PHARMACOLOGYDefinition of Terms

Pharmacology Pharmacodynamics Pharmacokinetics

-absorption-distribution-metabolism-elimination

Pharmacotherapeutics Pharmacognosy Toxicology Half Life, Peak Plasma Level Adverse Effects Efficacy and Potency MTC and MEC

Drug concentration in plasma after a single oral administration of drug

Drug concentration in plasma after multiple oral administrations of drugs

Drug concentration in plasma after a single intravenous (bolus) administration of drug

Drug Uses Palliative treatment Preventive treatment Diagnostic drugs Curative treatment Health maintenance drugs Contraceptive drugs

Dosage Forms Tablets

-is the most popular dosage form and usually the easiest to administer

-mostly contains a disintegrating agent in their formulation (cornstarch)-some are scored-some are enteric-coated

>should never be crushed or chewed>should never be administered with antacids, milk or other alkaline substances

*Timed or Sustained Release Tablets-for permitting drugs to be released from tablets in controlled fashion-forms:

>crystals of the active ingredient embedded in a wax>microencapsulated with varying degrees of thickness of the polymer coating>osmotic pumps

Capsules-is a dosage form in which a drug is enclosed in either a hard or soft soluble shell, usually made up of gelatin.-the shell generally dissolves in the stomach in 10-20 minutes-hard gelatin capsules or soft gelatin capsules

Troches-also called lozenges-are solid dosage forms that are generally disc shaped and dissolved slowly in the mouth

Suppositories-a dosage form that is to be inserted into one of the external body orifices, usually in the rectum, vagina or urethra-may exert a localized or systemic effect-cocoa butter is the most popular vehicle or base

>is waxy solid at room or refrigerator temperatures, but melts at body temperature

Solutions-is a clear liquid preparation that contains one or more solvents and one or more dissolved components, or solutes.-often colored and flavored-easy to administer particularly for the pediatric and geriatric age groups*Syrups

-are sweetened solutions that are often used to mask the unpleasant taste of certain drugs-has soothing effect*Elixirs

-contain a solvent mixture of alcohol and water as well as other components*Tinctures

-contain alcohol as the primary solvent but which may contain water as well-are available for internal or external use

*Douche-is intended to be used in cleansing a body part or cavity, usually the vagina-prepared by diluting a liquid concentrate or powder with water to make an appropriate strength

Suspensions-are liquid dosage forms that contain solid drug particles that are suspended in a suitable liquid medium-should never be administered intravenously

Emulsions-are dispersions of fine droplets of an oil in water or water in oil-those which contain an oil dispersed in water are primarily used orally-those which contain water dispersed in oil are used primarily for topical applications*must be shaken thoroughly prior to use

Topical Implants Parenteral products

Pharmacodynamics Drugs usually act in one of four ways:

1. To replace or act as substitutes for missing chemicals2. To increase or stimulate certain cellular activities3. To depress or slow cellular activities4. To interfere with the functioning of the foreign cells such as invading microorganisms or neoplasm

Receptor Sites-specific areas in a cell where many drugs are thought to act

-reacts with certain chemicals to cause an effect within the cell (enzyme system activation or inhibition)-agonism, antagonism (competitive and non competitive)

Drug-Enzyme Interactions Selective Toxicity

Drug-receptor interaction

Protein-bound drug molecules

Pharmacokinetics Critical Concentration/Therapeutic Index Loading dose/Maintenance dose Dynamic Equilibrium

-absorption, distribution, metabolism and excretionA. Absorption>passive diffusion>active transport>filtration

*First pass effect

Factors that affect absorption of drugs: Intravenous

-none (direct entry into the venous system) Intramuscular

-Perfusion or blood flow to the muscle-Fat content of the muscle-Temperature of the muscle

Subcutaneous-Perfusion or blood flow to the tissues-Fat content to the tissues-temperature of the tissue

Oral-Acidity of the stomach-length of time in the stomach-blood flow to the GIT-presence of interacting foods and drugs

Rectum-Perfusion or blood flow to the rectum-lesions to the rectum-length of time retained in the rectum for absorption

Mucous membranes (sublingual, buccal)-perfusion or blood flow to the area-integrity to the mucous membranes-presence of food or smoking-length of time retained in the area

Topical-perfusion or blood flow to the area-integrity of the skin

Inhalation-perfusion to the area-integrity of lung lining-ability to administer drug properly

B. Distribution-significant factors:

*ionization*lipid solubility*perfusion of reactive tissues

-affected by protein binding-affected by the blood brain barrier-affected by pregnancy and lactation

C. Biotransformation (metabolism)-needed in the maintenance of homeostasis-the liver enzyme systems serve as the single most important site of drug metabolism-the liver enzymes as the hepatic microsomal system-types:

1. Phase I Biotransformation>oxidation, reduction or hydrolysis>involves the hepatic cytochrome P450 enzyme systems2. Phase II Biotransformation>conjugation reaction-drugs that increase or induce the hepatic enzyme systems:

*Nicotine*Alcohol*Glucocorticoids

-drugs that inhibit or decrease hepatic enzyme system activity*Ketoconazole*Mexiletine*Quinidine

D. Excretion-removal of the drug from the body-kidneys, skin, saliva, lungs, bile and feces-water soluble drugs > glomerular filtration-affected by the pH of the urineFactors influencing drug effects:1. weight- adult dosages based on a 150 pound person2. age- extremes of ages (very young and very old)3. gender- more adipose in women4. physiological factors

-nervous and endocrine balance, acid-base balance, hydration and electrolyte balance5. pathological factors

-diseases that can affect absorption,-distribution, metabolism and excretion of the drug

6. Genetic factors-predictable differences in the pharmacodynamic and pharmacokinetic processes based on the hepatic enzyme

systems7. Immunological factors

-hypersensitivity8. Psychological factors

-placebo effect-health seeking behavior affects compliance to drug therapy

9. Environmental factors-environmental temperature to affect antihypertensive agents-sedatives affected by environmental noises

10. Tolerance11. Cumulation

-occurs with shorter frequency and a relatively larger dosage than recommended12. Drug to drug interaction

A. absorption- aspirin and antacidsB. distribution- methotrexate and aspirinC. metabolism- phenobarbital and warfarin

D. Excretion- Quinidine and Digoxin13. Drug-Food Interactions

-tetracycline and iron-tetracycline and calcium

14. Drug-Laboratory Test Interactions-Dalteparin and Liver Function Test

Adverse Effects>are undesired effects that may be unpleasant or even dangerous.>can be of several types:

1. Primary Actions2. Secondary Actions3. Hypersensitivity

1. Primary Actions-the development of adverse reactions from simple overdosage-the patient suffers from the extension of the desired effects-can be due to oversensitivity to the recommended dose2. Secondary Actions-undesirable secondary drug effect.3. Hypersensitivity-due to excessive responsiveness to either the primary or secondary effects of the drug

Drug AllergyFour main classifications:A. Anaphylactic Reactions-this allergy involves an antibody that reacts with specific sites in the body to cause the release of chemicals, including histamine, that produce an immediate reaction (mucous membrane swelling and constricting bronchi) that can lead to respiratory distress and even respiratory arrest.-signs/symptoms:

>rashes>diaphoresis>increased BP>Panic feeling>dilated pupils>increased HR>difficulty of breathing>respiratory arrest

-interventions:>Epinephrine

*massage the site to speed up the absorption process

B. Cytotoxic Reactions-this allergy involves antibodies that circulate in the blood and attack antigens (the drug) on cell sites causing death of that cell. This reaction is not immediate but may occur over a few days.-signs/symptoms:

>decreased RBC, WBC and platelets>elevated liver enzymes>decreased renal function

-intervention:>notify the prescriber>discontinue the drug>prevent infection>conserve energy

C. Serum Sickness Reaction-involves antibodies that circulate in the blood and cause damage to various tissues by depositing in blood vessels. This reaction may occur up to a week or more after exposure to the drug.-signs/symptoms:

>itchy rash>edema of the face and limbs>high fever>swollen lymph nodes

>swollen and painful joints-interventions:

>notify the prescriber>discontinue the drug>supportive and symptomatic treatment

D. Delayed Allergic Reaction-occurs several hours after exposure and involves antibodies that are bound to specific WBC-signs/symptoms:

>rashes>swollen joints

-interventions:>notify the prescriber and discontinue the med

Drug Induced Tissue Damage1. Dermatological Reactions-may range from a simple rash to potentially fatal exfoliative dermatitisA. Rashes

>Procainamide (antiarrythmic)-frequent skin care-avoid rubbing, tight or rough clothing, harsh soaps-administer antihistamine-steroids, antihistamine

B. Stomatitis-due to direct reaction to the drug or due to drug deposits in the end capillaries in the mucus membranes leading to inflammation

>Fluorouracil (antineoplastic)-swollen gums and tongue-difficulty swallowing-halitosis-pain in the mouth and throat

-interventions-mouth care-frequent small meals-arrange for dental consultation-antifungal or local anesthetic agents

C. Superinfections-due to the usage of broad spectrum antibiotics-signs/symptoms:

>variable (constitutional and nonconstitutional)-interventions:

>supportive care>antifungal>discontinue the drug

2. Blood Dyscrasia-bone marrow suppression due to drug effects-caused by chemotherapeutic drugs-signs/symptoms:

>nonspecific>low platelets >low RBC>low WBC

-interventions:>monitor blood counts>supportive measures>discontinue the drug until the recovery of the bone marrow

3. ToxicityA. Liver Injury-due to the extensive first pass effect-signs/symptoms:

>fever, malaise, nausea, vomiting

>jaundice, change in the color of the urine>elevated liver enzymes

*aspartate aminotransferase*alanine aminotransferase

>alterations of clotting factors>alterations in the bilirubin levels

-interventions:>discontinue the drug>notify the prescriber>supportive care

B. Renal Injury-due to plugging of the glomerular capillary network by an unchanged drug-aminoglycosides (Garamycin)-signs/symptoms:

>elevated results of renal function test (BUN and creatinine)>decreased hematocrit>electrolyte imbalances, edema>fatigue, malaise, rashes>irritability

-interventions:>notify the prescriber>discontinue the drug>supportive measures>dialysis

C. Poisoning-occurs when an overdose of a drug damages multiple body systems which could be fatal-assessment parameters and treatment varies depending on the drug

4. Alterations in Glucose MetabolismA. Hypoglycemia-due to antidiabetic drugs (oral hypoglycemic agents)

*Glypizide, Glyburide-signs/symptoms:

>fatigue, drowsiness, hunger, anxiety, headache, cold clammy skin, shaking and lack of coordination, increased HR, BP, numbness, tingling sensation of the mouth, tongue and/or lips, confusion, rapid, shallow breathing, coma-interventions:

>glucose (oral or IV)>supportive measures>safety measures>reassurance

B. Hyperglycemia-due to the stimulation of the breakdown of glycogen or alter metabolism in such a way as to cause a high serum glucose level-signs/symptoms:

>fatigue>polydipsia&polyphagia>polyuria >Kussmaul’s respiration>restlessness>flushed skin>nausea>fruity odor of breath

-intervention:>insulin therapy>supportive measures

5. Electrolyte ImbalancesA. Hypokalemia

-due to drugs affecting renal function like the loop diuretics (Furosemide)-signs/symptoms:

>potassium concentration <3.5 mEqs /L>weakness, numbness, tingling of the extremities, muscle cramps, nausea, diarrhea, decreased bowel sounds,

irregular and weak pulse, orthostatic hypotension and disorientation.>in severe cases, abdominal distention and acute abdomen

-interventions:>replace serum potassium>monitor patients response>supportive care

B. Hyperkalemia-due potassium sparing diuretics (Spironolactone)-due to drugs that cause cell injury (antineoplastic drugs)-signs/symptoms:

>serum potassium level higher than 5mEqs/L>weakness, muscle cramps>slow heart rate>low BP, decreased urine output>difficulty of breathing

-interventions:>sodium polystyrene sulfonate>supportive measures>safety measures>monitor cardiac effects and be prepared for cardiac emergency>dialysis

6. Sensory EffectsA. Ocular Toxicity-due to Chloroquine-due to blockage of end arteries to the retina-signs/symptoms:

>blurring of vision>color blindness>blindness

-interventions>monitor for untoward s/sx>notify the prescriber>discontinue the drug>supportive measures

B. Auditory Damage-sensorineural type of deafness-due to Macrolides (erythromycin) or Aspirin-signs/symptoms:

>dizziness, tinnitus, loss of balance and deafness-interventions:

>monitor for hearing changes>protect from injury>notify the prescriber

7. Neurologic EffectsA. General CNS EffectsB. Anticholinergic EffectsC. Parkinson-like syndromeD. Neuroleptic Malignant Syndrome

Drug Dosage CalculationSystems of Measurement:1.Metric System-the most widely used-gram as the basic unit of solid measurement-liter as the basic unit of liquid measurement

2. Apothecary System

-the very old system of measurement developed for use by pharmacists-minim as the basic unit of liquid measure-grain as the basic unit of solid measure-it uses Roman Numerals placed after the unit of measure to denote amount

3. Household System-the least accurate system of measurement-teaspoon as the basic unit of fluid measurement-pound as the basic unit of solid measurement 4. Avoirdupois System-an older system of measurement routinely used by pharmacists to compound medications-uses ounces and grains but measurement is different from the apothecary and household system

5. Other Systems of Measurement-Units

>reflects the biological activity of the drug in 1mL of a solution-Milliequivalents

> used to measure electrolytes

Drug Dosage CalculationsFormula for Oral and Parenteral Drugs:volume in mL = prescribed dose X volume

stock doseFormula for Intravenous Flow Rate Calculation:drops/minute=volume of the solution in mL x drop or drip factor

number of hours x 60 min/hour

Pediatric Drug Dosage CalculationFried’s Rule

child’s dose (age < 1 yr)= infants age in mos150 mos

x average adult doseYoung’s Rule

child’s dose = child’s age in years(1 -12years) child’s age in yrs + 12

x average adult dose

Clark’s Rulechild’s dose= weight of the child in pounds

150 lbs x average adult doseSurface Area Calculation

child’s dose= surface area in square meters1.73

Classification of Drugs Prescription Drugs Nonprescription Drugs Illicit Drugs

Drug Names Generic Name (nonproprietary name) Brand Name (trade name)

Parts of a Prescription1. Descriptive client’s information2. The date on which the prescription was written by the prescriber3. The Rx symbol4. Name and dosage strength of the prescribed medication5. Dispensing instruction for the pharmacist6. Directions for the client or the signa7. Refill and/or specialized labeling instructions8. The prescriber’s signature, address and tel #

Factors contributing to individual variation of drug response: Age Gender Body weight Body surface area BMR Genetics Placebo effect

Drug Interactions Additive effect Synergistic Effect Antagonistic effect

Nursing Process and drug Administration Assessment Diagnosis and Planning Implementation Evaluation

Rights of Medication Administration The right drug The right dose The right client Right time Right route Right documentation Right to refuse

Routes of Administration Oral Parenteral

-intradermal-subcutaneous-intramuscular-intravenous-intracardiac

Complications of Intravenous Administration Infiltration Extravasation Thrombophlebitis Pain Fluid overload Pyrogenic reactions Tissue necrosis

Sites of Intramuscular Injection Deltoid muscles Vastus lateralis Ventrogluteal and dorsogluteal muscles

Sites of Subcutaneous Injection Upper arm(lateral part) Thigh Buttocks Abdomen(lower part)

Antimicrobials Antibacterial Antiviral Antifungal Antiparasitic

Susceptibility of the body to infection Age

Exposure to pathogenic organisms Disruption of the body’s normal barriers to infection Inadequate immunological defenses Impaired circulation Poor nutritional status

Selection of antimicrobial agents Location of infecting organism Status of the client’s organ function Age of the client Pregnancy and lactation Risk of drug resacistance

Mechanisms of Action1. Interference with the biosynthesis of the cell wall.2. Prevention of the cells of the invading microorganisms from using substances essential to their growth and

development.3. Interference with the steps involved in protein synthesis, a necessary function to maintain the cell and allow for cell

division.4. Interference with the DNA synthesis.5. Alteration of the cell membrane permeability to

allow essential cellular components to leak out causing cell death.

