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BASIC PHARMACOLOGY Prepared by: Ms. Desiree Ann C. Reyes R.N. DEFINITION OF A DRUG A DRUG IS ANY SUBSTANCE USED TO DIAGNOSE, CURE, MITIGATE, TREAT OR PREVENT A CONDITION OR DISEASE. DRUGS COME FROM THREE MAIN SOURCES: PLANTS (DIGOXIN), ANIMALS (INSULIN) AND SYNTHETIC CHEMICALS FACTORS AFFECTING DRUG ACTION 1.ABSORPTION-refers to the time the drug enters the body until it enters the bloodstream. Parenteral route-absorption is generally rapid Oral-absorption can vary depending on GI motility, presence of food in the stomach and use of other drugs 2. DISTRIBUTION- once in bloodstream, drugs are distributed around the body. distribution can take as long as several hours, depending on blood flow, and cardiac output. -Barriers to Drug Distribution: Blood-Brain Barrier Placental Barrier 3. METABOLISM-a sequence of chemical events that change a drug after it enters the body. -liver is the principal site of drug metabolism. -liver enzymes involved in metabolism rely on adequate amounts of amino acids, lipids, vitamins and carbohydrates. -insufficient amount of major body hormones such as insulin or adrenal corticosteroids can reduce metabolism of drugs in liver. 4. EXCRETION- process by which drugs are eliminated from body -drugs can be excreted by kidneys, intestines, lungs, mammary, sweat and salivary glands. Example: PROBENICID is sometimes administered with penicillin to prevent excretion of penicillin and thus increase the effects of penicillin. ANTACIDS increase elimination of aspirin, thus decreasing its effects. 5. ACCUMULATION Therapeutic Levels Important goals is for drug to reach therapeutic levels and maintain therapeutic level. Toxicity-occurs when drug is eliminated more slowly than it is absorbed, causing excessive drug concentration. 6. UNDERLYING DISEASE -disease can lead to variable drug response -Diseases that may affect drug response: Cardiovascular disease Gastrointestinal disease Liver disease Kidney disease 7. CLIENTS AGE Pediatric-drug dosages are based on body weight (mg/kg) Geriatric-careful drug history should be obtained, including over-the-counter (OTC) drugs to determine if there are drug interactions or adverse effects. MEDICATION ORDERS STAT ORDER- INDICATES THAT THE MEDICATION IS TO BE GIVEN IMMEDIATELY AND ONLY ONCE ( DEMEROL 100 MG IM STAT) SINGLE ORDER- FOR A MEDICATION TO BE GIVEN ONCE AT A SPECIFIED TIME ( SECONAL 100 MG hs BEFORE SURGERY)

STANDING ORDER- MAY OR MAY NOT HAVE A TERMINATION DATE; MAY BE CARRIED OUT INDEFINITELY UNTIL AN ORDER IS WRITTEN TO CANCEL IT OR MAYBE CARRIED OUT FOR SPECIFIED NUMBER OF DAYS. PRN ORDER- PERMITS THE NURSE TO GIVE A MEDICATION WHEN, IN THE NURSE JUDGEMENT, THE PATIENT REQUIRES IT.

PLACEBO EFFECT- THE ANTICIPATION THAT A DRUG WILL BE HELPFUL/ THE NURSE SUPPORT AND ATTITUDE ARE CRITICAL PART OF DRUG THERAPY - BACK RUB, KIND WORD, POSITIVE APPROACH DRUG ADMINISTRATION General Principles for All Medications Administration of Oral Medications Administration of Rectal Drugs Administration of Nasal Medications Administration of Inhalants Administration of Ophthalmic Medications Administration of Otic Medications Administration of Topical Agents Administration of Vaginal Medications Administration of Parenteral Medications GENERAL PRINCIPLES FOR ALL MEDICATIONS Verify all new or questionable orders on the medication administration record (MAR) against physician orders. Prepare medications in a quiet environment Wash your hands. Observe universal precautions. Collect all necessary equipment.

