whose cell wall retains
a stain, known as gram’s stain, or resists decolorization w/ alcohol during C&S testing
- commonly associated w/ infections of the respiratory tract & soft tissues
- ex. Streptococcus pneumoniae
◦Gram-negative bacteria – are those whose cell walls lose a stain or are decolorized by alcohol- frequently ass. w/ infections of GU or GI tract- ex. Escherichia coli, a common cause of cystitis
◦Aerobic bacteria – depend on oxygen for survival, anaerobic bacteria (ass. w/ gangrene) do not use O2
◦Broad spectrum antibiotics – antibiotics that interfere w/
a biochemical reaction common to many organisms- has wide range of effects, therefore freq. ass. w/ adverse effects
Clinicians use drug w/ selective toxicity – ability to strike foreign cells w/ little or no effect on human cells
Consider contraindications like immunocompromised, have severe GI d’se, debilitated
◦Antibiotics are given in combination to promote synergy
Bacteria & Resistance to Antibiotics
Aminoglycosides- group of powerful antibiotics used to treat serious infections caused by gram (-) aerobic bacilli; bactericidal
amikacin (amikin), (P) gentamicin (garamycin), kanamycin (kantrex), neomycin (mycifradin), netilmicin (netromycin), streptomycin (generic), tobramycin (nebcin, tobrex)
Aminoglycosides
Aminoglycosides
- disrupts cell membrane- for tx of serious infections susceptible to penicillin when penicillin is contraindicated- can be used for C&S- rapidly absorbed via IM
Aminoglycosides
- crosses placenta & enters breast milk, use w/ caution esp. during pregnancy & lactation
Contraindications:Known allergyRenal or hepatic d’sePre-existing hearing loss
Active infection w/ herpes or mycobacterial infections
Myasthenia Gravis or parkinsonism
Lactating mothers
Aminoglycosides
Adverse EffectsCNS: ototoxicity leading to irreversible deafness, vestibular paralysis, confusion, depression, disorientation, numbness, tingling, weakness
Aminoglycosides
Renal toxicity – glomerulus Bone marrow depression leading to immune suppression superinfections, fever
GI: nvd, wt. loss, stomatitis, hepatic toxicity
Cardiac: palpitations, hypotension, HPN, hypersensitive reactions
Drug-Drug InteractionsDiuretic – the incidence of ototoxicity, nephrotoxicity, & neurotoxicity inc.
Anesthetics, neuromuscular blockers, succinylcholine, citrate anticoagulated blood = inc. neuromuscular blockade w/ paralysis is possible
Nursing Consideration
1. Check C&S reports – ensure that this is the DOC for this pt.
2. Ensure that pt. receives full course of aminoglycosides as px – to inc. effectiveness & dec. risk for dev’t of
resistant strains of bacteria
3. Monitor site of infection & presenting s/s (fever, lethargy) throughout the drug therapy – failure of this s/s to resolve may indicate the need to reculture the site. Arrange to continue
drug therapy for at least 2 days after all s/s resolve
4. Monitor regularly for signs of nephrotoxicity, neurotoxicity, & BMS – for disc. of drug or dec. dosage
5. Provide for safety measures – to protect from CNS effects, such as confusion, disorientation, or numbness & tingling, occur
6. Provide small, frequent, meals, offer frequent mouth care, & offer ice chips or sugarless candy to suck –
to provide relief from stomatitis, etc, maintain nutrition, provide fluid
7. Ensure hydration – to minimize renal toxicity
8. Ensure that the pt. is instructed about the appropriate dosage regimen & possible adverse effects – to enhance pt. knowledge about drug therapy & promote compliance
Cephalosporins- (P) Cefaclor, cefadroxil, cefazolin, cefotaxime, ceftazidime, ceftriaxone, cefuroxime, cephalexin, etc.
1st – 4th generation 1st – effective against gram (+) bacteria & gram (-) bacteria PEcK
2nd - 1st gen + HEN = HENPEck; less effective against gram (+) bacteria
3rd – more potent against gram (-) bacillias well as Serratia marcescens (HENPEcKS)
4th – active against gram (+) & (-) organisms including cephalosporin-resistant staphylococci & P. aeruginosa
Indication- both bactericidal & bacteriostatic- cause bacteria to build weak
cell walls when dividing- well absorbed from GI, IM , & IV administration- for UTI, respi, skin, GU, bone
infections
Contraindications- allergies, RF
Adverse Effect - GI: NVD, anorexia, abd. Pain, flatulence (common)- CNS: h/a, dizziness, lethargy, paresthesias- nephrotoxicity, superinfections, phlebitis
Drug-Drug Interactions- cepha w/ amino = inc. nephrotoxicity- oral anticoagulants = inc. bleeding- alcohol for 72 hrs disc. Of the drug = disulfiram-like reactions (h/a, n/v, chest pain, vertigo, etc.)
Nursing Considerations: (same as amino)
1.Check C&S report2.Monitor RFT3.Ensure pt. receives full course4.Monitor site of infection & presenting s/s
5.Provide small, frequent meals; mouth care
6. Monitor for signs of superinfection
7. Monitor injection sites regularly
8. Initiate safety measures9. Instruct pt.
Fluoroquinolones- (P) ciprofloxacin, gatifloxacin, levofloxacin, lomefloxacin, moxifloxacin, norfloxacin, ofloxacin, sparfloxacin, trovafloxacin- Cipro – effective against a wide spectrum of gram- negative bacteria (eg. E. coli, K. pneumoniae, N. gonrrheae)
enter the bacterial cellinterferes w/ the DNA actioncell death
- not recommended for use in children <18y/o
- can cross the placenta, enter breast milk
Contraindications & Cautions•w/ allergy, pregnant, & lactating women•w/ renal dysfxn, seizures
Adverse Effects CNS: h/a, dizziness, insomnia, depression
GI: NVD, dry mouth,
IS: BMD Others: fever, rash, photosensitivity, skin reactions
avoid sun & UV light exposure, use sunscreen, protective clothing
Clinically Imp’t Drug-Drug Interactions- when used w/ iron salts, sucralfate, mineral supplements, or antacids, effect is decreased- if taken w/ drugs that inc. the QTc interval or cause “torsades de pointes” (quinidine, procainamide, amiodarone, sotalol, bepridil, erythromycin, terfenadine, astemizole, cisapride, pentamidine, tricyclics, phenothiazines), severe ot fatal cardiac reactions are possible
- Combined w/ theophylline, leads to inc. levels of theophylline
- if combined w/ NSAIDS, inc. risk of CNS stimulation. If used, monitor closely esp. those w/ hx of seizures or CNS problems
- Nursing Considerations (Same as above)
Macrolides
• Interfere w/ protein synthesis in susceptible bacteria•Azithromycin (zithromax), clarithromycin (biaxin), dirithromycin (dynabac), (P) erythromycin (E-Mycin, ERYC, etc.)
• DOC x Legionnaire’s d’se, infections caused by Corynebacterium diphtheriae, ureaplasma, syphillis, & other STI’s
Indications•Bactericidal/bacteriostatic binds to bacterial cell membrane & change protein fxnprevent cell division/cell death
• Indicated for acute infections caused by susceptible strains of S. pneumoniae, Mycoplasma pneumoniae, Listeria monocytogenes, & Legionella Pneumophila; group A B-hemolytic streptococci; PIDs; URTI; etc.
•May bre used for endocarditis before dental procedures in pts. w/ valvular heart d’se who are allergic to penicillin•Topical macrolides – tx of ocular infection, acne vulgaris, minor skin abrasions, etc.