Anti-infective Activity1. Broad spectrum2. Narrow spectrum

--1. Bacteriostatic2. Bactericidal

Role of Human Immune ResponseResistance

1. Natural or Intrinsic Resistance2. Acquired Resistance

-could develop in a number of ways:*by producing an enzyme that deactivates the antimicrobial drug*by changing permeability to prevent the drug from entering the cell or altering the transport systems to exclude the

drug from active transport into the cell*by altering binding sites on the membrane or ribosomes, which then no longer accepts the drug*by producing a chemical antagonist to the drug

Preventing Resistance1. High doses2. Long duration of treatment3. Around the clock dosing

Treatment of Systemic Infection1. Identification of the pathogens2. Sensitivity of the pathogens3. Combination Therapy

reasons:*may allow the use of smaller dosage of each drug > fewer adverse effects*synergism*infection caused by more than one organism*delay in the emergence of bacterial drug resistance

1. Antibacterial agents Penicillin Cephalosporins Tetracyclines Macrolides Aminoglycosides Flouroquinolones Sulfonamides

a. Penicillin

Mode of action- exert their antimicrobial activity by inhibiting cell wall synthesis resulting in the destruction of the microorganism.

Penicillins differ in their: Chemical stability in the stomach acid Susceptibility to penicillinase Spectrum of action Route of administration Duration of action Site of action

Narrow spectrum Penicillins Penicillin G Penicillin V Penicillinase resistant

-nafcillin, oxacillin, cloxacillin, methicillin, dicloxacillin

Aminopenicillins Ampicillin Bacampicilin Amoxicillin

Extended spectrum Penicillins Mezlocillin Piperacillin Ticarcillin Penicillin-Clavulanic Acid combination Penicillin-Sulbactam combination Penicillin-Tazobactam combination

Things to consider: Monitor all patients with signs of hypersensitivity. Discontinue therapy at the first sign of hypersensitivity reaction.

Observe clients receiving penicillin in an emergency room Ticarcillin, Mezlocilllin or Piperacillin

may cause bleeding abnormalities. Closely monitor clients with renal impairment. Administration with bacteriostatic antibiotics (Erythromycin and Tetracycline) may diminish effectiveness. Probenecid blocks renal tubular excretion of Penicillin and may cause higher blood levels and longer duration of

action of Penicillin. High intravenous doses of sodium or potassium salts of Penicillin may cause electrolyte disturbances. Although not always essential, it is advisable to administer oral Penicillin on an empty stomach with a full glass of

water. To prevent peripheral IV site irritation, avoid infusing the medication rapidly.

b. Cephalosporins Mode of action

- Interfere with bacterial cell wall synthesis, thereby altering the osmotic stability of the actively growing bacterial cell and resulting in in its death.

Can be bactericidal or bacteriostatic Metabolized in the liver, excreted in the kidney

Cephalosporins: bactericidal or bacteriostatic Depends upon:

1. The susceptibility of the organism 2. The dose of the drug used3. The tissue concentration of the drug4. The rate of bacterial multiplication

First Generation Cephalosporins Tends to have greatest activity against several gram positive as well gram negative organisms and are generally

quite susceptible to beta lactamase produced by some bacteria. Cephalexin, Cephadroxil, Cephadrin,

Cefazolin, Cephalothin, Cephapirin

Second Generation Cephalosporins

Have a broader spectrum of activity against gram negative organisms and a somewhat diminished activity against gram positive organisms.

Tends to become resistant to inactivation by beta lactamases Cefaclor, Cefrozil, Loracarbef, Cefuroxime, Cefoxitin, Cefotetan, Cefonicid, Cefmetazole

Third Generation Cephalosporins Have even broader gram negative activity and less gram positive activity than do second generation agents. Tends to become resistant to inactivation by beta lactamases Cefdinir, Cefpodoxime, Ceftibuten, Cefoperazone, Cefotaxime, Ceftazidime, Ceftizoxime, Ceftriaxone

Fourth Generation Cephalosporins Have the greatest action against gram negative organisms among the four generations and minimal action against

the gram positive organisms*in the transition from the first generation to the fourth generation, there has been an increasing cost of the drug

Cefepime, Ceftidoren

Things to consider: Monitor clients for hypersensitivity Use with caution in patients with renal impairment Make IM injections deep to prevent or reduce inflammatory reactions IV administration for prolonged periods or in high doses may cause thrombophlebitis. Bacteriostatic antimicrobial agents may interfere with Cephalosporins’ bactericidal action. Probenecid administered with Cephalosporins may increase and prolong their plasma levels by interfering with their

renal tubular secretion. Use of potentially nephrotoxic drugs with Cephalosporins may increase the likelihood of renal toxicity. Avoid consuming alcoholic beverages while receiving cephalosporins and for at least 72 hours after completing the

dose after completing the drug course. Monitor for gastrointestinal distress, renal impairment and hematological changes.

c. Tetracyclines Inhibits protein synthesis in the cell wall of bacteria, thereby slowing its growth and reproductive rate so that it

becomes more susceptible to the body’s immune defense. Bacteriostatic at doses usually employed. Broad spectrum

The primary drawback in its use is the toxicity: Effect on the bone and enamel of tooth Photosensitivity Likelihood of superinfection with the repeated or prolonged administration of Tetracyclines

Things to consider: Avoid use in children under 8 because of possible interference with the development of teeth and bones and

staining of teeth Clients must avoid unprotected exposure to direct sunlight of UV light to reduce risk of phototoxicity IV therapy in excess of 2g/day may produce hepatotoxicity. Should not be used during pregnancy Monitor clients for fungal or bacterial superinfection, particularly involving the GI tract or vagina. Avoid use with calcium supplements, antacids, iron or dairy products as they may reduce the drug absorption. Should be given on an empty stomach 1 hour before or 2-3 hours after any meal or other medication Demeclocycline, Minocycline, Doxycycline, Oxytetracycline

Known Drug Interactions with Tetracycline:1. Penicillin2. Oral contraceptives3. Methoxyflurane4. Digoxin5. Calcium salts, Zinc salts, Aluminum salts, Bismuth salts, Iron, Urinary alkalinizers and Charcoal

d. Macrolides Inhibits protein synthesis in the bacterial cell wall. Used primarily for the oral therapy of infections caused by gram positive and gram negative organisms. Primarily metabolized in the liver with excretion in the kidneys Can be excreted also in the bile and feces Teratogenic and can be excreted in the breast milk Azithromycin, Clarithromycin, Erythromycin and Dirithromycin

Things to consider: Monitor clients for signs of hepatoxicity and nephrotoxicity Hypersensitivity reactions may occur. Oral doses should be taken 1 hour before or 2 hours after meals. Administer with food if GI upsets occur. Safety precautions (changing positions slowly and avoidance of driving) Maintenance of nutrition and hydration

Drug Interactions with Macrolides1. Digoxin- at risk of digoxin toxicity2. Oral anticoagulants, theophyllines, carbamazapine and corticosteroids3. Cycloserine

e. Aminoglycosides Act by inhibiting protein synthesis in the bacterial cell wall and may exert their bactericidal or bacteriostatic action,

depending on the drug dosage employed.