5. Review MAR for each client carefully to ensure safety: note medication, dosage, route, expiration date, and frequency. 6. Research drug compatibilities, action, purpose, contraindications, side effects, and appropriate routes. 7. Find medication for individual client and calculate dosage accurately. Confirm normal range of dose, particularly in pediatrics 8. Check expiration date on medication and look for any changes that may indicate decomposition (color, odor and clarity). 9. Compare label three times with the medication to decrease the risk of error. a. when removing package from drawer b. before preparing medication c. after preparing medication 10. Check need for PRN medications 11. Be sure medications are identified for each client. 12. Check for any allergies and perform all special assessments before administration. 13. Confirm clients identity by checking at least two of the three possible mechanisms for identification to ensure safety. a. ask client his name b. check clients ID band c. check bed tag (this is least reliable method) 14. Provide privacy, if needed. 15. Inform client of medication, any procedure, technique, purpose, and client teaching as applicable. 16. Stay with client until medication is gone; do not leave medication at bedside. 17.Assist the client as needed, and leave in position of comfort.

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18.Give medication within 30 minutes of prescribed time 19. Chart administration immediately in ink, marking your initials and document rationale if drug not administered. 20. Report any errors immediately and complete appropriate institutional documentation. 21. Liquid medicationsall routes of administrationMUST NOT be mixed together unless compatibility is verified. 22. Observe for any reactions and document both positive and negative responses. 23.Observe the 10 rights: RIGHT dose of the RIGHT drug to the RIGHT client at the RIGHT time by the RIGHT route with the RIGHT equipment, RIGHT documentation. Right History and Assessment, Drug approach and Right to Refuse, Right DrugDrug Interaction and Evaluation and Right Education and Information 24. To ensure safety do not give a medication that someone else prepared. ADMINISTRATION OF ORAL MEDICATIONS Special assessment: assess clients knowledge level, diet status, oral cavity, and ability to swallow medication. Use mortar and pestle to crush tablets, if appropriate. In general, enteric-coated tablets should not be crushed. Only scored tablets can be broken.

Special assessment: assess clients bowel function and ability to retain suppository/enema. Remove suppository from refrigerator. Provide privacy. Position client left laterally. Put on glove. Moisten suppository with water-soluble lubricant.

7. Insert suppository, tapered end first, approximately 2 inches (to pass internal sphincter). 8. Hold buttocks together. 9. Encourage client to retain suppository to melt. 10. If drug administered via enema, have client retain solution 2030 minutes. ADMINISTRATION OF NASAL MEDICATIONS Have client blow nose to clear mucus. Position client so that head can be tilted back to aid in gravitational flow or in specific position to reach sinuses. Push up on tip of nostril Place dropper angled slightly upward just inside the nostril; be careful not to touch nose with applicator.

3. Unless contraindicated, give medication with 60-100 mL water or juice to aid in swallowing and to increase intake. 4. All solid medications can be placed in one medicine cup unless an assessment needs to be made before administering a particular medication. 5. To reduce chance of contamination, place any removable lids open side up; place necessary medications into cap of container; transfer to medicine cup, replace lid and container. 6. Shake liquid medications, if necessary, to mix. 7. Read liquid amount at meniscus of med cup at eye level to ensure accuracy. 8. If needed, a syringe may be used to measure and administer liquid medications. 9. Wipe lip of bottle with damp towel to prevent stickiness. 10. Place client in upright position to enhance swallowing. 10. Have client swallow medication except with the following: a. Sublingual (SL) route: have client place medication under tongue. Do not allow fluids for 30 minutes ff administration. b. Buccal route: have client place medication between gum and cheek. Do not allow fluids for 30 minutes ff administration. c. IRON: have client use straw to prevent staining of teeth. 11. Stay with client until medication is gone. Use gloves if you place your finger in clients mouth. 12. Special concerns: use calibrated dropper, nipple or syringe when giving medication to an infant. Keep infant at 45 degree angle. See if medication is available in liquid form if client is a child or unable to swallow solid medication. Be sure not to use a childs favorite food, as this may result in distrust. If using an NG or stomach tube, for administration, check for correct placement before administering medication.

5. Squeeze atomizer quickly and firmly or instill correct number drops. 6. Remind client to keep head tilted for 5 minutes. 7. Inform client the drops may produce an unpleasant taste. 8. Leave tissues with client; instruct just to wipe nose, not blow, to allow for absorption. 9. Special Concerns: If client aspirates and begins to cough, sit client upright, stay until clients distress is relieved. If client is an infant, lay infant on its back ADMINISTRATION OF INHALANTS Special assessment: monitor vital signs and after treatments. Have client inhale and exhale deeply Have client place lips around mouthpiece without touching and inhale medication until lungs are fully inflated.

