Pharmacology

By: Jan Michael Khalid L. Macarambon, RN

Definition of Terms
Pharmacology is the science of drugs and their effects on biological systems y Drug a chemical that can cause a change in a biological system y Medicine is a formulation of a drug (e.g., tablet, capsule, etc.)
y

Drug Classification
Chemical according to structure y Pharmacologic according to physiologic activities and mechanisms of action y Therapeutic according to therapeutic indications
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Drug Names
Chemical name chemical structure of the compound y Generic name name selected by the original manufacturer of the drug based on the chemical structure that is used worldwide as established through the committee on International Nonproprietary names of the WHO; AKA nonproprietary name. y Trade/Brand name proprietary name owned by the company that manufactures the drug. Example: Chemical name N-Acetyl-para-aminophenol Generic name Acetaminophen Trade/Brand name Acephen, Tynenol
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Drug Sources
Plants (morphine) y Animals (insulin) y Minerals (calcium)
y y

Most modern drugs are synthetic chemical compounds

Pharmacodynamics
y

Is the process by which drugs influence the cell physiology to achieve the desired result

WHAT THE DRUG DOES TO THE BODY

Pharmacodynamics
Drugs can: 1. Inhibit 2. Activate 3. Replace They interact with specific sites called receptors Receptors cellular proteins or nucleic acids that regulate the cellular activities

Pharmacodynamics
Receptors are regulated in two ways: 1. Agonists (activators) bind to the receptor and act to produce a pharmacologic effect 2. Antagonists (blockers) bind to the receptor and prevent the cell from producing an effect

Pharmacokinetics
y

Is the process by which the body absorbs the drug into the bloodstream, distributes it to its site of action, metabolizes it, and excretes it

WHAT THE BODY DOES TO THE DRUG

Pharmacokinetics
ADME
1. 2. 3. 4.

Absorption Distribution Metabolism/biotransformation Excretion

Pharmacokinetics

Factors Affecting Pharmacokinetics

Age y Diseases y Individual Differences y Psychological Factors y Type & Amount of Drug Prescribed y Social Factors
y

Routes of Administration

Oral
Pills, capsules, tablets, liquids y SL, buccal, NG, gastrostomy, duodenostomy tubes are also included y Assess clients ability to take oral medications
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Intradermal Injection Sites

Ventral forearm y Upper chest y Shoulder
y

Subcutaneous Injection Sites

Outer aspects of the arms & thighs y Hip and lower abdomen y Above the iliac crest
y

Intramuscular
Ventrogluteal for 1 year and above y Preffered site
y

Intramuscular
y

Vastus lateralis below 1 year old

Intramuscular
y

Dorsogluteal clients w/ welldeveloped gluteal muscles

Intramuscular
y

Deltoid

Other Routes
Intravenous y Topical skin, ophthalmic, otic, nasal, vaginal, rectal y Respiratory inhalation
y

Infectious
Antibacterials y Antivirals y Antifungals y Antiparasitics y Antihelminthics
y

Antibacterials
4 Major Types: 1. Cell Wall Inhibitors a. Penicillins pen G, amoxicillin b. Cephalosporins cephalexin, cefuroxime c. Glycopeptides vancomycin 2. Protein Synthesis Inhibitors a. Aminoglycosides gentamycin, amikacin b. Macrolides erythromycin c. Lincosamides clindamycin d. Chloramphenicols, tetracyclines 3. Antimetabolites a. Sulfonamides cotrimoxazole 4. DNA Synthesis Inhibitors a. Quinolones ciprofloxacin b. Metronidazole

Antibacterials
Adverse effects : 1. Aminoglycoside - nephrotoxicity & ototoxicity 2. Sulfonamides - Steven-Johnsons syndrome, photosynsetivity 3. Quinolones insomnia 4. Tetracyclines - bone problems 5. Chloramphenicol - Gray syndrome, bone marrow depression 6. Erythromycin - hepatitis

Antibacterials
Nursing considerations : 1. Collect appropriate specimen for C & S before starting antibiotics. 2. Check clients history of allergies. 3. Avoid administering erythromycin and quinolones with food. 4. Pregnant precautions. 5. Report for diarrhea - pseudomembranous colitis (clindamycin) 6. Monitor adverse effects.

Antivirals
Mechanism of action - inhibits virus specific enzymes involve in DNA synthesis. They only control the growth of virus but it does not cure y Prototype - acyclovir (Zovirax), ganciclovir (Cytovene), vidarabine (ViraA), amantidine (Symmetrel), ribavirin (Virazole), zidovidine (Retrovir)
y

Antivirals
Adverse Effects - granulocytopenia, thrombocytopenia, nausea, nervousness, headache, nephrotoxicity Nursing consideration : 1. Pregnant and breastfeeding precautions. 2. Administer IV antivirals to avoid crystallization in renal tubules. 3. Give ribavirin only with aerosol generator. 4. Monitor CBC and creatinine level. 5. Refer for signs of bleeding. 6. Take amantidine after meals.
y

Antifungals
Mechanism of action - inhibit the synthesis of fungal sterol y Prototype - amphotericin B (Fungisone), nystatin, fluconazole (Diflucan), ketoconazole (Nizoral) y Adverse effects nephrotoxicity and neurotoxicity, bone marrow depression, chills, fever, joint pains, abdominal pain and headache
y

Antifungals
Nursing considerations : 1. Dilute amphotericin B with sterile water solution not with electrolyte solution. 2. Tell clients that fever, chills, GI upset, joint and muscle pain will subside as amphotericin B continues. 3. With oral candidiasis, let nystatin tablet dissolve in mouth rather than swallowing it. 4. Refrain ketoconazole with antacids. 5. Report for signs of bleeding, infection & fatigue