Contraindications & Cautions•Pts. w/ known allergy •Ocular preps for viral, fungal, or mycobacterial infections of the eye – exacerbated by loss of bacteria of the normal flora•Pts. w/ hepatic dysfxn, renal d’se, lactating women – can cause diarrhea & superinfections to the infant, pregnant women – teratogenic
Adverse Effects•Few adverse effects•Most frequent – GI: abd. Cramping, anorexia, DV, & pseudomembranous colitis•Neuro: confusion, uncontrollable emotions•Hypersensitivity reactions ranging from rash to anaphylaxis, superinfections r/t loss of normal flora
Drug-Drug Interactions• Inc. serum levels of digoxin• Oral anticoagulants, theophyllines, carbamezipine, or corticosteroids – may require reduced dosage & careful monitoring
• Cycloserine (anti-TB/leprotic) – inc. risk of renal toxicity
Astemizole – may lead to cardiac arrhythmias
Drug-Food Interactions• Given on empty stomach 1hr or at least 2-3 hrs. after meals• Should be taken w/ full, 8oz. Glass of H2O
Lincosamides
•(P)clindamycin), lincomycin•Similar to Macrolides but more toxic•Clindamycin: Reserved for severe infections caused by the same strains of bacteria that are susceptible to macrolides
•Rapidly absorbed from the GI tract or from IM injections•Has a half-life of 2-3 hrs.; metabolized in the liver, excreted in the urine & feces•Caution w/ hepatic or renal impairment
◦Crosses placenta & enters breast milk◦Severe GI reactions
◦Available in parenteral, topical, vaginal form
◦Lincomycin: indicated for severe infections If pen & macrolides cannot be used
◦Rapidly absorbed from GI /IM injection
◦Metabolized in the liver, excreted in the urine & feces
◦Half-life: 5 hrs.◦Caution w/ hepatic & renal impairment◦Crosses placenta, enters breast milk•Severe GI reactions – pseudomembranous colitis•Careful monitoring of GI activity & fluid balance•Stop drug at first sign of severe bloody diarrhea
• Toxic effects: pain, skin infections, BMD
Monobactam antibiotics
•Aztreonam – only currently available for use•Structure is unique among anitbiotics•Little cross-resistance occurs
• Is efective against gram (-) enterobacteria & has no effect on gram (+)/anaerobic bacteria•Alternative for those allergic to pen & cepha•Absorbed well in IM•Peak levels: 1-1.5 hrs•Crosses placenta & enters breast milk
•Half-life: 1.5-2 & is excreted unchanged in the urine
Indications- disrupts bacterial cell wall synthesis, w/c promotes leakage of cellular contents & cell death in susceptible bacteria
- tx of UT, skin, intra-abdominal, gynecological infections, septicemia caused by susceptible bacteria ( E. coli, Enterobacter, Serratia, Proteus, Salmonella,et)- available for IV & IM use only
Contraindications & Cautions
•Allergy to Aztreonam•Caution to pts. w/ hx of acute allergic reaction to Pen or Cepha•w/ renal/hepatic dysfxn•Pregnant & lactating women
Adverse Effects
◦Local GI effects◦Hepatic enzyme elevations◦Inflammation, phlebitis, discomfort @ injection sites
◦Potential allergic response (anaphylaxis)
Nursing Considerations1.Hx of allergic reactios, liver/renal d’se
2.Pregnancy & lactation status3.PA 4.Obtain specimen for C & S5.Monitor temp.6.Abd. Exam & LFT & KFT to determine any needed alteration in dosage
Nursing Dx◦Acute pain r/t GI & local effects of drug
◦Deficient knowledge regarding drug therapy
◦Deficient fluid volume
Implementation1.Check C&S
2. Monitor hepatic & renal fxn tests
3. Ensure full course therapy4. Monitor for signs of infection5. Small, frequent meals as
tolerated, mouth care, ice chips or sugarless candy
6. Adequate fluids
7. Ensure ready access to bathroom8. Pt. Instruciton (route, S/E,)
Evaluation• Monitor pt. response to the drug• Monitor for AE – orientation &
affect, GI effects, local inflammation)
•Evaluate effectiveness of teaching plan (pt. can name the drug, dosage, poss. AE, & speciic measures to help avoid AE)•Monitor effectiveness of comfort, safety measures, compliance
PENICILLINS and PENICILLANSE-RESISTANT ANTIBIOTICS•First antibiotic introduced for clinical use•Sir Alexander Fleming – used Penicillin molds to produce the original penicillin in 1920s•Developed to decrease AE & modifies to act on resistant bacteria
•With prolonged use, bacteria synthesized enzyme penicillinase – counteract the effects of penicillins•Led to the dev’t of group of drugs w/ a resistance to penicillinase•C & S should always be performed
Indication•Bactericidal effect•Tx of streptococcal infections, inc. pharyngitis, tonsillitis, scarlet fever, & endocarditis; pneumococcal infections; staphylococcal infections; fusospirochetal; ratbite fever; diphtheria; anthrax; syphilis, uncx gonococcal infection
Pharmacokinetics
•Rapidly absorbed from GI, taken on empty stomach•Excreted unchanged in the urine,•Enters breast milk & cause diarrhea & adverse reactions to the baby
Contraindications & Cautions (same w/ other antibiotics)
•Gi tract, superinfections, pain & inflammation @ injection site, hypersensitivity reactions, anaphylaxis
Important Drug-Drug Interactions•Penicillin & penicillinase-resistant anitbiotics w/ tetracycline – decrese effect of Pen•w/ aminglycosides – inactivation of Amino
Nursing Considerations (same as other antibiotics)
Example of Penicillins
•Penicillin G Benzathine (Bicillin, Permapen)•Penicillin G Potassium (Pfizerpen)•Penicillin G Procaine (Crysticillin-AS)•Penicillin V (Beepen-VK)
Example of Extended Spectrum Penicillins
•Ampicillin (D-amp, omnipen)•Amoxicillin (P) (amoxil, trimox)•Carbenicillin (geocillin)•Mezlocillin (Mezlin)•Piperacillin (Pipracil)•Ticarcillin (ticar)
Penicillinase-resistant Antibiotics
•Cloxacillin (P) (Cloxapen, Tegapen)•Dicloxacillin (dyapen, Dycill)•Nafcillin (nafcil, nallpen)•Oxacillin (bactocill, prostaphillin)
SULFONAMIDES (sulfa drugs)
•Are drugs that inhibit Folic Acid synthesis w/c is necessary for the synthesis of purine & pyramidines, a precursor of RNA & DNA•Not used much anymore cause of emergence of new antibiotics & resistant bacterias
• Remain as inexpensive & effective tx for UTI & trachoma
Example of Sulfa drugs•Sulfadiazine – for susceptible bacteria; absorbed from GI; peak levels: 3-6 hrs.
•Sulfisoxazole – for broad-spectruminfection (STD’s, otitis media); absorbed from GI; PL: 2hrs., HL: 4-8hrs.•Sulfasalazine (Azulfidine) – a sullfapyridine carried by ASA; for ulcerative collitis, Crohn’s d’se, RA; absorbed from GI; PL: 2-6hrs.; HL: 5-10hrs.
•Cotrimoxazole (septra, bactrim) – combination drug containing sulfamethoxazole & trimethoprim; very effective for otitis media; absorbed from GI; PL: 2hrs.; HL: 7-12hrs.
Indications:•Trachoma, nocardiosis (causes pneumonias, brain abscess, & inflammation), UTI & STD’s
Pharmacokinetics•Absorbed form GIT, metabolized in the liver, excreted in the urine•Teratogenic; distributed into the breastmilk
Contraindications•Allergy to sulfonamide, sulfonylureas, thiazide diuretics•Pregnant – can cause birth defects (kernicterus)•Lactation – diarrhea, rash•Renal d’se or hx of kidney stone
Adverse Effects1.Same w/ others + renal effects like crystalluria, hematuria, & proteinuria to nephrotic syndrome & poss. toxic nephrosis
2.CNS, BMD, dermatologic effects
Drug-Drug Interactions•Antidiabetic agents (glyburide, glipizide); if needed, monitor pt. & dosage adjustment must be made•Cyclosporine – increased risk of nephrotoxicity
Nursing Considerations (same w/ others)
1.On empty stomach w/ water to promote adequate absorption of the drug
2.Discontinue if hypersensitivity occursmonitor CBC, U/A to check for adverse effects
3.Instruct pt.
TETRACYCLINES• Inhibits protein synthesis of susceptible bacteria•Available in oral & topical forms, including ophthalmic infections for tx of minor skin infections•Demeclocycline, doxycycline, minocycline, oxytetracycline, (P) tetracycline
Indication•Rickettsiae, M. pneumonia, H. influenza, H. ducreyi, etc.•Uncx GU infections, some protozoal infections
Contraindications•Allergy to tartrazine•caution w/ children <8 yrs. of age
•Pts. Who have fungal, mycobacterial, or viral ocular infections esp. the ophthalmic preps.