4. Have client remove mouthpiece, hold breath long as able, and then exhale completely. 5. If necessary, repeat procedure until medication is gone. 6. Wash mouthpiece with warm water. 7. Wash mouthpiece with warm water. 8. Special Concerns: Have tissues handy; encourage expectoration of sputum. Be sure client is aware that coughing is expected after treatment. If mouth is placed directly on inhaler, it is possible that the tongue will absorb medication, resulting in inadequate dosing and tongue irritation. ADMINISTRATION OF OPHTHALMIC MEDICATIONS Check solution for color and clarity before administering. Warm solution in hands before adminstration. Have client lie on back or sit with head turned to affected side to aid in gravitational flow.

ADMINISTRATION OF RECTAL DRUGS

4. Cleanse eyelid and eyelashes with sterile gauze pad soaked with physiologic saline. Assess eye condition. 5. Have client look up. 6. Assist client in keeping eye open by pulling down on cheekbone with thumb or forefinger and pulling up on eyelid. Be sure lower conjunctiva is exposed. 7. Place necessary number of drops into lower conjunctiva near outer canthus

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8. If using ointment, squeeze into lower conjunctiva moving from inner to outer canthus. -do not touch eye with applicator -twist tube to break medication stream 9. Have client blink 2-3 times. 10. Wipe away any excess medication starting from inner canthus. 11. Repeat if necessary using clean tissue. 12. Special concerns: Ophthalmic medications are for individual clients; droppers and ointments should not be shared. Restrain infants and children if necessary. ADMINISTRATION OF OTIC MEDICATIONS Warm medication in hands prior to administration. Have client turn to unaffected side to aid gravitational flow. Clean outer ear using a wet gauze pad. Assess ear condition. Straighten ear canal by pulling pinna up and back for adults or down and back for infants 11. Provide client with pads if needed. ADMINISTRATION OF PARENTERAL MEDICATIONS (GENERAL PRINCIPLES) Special assessments for parenteral medications: Assess area for presence of lesions, rashes, or abscesses prior to administration. Assess for discomfort or impaired mobility which may affect site of selection. Assess client ability for self-injection, if appropriate. 2. Select appropriate needle size and syringe. Use tuberculin 1 mL syringe for volumes less than 1 mL. Needle lumen must be larger for solution with increased viscosity. 3.When medication comes in a vial, cleanse rubber stopper with alcohol pledget. 4. Without contaminating the plunger, draw up air equal to the amount of medication needed. 5. Inject the air into the vial to prevent negative pressure and aid in aspirating medication. 6. Remove the appropriate amount of medication. 7. Check to ensure no air bubbles are present, if bubbles are a problem, draw up slightly medication than is needed, return all medication to the vial, and withdraw medication again or tap syringe until air is all collected at top of barrel and can be expelled. 8. When using an ampule: tap the neck to force medication into ampule, wrap neck with alcohol pledget, snap off top toward self, place needle into ampule to withdraw medication. 9. When mixing a powder, use a filter needle when drawing up medication. Reconstitute according to manufacturers recommendations. 10. Replace protective cover on needle before proceeding. 11. Select appropriate site, avoiding bruised or tender areas; rotate sites as much as possible. 12. Cleanse site with alcohol pledget to decrease contamination. Use gloves to avoid contact with blood. 13. Insert needle quickly with bevel up, leaving a small amount of needle showing, and release hold (to decrease pain). With the exception of heparin, aspirate to check for blood. If blood is present, remove needle and start again. When giving medications IV, a blood return is desired. 14. Inject medication slowly. 15. Place alcohol pledget over site with gentle pressure. 16. Remove needle and massage area; do not massage area if giving heparin or a Z-track injection. 17. Record site when documenting medication administration to assist in site rotation and avoid tissue atrophy. 18. Variations on preparing medications: Disposable injection systems have already prepared catridges with attached needle appropriate to route and viscosity. To add medication, add sterile air from cartridge to vial, then add medication from vial to cartridge. When combining two medications from an ampule and a vial, first determine appropriate volumes, as well as the total volume. Withdraw appropriate volume of medication from vial, followed by medication in ampule. When combining medications from two vials, determine appropriate volume for each drug and total volume. Inject air into vial A, then into vial B. Withdraw medication from vial B, then return to vial A.