Things to consider: Monitor clients for signs of nephrotoxicity. Neuromuscular blockade and respiratory paralysis may occur when administered with or shortly after anesthetics or

,muscle relaxants. Provide good hydration to reduce the likelihood of hepatoxicity and nephrotoxicity. Avoid use of other drugs that produce ototoxicity and nephrotoxicity. To prevent IV site irritation, avoid infusing the medication rapidly. Amikacin, Gentamycin, Kanamycin, Neomycin, Netilmicin, Streptomycin, Tobramycin, Paromomycin

Other Antibacterial Agents: Report evidence of allergic reaction Report symptomatic improvement Review administration and storage instructions that accompany the product. To prevent peripheral IV site irritation, avoid using the medication rapidly. Astreonam, Bacitracin, Chloramphenicol, Clindamycin, Enoxacin, Imipenem, Lincomycin, Metronidazole,

Ciprofloxacin. Ofloxacin, Norfloxacin, Vancomycin, Spectinomycin, Sulfonamides

Urinary tract Anti- infectives Nalidixic Acid Cinoxacin Nitrofurantoin Methenamine Products

- Methenamine mandelate- Methenamine hippurate

Trimethoprim

Adverse effects of Antibacterials: Hypersensitivity reactions Organ toxicity Hematological disorders

Classification of Antimicrobials Bactericidal or bacteriostatic Narrow or Extended (broad) spectrum

Other Agents Used in the Treatment of UTI Phenazopyridine HCl (Pyridium) Neomycin and Polymyxin B

Drugs Used in TB Two forms:

1. Prophylaxis- aimed at reducing the number of organisms to prevent s/sx2. Treatment of active infection

Antitubercular DrugsFirst Line Anti TB Drugs

Isoniazid- inhibits mycolic acid synthesis

Rifampicin- inhibits DNA polymerase

Pyrazinamide Ethambutol Streptomycin

Other Anti TB drugs Second line anti TB drugs

1. Capreomycin2.Aminosalicylate3. Cycloserine

Things to consider: Determine prior drug use of anti TB drugs Note color and nature of the sputum Teach client appropriate hygiene to ensure safety of others Stress the importance of completing the course of treatment.

2. Anti-Fungal Drugs Fungal infections:

1. superficial2. localized skin infection3. life-threatening systemic infections

Nystatin (Mycostatin) Flucytosine (Ancobon)

Ketoconazole (Nizoral) Amphotericin B (Fungizone Intravenous) Griseofulvin (Fulvicin) Fluconazole (Diflucan) Itraconazole (Sporanox)

3. Anti-Viral Drugs Amantadine HCl (Symmetrel) and Rimantadine HCl (Flumadine) Vidarabine (Vira A) Rivabirin (Virazole) Interferon Alfa Zidovudine (AZT) Didanosine (Videx) Zalcitabine

Other anti-viral drugs Ganciclovir and Foscarnet

Miscellaneous anti-infective: Pentamidine isethionate Furazolidone

Leprostatic Agents Rifampicin Dapsone Clofazimine (Lamprene)

Anti-Malarial Drugs Chloroquine Primaquine phosphate Halofantrine Quinine Mefloquine Hydroxychloroquine

Anti-Protozoal Drugs Metronidazole

Paromomycin Emetine Atovaquone

4. Anti-Parasitic DrugsRound worm (ascariasis) Pyrantel Pamoate

or MebendazolePinworm (Enterobiasis) Pyrantel Pamoate

or MebendazoleThreadworm (Strongyloidiasis) ThiabendazoleBeef tape worm (Taeniasis) Praziquantel

Whipworm (Trichuriasis) Mebendazole

Hookworm (Uncinariasis) Mebendazole of Pyrantel Pamoate

Tapeworm (Dipylidium caninum)

Albendazole

Dermatological Parasitic Disorder Lindane- scabicide/pediculocide Crotamiton- scabicide Malathion- pediculocide Pyrethrins and piperonyl butoxide

Analgesics and Antipyretics Types:

1. Opioid Analgesics2. Non opioid analgesics

A. Opioids1. Morphine SO42. Oxycodone3. Codeine

Opioid antagonists:1. Naloxone2. NaltrexoneB. Non Opioid

1. Nalbuphine2. Pentazocine HCl

Analgesics Used to treat Headaches For Vascular Headaches

1. Ergotamine TartrateDihydroergotamine MesylateMethysergide maleate

2. Sumatriptan succinate

Analgesic/Antipyretic Acetylsalicylic Acid Acetaminophen Phenacetin Ibuprofen Ketoprofen Mefenamic Acid

Anti-hypertensive DrugsHypertension Risk GroupsRisk Groups Number of Risk Factors

Risk Group A No cardiovascular risk factors or conditionsRisk Group B One cardiovascular risk factor but no diabetes or other risk

conditionsRisk Group C Diabetes and/or any of the other risk conditions

A. Diuretics

-attributed to the ability of this group to reduce the plasma volume1. Thiazides

Hydrochlorothiazide2. Loop Diuretics

Furosemide, Ethacrynic Acid, Bumetanide, Torsemide-more potent than thiazide diuretics-with comparable effects with thiazides in normal renal function-superior to thiazides in renal insufficiency

3. Potassium Sparing DiureticsSpironolactone (Aldactone)Triamterene (Dyrenium)Amiloride (Midamor)

-not as effective as thiazides and loop diuretics-may be used alone-may be used in combination (prevention of hypokalemia)

B. Beta Blockers if diuretic therapyC. Calcium Channel Blockers failsD. ACE Inhibitors

E. Centrally Acting Antiadrenergic Agents-sedation as a major side effects

1. Methyldopa>>metabolized to alpha methylnorepinephrine

(false neurotransmitter)

replace epinephrine on the adrenergic storage sites

>>stimulation of alpha 2 adrenergic receptors

vasodilation of arteries

2. Clonidine (Catapres)>>stimulates the alpha 2 adrenergic receptors in the CNS-action is apparent 30 – 60 minutes after administration oral dose-maximum effect is 3 – 5 hours after administration-may cause rebound hypertension (should be gradually discontinued over a period of 2 to 4 days)

Clonidine-TTS>releases the drug very slowly over 7 days*administered 2 – 4 times a day

3. Guanfacine-with similar mechanism of action and secondary effects to Methyldopa and Clonidine

4. Guanabenz-similar to Guanfacine

F. Peripherally Acting Anti-Adrenergic Agents1. Rauwolfia Derivatives-depletes the neurotransmitter norepinephrine at peripheral sympathetic nerve junctions-with low daily dose-once a day administration

Reserpine RescinnamineDeserpidine Rauwolfia serpentina

-AR:-depression-exacerbation of PUD-nasal congestion

2. Guanethidine Monosulfate (Ismelin Sulfate)-depletion of catecholamines to peripheral adrenergic neurons-AR:

>postural hypotension>impairment of sexual function in males>diarrhea

*all are dose dependent

3. Guanadrel sulfate (Hylorel)-similar effects with Guanethidine

4. Prazocin (Minipress), Terazosin (Hytrin) and Doxazosin (Cardura)-selective blockers of post synaptic alpha adrenergic receptors

*Terazosin and Doxazosin-also used for BPH

G. VasodilatorsHydralazine (Apresoline), Minoxidil (Loniten), Nitroglycerin IV

Cardiotonic Drugs

1. Cardiac Glycosides (digoxin, digitoxin)-originally derived from a foxglove or a digitalis plant-available for oral and parenteral use-excreted unchanged in the urine-has a narrow margin of safety-indicated in the treatment of CHF-antidote of digoxin toxicity (Digoxin Immune Fab)-Mechanisms of action:

*positive inotropic effect*increased cardiac output and renal perfusion*negative chronotropic effect* decreased conduction velocity through the AV node

Nursing Considerations:1. Need for a loading dose2. Apical pulse monitoring (rate and rhythm)- may suggest digoxin toxicity3. Narrow margin of safety4. Easily degraded by the environmental conditions5. Avoid IM injection (slow IV push)6. Orally administered with an empty stomach7. Weight monitoring8. Maintain emergency equipment on standby9. Therapeutic digoxin level: .5 to 2 ng/ml10. Comfort measures as regards to the adverse effects:

*headache*GI upsets & anorexia*weakness*risk of arrhythmia*drowsiness*vision changes

11. Drug InteractionsDrugs that decrease digoxin effects:a. thyroid hormonesb. metoclopramidec. penicillamine

Drugs that increase digoxin effects:a. verapamil e. erythromycinb. amiodarone f. tetracyclinec. quinidine g. cyclosporined. quinine

2. Phosphodiesterase Inhibitors-Inamrinone (Inocor):

*for IV use as alternative drug for CHF-Milrinone (Primacor):

*for IV use for short term treatment of CHF

-mechanism of action:*blocks the enzyme phosphodiesterase – increase in cAMP – increase in intracellular calcium - positive inotropic effect

Nursing considerations:1. Easily degraded by environmental conditions2. Monitoring of HR and BP3. Painful upon infusion4. Maintain emergency equipments5. Patient education as regards to the drug therapy6. Responsibilities as regards to the adverse effects:

*arrhythmias, hypotension and chest pain*nausea, vomiting, anorexia and abdominal pain*thrombocytopenia*hypersensitivity reactions

-contraindications:*acute MI*fluid volume deficit*severe aortic and pulmonary valvular stenosis

-drug interaction:*precipitates if mixed with Furosemide

Antiarrhythmic Drugs-proarrhythmic drugs

Classes of Antiarrhythmic drugs:1. Class 1-blockers of Na channelsA. Class 1a

-Quinidine, Dysopyramide, Procainamide and MoricizineB. Class 1b

-Lidocaine, MexiletineC. Class 1c

-Flecainide and PropafenoneMechanisms of action

-stabilize the cell membrane by binding to sodium channels-have a local anesthetic effect-for the treatment of life-threatening ventricular arrhythmias-Quinidine, Flecainide and Propafenone are also indicated in atrial arrhythmias

Nursing Considerations:1. Hepatic metabolism and renal excretion2. Crosses the placenta and enters the breast milk3. Cardiac rhythm monitoring4. Maintain emergency equipment on standby5. IV if cannot tolerate oral route6. Dosage titration7. Establish safety precautions (CNS effects)8. Responsibilities in relation to CI and AR

CI- hypersensitivity, bradycardia or heart block,CHF, hypotension and shock, renal or hepatic dysfunction, pregnancy and lactationAR- CNS effects, GI effects, CVS effects and respiratory depression

2. Class II-are beta blockers

*acebutolol- PVC*esmolol- short term management of supraventricular tachycardia*propranolol- antihypertensive, antianginal and antimigraine

- supraventricular tachycardia caused by digoxin and catecholaminesMechanism of Action:

-blocks beta receptors in the heart and the kidneys --- decreased HR, cardiac excitability and cardiac output, slowing conduction through the AV node and decreasing the release of reninNursing considerations:1. Hepatic metabolism and renal excretion2. Teratogenic and excreted in the breast milk3. CI in sinus bradycardia and AV block, cardiogenic shock, asthma or respiratory depression, diabetes, thyroid dysfunction

4. AR- CNS effects (dizziness, insomnia, dreams and fatigue), CVS effects (hypotension, bradycardia, AV block, arrhythmias and alterations in the peripheral perfusion), respiratory effects (bronchospasm and dyspnea), GI problems, loss of libido, decreased exercise tolerance and alterations in the blood glucose levels5. Drug Interactions-drug effect increases with:

*verapamil*insulin

3. Class III-block potassium channels

Amiodarone- IV or oral, for life threatening arrhythmias onlyBretylium- IV or IM, for short term useIbutilide-atrial arrhythmias of less than 90 daysSotalol

Mechanism of Action:-Blocks the potassium channels and slows the outward movement of potassium-For the treatment of atrial and ventricular arrhythmiasNursing considerations

1. Hepatic metabolism and renal excretion2. Potentially teratogenic and excreted in the breast milk3. Ibutilide and Dofetilide should not be used in patients with AV block4. Use with caution in shock, hypotension and respiratory depression5. AR involve the CNS (dizziness), GI (nausea,

vomiting), muscular (weakness), CVS (hypotension, CHF, arrhythmia)Amiodarone- liver toxicity, ocular abnormalities, arrhythmia

6. Drug Interactionsa. quinidineb. digoxin

4. Class IV-calcium channel blockersVerapamil, Diltiazem-paroxysmal supraventricular tachycardiaVerapamil

-for the treatment of rapid ventricular response to atrial flutter and fibrillationNursing considerations

1. IV administration2. Hepatic metabolism and renal excretion3. Teratogenic and excreted in the breast milk4. CI in patients with previous hx of hypersensitivity reaction, sick sinus syndrome and heart block5. AR include dizziness, headache, depression, fatigue and weakness

Other AR include GI upset, hypotension, shock,arrhythmias and edema.

6. Drug Interactionsa. beta blockers- more cardiac depressionb. digoxin, carbamazepine, prazocin and quinidine- more AV slowingc. atracurium, pancuronium, rurocuronium, tubocurarine, gallamine, metocurine and vecuronium- increased

respiratory depressiond. cyclosporine- more toxic if combined with diltiazem

Other Antiarrhythmic DrugsA. Adenosine- DOC usually for supraventricular tachycardia

-short duration of action (15 seconds)-very few AR (headache, flushing and dyspnea of short duration)-slows the conduction at the AV node, increase the refractory period, decreases the automaticity at the AV node

Nursing consideration1. Continuous monitoring while on drug therapy

B. Digoxin-slows down calcium outflow from the cell-also effective in atrial arrhythmias

Antianginal Agents

1. NitratesAmyl Nitrate, Isosorbide Mono/Dinitrate, Nitroglycerin

-are drugs that act directly on smooth muscles to cause relaxation and depress the muscle tone-with fast onset of action

Nursing consideration: Hepatic metabolism and renal excretion Teratogenic and excreted in the breast milk CI in patients with previous allergy, severe anemia, head trauma or brain injury and pregnancy and lactation AR- related to profound vasodilatation

Drug Interactionsa. ergot derivativesb. heparin

2. Beta Blockers3. Calcium Channel Blockers

Hypolipidemic Agents

1. Bile Acid SequestrantsCholestyramine, Colestipol and Colesevelam

Mechanism of Action-binds with bile acids, leading to their excretion in the feces --- low bile acids in the hepatic circulation --- more

hepatic bile acid production --- utilization of more LDL --- lower plasma cholesterol level>indicated in primary hypercholesterolemia>Cholestyramine can be used in pruritus secondary to partial biliary obstruction

Nursing Considerations1. CI include previous hypersensitivity reaction, complete biliary obstruction, abnormal intestinal function, pregnancy

and lactation2. AR are related to the changes of serum cholesterol (anxiety, fatigue, headache and drowsiness), GI (constipation,

fecal impaction, hemorrhoid), bleeding, fat soluble vitamin deficiencies3. Before administration, these drugs must be mixed with fluids to be effective. (Colestipol must be mixed with

carbonated beverages to be effective)4. Tablets should not be crushed5. To be given before meals6. Administer oral meds 1 hour before or 4-6 hours after meals7. Bowel program8. Comfort measures9. Patient education

2. HMG CoA Reductase InhibitorsMechanism of Action-inhibits the early rate limiting step in the synthesis of cellular cholesterol.-LDL decrease, HDL increaseAtorvastatin- associated with severe liver disease

-can be used in children at 10-17 years of ageFluvastatin- hypersensitivity reactionLovastatin- oldest, very long acting

- can cause rhabdomyolysisPravastatin- is the only statin with the outcome data to show that it is effective in decreasing CAD and the incidence of MI.Rosuvastatin- newest statin

- better than the older statins in increasing the HDL and decreasing the LDL- increased risk of rhabdomyolysis in Asians