Antiparasitics
2 Types: y Antimalarial chlroquine, mefloquine, primaquine, quinine, pyrimethamine y Antiamebiasis metronidazole (Flagyl), iodoquinol, furozolidone (Furoxone)

Antiparasitics
Mechanisms of action: y Antimalarial alters protozoal DNA, depleting folates, & reducing nucleic acid production y Antiamoeba block protein synthesis

Antiparasitics
Nursing considerations : 1. Administer anti-malarial drugs with food. 2. Take seizure precautions while administering antimalarial drugs. 3. Refer cinchonism during quinine treatment: - tinnitus, headache, vertigo, fever, and visual changes. 4. Inform clients that iodoquinol falsify thyroid function test for up to 6 months.

Antihelminthics
Prototype mebendazole (Vermox), thiabendazole, niclosamide (Niclocide), piperazine (Antepar), praziquantel (Biltricide) y Mechanism of action paralyze larva and adult helmints by acting on parasite microtubules
y

Antihelminthics
Adverse effects - GI upset, urinary odor (thiabendazole), headache, dizziness, fatigue Nursing considerations : 1. Treat all the family members for nematodes infection to prevent recurrence. 2. Praziquantel must swallowed rapidly because of its bitter taste to avoid gagging. 3. Other antihelmintics should be chewed.
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Oncologic
Alkylating Agents y Antitumor Antibiotic Agents y Antimetabolites y Mitotic Inhibitors y Hormonal Medications
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Alkylating Agents
inhibits cell production by causing cross linking of DNA Busulfan hyperuricemia Chlorambucil gonadal suppression Cisplatin ototoxicity and nephrotoxicity Cyclophosphamide hemorrhagic cystitis.
y

Antitumor Antibiotic Agents

interfere in DNA and RNA synthesis Plicamycin affects bleeding time Doxurubicin cardiotoxicity Bleomycin pulmonary toxicity
y

Antimetabolites
y

replace normal proteins required for DNA synthesis by inhibiting the S phase Cytarabine hepatotoxicity 5-flourouracil phototoxicity reaction and cerebellar dysfunctions 6-marcaptopurine hyperuricemia Methotrexate photosensitivity, given with leucoverin to lessen its toxicity

Mitotic Inhibitors
y

prevent mitosis acting on the M phase causing cell death Vincristine sulfate neurotoxicity, numbness

Hormonal Medications
block the normal hormones in hormone sensitive tumors Tamoxifen citrate visual problems, elevate cholesterol & triglycerides level Diethylstilbestrol impotence and gynecomastia in men
y

Side Effects
stomatitis y - bland diet, avoid strong mouthwash y - soft tooth brush, ice chips diarrhea, nausea and vomiting y - anti-emetic, replace fluids and electrolytes y - alopecia y - reassure that it is temporary y - encourage o wear wigs, hats and head scarf skin pigmentation y - inform that it is only temporary tumor lysis syndrome y - hyperuricemia & hyperkalemia y - force fluids infection y - notify physician if WBC is <2000/mm3 y - monitor for signs of infection y - reverse isolation - low bacteria diet anemia y - iron, B-12, folic acid rich food y - provide rest periods bleeding y - avoid NSAIDs y - minimize invasive procedures y - use soft toothbrush and electric razor menstrual changes y - reassure that menstruation will resume
y

Neurologic
1. 2. 3. 4. 5. 6. 7. 8.

Cholinergic Agents/Parasymphatomimetics Anticholinergics/Parasymphatolytics Adrenergic Agents/Symphatomimetics Adrenergic Blocking Agents Skeletal Muscle Relaxants Anticonvulsants/Antiepileptics Antiparkinsonian Agents CNS Stimulants

Cholinergic Agents
Mechanism of action stimulates cholinergic receptors by mimicking acetylcholine or inhibition of enzyme cholinesterase y Indications glaucoma, urine retention, Myasthenia Gravis, antidote to neuromuscular blocking agents : tricyclic antidepressants and atropine
y

Cholinergic Agents
Prototype synthetic acetylcholine, pilocarpine, carbachol, bethanecol (Urocholine), edrophonium (Tensilon), neostigmine (Prostigmine), pyridostigmine (Mestinon) y Adverse effects blurring of vision, miosis, increase in salivation, intestinal cramps, bronchoconstriction, wheezing, DOB, hypotension and bradycardia
y

Cholinergic Agents
Nursing considerations : 1. Warn & monitor clients of the side effects. 2. Have atropine available for use as antidote.

Anticholinergic Agents
Mechanism of action block the binding of acetylcholine in the receptors of parasympathetic nerves y Indications use preoperatively to dry up secretions; treat spasticity of GI or urinary tract, use for treatment of bradycardia, asthma, parkinsonism; use for antidote in organophosphate poisoning.
y

Anticholinergic Agents
Prototype atropine, scopalamine (Triptone), dicyclomine (Bentyl), propantheline (Pro-Banthine) y Adverse effects - dry mouth , dilatation of pupils, tachycardia, urinary retention, ileus, heat stroke
y

Anticholinergic Agents
Nursing considerations : 1. Keep client in cool environment. 2. Watch out for signs of heatstroke and dehydration. 3. Encourage clients to increase fluid intake and use of sugarless gum/candy for dry mouth. 4. For GI spasticity, administer 30 minutes before meals and at bed time.