5. Instill necessary number of drops along side of canal without touching ear with dropper. 6. Maintain position of ear until medication has totally entered canal. 7. Have client remain on side for 5-10 minutes to allow medication to reach inner ear. 8. Cotton may be used to keep medication in canal, but only if it is premoistened with medication. 9. Repeat procedure for other ear if necessary. 10. Special Concern:restrain infants and children if necessary. ADMINISTRATION OF TOPICAL AGENTS Provide privacy and expose only appropriate area to promote comfort. Cleanse area of old medications using gauze pads with soap and warm water. Use gloves and gauze, tongue depressor or sterile applicator, if integument broken Assess area for any changes or contraindications of application

5. Spread medication over site evenly and thinly. 6. If necessary cover area loosely with a dressing. 7. Special Concerns: Clients often receive topical agents for image-altering problems. When applying nitroglycerin ointment, take clients blood pressure 5 minutes before and after application. Wash hands after administration to prevent selfabsorption. When using transderm patches, use gloves to avoid inadvertent drug absorption. ADMINISTRATION OF VAGINAL MEDICATIONS Provide privacy. Put on gloves. Have client void. Place client on a bedpan in dorsal recumbent position with hips and knees flexed. Cleanse perineum with warm, soapy water, working from outer to inner position. Moisten applicator tip with water-soluble lubricant. 7. Separate labia to insert applicator approximately 2 inches, angled downward and back. 8. Instill medication. 9. If giving douche, dry clients buttocks; otherwise have client remain in position approximately 15-20 minutes (there is no sphincter to hold suppository in place). 10. Wash applicator with warm, soapy water.

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INTRADERMAL ADMINISTRATION Use size 26g-27g, 1 inch needle on a 1 mL or tuberculin syringe (volume will be approximately 0.1 mL). Stretch skin taut. Insert needle at 10-15 degree angle approximately 1-2 mm depth with needle bevel upward. When wheal appears, remove needle; do not massage site. Possible sites: Ventral forearm Scapula Upper chest SUBCUTANEOUS (SC) ADMINISTRATION Use size 25g to 27 g, -1 inch needle, maximum volume 1.5 mL. Pinch skin to form SC fold. Insert needle at 45 degree angle in thigh or armor 90 degree in abdomen (to avoid entering muscle) Possible sites: Lateral aspect of upper arm (deltoid) Anterior thigh Abdomen; 1 inch away from umbilicus Back, in scapular area INTRAMUSCULAR ADMINISTRATION Use size 18g-23g, 1-2 inch needle, maximum volume 5 mL. Stretch skin taut. Insert needle at 90 degree angle. Possible sites: GLUTEUS MINIMUS (ventrogluteal): Landmarks are anterior superior iliac spine, iliac crest, greater trochanter of femur. VASTUS LATERALIS (anterior thigh) RECTUS FEMORIS (medial thigh) GLUTEUS MEDIUS (dorsogluteal): Landmarks are posterior superior iliac spine, iliac crest, greater trochanter of femur. Deltoid WELL, INT, MALE ADAPTOR, CAPPED JELCO, OR HEPARIN LOCK SWAB INJECTION PORT WITH ALCOHOL AT EACH STEP USE SASH METHOD TO GIVE MEDICATION S: FLUSH WITH 2 ML SALINE A: ASMININSTER MEDICATION AT PRESCRIBED REAT USING A SHORT NEEDLE WITH A GAUGE EQUAL TO OR SMALLER THAN CATHETER (25 G, IN) S: FLUSH WITH 2 ML SALINE ( MAINTAIN POSITIVE PRESSURE TO PREVENT BLOOD BACK-UP INTO CATHETER). NOT REQUIRED IF DRUG COMPATIBLE WITH HEPARIN H: FLUSH WITH 10-100 UNITS HEPARIN IF REQUIRED BY FACILITY POLICY SECONDARY PIGGBYBACK/ADD-A-LINE ( ADDED TO AN EXISTING IV LINE) WITH REGULAR TURNED OFF, SPIKE TUBING INTO IV BAG WITH MEDICATION SQUEEZE DRIP CHAMBER; FILL HALFWAY WITH SOLUTION RUN FLUID THROUGH TUBING IF USING ADD-A-LINE TUBING, LOWER MAIN IV BAG ON HANGER PROVIDED, OTHERWISE HANG AT SAME LEVEL AS PRIMARY BAG SWAB MOST PROXIMAL PORT WITH ALCOHOL FOR ADDA-LINE SYSTEMS, OTHERWISE LOWER PORT IS ACCEPTABLE