Simvastatin- lowers cholesterol and prevent MI in patients known to have hypercholesterolemia and CADMechanism of Action

-block the formation of cellular cholesterol, leading to a decrease in the serum cholesterol and decrease in the serum LDLs with a slight or no increase in HDLs

-with marked first pass effectNursing Consideration

1. Hepatic metabolism, renal and fecal excretion2. All statins are potentially nephrotoxic except

Atorvastatin3. Pregnancy category X and excreted in the breast milk4. Long term drug therapy5. CI in pregnancy, lactation, severe liver disease, previous hypersensitivity and impaired endocrine function6. AR include CNS effects (dizziness, headache, blurred vision, insomnia, fatigue, cataract devt) and GI effects

*Rhabdomyolysis in Lovastatin, Atorvastatin, Fluvastatin and Rosuvastatin7. Administer the drug at bedtime except Atorvastatin8. Monitor serum cholesterol and LDL

9. Periodic ophthalmoscopic exam10. Diet and exercise for 3-6 months before beginning drug therapy11. Withhold in any condition suggesting myopathy12. Use of contraceptive

Drug to Drug InteractionsErythromycin, Cyclosporine, Gemfibrozil, Niacin or antifungal drugs ---- RHABDOMYOLYSISDigoxin and Warfarin- increased toxicityOral contraceptives- increased estrogen levelsGrapefruit juice- increased drug concentration and toxicity

3. Cholesterol Absorption Inhibitors-recently approved for its therapeutic use-localizes in the brush border of the small intestines--- increased clearance of cholesterol from the serumEzetimibe-as an adjunct to diet and exercise-as a drug to be combined with other hypolipidemic agents-absorbed from the GIT (peak after 4-6 hours), 22 hours half life-metabolized in the liver and small intestines, excreted in the urine and feces-no data yet on its risks during pregnancy and lactationNursing considerations

1. Monitor serum cholesterol, triglyceride and LDL levels before and after therapy2. Monitor liver function test3. Should have attempted first to diet and exercise4. Use of contraceptives5. CI in patients with previous hypersensitivity reaction, pregnancy, lactation, severe liver disease6. AR include GI (mild abdominal pain and diarrhea), CNS (headache and dizziness), URTI, muscle aches

Drug InteractionsBile Acid Sequestrants and Fibrates

-bloating and flatulenceCholestyramine, Fenofibrate, Gemfibrozil or antacids

-increased serum levels of Ezetimibe-2 hours before or 4 hours after taking these drugs

Cyclosporine-ototoxicity

Fibrate-cholelithiasis

Warfarin- increased levels

DRUGS AFFECTING BLOOD COAGULATIONAnticoagulants vs. Thrombolytics

1. AntiplateletsAbciximab- PTCA, angina and non Q wave MIAnagrelide- essential thrombocytopeniaAspirin- prevention of TIA, strokes and MICilostazol- claudicationClopidogrel- prevention of MI, peripheral artery disease, ischemic stroke and acute coronary syndromeDipyridamole- Prevention of thromboembolismEptifibatide- acute coronary syndromeSulfinpyrazone- Prevent reinfarction in MI, thromboembolism, also an antigoutTiclopidine- alternative to aspirinTirofiban- used in combination with Heparin in PTCA

Mechanism of Action-inhibits platelet adhesion and aggregation by blocking receptor sites on the platelet membrane, preventing platelet

to platelet interaction*Anagrelide- blocks the production of platelets in the bone marrow

Nursing Considerations1. Hepatic metabolism and renal excretion2. Avoidance in pregnancy and lactation3. Provide small, frequent meals if with GI irritation

4. Comfort measures and analgesia for headache5. Safety measures- increased risk of bleeding6. Precautionary measures during invasive procedures7. Proper documentation8. Patient education9. Support and encouragement

2. AnticoagulantsMechanism of Action

-interferes with the clotting cascade and thrombin formationWarfarin

-oral drug that interferes with the production of vit K dependent clotting factors-metabolized in the liver and excreted in the urine and feces-onset of action is 3 days, duration is 4-5 days-used in patients with atrial fibrillation, artificial heart valves or valvular damage, MI-avoid in pregnancy and lactation

Heparin- inhibits the conversion of prothrombin to thrombin, thus blocking the conversion of fibrinogen to fibrin.-IV or SC-excreted in the urine-avoid in pregnancy but can be used during lactation-can be used in DIC (Disseminated Intravascular Coagulation), stroke and MI.

Antithrombin III- antithrombin III deficiency-safe during pregnancy and lactation

Argatroban- thrombin inhibiting drugBivalirudin- thrombin inhibiting drug vcDesirudin- thrombin inhibiting drug in DVTNursing Considerations

1. Evaluate for the therapeutic effectiveness of Warfarin (PT 1.5 to 2.5 times the control value or INR of 2-3)2. Evaluate for the therapeutic effects of Heparin (WBCT- 2.5 to 3 times the control or PTT 1.5 to 3 the control value)3. Evaluate for any sign of untoward bleeding4. Safety precautions5. Proper documentation6. Maintain antidotes on standby7. Monitor the patient for any reaction to added or withdrawn drug associated with anticoagulants

8. Patient education9. Support and encouragementLow Molecular Weight Heparins

-inhibits thrombus and clot formation by blocking Xa and IIa-fewer adverse effects (do not greatly affect thrombin, clotting or prothrombin time)-block angiogenesis

3. Thrombolytic AgentsMechanism of Action

-works by activating the natural anti-clotting system, conversion of plasminogen to plasminAlteplase- used in MI, Acute pulmonary embolism and strokeReteplase- MITenecteplase- MIStreptokinase- CA thrombosis, pulmonary embolism, DVT, arterial thrombosis and embolismUrokinaseNursing Considerations

1. Hepatic metabolism2. Avoid in pregnancy and lactation3. Evaluate for any sign of bleeding4. Monitor coagulation studies regularly5. Administer within the golden period.

6. Prepare for possible blood transfusion7. Monitor cardiac rhythm and have emergency equipments on standby8. Precautionary measures during invasive procedures9. Proper documentation10. Support and encouragementDrug Interactions

Anticoagulants and antiplateletsAntihemophilic Agents

1. Antihemophilic Factor VIII2. Coagulation Factor VIIa3. Factor IX Complex

Mechanism of Action-replacement of the deficient or absent clotting factor/s

Nursing Considerations1. Relatively contraindicated during pregnancy and absolutely contraindicated during lactation.2. IV route of administration to ensure effectiveness3. Monitor clinical response and clotting factor levels regularly4. Monitor for any sign of thrombosis5. Decrease the infusion if adverse effects occur (Headache, chills, fever and tingling sensation)6. Prepare for a possible blood transfusion7. Proper documentation8. Patient education

Systemic Hemostatic AgentsAprotinin

-from a bovine lung tissue-form complexes with clot dissolving factors-IV route of administration-excreted by the kidneys (half life of 150 minutes)-relatively contraindicated during pregnancy and lactation

Aminocaproic Acid-inhibits plasminogen activating substance and has an antiplasmin activity

Nursing Considerations1. Monitor clinical response and clotting factor levels regularly2. Monitor for signs of thrombosis3. Support and safety measures if hallucinations occur4. Comfort measures5. Patient education6. Support and encouragement7. CI in the presence of hypersensitivity to this drug and DIC.8. Caution in cardiac disease, renal or hepatic dysfunction, pregnancy and lactation9. AR- excessive clotting (most common), CNS effects (hallucinations, drowsiness, dizziness, headache and psychotic

states), GI effects (nausea, cramps and diarrhea), muscular (weakness, fatigue, malaise and muscle pain), renal (intrarenal obstruction and dysfunction)Aprotinin- arrhythmia, MI, CHF and hypotension

Drug Interactions1. Heparin- increased risk of bleeding2. OCP or estrogens- hypercoagulation states

Topical Hemostatic Agents1. Absorbable gelatin (Gelfoam)2. Microfibrillar collagen (Avitene)