Adrenergic Agents
Mechanism of action stimulate alpha and beta adrenergic receptor directly or trigger the release of catecholamines indirectly causing sympathetic effects y Indications cardiopulmonary arrest, hypotension, COPD and asthma, nasal congestions, allergic reaction, anaphylactic shock
y

Adrenergic Agents
Prototype - epinephrine, norepinephrine, ephedrine, dopamine, dobutamine, phenylephrine, terbutaline, albuterol, isoproterenol y Adverse Effects restlessness, insomnia, tremors, nausea, palpitations, angina, tachycardia, HPN
y

Adrenergic Agents
Nursing considerations : 1. Contraindicated in clients w/ hyperthyroidism, pheochromocytoma & cardiovascular disease. 2. Monitor vital signs and advice precautions. 3. Should be taken with food.

Adrenergic Blocking Agents

2 Types: y Alpha blockers phentolamine (Regintine), phenoxybenzamine, prazosin (Minipress), reserpine (Serpasil), terazosin (Hytrin), clonidine (Catapress), methyldopa (Aldomet) y Beta blockers atenolol (Tenormin), esmolol (Brevibloc), metoprolol (Lopressor), nadolol (Corgard), propanolol (Inderal), timolol ( Blocadren)

Adrenergic Blocking Agents

Mechanism of actions: y Alpha blockers inhibits action of areceptors in vascular smooth muscle to cause vasodilatation y Beta blockers compete with epinephrine in b-receptors in heart, pulmonary airways, peripheral circulation and CNS

Adrenergic Blocking Agents

Indications - Raynauds disease, hypertension, pheochromocytoma, angina, arrhythmias, mitral valve prolapse, glaucoma y Adverse effects - orthostatic hypotension, bradycardia, CHF, depression, insomnia and vertigo, bronchospasm and dyspnea, nasal stuffiness, cold extremities
y

Adrenergic Blocking Agents

Nursing considerations : 1. Administer oral alpha-blockers with milk to minimize GI side effects. 2. Administer oral beta-blockers before meals and at a.m. if insomnia occurs. 3. Check clients apical pulse rate before drug administration, refer if below 60 bpm. 4. Hypotensive precautions. 5. Warn clients not to drive or operate dangerous machinery until he/she has adjusted to medications.

Skeletal Muscle Relaxants

Mechanism of action depress CNS, inhibit calcium ion release in the muscle, enhance the inhibitory action of GABA (gamma-amino butyric acid) y Indications for acute musculoskeletal pain, for muscle spasticity associated with multiple sclerosis, cerebral palsy, CVA, and spinal cord injury.
y

Skeletal Muscle Relaxants

Prototype methacarbamol (Robaxin), baclofen (Lioresal), dantrolene (Dantrium), metaxalone (Skelaxin), orphanedrine (Norgesic), chlorzoxazone y Adverse effects hypotonia, ataxia, hypotension, drowsiness, blurred vision, bradycardia, depression, urine retention
y

Skeletal Muscle Relaxants

Nursing considerations : 1. Caution clients that mental alertness may be impaired. 2. Monitor neuromuscular status, bowel and bladder functions. 3. Inform clients that maximum benefit of baclofen is attained for 1-2 months. 4. Reduce baclofen dosage gradually because of associated withdrawal symptoms : Confusion, hallucinations, paranoia & rebound spasticity.

Anticonvulsants
3 Types: y Hydantoins phenytoin (Dilantin) y Barbiturates phenobarbital (Luminal) y Miscellaneous carbamazepine (Tegretol), diazepam, clorazepate (Tranxene), valproic acid (Dapakene), ethosuximide (Zarontin)

Anticonvulsants
Mechanism of action treat seizures by depressing abnormal neuronal activity in motor cortex y Adverse effects sedation & drowsiness, gingival hyperplasia, diplopia, nystagmus, vertigo, dizziness, thrombocytopenia, aplastic anemia
y

Anticonvulsants
Nursing considerations : 1. Advise female clients to use contraceptives. 2. Inform clients taking phenytoin that harmless urine discoloration is common. 3. Warn clients with diabetes that hydantoins may increase blood sugar level and that valproic acid may produce a false positive result in urine ketone test. 4. Teach clients receiving carbamazepine to identify symptoms of bone marrow depressions. 5. Reassure that barbiturates are not addictive at a low dosage. 6. Avoid taking alcohol with barbiturates. 7. Administer IV phenytoin slowly to avoid cardiotoxicity. 8. Avoid mixing other drugs in same syringe with phenytoin.

Antiparkinsonian Agents
2 Types: y Anticholinergic agents trihexyphenidyl (Artane), benztropine (Congentin) y Dopaminergic agents Levodopa, carbidopa-levodopa (Sinemet), amantidine (Symmetrel), pergolide (Permax), selegiline (Eldepryl), bromocriptine

Antiparkinsonian Agents
Mechanism of actions: y Anticholinergic agents inhibit cerebral motor centers y Dopaminergic agents increasing dopamine concentrations or enhancing neurotransmitter functioning

Antiparkinsonian Agents
Adverse effects of dopaminergic agents: y levodopa nausea, vomiting, anorexia, orthostatic hypotension, dark-colored urine and sweat y amantidine ankle edema, constipation y bromocriptine palpitations, tachycardia

Antiparkinsonian Agents
Nursing considerations : 1. Give dopaminergic agents after meals to reduce GI symptoms. 2. Reassure client that levodopa may cause harmless darkening of urine and sweat. 3. Avoid taking Vit B6 (pyridoxine) with levodopa because it speed up metabolism. 4. Educate clients to minimize orthostatic hypotension. 5. Elevate leg to reduce ankle edema.