Adverse Effect•Glossitis, dysphagia, damage to teeth & bones•Anemia, intracranial HPN
Drug-Drug Interactions• If taken w/ pen G, pen G decreases• If used, dosage of pen is increased•Also w/ contraceptives•Methoxyflurane – inc. risk of nephrotoxicity•Digoxin – toxicity•Dec. absorption w/ Ca salts, bismuth salts, Fe, urinary alkalinizers, & charcoal
Drug-Food Interaction•Not absorbed effectively w/ food/dairy products•1 hr. before & 2-3 hrs. after a meal or other medcation
Nursing Consideration (same as sulfonamides)
ANTIMYCOBACTERIAL ANTIBIOTICS- cause TB & Leprosy- has the ability to hold a stain even in the presence of a “destaining” agent- because of this property, they are called “acid-fast” bacteria- takes several years before they can be eradicated
• Anti – TB drugs- affects lungs, GUT, bones, & the meninges
First line drugs:•(P) Isoniazid (Nydrazid) – affects the mycolic acid of the bacterium•Rifampin (Rifadin, Rimactane) – alters DNA & RNA activity in the bacterium
•Ethionamide (Trecator SC) – prevents cell division•Rifapentine (Priftin) - alters DNA & RNA activity, causing cell death
*If the d’se continues to progress because of the emergence of resistant strains
2nd line of drugs•Ethambutol (Myambutol) – inhibits cellular metabolism
•Pyrazinamide (generic) - both bactericidal & bacteriostatic
3rd line:•Capreomycin (Capastar) – idiopathic•Cycloserine (Seromycin) – inhibits cell wall synthesis & leads to cell death
• Leprostatic Drugs•(P) Dapsone•Clofazimine (Lapmrene)
Indication, Pharmacokinetics, & Contraindication/caution (same as w/ other antibiotics)
*if needed during pregnancy, combination of INH, ehtambutol, & rifampin is considered safest
Adverse Effects•CNS: neuritis, dizziness, h/a, malaise, drowsiness & hallucinations are often reported•GI: same•Discoloration of body fluids – urine, sweat, tears
Drug-Drug Interactions•Rifampin & INH – toxic to liver•Quinidine. Metoprolol, oral contraceptives – inc. metabolism & dec. effectiveness of drugs
New Class of Antibiotics•Ketolides – RI, given OD; Telithromycin (Ketek)
- for tx of CAP, acute bacterial exacerbations of chronic bronchitis & acute bacterial sinusitis
- given 800-mg oral dose•Ertapenem (Invanz) – CAP, skin infections
ANTIVIRALS acyclovir amantadine didanosine foscarnet ganciclovir idoxuridine ribavirin trifluridine vidarabine zidovudine
General Information & Action
- inhibit viral growth by inhibiting an enzyme within the viral cell, DNA polymerase- DNA synthesis is inhibited & the cell cannot replicate- Amantadine prevents virus from entering body cells
•Viruses – warts, common cold “flu”, chicken pox & measles•To carry on any metabolic processes, including replication, a virus must enter a cell •Interferons – tissue hormone that is released in response to viral invasion; blocks viral replication
Indication•Effective for a single class of virus•Acyclovir & Vidarabine – used in the tx of severe virus infections•Amantadine - prevention of Influenza A infections; Parkinson’s d’se because of its action on dopamine release in the EP tracts in the CNS
• Ganciclovir & Foscarnet – used to treat retinitis caused by CMV• CMV – common on patients whose natural immune process are depressed• Didanosine & Zidovudine – slow the progression of AIDS
• Idoxuridine & Trifluridine – currently used only for viral eye infections – herpes simplex• Ribavirin – used in tx of RSV infections in infants & young children
Contraindications• Hypersensitivity
•Zidovudine & Idoxuridine – can appear in breast milk therefore…
Adverse Reactions & Side Effects
•Vary greatly among the individual antiviral drugs•Some have life-threatening reactions
•Lightheadedness, dizziness, insomnia, nausea, orthostatic hypotension, urinary retention•NV, h/a, depression, rash, hair loss, •Rash, inflammation, burning at site of injection & topical application
Nursing Precautions
•Patients w/ renal & hepatic dysfxns should be monitored carefully•Safety among pregnant women & young children•Ribavirin – safety among adults
• Because drug is given by continuous aerosol administration – caution to pregnant nurses or of child-bearing age – avoid exposure to the drug
Interactions
• Varies among the individual antiviral drugs
ANTIFUNGALS•From annoying “athlete’s foot” to potentially fatal systemic infections•Caused by fungus called mycosis•Fungus – has a rigid cell wall made up of chitin & various polysaccharides & a cell membrane that contains ergosterol
• Candida can cause “thrush” on GIT & vagina
Systemic Antifungals- can be toxic to the host- culture of fungus is imp’t
• Amphotericin B (Fungizone, Albecet, Amphotec, AmBisome)
• Flucytosine (Ancoban)• Griseofulvin (Fulvicin, Grifulvin V, Grisactin, Gris-PEG)
•Nystatin (Mycostatin, Nilstat, Nystex)•Azoles – newer drug used to tx systemic fungal infections Ketoconazole (Nizoral), Fluconazole (Diflucan)
Indications•Acts on cell permeability of fungus leading to cell death & prevention of replication
Contraindications & Cautions•w/ known allergy•Pregnancy & lactation (exception to the terbinafine)•w/ renal/liver d’se
Adverse Effects•h/a, dizziness, fever, shaking, chills, malaise•NVD, dyspepsia, anorexia•Rash & pruritus
Drug-Drug Interactions•Pts. Who receive Amphotericin B should take neither nephrotoxic drugs nor corticosteroids•Cyclosporine, digoxin, oral hypoglycemics, & phenytoin = inc serum levels of azole family
• azole + lovastatin, simvastatin, astemizole, cisapride, triazolam, & midazolam = potentially severe CV events
Assessment: History & Patient Assessment- establishment of baseline dataHx of allergyHx of liver/renal dysfxnPregnant? Lactating?Culture of infected areaorientation & reflexesSkin color & lesionsRFT/LFT
Nursing Dx•Acute pain r/t GI, CNS, local effects of drug•Disturbed sensory perception r/t CNS effects•Deficient knowledge regarding drug therapy
Implementation•Arrange for appropriate C&S tests
•Administer entire course of the drug to get the full beneficial effects•Monitor IV sites to ensure that phlebitis does not occur•Monitor renal & hepatic fxn•Provide comfort & safety if CNS effects occur•Provide small, frequent meals•Provide pt. instruction
The patient should:•Follow appropriate dosage regimen•Take safety precautions – changing position slowly, avoiding driving & hazardous tasks if CNS effects occur•Take oral drug w/ meals & try small, frequent meals if GI upset is a problem
•Report to a health care provider any of the ff:
- sore throat- unusual bruising &
bleeding- yellowing of eyes or skin- severe n/v- severe local irritation w/
local application, w/c could indicate a sensitivity reaction & worsening of the infection
Evaluation•Monitor pt. response to the drug•Monitor for adverse effects•Evaluate effectiveness of the teaching plan•Monitor effectiveness of comfort & safety measures & compliance w/ the regimen
TOPICAL ANTIFUNGALS•Fungi that cause mycoses of the skin & mucos membranes are called dermatophytes• Includes tinea infections & candida infections•Fungizone, gentian violet, miconazole•Too toxic but effective in tx of local fungal infections
• Should not be used near open wounds• Can cause serious local irritation, burning & pain. Stop if this conditions occur
ANTIPROTOZOAL AGENTS•CA: amebiasis, gardiasis, & trichomoniasis•Malaria – p. falciparum, p. vivax, p. malariae, p. ovale•Ex. of drugs: quinine & chloroquine•Quinine – may lead to severe diarrhea & a condition called cinchonism (n/v, tinnitus, vertigo)
Action/Indications• Interrupt plasmodial reproduction of protein synthesis in the RBC stage of the life cycle
Contraindications•Known allergy•Liver d’se or alcoholism•Lactation•Caution w/ retinal d’se
•Psoriasis or porphyria (metabolism)•w/ damage to mucous membranes•w/ prolonged QTc interval, if using halofantrine
Adverse Effects•CNS: h/a, dizziness, fever, shaking, chills, malaise
• GI: n/v, dyspepsia, anorexia, liver toxicity• Skin: rash, pruritus, loss of hair ass. w/ changes in protein synthesis• Eye: possible blindness r/t retinal damage• Ototoxicity r/t add’l nerve damage• Cinchonism
Drug-Drug Interactions•Quinine + quinine derivatives =cardiac toxicity & convulsions•Halofantrine – increased risk for cardiac arrythmias & death if they take other drug that prolong the QTc interval•Fansidar – sulfadoxine +pyrimethamine – tx of p. falciparum when chloroquine resistance is suspected
Nursing Considerations (same w/ antifungals)
Other Protozoal Infections•Amebiasis – intestinal infection caused by entamoeba hystolytica, a.k.a. amebic dysentery•Leishmaniasis (skin d’se) – passed from sand flies
• Trypanosomiasis caused by typanosoma causing acute CNS inflammation that result to lethargy, prolonged sleep, even death (African sleeping sickness) transmitted by tsetse fly
• Trichonomiasis – caused by flagellated protozoans – trichomonas vaginalis – vaginits – reddened, inflamed vaginal mucosa, itching, burning, & yellowish-green discharge
•Gardiasis – caused by giardia lamblia from contaminated food/water, cause diarrhea, rotten egg-smelling stool, pale, mucous-filled stool, epigastric distress, wt. loss, malnourishment•Pneumocystis caranii pneumonia (PCP) – if pt. is immunosuppressed due to AIDS or ARC, etc.