-increased risk of infection on the site3. Thrombin (Thrombinar, Thrombostat)

-derived from bovine sources-may precipitate an allergic response

Drugs Used to Treat Anemias1. Erythropoeitin

-Epoetin alfa, Darbopoetin alfaNursing considerations

1. No adequate study in pregnancy and lactation (Darbopoetin) crosses the breast milk 2. Confirm the chronic renal nature of the patient’s anemia3. Epoetin- 2-3x a week, Darbopoetin- once a week4. Do not mix with other drugs- incompatibilities5. Monitor access lines for clotting6. Arrange for hematocrit reading before drug administration (if no response within 8 weeks--- reevaluation)7. Evaluate iron stores8. Maintain seizure precaution on standby9. Comfort measures in relation to adverse effects

CNS effects, GI effects, CVS effects

2. Iron Preparations-Ferrous Fumarate, Ferrous Sulfate, Ferrous Gluconate, Iron Dextran, Iron Sucrose and Sodium Ferric

Mechanism Of Action-incorporated into the hemoglobin-trapped into the RES for storage

Nursing Considerations1. Confirm iron deficiency anemia2. Collaborate with the physician3. Administer with meals (avoid eggs, milk, coffee and tea). Use a straw4. IM injection should apply the z track technique5. Hgb and Hct monitoring before and during the therapy6. Comfort measures as regards to AR

-GI irritation is the most common (GI upset, nausea, vomiting, anorexia, dark stoolsand constipation)-CNS effects (toxicity- coma and death)-anaphylaxis, local irritation, staining of the tissues and phlebitis

Drug Interactions1. Antacids, H2 blockers, tetracycline

-decreases absorption (should be spaced 2 hours apart)2. Ciprofloxacin, norfloxacin and Ofloxacin

-decreases anti-infective activity because of inefficient absorption (2 hours apart)3. Chloramphenicol

-increased iron level4. Levodopa

-may decrease its effect

3. Folic Acid Derivativesand Vitamin B12

Leucovorin- folic acid preparation-used in chemotherapy in patients receiving methotrexate-oral, IM and IV

Folic Acid (Folvite)-oral, sc, IM, IV

Hydroxocobalamin-traditional treatment of pernicious anemia and vit B12 deficiency-IM everyday for 5-10 days then once a month for life

Cyanocobolamin-relatively shorter duration of action-can be given as intranasal gel(Nascobal) intranasal spray in one nostril given once a week

Nursing Considerations1. Liver metabolism and renal excretion2. To be used with caution in pregnant and lactating women3. Caution in patients with nasal erosions and ulcers4. AR- pain and discomfort on the injection sites

-nasal irritation

Drugs Affecting the Respiratory SystemAnatomy and Physiology of the Respiratory SystemUpper Respiratory Tract Conditions

-common colds-seasonal rhinitis-sinusitis-pharyngitis and laryngitis

Lower Respiratory Tract-atelectasis -bronchitis-pneumonia -bronchiectasis-obstructive pulmonary diseases

*asthma*COPD (emphysema and chronic bronchitis)

-cystic fibrosis-respiratory distress syndrome

1. Antitussives

Codeine, Hydocodone, Dextromethorphan, Benzonatate-drugs that suppress the cough reflex-metabolized in the liver, excreted in the kidneys-cross the placenta and excreted in the breastmilk

Nursing Considerations1. Collaborate with the physician2. Non pharmacologic management of cough3. Patient education4. AR- sedation and drowsiness

-can cause drug dependence-drying effect on the mucous membranes and increased viscosity of respiratory tract

secretions-drying effect can lead to nausea, constipation and dry mouth

2. DecongestantsA. Topical Nasal Decongestants

Ephedrine, Oxymetazoline, Phenylephrine, Tetrahydrozoline, XylometazolineMechanism of Action

-sympathomimeticsNursing Considerations1. Metabolized in the liver and excreted in the kidneys2. Caution during pregnancy and lactation3. Patient education on the proper administration of the drug4. Not to be used for more than 5 days5. Can be found in the OTC preparations---- prevent overdosage6. Safety measures- dizziness and sedation7. Institute non pharmacologic management of pain8. Support and encouragementB. Oral Decongestants

Pseudoephedrine-systemic effect (sympathomimetic)

Nursing Considerations1. metabolized in the liver, excreted in the urine2. caution in pregnancy and lactation3. check OTC preparations to prevent overdosage4. safety measures5. not to use for more than a week6. patient teaching7. support and encouragement

8. CI in glaucoma, hypertension, diabetes, thyroid disease, coronary disease, and prostate problems

9. AR- rebound congestion, anxiety, tenseness, restlessness, tremors, hypertension, arrhythmias, sweating and pallorC. Topical Nasal Steroid Decongestants

Beclomethasone, Budesonide, Dexamethasone, Flunisolide, Fluticasone, Triamcinolone-treatment of allergic rhinitis unresponsive to other decongestants

Mechanism of Action-the exact mechanism is unknown

Nursing Considerations1. generally not absorbed systemically2. patient education as to the proper use of the different drug preparations3. clear the nasal passages before administering the drug4. benefits may take 2-3 weeks to appear5. monitor for the development of acute infection6. support and encouragement7. CI in acute bacterial, viral and fungal infections8. AR- local burning, irritation, stinging, dryness of the mucosa and headache

3. AntihistaminesFirst Generation

-Brompheniramine, Cetirizine, Chlorpheniramine, Diphenhydramine, Hydroxyzine, ClemastineSecond Generation

-Dexloratadine, Fexofenadine, LoratadineMechanism of Action

-blocks the effects of histamine at histamine 1 receptor, bringing relief to patients suffering from itchy eyes, swelling, congestion and drippy nose

-relieve respiratory symptoms and treat allergies-also have anticholinergic and anti-pruritic effect

Nursing Considerations1. Metabolized in the liver, excretion in the urine and feces2. Cross the placenta and excreted in the breast milk3. Administer with an empty stomach (1 hour before or 2 hours after meals)4. Provide safety measures5. Increase humidity and push fluids6. Have the patient void before administration to prevent urinary retention7. Skin care (dryness)8. Check OTC preparations

9. Avoid alcohol or other CNS depressant10. CI in pregnancy and lactation, cardiac arrhythmias, renal or hepatic impairment11. AR- drowsiness and sedation

-anticholinergic affects (dryness of the GI and respiratory mucosa, nausea, arrhythmia, dysuria, urinary hesitancy and itching associated with dryness)

4. ExpectorantsGuaifenesin-liquefy the lower respiratory tract secretions, reduce the viscosity of these secretions and making it easier to cough

up phlegm

5. MucolyticsAcetylcysteineDornase Alfa

Mechanism of Action-break down mucus in order to aid the high risk respiratory patient in coughing up thick tenacious secretions.