CNS Stimulants
Mechanism of action increase excitatory CNS neurotransmitter activity and blocks inhibitory impulses y Indications for obesity (amphetamines), attention deficit hyperactivity disorders, narcolepsy, drug-induced respiratory depressions
y

CNS Stimulants
Prototype amphetamines, methylphenidate (Ritalin) y Adverse effects - nervousness, insomnia, restlessness, hypertension, tachycardia, headache, anorexia, dry mouth
y

CNS Stimulants
Nursing considerations : 1. Should be given at morning. 2. Dont stop amphetamine abruptly to avoid withdrawal symptoms. 3. Monitor blood pressure and pulse. 4. Ice chips or sugarless gum for dry mouth. 5. Watch out for growth retardation in children taking methylphenidate.

Psychiatric
Sedatives, hypnotics, & anxiolytics y Antidepressants & mood stabilizers y Antipsychotics/neurolepti cs
y

Anxiolytics
3 Types: y Benzodiazepines diazepam (Valium), lorazipam (Ativan), alprazolam (Xanax), flurazepam (Dalmane) y Barbiturates amobarbital, phenobarbital, secobarbital y Miscellaneous chloral hydrate (Noctec), buspirone (Buspar), paraldehyde

Anxiolytics
Mechanism of actions: y Benzodiazepines increase the effect of inhibitory neuro transmitter GABA (gamma-amino butyric acid) y Barbiturates and Miscellaneous agents depress CNS

Anxiolytics
Indications - induce sleep, sedate and calm clients y Adverse effects - hangover-effect, dizziness, CNS depression, respiratory depression, drug-dependence
y

Anxiolytics
Nursing considerations : 1. Warn clients of injuries and falls. 2. Brief period of confusion and excitement upon waking up is common with benzodiazepines. 3. Warn clients not to discontinue medications abruptly without consulting a physician. 4. Avoid alcohol while taking these drugs. 5. Rotate and dont shake the ampules of barbiturates. Dont mix with other drugs. 6. Warn female clients that diazepam is associated with cleft lip.

Antidepressants
4 Types: y Tricyclic antidepressants amitriptyline (Elavil), protriptyline (Vivactil), imipramine (Tofranil), desipramine y MAO (monoamine oxidase inhibitors) isocarboxazid (Marplan), phenelzine (Nardil), tranylcypromine (Parnate) y Second-generation antidepressants fluoxetine (Prozac), trazodone (Desyrel) y Lithium

Antidepressants
Mechanisms of actions: y Tricyclic antidepressants increase receptor sensitivity to serotonin and/or norepinephrine y MAO inhibitors inhibit the enzyme MAO that metabolize the neurotransmitters norepinephrine and serotonin y Second generation antidepressants inhibits the reuptake of serotonin y Lithium increase serotonin & norepinephrine uptake

Antidepressants
y

Adverse effects - dry mouth, blurred vision, urine retention, constipation (anticholinergic effects), orthostatic hypotension, insomnia, hypertensive crisis (MAO), dehydration (Lithium)

Antidepressants
Nursing considerations : 1. Caution client to rise slowly to reduce the effects of orthostatic hypotension. 2. Take antidepressant with food to enhance absorption 3. Explain to client that full response may take several weeks (2 weeks). 4. Assess client for constipation resulting from tricyclic antidepressant use. 5. Client taking MAO inhibitors should avoid tyramine-rich foods to avoid hypertensive crisis such as aged cheese, sour cream, yogurt, beer, wine, chocolate, soy sauce and yeast. Pentholamine (Regintine) is the drug of choice for hypertensive crisis. 6. Inform physician and withhold fluoxetine if client develop rashes. 7. Take lithium with food to reduce GI effects > 1.5 mEq/L blood level may cause toxicity manifested by: confusion, lethargy, seizures, hyperreflexia, maintain salt and adequate fluid intake, tremors may occur but it is temporary, monitor white blood cell count (increase).

Antipsychotics
2 Types: y Phenothiazines chlorpromazine (Thorazine), trifluoperazine (Stelazine), thioridazine (Mellaril) y Other Agents clozapine (Clozaril), haloperidol (Haldol)

Antipsychotics
Mechanism of action block dopamine receptor in the limbic system, hypothalamus, and other regions of the brain y Adverse effects -Extra pyramidal symptoms such as dystonia, pseudoparkinsonism, and an irreversible tardive dyskinesia as manifested by : lip smacking, fine wormlike tongue movement, involuntary movements of arms and leg. -Neuroleptic malignant syndrome fever, tachycardia, tachypnea, diaphoresis, cardiovascular collapse, muscle rigidity, seizures. -Orthostatic hypotension
y

Antipsychotics
Nursing considerations : 1. Teach family members the signs of EPS and NMS, and report to physician immediately. 2. Normalization of symptoms may not occur for several weeks after beginning of therapy. 3. Avoid administering haloperidol intravenously. 4. Watch out of neutropenia with clozapine. 5. Watch out for orthostatic hypotension and photosensitivity with phenothiazine. 6. Be sure that oral doses are swallowed, and not hoarded.