Other Antiprotozoal Agents•Metronidazole (Flagyl, MetroGel, Noritate)- amebiasis, trichomoniasis, & gardiasis
- crosses placenta & enters fetal circulation, passes into breastmilk•Others: Pentamidine (Pentam 300, NebuPent); Atovaquone (Mepron)
Indication Inhibit DNA synthesis
Contraindications•Allergy, hypersensitivity, pregnancy•Caution w/ CNS d’se because of possible exacerbation•Hepatic d’se•Candidiasis – superinfection•Lactation
Adverse Effects•CNS: h/a, dizziness, ataxia, loss of coordination peripheral neuropathy•GI: NVD, unpleasant taste, cramps & changes in liver fxn•Superinfections
ANTIHELMINTIC AGENTS- about 1 B people have worms in their GIT or other tissues- common in tropical areas- helminths that most commonly infect humans are of 2 types: nematodes / roundworms & platyhelminths/flatworms
Intestine-Invading Worms- Involves the prevention of reinfection or spread of an existing infection•Nematodes or roundworms include pinworms, whipworms, threadworms, Ascaris, & hookworms•Pinworm – stay in the intestine, cause perianal itching, or occ. vag. itching
•Whipworms – attach to the wall of the colon; cause colic & bloody diarrhea when they inc. in #; may result in prolapse of the intestinal wall & anemia r/t bld. Loss•Threadworms – more pervasive; after burrowing, lay eggs, hatch into larvae that invade lungs, liver, & heart
- may result to death from pneumonia or from lung or liver abscesses•Ascaris – most prevalent helminthic infection; hatch in the small intestine to the lungs, cause cough, fever, & other signs of pulmonary infiltrate
- migrate back to the intestine, grow to adult size
- cause abdominal distention & pain
- severe case: intestinal obstruction by masses of worms can occur•Hookworms – attach to the small intestine & suck bld. from it; cause damage to the intestinal wall, cause severe anemia w/ lethargy, weakness, & fatigue
- malabsorption may occur; tx for anemia & fluid & electrolyte disturbances is an imp’t part of therapy
Platyhelminths: Cestodes•Flatworms include cestodes (tapeworms) – live in the human intestine & the flukes (schistosomes)
•Cestodes – segmented flatworms, may experience some abdominal discomfort & distention, wt. loss
- pts. Require psychological support when the worm comes out of their mouth, or nose w/c occur occasionally
Tissue-Invading Worm Infections•Trichinosis – ingestion of the encysted larvae of the roundworm, Trichinella spiralis, in undercooked pork
- deposited in intestinal mucosa, pass into bloodstream, throughout the body
- penetrate skeletal muscle, cause inflammatory reaction to cardiac muscle & brain
- can cause fatal pneumonia, heart failure, encephalitis• Filariasis – infection of the bld. & tissues; cause inflammation of lymphatic system lead to swelling of hands, feet, legs, arms, scrotum, breast - elephantiasis
•Schistosomiasis - infection by fluke carried by snail; larvae attach to the skin, burrow into the bloodstream & lymphatics
-Move into the lungs & liver, migrate into intestine & urinary bladder
-Lay eggs, expelled in feces & urine
-Pruritic rash/”swimmer’s itch”
- after 1-2 mos., may experience fever, chills, h/a, abdominal pain, diarrhea, blockage of bld. Flow leading to hepatomegaly / spleenomegaly & signs of CNS & cardiac ischemia
ANTIHELMINTICS
•Mebendazole (Vermox) – effective against pin, round, whip, & hookworms
- available in chewable tablet, in typical 3-day course, can be repeated in 3 wks. If needed
- few adverse effects
•Pyrantel (antiminth, pin-rid, pin-X, reese’s pinworm
- oral; effective against pin & roundworms; given as single dose
• Thiabendazole (mintezol)• Albendazole (albenza)• Ivermectin (stromectol
Indication- Interfere w/ metabolic processes in particular worms
Contraindications•Known allergy•Lactation•Pregnancy•Caution w/ renal/hepatic d’se, diarrhea, & malnourishment
Adverse Effects•Abdominal discomfort, diarrhea, or pain•h/a & dizziness•Fever, shaking, chills, malaise•Rash, pruritus, loss of hair•Changes in protein synthesis to Steven-Johnson sydrome ass. w/ thiabendazole
Drug-Drug Interactions
•Theophylline + thiabendazole = increased levels of theophylline•Albendazole + dexamethasone/praziquantel/ cimetidine = increased toxicity of albendazole
Assessment•Screen for hx of allergy hepatic or renal dysfxn•Pregnancy, lactation•Physical assessment•Culture of stool for ova & parasite•Examine reflexes & muscle strength•Hepatic evaluation including LFT RFT
•Examine skin (lesion, color, temperature, & texture) & abdomen
Nursing Dx•Acute pain r/t GI, CNS, skin effects of drug•Disturbed personal identity r/t diagnosis & treatment•Deficient knowledge regarding drug therapy
Implementaiton•C & S•Administer complete course of drug; ensure chewable tabs are chewed•Take w/ food, avoid high-fat meals•Monitor hepatic & renal function before & periodically during tx
• Provide comfort & safety measures if CNS effects occur
• Provide oral hygiene & ready access to bathroom facilities
• Small, frequent nutrition, monitor nutritional status
• Ensure pt. instruction
The pt. should:• Take safety precaution – changing position slowly, avoid driving & hazardous tasks
◦Take drug w/ meals & try small, frequent meal if GI upset occur
◦Note importance of hand washing & hygiene measures
◦Report fever & severe diarrhea, or aggravation of condition, w/c could indicate a resistant strain or non-effective therapy to a health care provider
Evaluation•Monitor pt. response to the drug•Monitor for adverse effects (nutritional state, orientation & effect, skin color & lesions, hepatic & renal fxn, abdominal discomfort & pain•Evaluate effectiveness of teaching plan•Monitor compliance, comfort, & safety measures
ANTINEOPLASTIC AGENTS- use components of immune system instead of destroying cells directly- 2nd leading cause of death n US- genetically different cells divide passed to daughter cells tumor/neoplasm
- cancerous cells exhibit anaplasia
- anaplasia – loss of cellular differentiation & organization- metastasis
Alkylating Agents•Busulfan, Carboplatin, Chlorambucil, Cisplatin, Cyclophosphamide, Ifosfamide, Mechlorethamine, Thiotepa
Antimetabolites•Cytarabine, Fludarabine, Fluorouracil, Mercaptopurine, methotrexate
Antitumor Anitbiotics•Bleomycin, Dactinomycin, Daunorubicin, Doxorubicin
Hormonal Agents•Diethylstilbestrol, Leuprolide, Megestrol, Tamoxifen, Testosterone
Vinca Alkaloids•Vinblastine, Vincristine
Individual Agents•Asparaginase, Procarbazine
General Information & Action•Goal: Interruption or alteration of phase of the cell cycle•Classified as cell cycle specific/nonspecific•Cell cycle specific – agents that affect the cell during 1 phase of the cell life cycle; have their greatest activity during the S phase, blocking DNA synthesis
• Cell cycle nonspecific – those that exert their effects during >1 phase• Destroys normal cells as well as malignant cells• Adverse reactions – are most often a result of changes in normal cell growth• Cancer cells – rapidly dividing; drug affects them directly
• Also affects other body cells that normally reproduce rapidly: cells of GIT, hair follicles, bone marrow
General Use• For cure, control, or palliation (temporary relief of symptoms) of leukemias, lymphomas, solid tumors & preparation for BMT
•Some drugs (methotrexate) – used to treat RA•Often used in combination, to reduce risk drug of drug toxicity & increase therapeutic response•Also used for surgery & radiation•Adjuvant therapy – drugs given after removal of all known cancer present
Contraindications•Consumption of alcohol•Hypersensitivity•History of BMD
Adverse Reaction•BMD (myelosuppression)•Nausea, vomiting, anorexia, diarrhea•Alopecia
•Amenorrhea•Stomatitis, mucositis•Pneumonitis skin eruptions•Male impotency•Heart failure & resp. changes•Anaphylaxis•Metabolic alterations, neurotoxicity•Decreased kidney function•Paralytic ileus•Septic shock
Nursing Considerations1.Accurate identification of kind of cell involved in the neoplasm
2.Proper evaluation of the pt’s condition – ideally: no major infection, bleeding or other serious illness
3.Spills of chemo drugs should be cleaned up immediately by trained personnel
4. Follow special protective procedures for drug mixing, administration, disposal of equipment, unused drugs
5. Vesicant drugs that accidentally leak into surrounding tissues from IV site require immediate tx to prevent tissue damage
6. 24 hr. monitoring of reactions may be needed
NONNARCOTIC ANALGESICS/NONSTEROIDAL ANTI-INFLAMMATORY AGENTS Individual agents: acetaminophen, misoprostol, phenazopyridine
NSAIDs: ibuprofen, indomethacin, naproxen, piroxicam, sulindac
Salicylates: aspirin, choline magnesium trisalicylate, choline salicylate, salsalate
General Information & Action•Salicylates, salicylate-like & NSAIDs – inflammatory diseases (RA, DJD, lupus erythematosus, & scleroderma)•NSAIDs – have analgesic, anti-inflammatory, & antipyretic actions
•Analgesic/anti-inflammatory – inhibition of prostaglandin synthesis•Antipyretic – inhibition of both prostaglandin synthesis & vasodilation
Major Subgroups:•Acetaminophen – prostaglandin inhibition in CNS; peripheral & anti-inflammatory effects, minimal
•Misoprostol – synthetic prostaglandin, marketed as antiulcer
- Inhibit gastric acid secretion & thought to increase mucus production thereby protecting against adverse GI effects of prostaglandin inhibitors (ie. salicylates, NSAIDs); px concurrently w/ NSAID therapy
•NSAIDs – anti-prostaglandin agents – enhanced by inhibition of lysosomal enzyme release of substances causing inflammation•Salicylates – have antipyretic, analgesic, & anti-inflammatory properties
- cholin salicylate – only liquid salicylate available
- salsalate – converted to salicylate in the liver & has fewer GI adverse effects
General Use• To control mild to moderate pain, fever & inflammation (RA, OA)
• Acetaminophen – has no anti-inflammatory effect, useful only to reduce pain & fever
•Phenazopyridine (spasmolytic) – used only for pain r/t urinary tract•ASA, ibuprofen, & acetaminophen – are popular nonprescription drugs for h/a, mild to moderate pain•ASA & Aceta – found in many OTC drug combinations
Contraindications•Hypersensitivity - ASA•Acetaminophen – safe for use in pregnancy – occasionally•All salicylates are contraindicated in persons <21 y/o – Reye’s syndrome, a potentially fatal d’se involving brain & liver dysfunction
Adverse Effects•GI irritation & discomfort – NVD, abdominal pain, flatulence, GI bleeding & ulceration•Tinnitus, hearing loss, weakness, profuse sweating, slowed respiration & HR
Nursing Consideration1.Patients w/ hx of bleeding should be monitored closely – coz of prolonged bleeding time
2.Caution w/ severe CV, liver, or kidney d’se
3.w/ pregnant women4.w/ asthma or nasal polyps, allergy to ASA – higher risk for hypersensitivity
Drug-Drug Interactions•w/ narcotics – additive analgesic effect•w/ anticoagulants, some cephalosporins, plicamycin, thrombolytic agents, valproic acid – prolonged bleeding time
•Diuretics & other antihypertensive drugs may be diminished – fluid retention•w/ zidovudine – toxicity w/ acetaminophen•Large doses of Acetaminophen – can cause necrosis of liver•w/ corticosteroid + salicylates = GI ulceration & bleeding
•w/ phenytoin, sulfonlyureas, & sulfonamides = toxicity & shortened duration of action
ANXIOLYTIC/SEDATIVE/HYPNOTIC/MINOR TRANQUILIZER
A. Benzodiazepine – “lam”, “pam”• Diazepam (P)• Midazolam Hcl• Clonazepam• Alprazolam
Action- act in the limbic system & the RAS to make GABA more effective- for anxiety d/o, alcohol withdrawal, hyperexcitability & agitation
Contraindication• Allergy to any benzodiazepine
•Psychosis – exacerbated by sedation•Glaucoma, shock, coma, acute alcoholic intoxication•Pregnancy – cleft lip/palate, inguinal hernia, cardiac defects, microcephaly, or pyloric stenosis•Lactation•Caution w/ elderly/debilitated pts.