5. Z-track injection for irritating solutions: Needle size: replace needle used to draw up medication with one 2-3 inches long, 20-22 g Pull skin away from site laterally with nondominant hand to ensure medication enters muscle. Wait 10 seconds after injecting medication before withdrawing needle. Release skin; do not massage (to seal needle track) Encourage physical activity Possible sites: gluteus medius best, but may use any IM site except deltoid. ADMINISTRATION OF INTRAVENOUS (IV) MEDICATIONS A. GENERAL PRINCIPLES: CHECK SITE FOR COMPLICATIONS (REDNESS, SWELLING, TENDERNESS) CHECK FOR BLOOD RETURN PREPARE MEDICATION ACCORDING TO MANUFACTURERS SPECIFICATIONS APPROPRIATE TUBING SELECTION VARIES ACCORDING TO INSTITUTION POLICY. GENERALLY, RATES GREATER THAN OR EQUAL TO 12 HOURS REQUIRE MICROTUBING (60 gtts/ml), ALL OTHERS REQUIRE MACROTUBING ( 10,15, OR 20 gtts/ml. 5. GLOVES SHOULD BE WORN WHEN CONTACT WITH BLOOD OR OTHER BODY FLUIDS IS A POSSIBILITY. B. INTERMITTENT THERAPY ( ALSO KNOWN AS HEPARIN

6. ATTACH 20 G, 1-INCH NEEDLE TO TUBING, IF A NEEDLESS SYSTEM IS NOT BEING USED 7. INSERT NEEDLE INTO INJECTION PORT 8. REGULATE RATE WITH CONTROL AND WATCH TO COUNT DROPS 9. WHEN MEDICATIONS ABSORBED, MAIN LINE WILL START TO DRIP AGAIN 10. TURN OFF SECONDARY TUBING 11. RETURN MAIN BAG TO ORIGINAL POSITION 12. SPECIAL CONCERNS BE SURE TO LABEL TUBING WITH DATE USE NEW TUBING EVERY 24-72 HOURS (ACCORDING TO POLICY) INTRAVENOUS PUSH MEDICATIONS USING AN APPROPRIATE SIZED NEEDLE, PREPARE MEDICATION AS ORDERED CLEANSE INJECTION PORT WITH ALCOHOL OR OTHER APPROPRIATE CLEANSER.

COMPLICATIONS OF IV THERAPY 1. INFECTION S/SX: redness, swelling, drainage at site, chills, fever, malaise, headache, nausea, vomiting, backache and tachycardia. Interventions: Maintain strict asepsis when caring for the IV site Monitor for signs of local and systemic infection Change tubing and site dressing every 24-72 hours according to agency policy. Label the IV site, bag or bottle and tubing with the date and time