Musculoskeletal
General Anesthetics y Local & Topical Anesthetics y Analgesics
y

General Anesthetics
2 Types: y Inhalation anesthetics enflurane (Ethrane), halothane, isoflurane (Forane), nitrous oxide y Injection anesthetics fentanyl (Sublimaze), ketamine (Ketalar), thiopental Na (Penthotal), etomidate (Amidate)

General Anesthetics
y

Mechanism of action cause CNS depression, by producing loss of consciousness, unresponsiveness to pain stimuli, and muscle relaxation

General Anesthetics
Nursing considerations : 1. Instruct client NPO for 8 hours before administration. 2. Monitor cardio pulmonary depression and hypotension. 3. Monitor urinary retention. 4. Monitor body temperature malignant hyperthermic crisis : dantrolene (antidote) 5. Avoid alcohol or CNS depressants for 24 hours after anesthesia. 6. In patient who received halothane, monitor signs of hepatic fatal side effects : - rash, fever, nausea, vomiting, jaundice and altered liver function.

Local & Topical Anesthetics

2 Types: y Local : bupivacaine, lidocaine, tetracaine, procaine, mepivacaine, prilocaine y Topical : benzocaine, butacaine, dibucaine,lignocaine
y

Mechanism of action block transmission of impulses across nerve cell membrane

Local & Topical Anesthetics

Adverse effects cardiac dysrhythmias y Nursing considerations : 1. Lignocaine + prilocaine (EMLA cream) should be applied topically 60 minutes before procedure. 2. Administer cautiously to the areas of large broken skin. 3. Observe for fetal bradycardia in pregnant clients.
y

Analgesics
2 Types: y Narcotic analgesics codeine, meperidine (Demerol) morphine, butorphanol (Stadol), nalbuphine (Nubain) y Non narcotic analgesic NSAIDs aspirin (aminosalicylic acid), mefenamic acid (Ponstan), ibuprofen (Motrin), naproxen, ketoprofen (Orudis), ketorolac paracetamol and acetaminophen (Tylenol)

Analgesics
Mechanisms of action: y Narcotic analgesics alter pain perception by binding to opioid receptors in CNS. y Non-narcotic analgesic relieves pain and fever by inhibiting the prostaglandin pathway.

Analgesics
Nursing considerations : 1. Monitor respiratory depression & hypotension in clients taking narcotic analgesic. 2. Injury and accident precautions in clients taking narcotic analgesic. 3. Warn clients about possibility of dependency, and do not discontinue narcotics abruptly in the narcotic-dependent clients. 4. Naloxone is antidote for narcotic overdose. 5. Advice clients to take NSAIDs with food and monitor bleeding complications. 6. Aspirin is contraindicated in clients below 18 years old with flulike symptoms. 7. Monitor hearing loss in clients taking aspirin. 8. Monitor liver function in clients taking acetaminophen. 9. N-acetylcysteine is antidote for paracetamol overdose.

Cardiovascular
y y y y y y y y y y y y

Anticoagulants Thrombolytics Hemostatic Agents Antiplatelets Cardiac Glycosides Nitrates Anti-arrhythmics Antilipemics ACE Inhibitors Calcium-Channel Blockers Diuretics Vasodilating Agents

Anticoagulants
2 Types: 1. Heparin SQ & IV 2. Warfarin Oral Mechanism of actions : y Heparin prevents thrombin from converting fibrinogen to fibrin. y Warfarin suppress coagulation by acting as an antagonist of vitamin K after 4-5 days

Anticoagulants
Indications thrombosis, pulmonary embolism, myocardial infarction y Adverse effect bleeding
y

Nursing Considerations
HEPARIN sodium y if given SQ dont aspirate or rub the injection site (above the scapula - best site). y therapeutic level 1.5-2.5 times normal PTT; y normal PTT is 20-35 sec. = 50-85 sec. y antidote : (protamine sulfate)
1.

Nursing Considerations
2. y y y y y y y

WARFARIN sodium (coumadin) warfarin is used for long-term. onset of action is 4-5 days. therapeutic level is 1.5-2.5 times normal PT; normal PT = 9.6 -11.8 sec. = 25 - 30 sec. should be taken at the same time of the day to maintain at therapeutic level. reduce intake of green leafy vegetables. antidote : Vitamin K ( Aquamephyton)

Thrombolytics
Mechanism of action activates plasminogen to generates plasmin (enzyme that dissolve clots) y Indication - use early in the course of MI (within 4-6 hours of the onset) y Prototype Streptokinase, Urokinase y Nursing considerations - monitor bleeding, antidote : Aminocaproic acid
y

Hemostatic Agents
Mechanism of action terminates/stops bleeding y Indications treatment of bleeding as a side effect for anticoagulant/thrombolytic therapy y Prototype Aminocaproic acid (Amicar), Tranexamic acid (Hemostan), Protamine sulfate,Vitamin K (aquaMEPHYTON, Konakion)
y

Antiplatelets
Mechanism of action inhibit the aggregation of platelet thereby prolonging bleeding time y Indication - used in the prophylaxis of long-term complication following M.I, coronary revascularization, and thrombotic CVA
y

Antiplatelets
Prototypes - aspirin, Dipyridamole (Persantin), Clopidoigrel (Plavix), Ticlopidine y Nursing Considerations - Monitor bleeding time ( NV = 1-9 mins), take the medication with food
y

Cardiac Glycosides
increase intracellular calcium, which causes the heart muscle fibers to contract more efficiently, producing positive inotropic & negative chronotropic action y Indications use for CHF, atrial tachycardia and fibrillation
y

Cardiac Glycosides
Prototype digoxin (Lanoxin) and digitoxin (Crystodigin) Nursing considerations : 1. Monitor for toxicity as evidence by : nausea, vomiting, anorexia, halo vision, confusion, bradycardia and heart blocks. 2. Do not administer if pulse is less than 60 bpm. 3. Should be caution in patient with hypothyroidism and hypokalemia. 4. Antidote : Digi-bind 5. Phenytoin is the drug of choice to manage digitalis-induced arrhythmia
y