•Renal/hepatic dysfunction
Adverse Effects•CNS: sedation, drowsiness, lethargy, blurred vision, h/a, apathy, lightheadedness, confusion•GU: urinary retention, hesitancy, loss of libido, *do not stop abruptly
B. Barbiturates- general CNS depressant;
relief of s/s of anxiety, insomnia, seizure
C. Non-Barbiturate, Non-benzodiazepine• Buspirone (Buspar), Nabilone
(cesamet)*used for long term therapy; takes
3-6 wks. to take effect
ANTIDEPPRESSANT AGENTS- Obsessive-Compulsive disorder, Panic, PTSD, Premature Ejaculation
TCA (Tricyclic Antideppressant)•Elavil (Amitriptyline)•Tofranil (Imipramine Hcl)•Anafranil (Clomipramine Hcl)•Mellaril (Thioridazine Hcl)
SSRI (Selective Serotonin Reuptake Inhibitor)•Paxil (Paroxetine Hcl)•Prozac (Fluoxetine Hcl)•Zoloft (Sertraline Hcl)
MAOI (Monoamine Oxidase Inhibitor) – NO for tyrmaine•Pamoate•Nardil•Marplan
Nursing Consideration•Limit drug access if pt. is suicidal•Maintain 4-8 wks. Initial dosage reduce dosage if minor S/E occurs
ANTIPSYCHOTIC/ MAJOR TRANQUILIZERS/NEUROLEPTICS/DOPAMINE ANTAGONIST
A.Typical (old) – “zine”• Chlorpromazine (P)• Thorazine• HaldolB. Atypical (new) – after 1990 -
<effect on EPS (extrapyramidal system)
•Resperidone (Resperdal)•Clozapine (Clozaril); (P)•Olanzapin (Zyprexia)
Adverse Effect•Agranulocytosis•Photosensitivity•Orthostatic hypotension•Akathisia•Tardive dyskenisia•Dystonia
Antipsychotic – Antimanic•Lithium – Oskalith, Carbolith, Lithobid
CNS Stimulants- for tx of attention-deficit
d/o; narcolepsy•Dexymethylphenidate•Dextroamphetamine•Methylphenidate (Ritalin); (P)
ANTIEPILEPTIC AGENTS
Tonic-clonic (Grand Mal) Seizure
A.Hydantoins- Phenytoin (P)B.Barbiturates – Phenobarbital (P)
C.Benzodiazepines – diazepam (P)
Absence (Petit Mal) SeizureA.Succinimides – Ethosuximide (P)
B.Other drugs – Valproic acid (P); Acetazolamide
Partial (Focal) Seizure• Carbamezipine (P)
ANTIPARKINSONISMA. Dopaminergic (DA Agonist)
- Carbidopa (Sinemet)- Amantadine (Symmetrel)- Levodopa (Larodopa)
B. Anticholinergic - ABCs- A – Atropine So4, Artane, Akineton- Benadryl- Cogentin (Benztropine Mesylate
Action- to achieve balance b/w acetlycholine & dopamine (DA)
Contraindication•Anticholinergic – narrow-angle glaucoma, tachycardia, thyrotoxicosis•No for children <12 y/o•Levodopa – lactation
Adverse Reaction•Changes in BP & cardiac arrythmias•Levodopa - precipitates psychosis, melanoma, hemolytic anemia,•Anticholinergic – dry mouth, blurred vision, constipation, urinary retention
MUSCLE RELAXANTS•Centrally Acting – Baclofen, Carisoprodol, Cyclobenzaprine, Diazepam, Methocarbamol•Direct-acting Agents – dantrolene
Action- for muscle spasm, sprain, SCI, cerebral palsy
Contraindications•Hypersensitivity to drug or tartrazine (yellow food color)•pt. w/ glaucoma, gastric & intestinal obstruction, prostatic hypertrophy
Adverse Reaction•CNS depression – drowsiness, ataxia•Anticholinergic effects
•Blood – leukopenia, thrombocytopenia, agranulocytosis•Caution w/ seizure d/o•hepatotoxicity
NARCOTIC ANALGESIC
•Narcotic – codeine, hydrocodone, hydromorphone, meperidine, methadone, morphine, oxycodone, propoxyphene
•Mixed narcotic - agonist/antagonist
Action- interferes w/ pain receptors in nerve endings, change pain perception, or change pain reaction through responses in the autonomic & skeletal muscle
Contraindication•Hypersensitivity
• Narcotics – head injury, respiratory depression & shock
Adverse Reaction• CNS: euphoria or sedation, dizziness, resp. depression• GI: vomiting (CTZ), constipation• GU: urinary retention
• Morphine: biliary colic• CV: flushing, inc. HR, palpitations, hypotension, fainting
ALPHA-ADRENERGIC BLOCKING AGENTS•(alpha blockers) – block the effects of the catecholamines epinephrine & norepinephrine on alpha-adrenergic receptors in ANS•Prevents vasoconstriction caused by catecholamines•Primary site – smooth muscle of bld. vessel wall
•Causes relaxation of bld. vessel wall, increasing bld. flow• Inhibit effects of glands – sweat & salivary•Agents: phenoxybenzamine, phentolamine
Indication•Blood vessel spasm – Raynaud’s d’se
•HPN, sweating – adrenergic excess (pheochromocytoma, pt. taking MAOI, eats food w/ tyramine)
Contraindication• In any condition in w/c a sharp drop in BP is undesirable•Hypersensitivity, pregnancy, lactation
Adverse Reaction•Orthostatic hypotension, circulatory failure•Dizziness, weakness, fainting•Tachycardia esp. to pts. w/ heart d’se•GI irritation, NVD
Nursing Consideration•Pts. w/ severe cerebral or coronary arteirosclerosis, gastritis, ulcer – stimulate motility & contractility
Drug-Drug Interactions•antiHPN, block effects of adrenergic drugs (phenylephrine, ephedrine) – used as OTC decongestants
BETA-ADRENERGIC BLOCKING AGENTS
•Atenolol, metoprolol, nadolol, propranolol, timolol•2 types of beta-adrenergic receptors – beta-1 & beta-2
Action•Beta-1 – increased contractility (+ inotropic effect), HR (+ chronotropic effect), & AV conduction (+ dromotropic effect)•Beta-2 – located in smooth muscle of bronchi, bld. vessel, & uterus – cause bronchodilation, vasodilation, relaxation of uterus
•Blocks beta-1 & beta-2 receptor stimulation – slows HR, dec. in myocardial contractility, CO, BP
Indication•For angina pectoris, HPN, tachyarrhythmias, pheochromocytoma, prevention of MI & migrane h/a
•Timolol – used for glaucoma•Useful for symptoms of hyperthyroidism•Propranolol – only betablocker for hypertrophic subaortic stenosis – causes angina, palpitations, syncope; control tremors
Contraindication•CHF, heart block, bradycardia caused by arrhthymias•w/ asthma, COPD, any conidtion involving acute bronchospasm
Adverse Reaction•CV reactions•Dizziness, fatigue, weakness, depression insomnia
•Raynaud’s phenomena*do not withdraw abruptly (sympathomimetic (adrenergic symptoms)
Drug-Drug Interaction•w/ cardiac glycosides, Ca channel blockers, GA quinidine – may exaggerate bradycardia & cardiac depression
•Antidiabetic drugs (insulin) – prolonged hypoglycemia•HPN drugs, phenothiazines, & nitrates•Bronchodilators, catecholamines (epi, norepi, DA)•Cimetidine, oral contraceptives, furosemide, or hydralzine•Thyroid prep. – dec. effect
CALCIUM CHANNEL BLOCKERS- Diltiazem, felodipine, nicardipine, nifedipine, verapamil
Action•Contraction of the heart muscle, & tone of blood vessels