Drugs Used to Treat Obstructive Disorders1. Bronchodilators

A. XanthinesAminophylline, Dyphylline, Caffeine and Theophylline

-were once the first line drugs used in asthma-narrow margin of safety

Mechanism of Action-direct effect on the smooth muscle of the bronchi and blood vessels by affecting the mobilization of intracellular

calcium (theory)-stimulates the release of two prostaglandins--- smooth muscle relaxation-inhibits the slow reacting substance of anaphylaxis and histamine

Indications-bronchial asthma and COPD-additional uses: apnea, Cheyne-Stokes respiration, bradycardia in premature infants

Nursing Considerations1. Hepatic metabolism and renal excretion2. Crosses the placenta and enters the breast milk3. Monitor the patient’s response to the drug4. Frequent monitoring of blood levels5. Patient teaching6. Comfort measures in relation to AR

GI upset, nausea, irritability, tachycardia, seizures, brain damage and even death7. CI in patients with GI problems, respiratory problems, CAD, renal or hepatic disease, alcoholism,

hyperthyroidismDrug Interactions

-Nicotine: increases xanthine metabolism

2. SympathomimeticsAlbuterol- older than 2 years of ageBitolterol- older than 12 years of ageEphedrine and Epinephrine- acute bronchospasmFormoterol- older than 12 years of ageIsoetharineIsoproterenol- bronchospasm in anesthesia

-more cardiac side effectsLevabuterol- older than 6 years of ageMetaproterenol- older than 6 years of ageSalmeterol- exercise induced asthma

-older than 4 years of ageTerbutaline- older than 12 years of age

-oral, parenteral or inhalationMechanism of Action

beta 2 selective adrenergic agonistsNursing Considerations1. Hepatic metabolism and renal excretion2. Relatively contraindicated in pregnancy and lactation3. To prevent exercise induced asthma-- 30-60 minutes before exercise4. Safety measures5. Patient education6. Use minimal amount effective for the shortest period to prevent or minimize AR

-sympathomimetic stimulation7. CI- conditions that would be aggravated by sympathetic stimulation (cardiac disease, vascular disease, arrhythmias, diabetes, hyperthyroidism, pregnancy and lactationDrug Interactions

Cyclopropane and halogenated hydrocarbons-will sensitize the myocardium to catecholamines and cause serious cardiac complications

3. Anticholinergic BronchodilatorsIpratropium, Triotropium-not as effective as the sympathomimetic agents

Mechanism of Action-affects the vagus nerve to block parasympathetic impulses

Nursing Considerations1. Adequate hydration and provide environmental controls2. Encourage to void to prevent urinary retention3. Safety measures4. Small frequent meals and sugarless lozenges5. Caution with the use of inhalator- not to exceed 12 times a day6. Patient education7. Support and encouragement8. AR- anticholinergic effects (dizziness, headache, fatigue, nervousness, dry mouth, sore throat, palpitations and urinary retention)9. CI- Narrow angle glaucoma, bladder neck obstruction, prostatic hypertrophy, conditions aggravated by dry mouth and throat

4. Inhaled SteroidsBeclomethasone, Budesonide, Flunisolide, Fluticasone, Triamcinolone-inhalation decreases the systemic effects

Nursing Considerations1. Hepatic metabolism and renal excretion2. Avoid n pregnancy and lactation3. Not to be administered in acute asthma or status asthmaticus4. Taper systemic steroids5. Topical decongestant first before the steroid6. Advise to rinse the mouth after use7. Monitor for signs of respiratory infection8. Patient education9. Support and encouragement10. AR- sore throat, hoarseness, coughing, dry mouth, pharyngeal and laryngeal fungal infections

-systemic adverse effects11. CI- emergency, pregnancy and lactation, active infection of the respiratory tract

5. Leukotriene Receptor AntagonistZafirlukast, Montelukast and Zileuton

6. Mast Cell StabilizersCromolyn, Nedocromil

Drugs Affecting the Gastrointestinal Tract

Drugs Used to Treat Peptic Ulcer Disease

1. H2 BlockersCimetidine, Ranitidine, Famotidine and Nizatidine

Mechanism of Action and Indications-block H2 receptors---reduced HCl and pepsin production---healing of PUD-active duodenal ulcer and benign gastric ulcer-Zollinger-Ellison Syndrome-Prophylaxis of stress-induced ulcer and acute upper GI bleeding

Nursing Consideration1. Administer oral drug with or before meals and at bedtime2. Decrease the dosage in hepatic or renal dysfunction3. Monitor continuously for AR especially if given through IV

-GI (diarrhea and constipation), CNS (dizziness, headache, somnolence, confusion, hallucinations), CVS (arrhythmias and hypotension), gynecomastia and impotence4. Arrange for regular follow up5. Patient education6. Support and encouragement7. Drug Interactions

-warfarin, anticoagulants, phenytoin, beta blockers, alcohol, quinidine, lidocaine, theophylline, chloroquine, benzodiazepines2. Antacids

Aluminum salts, Calcium salts, Megaldrate, Magnesium salts, Sodium bicarbonateMechanism of Action

-neutralize stomach acid by direct chemical reactionIndications-hyperacidity-gastric hyperacidity-peptic ulcer-hiatal hernia-peptic esophagitisNursing considerations:

1. Administer the drug apart from other oral medications2. Periodically monitor serum electrolytes3. Periodically monitor acid base balance4. Patient education5. Support and encouragement6. AR- rebound hyperacidity, alkalosis (nausea, vomiting, neuromuscular changes, headache, irritability, muscle

twitching and even coma), hypercalcemia, milk alkali syndrome, constipation, diarrhea, hypophosphatemia, fluid retention and CHF

7. CI- allergy, any condition that can be aggravated by acid base imbalance (GI obstruction, renal dysfunction and pregnancy and lactation)

8. Drug InteractionTetracycline, Phenothiazines, Ketoconazole-absorption affectedQuinidine-increased blood levelAspirin-decreased blood level

3. Proton Pump InhibitorsEsomeprazole, Omeprazole, Lanzoprazole, Pantoprazole, Rabeprazole

Mechanism of Action-prevent the final step in HCl production and thereby decrease the acid level in the stomach

Indications-duodenal ulcers -benign active gastric-GERD ulcer-erosive esophagitis

Nursing Considerations1. Administer before meals2. Safety and comfort measures3. Medical follow-up check up if s/sx persist beyond 4-8 weeks of therapy4. Patient education

4. Antipeptic Agents (Cytoprotectives)

Sucralfate

5. ProstaglandinMisoprostol

Digestive Enzymes2 Digestive Enzymes for Replacement:

1. Saliva Substitute-for dry mouth due to stroke, radiation therapy, chemotherapy

2. Pancrelipase-cystic fibrosis and pancreatic dysfunction

Laxatives and Antidiarrheal Agents1. Laxatives

-chemical stimulantsCascara, Senna, Castor Oil, Bisacodyl

-bulk stimulantsMagnesium sulfate, Magnesium citrate, Magnesium hydroxide, Lactulose, Polycarbophil, Psyllium

-lubricating laxativeDocusate, Glycerin and mineral oil

Indications-short term relief of constipation-to prevent straining-for diagnostic procedures-for poisoning-as an adjunct for antihelminthic therapy

2. Gastrointestinal StimulantsDexpanthenol, Metoclopramide

3. Antidiarrheal DrugsBismuth subsalicylate, Loperamide, Opium derivative

Antipsychotic Drugs-reduce excessive dopamine activity, by blocking post synaptic dopamine receptors in the cerebral cortex, basal

ganglia, hypothalamus, limbic system, brainstem and medulla Phenothiazines

Chlorpromazine PerphenazineProchlorperazine TrifluoperazineThioridazine Triflupromazine

Non PhenothiazinesClozapine PimozideHaloperidol ThiothixineRisperidone Loxapine-indications:

a. schizophreniab. organic psychosisc. manic phase of bipolar affective disorder

-also referred to as “Major Tranquilizers” or “Neuroleptics”-nursing considerations:a. impairment of physical and mental activitiesb. avoidance of activities requiring mental alertnessc. avoidance of the use of alcohol and other CNS depressantsd. monitor for the presence of EPS, anticholinergic effects and orthostatic hypotensione. monitor for the occurrence of tardive dyskinesia

EPS/ Pseudoparkinsonism/ Parkinson-like Diseasea. tremors and other involuntary movementsb. akathisia

-differentiate from increased agitation-give propranolol or lorazepam-reduce the dosage of anti-psychotic agent

c. dystonias, dyskinesias-give anticholinergic agents

Tardive Dyskinesia-an EPS that does not usually appear until 2 or more years of antipsychotic drug therapy-result of dopamine receptor hypersensitivity due to prolonged blockage-mild:

>rhythmic involuntary movement of facial muscles*fly catching movement of the tongue*lip smacking and chewing movt.-severe:

>dyskinetic movements of the extremities*jerks of the limbs, fingers and toes

>reversible upon the discontinuation of the drug during the first two years