Nitrates
Mechanism of action produce vasodilatation including coronary artery y Indication angina pectoris, MI, peripheral arterial occlusive disease y Prototype isosorbide dinitrate (Isordil), nitroglycerine (Deponit, Nitrostat) y Adverse effects headache orthostatic hypotension
y

Nitrates
Nursing Considerations : 1. Transdermal patch y - apply the patch to a hairless area using a new patch and different site each day. y - remove the patch after 12-24 hours, allowing 10-12 hours patch free each day to prevent tolerance. 2. Sublingual medications y - note the BP before giving the medication. y - offer sips of water before giving because dryness may inhibit absorption. y - one tablet for pain and repeat every 5 mins. for a total of three doses; if not relieved after 15 mins., seek medical help. y - stinging or burning sensation indicates that the tablet is fresh. y - instruct patient not to swallow the pill y - sustained release medications should be swallowed and not to be crush. y - protect the pills from light.

AntiAnti-arrhythmics
Class I (block Na channels) IA - quinidine, procainamide IB - lidocaine IC - flecainamide y Class II (Beta-blockers) propanolol, esmolol y Class III (block K channels) amiodarone, bretylium y Class IV (block Ca channels) verapramil, diltiazem
y

AntiAnti-arrhythmics
Nursing considerations : 1. Watch out for signs of CHF. 2. Have client weigh themselves and report weight gain. 3. Watch out for signs of lidocaine toxicity : - confusion and restlessness

Antilipemics
Mechanism of action interfere with cholesterol synthesis as well as decreasing lipoprotein & triglyceride synthesis Prototype : y cholesterol-lowering agents cholestyramine, colestipol, lovastatin, atorvastatin (Lipitor) y triglyceride-lowering agents gemfibrozil, clofibrate
y

Antilipemics
Nursing considerations : y - monitor liver functions while using statins. y - prevent constipation, flatulence, cholelithiasis y - encourage increase fluid and fiber intake.

ACE Inhibitors
Mechanism of action prevent peripheral vasoconstriction by blocking conversion of angiotensin I to angiotensin II decreasing peripheral resistance y Prototype captopril (Capoten), enalapril (Vasotec), quinapril, lisinopril y Adverse effects it cause hyperkalemia, induce chronic cough
y

ACE Inhibitors
Nursing considerations : y - not to discontinue medications because it can cause rebound hypertension. y - avoid using K+ sparing diuretics.

CalciumCalcium-Channel Blockers
Mechanism of action decrease cardiac contractility and the workload of the heart, thus decreasing the need for O2, it also promotes vasodilatation of the coronary and peripheral vessels y Indications hypertension, angina, arrhythmia
y

CalciumCalcium-Channel Blockers
Prototype Nifedipine (calcibloc, adalat), Amlodipine (norvasc), Felodipine (Plendil), Verapramil (Isoptin) y Adverse Effects bradycardia, hypotension, headache, reflex tachycardia, constipation
y

CalciumCalcium-Channel Blockers
Nursing considerations : y - Administer between meals to enhance absorption. y - Take clients pulse rate before each dose, withhold if pulse is below 60 bpm. y - Refer for signs of congestive heart failure.

Diuretics
CARBONIC ANHYDRASE INHIBITORS y - Acetazolimide (Diamox) y - increase Na+, K+, & HCO3 secretion, along with it is H2O y - metabolic acidosis OSMOTIC DIURETIC y - Mannitol y - Increase osmotic pressure of the glomerular filtrate. y - hypotension THIAZIDE DIURETICS y - hydrochlorothiazide - blocks Na and K reabsorption; reabsorb Ca y - hypercalcemia LOOP DIURETICS y - Furosemide (Lasix) y - blocks Na, K, and Ca reabsorption y - hypocalcemia POTASSIUM SPARING DIURETICS y - Spironolactone (Aldactone) y - excrete Na and water but it reabsorb K y - hyperkalemia
y

Respiratory
Bronchodilators y Glucocorticoids y Mast Cell Stabilizers y Antihistamines (H1) y Anti-TB y Decongestants, Antitussives, & Expectorants
y

Bronchodilators
2 Types: 1. Symphatomimetic albuterol, salbutamol, isoproterenol, salmeterol, terbutaline 2. Xanthines aminophylline, theophylline

Bronchodilators
Mechanism of actions: y - sympathomimetic (b-receptor agonist) bronchodilators dilate airways y - xanthine bronchodilators stimulate CNS for respiration Indications bronchospasm, asthma, bronchitis, COPD

Bronchodilators
Adverse effects palpitations and tachycardia, restlessness, nervousness, tremors, anorexia, nausea and vomiting, headache, dizziness Nursing considerations : y - Contraindicated hyperthyroidism, cardiac dysrhythmia, or uncontrolled seizure disorder y - Should be used with caution in patient with HPN and narrow-angle glaucoma
y

Glucocorticoids
Mechanism of action act as antiinflammatory agents and reduce edema of the airways, as well as pulmonary edema y Prototype dexamethasone, budesonide, fluticasone, prednisone, beclomethasone y Adverse effects Cushings syndrome, neutropenia, osteoporosis
y

Glucocorticoids
Nursing considerations : y - Take drugs at meal time or with food. y - Eat foods high in potassium, low in sodium. y - Instruct client to avoid individuals with RTI. y - Instruct client not to stop medication abruptly, it should be tapered to prevent adrenal insufficiency y - Avoid taking NSAID while taking steroids. y - Take inhaled bronchodilators first before taking inhaled steroids, and rinse mouth after using.