•Decrease the ability of Ca to enter the cells of myocardium & smooth muscle of peripheral blood vessels•Dilate coronary arteries & help prevent coronary artery spasm•Decrease force of contraction, slows AV conduction, reduces HR
Indication•Angina pectoris, HPN, coronary artery spasm•Tx of menstrual cramps, premature labor
Contraindication•Hypersensitivity•Bradycardia, 2nd & 3rd-degree heart block, or severe CHF (Diltiazem & Verapamil)
Adverse Reaction•CV: Hypotension, changes in HR, cardiac arrhythmias•GI: nausea, constipation•CNS: dizziness, h/a•CHF s/s: SOB, dyspnea, peripheral edema
Drug-Drug Interactions•w/ B-adrenergic blockers, quinidine, carbamezipine•Phenobarbital, phenytoin, cardiac glycoside
GENERAL & LOCAL ANESTHETIC AGENTS
General – are CNS depressants used to produce loss of pain sensation & consciousness•Barbiturates:methohexital, thiopental (P)
•Non-barbiturate: droperidol, etomidate, ketamine,
midazolam (P), propofol•Gases: cyclopropane,
ethylene, nitrous oxide (P)•Volatile liquids: desflurane,
enflurane, halothane (P)
Local Anesthetics – used to cause loss of pain
sensation & feeling in a designated part of a body without the systemic effects ass. w/ severe CNS depression•Esters: benzocaine (P), butamben, procaine•Amine: Bupivacaine, lidocaine(P)
NEUROMUSCULAR JUNCTION BLOCKING AGENTS
Non-depolarizing Neuromuscular blockers – acts as antagonists to Ach at the NMJ & prevent depolarization of muscle cells•Atracurium, tubocurarine (P), vecoronium
Depolarizing neuromuscular blocker – acts as ACH agonist causing stimulation of the muscle cells & then preventing it from repolarizing•succinylcholine
*Both of these types cause paralysis/loss of muscular function, for performance of SP or facilitation of MV
Indication- adjunct to GA, facilitate mechanical intubation, facilitate ECT
ADRENERGIC AGENTS (Sypmathomimetic drugs)
•Dobutamine, dopamine (P), epinephrine, norepinephrine, terbutaline, albuterol
Indication• increases HR, bronchodilation, vasoconstriction, glycogenolysis,
shock, bronchospasm, asthma
Contraindication•pheochromocytoma, tachyarrhythmias, ventricular fibrillation, PVD,
Adverse EffectSNS: arrhythmia, HPN, palpitation, angina, dyspnea, N/V, h/a, sweating, piloerection
Drug-Drug Interactions• Increased effects of TCAs & MAOI
CHOLINERGIC AGENTS•Direct-Acting Cholinergic Agonists
- Bethanecol (P), pilocarpine
• Indirect-Acting Cholinergic Agonists
- donepezil (P), edrophonium, neostigmine,
pyridostigmine (P)
Are chemicals that act at the same site as the neurotransmitter acetylcholine (Ach)
Found in PNS – stimulation of these sites produces a response similar to what is seen when the PNS is activated
Referred to as parasympathomimetic drugs
Action•slows HR, vasodilation, bronchoconstriction, inc. secretion from bronchial mucus, inc. GI activity, inc. bladder tone, pupil constriction
ADRENOCORTICAL AGENTS
Glucocorticoids – anti-inflammatory & immunosuppressive effect; affect K, NA, &
h2o levels•betamethasone, prednisolone (P)
Mineralocorticoids – inc. NA reabsorption, inc. K &
Hexcretion, renal
insufficiency,hypotension•hydrocortisone, fludrocortisone (P)
THYROID & PARATHYROID AGENTS
Thyroid Hormones – hypothyroidism (myxedemcoma); inc. metabolic rate, prevention of goiters, mngt. of thyroid Ca• levothyroxine (P) (Synthroid)
Antithyroid Agents– acute thyrotoxicosis; to block thyroid function in
radiation emergencies•propylthiouracil (PTU), radioactive idodide (I 131), K iodide
Antihypocalcemic Agents - • calcitrol (P)
Antihypercalcemic - Paget’s d’se, osteoporosis
•(Biphosphonates) alendronate (P), calcitonins, gallium
ANTIDIABETIC AGENTSParenteral Antidiabetic• insulin
Oral AntidiabeticSulfonylureas: 1st generation•Chlorpropamide (P)•Talbutamide
Sulfonylureas: 2nd generation•Glipizide•Glyburide (P)
Nonsulfonylureas•acarbose (P)•metformin,
Glucose-elevating agent•glucagon, diazoxide
DRUGS AFFECTING FEMALE REPRODUCTIVE SYSTEM
Progestins - Includes female hormone progesterone
Eg. Levonorgestrel (P); estradiol (P)
Fertility drugs – stimulate the female reproductive system
Eg. Clomiphene
Oxytocics – stimulate uterine contractions & assist labor
Eg. Oxytocin (P) Abortifacients – used to induce abortion
Eg. Dinoprostone (P); Carboprost
Tocolytics – used to relax gravid uterus to polong pregnancy
Eg. Ritodrine (Yutopar) (P)
DRUGS AFFECTING THE MALE REPRODUCTIVE SYSTEM
ANDROGEN – more anabolic effects rather than androgenic (male sexual characteristic); improve penile dysfunction; hypogonadism (underdeveloped testes); tx of breast CaEg. Testosterone (P); Danazol
Anabolic steroids – stanozolol (P); oxymetholone
Drugs for treating Penile Dysfunction – sildenafil (P); alprostadil
DRUGS ACTING ON THE CARDIOVASCULAR SYSTEM• Drugs affecting Blood Pressure• Cardiotonic Agents• Antiarrhthmic Agents• Antianginal Agents• Lipid-lowering Agents• Drugs Affecting Blood Coagulation• Drugs Used to Treat Anemias
Drugs Affecting BP (ABCD)A – Angiotensin-Converting Enzyme Inhibitors (ACE) – “pril”; stops the phase of RAS •Benazepril, enalapril, capropril (P)
A – Angiotensin II Receptor Blockers•Losartan (P), telmisartan
Betablocker
Ca Channel BlockersDiureticsOthers: Vasodilators•hydralazine; NitroprussideGanglionic Blocker•mecamylamineAntihypotensive agent•midodrine
Action- prevent conversion of AI to AII, a powerful vasoconstrictor & stimulator of aldosterone release- conjunction w/ digoxin & diuretics to tx CHF & left ventricle dysfunction
Contraindication•Allergy to ACE inhibitors• Impaired renal function•Pregnancy & lactation•Caution w/ CHF & salt/volume depletion
Adverse Effects•Tachycardia, chest pain, CHF, cardiac arrhythmias
•GI irritation, ulcers, constipation, liver injury•Proetinuria, RF•Rash, alopecia, dermatitis, photosensitivity
Drug-Drug Interaction•w/ Allopurinol
Drug-Food•Empty stomach
CARDIOTONIC AGENTS
Cardiac Glycoside•Digoxin (P) (Lanoxin)
Phosphodiesterase Inhibtors• Inamrinone (P)
Digoxin Antidote•Digoxin Immune Fab
Action & Indication- increase intracellular Ca & allow more Ca to enter myocardial cells during depolarization causing: + inotropic effect (inc. force of myocardial contraction
- Increased cardiac output& renal perfusion
- Slow HR owing to slowing of cellular repolarization (- chronotropic effect)
- Decreased conduction velocity through AV node
Contraindication & Caution•Allergy w/ digitalis preparation•Vent. tach./vent. fib.