Mast Cell Stabilizers

Mechanism of action stabilize mast cells that release histamine triggering asthmatic attacks y Prototype cromolyn sodium (Intal) Nursing Consideration: y - Should be given before asthmatic attacks. y - Administer oral capsule at least 30 mins before meals for better absorption. y - Drink a few sips of water before & after inhalation to prevent cough & unpleasant taste y - Assess for lactose-intolerance
y

H1 Blockers
Mechanism of action decrease nasopharyngeal secretions and decrease nasal itching by blocking histamine in H1receptor y Indications common colds, rhinitis, nausea and vomiting, urticaria, allergies and as sleep aid
y

H1 Blockers
Prototype - Astemizole (Hismanal), Loratidine (Claritin), Brompheniramine (Dimetapp), Diphenhydramine (Benadryl), Cetirizine (Iterax), Celestamine (Tavist) Nursing Considerations : y - Administer with food and drink. y - Given IM via Z-track method or orally. y - Precautions in handling machine and driving while taking these drugs. y - Ice chips or candy for dry mouth
y

AntiAnti-TB
First Line: y Rifampicin y Isoniazid y Pyrazinamide y Ethambutol y Streptomycin
y

Second Line: y Cycloserine y Kanamycin y Ethonamide y Para-aminosalicylic Acid

y

AntiAnti-TB
- active tuberculosis are treated with drug combination for 6-9 mos. y - multidrug-resistant strain (MDR-TB) are medicated for 1 year up to 2 years y - given before meals
y

Rifampicin
- given on an empty stomach with 8 0z. of water, 1 hour before or 2 hours after meals and avoid taking antacids with medications. y - hepatotoxic thus avoid alcohol. y - instruct the client that urine, feces, sweat, and tears will be redorange in color.
y

Isoniazid
y y y

y y

- should be given 1 hr before or 2 hrs after meals because food may delay absorption. - should be given at least 1 hr before antacids. - instruct to notify physician for signs of hepatoxicity (jaundice), and neurotoxicity, numbness of extremities. - administer with Vitamin B6 to counteract the neurotoxic side effects. - avoid alcohol.

Pyrazinamide
- given for 2 months. y - increase serum uric acid and cause photosensitivity.
y

Ethambutol
- contraindicated in children under 13 years old. y - obtain a baseline visual acuity because it can cause optic neuritis. y - Instruct the client to notify the physician immediately if any visual problems occurs.
y

Streptomycin
- aminoglycoside antibiotic given IM. y - nephrotoxic and ototoxic. y - obtain baseline audiometric test and repeat every 1-2 months because the medications impairs the CN VIII.
y

Cough & Cold Remedies

3 Types: 1. Decongestants 2. Antitussives 3. Expectorants

Decongestants
Mechanism of action acts through sympathomimetic action, usually by constricting arterioles & reducing blood flow to the area y Prototype phenylephrine
y

Antitussives
Mechanism of action suppresses the cough center in the medulla y Prototype dextromethorpan
y

Expectorant
Mechanism of action facilitate the secretion of fluid in the respiratory tract, thus liquefying secretions and allowing for easier expectoration during a cough y Prototype guaifenesin (Robitussin)
y

Gastrointestinal
Antacids y H2 Blockers y Proton-Pump Inhibitors y Mucosal Barriers y Anti-diarrheals y Laxatives y Emetics y Antiemetics
y

Antacids
Mechanism of action neutralize the stomach acidity y Prototype aluminum/magnesium compounds (Maalox), sodium bicarbonate (Alka-Seltzer), calcium carbonate (Tums), magnesium hydroxide (Milk of Magnesia)
y

Antacids
y

Adverse effects - metabolic alkalosis, stone formation, electrolyte imbalance, diarrhea (magnesium), constipation (aluminum)

Antacids
Nursing considerations : y - Give 1 hr after meals. y - Avoid giving medications within 1-2 hrs of antacid administration (decreases absorption). y - Take fluids to flush after intake of antacid suspensions. y - Monitor for changes of bowel patterns.

H2 Blockers
Mechanism of action - blocks H2 receptors in the stomach, reducing acid secretions y Prototype cimetidine (Tagamet), ranitidine (Zantac), famotidine (Pepcid), nizatidine (Axid)
y

H2 Blockers
Nursing considerations : y - Given before or with meals y - Avoid giving other drugs with cimetidine y - Gynecomastia may develop with chronic use of cimetidine

ProtonProton-Pump Inhibitors
Mechanism of action inhibit the proton H+ to combine with Cl- to form hydrochloric acid y Prototype omeprazole (Losec), Lansoprazole (Lanz), pantoprazole (Pantoloc) Nursing considerations : y - Given before meals preferably at morning.
y

Mucosal Barriers
Mechanism of action - coats the mucosa to prevent ulcerations y Prototype - sucralfate (Carafate), misoprostol (Cytotec) Nursing consideration : y - Given before meals. y - Misoprostol is contraindicated for pregnants. y - Sucralfate cause constipation.
y

AntiAnti-diarrheals
Mechanism of action decreases stomach motility and peristalsis y Prototype diphenoxylate (Lomotil), loperamide (Imodium), kaolin/pectin mixture (Kaopectate)
y

AntiAnti-diarrheals
Nursing considerations : y - Monitor for rebound constipation. y - Be cautious taking if with infectious diarrhea. y - Monitor atropine toxicity with diphenoxylate. y - Clay, white or pale stool is common with kaopectate.

Laxatives
a.

lactulose (Cephulac), Na biphosphate (Fleet enema) & magnesium salt (Milk of Magnesia)
x - retain fluid and distend intestine

b. c.

ducosate (Dialose)
x - emulsify fecal fat and water

bisacodyl (Dulcolax) & senna (X-prep)

x - irritates intestinal mucosa and stimulate intestinal smooth muscles

d. e.

bulk-forming laxative (Metamucil)

x - increase fecal bulk and water content

mineral oil
x - lubricates & prevent colon absorption

Emetics
Mechanism of action induce vomiting through stimulation of vomiting center of medulla y Indications ingestion of poisonous or toxic substances y Prototype - ipecac syrup, apomorphine
y

Emetics
Nursing considerations : y - Consult poison control center before induction of vomiting. y - Administer ipecac syrup with large amount of fluid.

Antiemetics
Mechanism of action inhibit the vomiting reflex y Prototype metoclopramide (Plasil)
y

Endocrine
Thyroid Agents y Parathyroid Agents y Oral Hypoglycemic Agents y Insulin y Estrogen/Progesterone
y

Thyroid Agents
Mechanism of action function as natural or synthetic hormones y Prototype Proloid (thryroglobulin ), Synthroid (levothyroxine), Cytomel ( liothyronine)
y

Thyroid Agents
Nursing considerations : y - Taken in the morning. y - Caution with coronary artery disease. y - Monitor for signs of hyperthyroidism and refer for decreasing the dose.

Parathyroid Agents
Mechanism of action reduce bone resorption, promotes calcium absorption y Prototype calcitonin (Calcimar), etidronate (Didronel), calcitrol (Rocaltrol), calcifediol (Calcedrol) Nursing considerations : y - Monitor signs of calcium imbalance y - Report for bone pains. y - Remain sitting upright after taking etidronate
y

Oral Hypoglycemics
Sulfonylureas y Biguanides y Alpha-glucosidase Inhibitors y Thiazolinidine y Meglitinidines
y

Sulfonylureas
- stimulate insulin secretions and increase tissue sensitivity to insulin. First Generation : y Chlorpropamide (Diabenese) disulfiram precautions y Tolbutamide (Orinase) congenital defect Second Generation : y Glypizide, Glymepiride
y

Biguanides
y

- facilitates insulin action on the peripheral receptor site. Metformin and Glucophage (Glucovance) side effect is lactic acidosis

AlphaAlpha-glucosidase Inhibitors
y

- delay carbohydrate absorption in the intestinal system. Acarbose (Precose) side effect is diarrhea

Thiazolinidine
y

- increase tissue sensitivity of insulin. Rosiglitazone (Avandia)

Meglitinidines
y

- stimulate insulin release in pancreatic Bcells. Repaglinide (Prandin)

Insulin
Insulin Immediate-acting (lispro) Short-acting (regular, semilente) Intermediateacting (NPH, Lente) Long-acting (ultralente) Mixed (reg. 30%, NPH 70%) Onset - -1 Peak -1 24 Duration 3 68

12

6 12

18 24

24

10 30 48

24 36 25

Insulin
Nursing considerations : y - Usually given before meals. y - Roll the bottle in palm of hands, dont shake. y - Inject amount of air that is equal to each dose into the bottle short acting last (clear). y - Aspirate short acting first, then long or intermediate (cloudy). y - Alcohol is recommended for cleansing bottle but not with skin. y - Pinch skin, avoid I.M, dont aspirate. y - Rotate the injection site an inch a part. y - Prefilled syringes are stored vertically, needle-up. y - May increase dose during illnesses. y - Used bottles stored in room temperature, unused bottle stored in refrigerator. y - Monitor for acute hypoglycemia : a. 3-4 commercially prepared glucose tablet b. 4-6 ounce of fruit juice or regular soda c. 2-3 teaspoon or honey d. Glucagon 1 gm SQ or IM e. D50-50 IV.

Estrogens & Progesterones

Prototype conjugated estrogen (Premarin), estrone (Bestrone), estradiol (Estrace), diethylstilbestrol (DES) y Indications prostate cancer, contraceptions, estrogen replacement Adverse effects : estrogen - endometrial CA, gallbladder disease, HPN, migraine, breast tenderness progesterone - altered menstrual flow, risk of thrombo embolism
y

Estrogens & Progesterones

Nursing considerations : 1. Mix estrogen or progestins prior to IM administration by rolling vials between palms. 2. Monitor blood pressure. 3. Teach patient how to perform BSE. 4. Regular follow-up examination is required to detect associated risk of acquiring CA.

Gynecologic
Uterine Stimulating Agents y Uterine Inhibiting Agents y Lactation Suppressants
y

Uterine Stimulating Agents

Mechanism of action stimulates uterine smooth muscles, ripening of cervix y Prototype Oxytocin (Pitocin), ergonovine (Ergotrate), methylergonovine (methergine), carbopost (Prostin), dinoprostone (Prostin E2) Adverse reactions : y - fetal bradycardia (oxytocin), y - hypertension (ergonovine), palpitations y - allergic reactions (Prostaglandins)
y

Uterine Inhibiting Agents (Tocolytics) Tocolytics)

Mechanism of action relaxes the uterus by stimulating the B2- adrenergic receptors y Prototype ritodrine (Yutopar), terbutaline (Brethine) y Adverse effects tremors, nausea, vomiting and tachycardia
y

Lactation Suppressants
Mechanism of action decrease serum prolactin levels y Prototype bromocriptine (Parlodel) y Adverse effects drowsiness, headache, nausea, palpitations
y