• Heart block; MI• Pregnant & lactating
ANTIARRHYTHMIC AGENTS
Class Ia – stabliize cell membrane by binding to Na channels; Ventricular A.•quinidine (P); procainamide
Contraindication•Allergy•bradycardia/heart block •CHF; hypotension, shock
• lactation; electrolyte disturbances; renal/hepatic dysfunction; pregnancy
Adverse Effects•CNS: dizziness, drowsiness, fatigue, twitching, mouth numbness, slurred speech, vision changes, tremors•GI: change in taste, n/v
• CV: hypotension, vasodialtion, cardiac arrest• RS: resp. depression• Others: rash, hypersensitivity, loss of hair, BMD
Class Ib – Antiarrhythmics• lidocaine (P) Class Ic Antiarrhythmics• flecainide
Class II Antiarrhythmics•propranolol (P)
Class III Antiarrhythmics•amiodarone; bretyllium (P); sotalol
Class IV Antiarrhythmics•diltiazem (P); verapamil
Other: •adenosine; digoxin
ANTIANGINAL AGENTS
Nitrates – direct relaxation of smooth muscle, reduces myocardial workload; for prevention & tx of angina pectoris
• Isosorbide mononitrate•Nitrogylcerin (NTG) (P)
Contraindication•Allergy to nitrates•Severe anemia•Head trauma/cerebral hemorrhage•Pregnancy/Lactation•hepatic/renal d’se•Caution w/ hypotension, conditions limiting CO (eg. tamponade)
Adverse Effects•CNS: h/a, dizziness, weakness•GI: n/v, incontinence•CV: hypotension, tachycardia, angina•Skin: flushing, pallor, sweating, increased perspiration
B-blockers – block B-adrenergic receptors & vasoconstriction•metoprolol•Nadolol•Propranolol
Ca-Channel Blockers – prevent movement of Ca into cardiac & smooth muscle cell
•Amlodipine•Bepridil•Diltiazem (P)
LIPID-LOWERING AGENTS/ANTILIPEMICS
Bile acid sequestrant•Cholestyramine (P) –
HMG-CoA Reducatse Inhibitors- block formation of cellular cholesterol, leading to decrease in serum cholesterol
•Lovastatin (Mevacor) (P) •Simvastatin (Zocor)•Other: clofibrate, niacin, HRT
Contraindication•Allergy w/ statins or fungal byproducts or compounds•Active liver d’se•Pregnancy/lactation• Impaired endocrine function
Adverse EffectsGI: flatulence, abdominal pain, cramps, n/v, constipation, acute liver failure
CNS: h/a, dizziness, blurred vision, insomnia, fatigue, cataract dev’t
MS: RhabdomyolysisES: ARF
DRUGS AFFECTING BLOOD COAGULATION
Antiplatelet drugs – inhibit platelet adhesion & aggregation by blocking receptor sites on platelet membrane •Aspirin (P)•Clopidogrel (Plavix)
Contraindication•Allergy to specific drug•Pregnancy, lactation•Presence of known bleeding disorder•Recent surgery•Closed head injuries
Adverse effects•Bleeding•Skin rash
Anticoagulants – interferes clotting process; tx of thromboembolic disorders (eg. atrial fib., MI, pulmonary embolus, stroke)
Antithrombin•Heparin (P)•Warfarin
Low-Molecular-Weight Heparins – inhibit thrombus & clot formation by blocking clotting factors•Enoxaparin (P)
Anticoagulant Adjunctive Therapy•Protamine sulfate•Vitamin K
Contraindication•Known allergy to drugs
w/ hemorrhagic disorders•Recent trauma, spinal punture•GI ulcers recent sx•Caution w/ CHF, thyrotoxicosis, psychosis
Hemorheologic agent•Pentoxifylline
Thrombolytic agents – breaks down fibrin threads & dissolves clot•Alteplase•Reteplase•Streptokinase(P)•Urokinase
Drugs used to control bleeding – replacement factors that are genetically missing; prevent blood loss, treat bleeding episodes •Antihemophilic agent•Antihemophilic factor(P)•Factor IX complex
Contraindication•Allergy to mouse proteins•Liver d’se – factor IX•Lactation/pregnancy
Adverse Effects•Risk w/ use of blood products•h/a, flushing, chills, fever, lethargy
• n/v, stinging, itching, burning at site of injection
Systemic Hemostatic Agents•Aminocapoic acid (P)•Aprotinin
Topical hemostatic agent•Absorbable gelatin (P)•Microfibrillar collagen•Thrombin
DRUGS USED TO TREAT ANEMIAS
Erythropoietin•Darbopoetin alfa•Epoetin alfaIndication & Action•Acts like the natural glycoprotein erythropoietin to stimulate the production of RBCs in the bone marrow
•Tx of anemia in RF & for pts. on dialysis•To decrease need of BT•Tx of anemia associated w/ AIDS therapy•Tx for anemia associated w/ cancer chemotherapy
Contraindication & Caution•Uncontrolled HPN
•w/ allergy to mammalian-cell derived product/human albumin• lactation
Adverse Effects•CNS effects – asthenia, potential for seizure•GI sx•CV: HPN, edema, possible chest pain
•Possible clotting of access line r/t direct cellular effects of the drug
Iron preparations•Ferrous fumarate•Ferrous gluconate•Ferrous sulfate (P)• Iron dextran
Indications•Elevate serum iron concentration•Tx of IDA•Adjunctive therapy for pt. receiving epoetin alfa
Contraindication & Caution•w/ known allergy
•Hemochromatosis (excessive iron)•Hemolytic anemias•Peptic ulcer, colitis, regional enteritis
Adverse Effects•GI irritation/upset: + dark stools constipation•CNS toxic
• Parenteral Iron: anaphylactic reaction, local irritation, staining of the tissues, phlebitis
Folic acid derivatives•Folic acid (P)•Leucovorin
Indication & Action•Essential for cell growth & division•Production of strong stoma in RBCs•Necessary for maintenance of myelin sheath in nerve tissue•Dietary deficiencies•Pregnancy & lactation
Contraindication & Caution•w/ caution to pregnant & lactating patients
Adverse effects•Pain & discomfort at injection sites•Nasal irritation w/ the use of nasal spray
Vitamin b12•Cyanocobalamin•Hydroxocobalamin (P)
DRUGS ACTING ON THE RENAL SYSTEM
DIURETIC AGENTS
Thiazide Diuretics (DCT)•Hydrochlorothiazide (P)
Thiazide-Like Diuretics•Chlorthalidone (P)
Loop Diuretics (LoH)•Furosemide (P)
Carbonic Anhydrase Inhibitors (PT)•Acetazolamide (P)
Potassium-Sparing Diuretics (DT & collecting duct)•Spironolactone (P)
Osmotic Diuretic (glomerulus, tubule)•Mannitol (P)• Isosorbide
General Action & Indication•Prevents reabsorption of excessive proportion of sodium ions in glomerular filtrate
•Cause increased intravascular volume & hydrostatic pressure, w/c could result in leaking of fluids at capillary level•For tx of edema (CHF)•Acute pulmonary edema•Liver/renal disease•Tx of HPN
•Decrease fluid pressure in the eye (intraocular pressure; glaucoma)•Tx of hyperkalemia
Contraindication & Caution•Allergy•w/ fluid & electrolyte imbalance•severe renal d’se
•Systemic lupus erythematosus (SLE)•DM (glucose-elevating effects)•Gout (abnormality in renal tubule reabsorption & secretion)•Liver d’se•Pregnancy & lactation
Adverse Effects•GI upset•Fluid & electrolyte imbalances•Hypotension•Electrolyte disturbances
DRUGS AFFECTING THE URINARY TRACT & THE BLADDER
Urinary Tract Anti-Infectives•Methylene blue•Nalidixic acid•Norfloxacin
Urinary Tract Antispasmodics•Oxybutynin
Urinary Tract Analgesic•Phenazopyridine
Bladder Protectant – protect from irritation r/t solutes in the urine; has anticoagulant & fibrinolytic effects•Pentosan Polysulfate Sodium
Drug Used to Treat BPH (a- adrenergic blocking agent) – used to block dilation of arterioles in bladder & urinary tract
•Doxazosin (P)•Finasteride•terazosin
DRUGS ACTING ON THE RESPIRATORY SYSTEM
DRUGS ACTING ON THE UPPER RESPIRATORY TRACT
Antitussive•Codeine•Dextromethorphan•Hydrocodone
DecongestantsTopical Nasal Decongestants•Ephedrine (P)•PhenylephrineOral Decongestants•Pseudoephedrine (P)Topical Nasal Steroid Decongestants•Beclomethasone•Dexamethasone flunisolide
Antihistamines•Azatadine•Brompheniramine•Cetirizine•Desloratadine•Diphenhydramine (P)
Expectorants•Guaifenesin•Terpin hydrate
Mucolytics•Acetlycysteine (P)•Domase alfa
DRUGS USED TO TREAT OBSTRUCTIVE PULMONARY DISORDERS
• Asthma• COPD; emphysema; RDS
Bronchodilators/Antiasthmatics, Xanthines•Aminophylline
• Theophylline (P)
Action & Indication• Directly affects smooth muscle of RT both in bronchi & blood vessels• Increase vital capacity that has been impaired by bronchospasm or air trapping
Contraindication•w/ GI problems•coronary d’se, respiratory dysfunction•Renal/hepatic d’se,alcoholism•Hyperthyroidism
Adverse Effects•Normal level: 10-20 mcg/ml•GI upset, irritability, tachycardia
•Seizure, brain damage, death
Sympathomimetics•Terbutaline•Ephedrine•Epinephrine (P)
Indication•Bronchospasm in reversible obstructive airway d’se
Contraindication•Cardiac/vascular d’se, arrhythmias•Diabetes. Hyperthyroidism•Pregnancy, lactation
Adverse Effects•CNS stimulation•GI upset•Cardiac arrhythmias, HPN
• Bronchospasm, sweating• Pallor, flushing
Anticholinergics• Ipratropium
Inhaled Steroids•(P) flunisolide
Action & Indication•Used to decrease inflammatory response in airway• Increase airflow & facilitate respiration
• Promotes B-adrenergic receptor activity w/c may promote smooth muscle relaxation & inhibit bronchoconstriction
• Prevention & tx of asthma
Contraindications•Not for use during acute asthma attack/status asthmaticus
• Pregnancy/lactation• w/ active infection of Resp. sys.
Adverse Effects•Sore throat, hoarseness, coughing, dry mouth•Pharyngeal/laryngeal fungal infection
Leukotriene Receptor Antagonists•Zafirlukast (P)•Montelukast
Indication•Blocks s/s of asthma (eg. neutrophil & eosinophil migration, smooth muscle contraction)
•For prophylaxis & chronic tx of bronchial asthma in adults & <12y/o•Not indicated for acute asthmatic attacks
Contraindications•w/ hepatic/renal impairment•Pregnancy & lactation
Adverse Effects•h/a, dizziness, myalgia•Nvd, abd. Pain, elevated liver enzymes•Generalized pain, fever
Lung Surfactants•Beractant (P)• Calfactant
Indication•Reduces surface tension w/n the alveoli allowing expansion & gas exchange•Prophylactic tx for those at risk for RDS
Adverse Effects•Patent ductus arteriosus, hypotension
• Intraventricular hemorrhage, pneumothorax•Hyperbilirubinemia, sepsis
Mast Cell Stabilizers•(P) Cromolyn•Nedocromil
Action/Indication•Prevent release of inflammatory & bronchoconstricting substances•Prevents allergic asthmatic response•Tx of chronic bronchial asthma, exercise-induced asthma, allergic rhinitis
Contraindication•Known allergy to drug•Cannot be used during an acute attack•Cromolyn not recommended for <2y/o children•Nedocromil not recommended for >12y/o
Adverse Effects•Swollen eyes, h/a, dizziness, fatigue•dry mucosa, nausea, cough•Should not be discontinued abruptly
DRUGS ACTING ON THE GI SYSTEM
Drugs Affecting GI secretions
5 types of drugs used to treat ulcers:
1. Histamine-2 (H2) antagonists – block the release of HCL acid in response to gastrin
•Cimetidine (P)•Famotidine•Ranitidine
Action/Indication•Block histamine-2 receptor sites w/c leads to reduction in gastric acid secretion & reduction in overall pepsin production•H2 receptor sites – heart – cardiac arrhythmias•Short-term tx of active doudenal ulcer or benign gastric ulcer
•Tx of pathological hypersecretory conditions (Zollinger-Ellison syndrome)•Prophylaxis of stress-induced ulcers, acute upper GI bleeding•Tx of erosive GER•Relief of symptoms of heartburn, acid indigestion, & sour stomach (OTC prep.)
Contraindications/Cautions•Known allergy•Caution w/ pregnancy/lactation•Hepatic/renal dysfunction
Adverse Effects•Diarrhea/constipation•Dizziness, h/a, somnolence, confusion, hallucination
•Cardiac arrhythmias, hypotension•Gynecomastia (w/ long-term use w/ cimetidine), impotence
2. Antacids – interact w/ acids at the chemical level to neutralize them
•Aluminum•Sodium bicarbonate (P)•Magnesium/Ca salts•Magaldrate
Action/Indication•Symptomatic relief of upset stomach associated w/ hyperacidity (w/ peptic ulcer, gastritis, peptic esophagitis, hiatal hernia)
hernia of upper stomach: a hernia in which the part of the stomach around the esophagus entrance is forced up into the chest cavity through the normal opening in the diaphragm for the esophagus. Hiatal hernia is associated with heartburn and can usually be corrected by surgery.
Microsoft® Encarta® 2009. © 1993-2008 Microsoft Corporation. All rights reserved.
Contraindication/Caution•Known allergy•Caution w/ electrolyte imbalance, GI obstruction
Adverse Effects•Rebound acidity•Alkalosis w/ resultant metabolic changes (n/v, neuromuscular changes, h/a, irritability, muscle twitching, coma)
• Hypercalcemia & milk-alkali syndrome (seen as alkalosis, renal Ca deposits, severe electrolyte disorders)
• Constipation/diarrhea• Hypophosphatmeia (due to
Al salts)• Fluid retention, CHF (Na
HCO3)
3. Proton Pump Inhibitors (PPI) – suppress the secretion of HCL acid into the lumen of the stomach•Omeprazole (P)• lansoprazole
Indication/Action•Act at specific secretory surface receptors to prevent final step of acid production
•For short-term tx of active doudenal ulcers, GERD, erosive esophagitis, benign active gastric ulcer•Long-term tx of pathological hypersecretory conditions•As maintenance therapy for healing of erosive esophagitis & ulcers
Contraindications/Cautions•w/ known allergy•Pregnant/lactating women
Adverse Effects•Dizziness, h/a asthenia (loss of strength), vertigo, insomnia, apathy•Diarrhea, abd. pain, n/v, dry mouth, tongue atrophy
•Cough, stuffy nose, hoarseness, epistaxis•Rash, pruritus
4. Antipeptic Agents – coat any injured area in the stomach to prevent further injury from acid•Sucralfate
Action/Indication•Protect sites against acid, pepsin, & bile salts•prevents furhter beakdown of the area & promotes ulcer healing• Inhibits pepsin activity in gastric juices•Short-term tx of doudenal ulcers
5. Prostaglandins – inhibit the secretion of gastrin & increase the secretion of mucus lining of the stomach, providing a buffer•Misoprostol
Action/Indication•Prevent NSAID-induced gastric ulcers
Contraindication•Abortifacient
Adverse Effects•Nvd, dyspepsia•Miscarriages, excessive bleeding, spotting, cramping, hypermenorrhea, dysmenorrhea
6. Digestive Enzymes – suffered strokes, salivary gland disorders, surgery of head/neck, cystic fibrosis, pancreatic dysfunction•Pancrelipase•Pancreatin (P)•Saliva substitute
Action/Indication•Contains electrolytes & carboxymethylcellulose to act as thickening agent in dry mouth conditions•Help digestion & absorption of fats, proteins, & CHO•Replacement therapy in pts. w/ cystic fibrosis, chronic pancreatitis, ductal obstruction,
• pancreatic insuffciency, steatorrhea, malabsorption syndrome, after pancreatectomy, gastrectomy
Contraindication/Caution•Known allergy to parabens or any component of the drug•w/ pt. w/ CHF, HPN, RF•Known allergy to the product or to pork products
Adverse Effects•Cx from abnormal electrolyte absorption (eg. increased level of Mg, Na, or K•GI irritation
LAXATIVE & ANTIDARRHEAL AGENTS
•Speed up or improve movement of intestinal contents along GIT• Increase tone of GIT & to stimulate motility throughout the system
• Used to decrease mov’t along GIT when rapid mov’t decreases the time for absorption of nutrients, leading to loss of H2O & nutrient
LAXATIVES Chemical stimulants•Bisacodyl
•Cascara•Castor oil (P)
Bulk Laxatives•Lactulose•Mg citrate (P)•Mg hydroxide
Lubricants•Mineral oil (P)
GI Stimulants•Metoclopramide (P)•Dexpanthenol
Antidiarrheal Agents•Bismuth subsalicylate•Loperamide (P)•Opium
EMETIC & ANTIEMETIC AGENTS
Emetic Agent• Ipecac syrup (P)
Indication/Action• In cases of overdose or poisoning•Gastric lavage
• Irritates GI mucosa w/c stimulates CTZ
Contraindication/Caution• Ingestion of caustic alkali or corrosive mineral acids – potential for upper GI & airway serious damage•When volatile petroleum distillate (kerosene) have been swallowed - aspiration
•Comatose/semi-comatose pt.; s/s of convulsion
Adverse Effects•GI upset, mild CNS depression•Cardiotoxicity
Antiemetic – decrease or prevent nausea or vomiting•Reduces hyperactivity of the vomiting reflex either decrease local response to stimuli or block CTZ
Phenothiazine•Chlorpromazine•Prochlorperazine (P)•Promethazine
Nonphenothiazines•Metoclopramide
Anticholinergics/Antihistamines•Meclizine (P)•Cyclizine•Buclizine
5-HT3 receptor blockers•Ondansetron•Dolasetron
Miscellaneous•Dronabinol•Hydroxyzine• trimethobenzamide
Contraindication/Caution•w/ coma/severe CNS depression•Brain damage/injury•Hypo/hypertension•Severe liver dysfxn/renal•Active eptic ulcer•Prenancy/lactation
Adverse Effect• interference w/ normal CNS response•Cardiac arrhythmias•Autonomic effects – dry mouth, anorexia, pallor, photosensitivity