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Ensure that the IV solution is not hanging for more than 24 hours. If infection occurs, discontinue the IV, place a sterile cover on the venipuncture device. Restart an IV in the opposite arm 2. PHLEBITIS-inflammation of the vein that can occur from mechanical or chemical trauma or from local infection. S/SX: heat, redness, tenderness at site, not swollen or hard, intravenous infusion sluggish Interventions: Use an IV cannula smaller than the vein Avoid using the lower extremities. Change the venipuncture site every 48 to 72 hours depending on agency policy. If Phlebitis occurs, remove the IV device immediately and restart it in the opposite extremity. Notify the physician if phlebitis is suspected, and apply warm, moist compresses as prescribed. 3. INFILTRATION-seepage of the intravenous fluid out of the vein and ito the surrounding interstitial spaces. -also called EXTRAVASATION S/SX: edema, pain, and coolness at the site, may or may not have blood return Interventions: Remove the IV device immediately. Do not rub the infiltrated area. Elevate the extremity and apply warm or cool compresses as prescribed. 4. CIRCULATORY OVERLOAD-results from the administration of fluids too rapidly. S/SX: increased blood pressure, distended jugular veins, rapid breathing, dyspnea, moist rales and crackles Interventions: Calculate and monitor the drip (flow) rate frequently. Use an infusion controller device. Decrease the flow rate to a minimum at a keep vein open rate, elevate the head of the bed, keep the client warm, assess lung sounds and for edema and notify the physician. 5. AIR EMBOLISM- a bolus of air enters the vein through an inadequately primed IV line, during tubing change or during removal of IV. S/SX: tachycardia, dyspnea, hypotension, cyanosis, decreased level of consciousness Interventions: Prime tubing with fluid before use, and monitor for any air bubbles in the tubing. Secure all connections Replace the IV fluid before the bag or bottle is empty. If suspected, clamp the tubing, turn the client on the left side with the head of the bed lowered (Trendelenburg) to trap the air in the Right atrium and notify the physician. LEGAL REGULATION OF DRUGS PREGNACY CATEGORIES The Food and Drug Administration has established five categories to indicate the potential for a systematically absorbed drug to cause birth defects. CATEGORY A Adequate studies in pregnant women have not demonstrated a risk to the fetus in the first trimester of pregnancy, and there is not evidence of risk in later trimesters. CATEGORY B Animal studies have not demonstrated a risk to the fetus but there are no adequate studies in pregnant women, or animal studies have shown an adverse effect, but adequate studies in pregnant women have not demonstrated a risk to the fetus during the first trimester of pregnancy, and there is no evidence of risk in later trimester. CATEGORY C Animal studies have shown an adverse effect on the fetus but there are no adequate studies in humans; the benefits from the use of the drugs in pregnant women may be acceptable despite its potential risks. Or there are no animal reproduction studies and no adequate studies in human. CATEGORY D There is evidence of human fetal risk, but the potential benefits from the use of the drug in pregnant women maybe acceptable despite its potential risks. CATEGORY X Studies in animal or humans demonstrate fetal abnormalities or adverse reaction; reports indicate evidence of fetal risk. The risk of use in a pregnant woman clearly outweighs any possible benefit. REGARDLESS OF THE DESIGNATED PREGNANCY CATEGORY OF PRESUMED SAFETY, NO DRUG SHOULD BE ADMINISTERED DURING PREGNANCY UNLESS IT IS CLEARLY NEEDED. CONTROLLED SUBSTANCES The controlled substances Act of 1970 also has established categories for the ranking of the abuse potential of various drugs. The same act gave control over the coding of drugs and the enforcement of these codes to the FDA and the Drug Enforcement Agency (DEA), a part of the department of justice the FDA studies the drug and determines their abuse potential are called CONTROLLED SUBSTANCES. SCHEDULE I (C-I) High abuse potential and no accepted medical use. Heroin, Marijuana, LSD SCHEDULE II (C-II) High abuse potential with severe dependence liability Narcotics, amphetamines and barbiturates SCHEDULE III (C-III) Less abuse potential that Schedule II drugs and moderate dependence liability Nonbarbiturate sedatives, sedatives, nonamphetamine stimulants, limited amounts of certain narcotics. SCHEDULE IV (C-IV) Less abuse potential than Schedule III and limited dependence liability Some sedatives, antianxiety agents, and nonnarcotic agents. SCHEDULE V (C-V) Limited abuse potential. Primarily small amounts of narcotics (codeine) used as antitussives or anti diarrheals. Schedule V drugs may be used without a prescription directly from a pharmacist. The purchaser must be at least 18 years of age and must furnish suitable identification. KEYS FOR DOCUMENTATION

If any portion of the drug order is illegible or questionable, clarify BEFORE administering. Never abbreviate names of medications. Always write drug dosages using correct form: Leave space between a number and its unit: ex: 10 mg Place a zero to the left of a dosage less the one whole number : ex: 0.1mg Never place a zero after a whole number ex: 5 mg not 5.0 mg

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4. Never document the medication as having been given unless you personally give the drug and observe the childs response to the medication. 5. Document on medication record: -date,time, and site/route of medication -full name and dosage of drug given. -full name of nurse administering the medication. -ease, lab values, urine output, responsivity, etc. 6. Note any side effects or untoward reactions, and actions taken by nurse as a result. 7. Describe who has been notified, when, and why, if any unexpected action/reaction occurred as result of drug administration. Against gram negative bacterial infections; eye infections A/R: ototoxicity, nephrotoxicity and neuromuscular blockage

PENICILLINS Representative Drug: Penicillin G Potassium (Pentids) Inhibits cell wall synthesis of microorganisms; bactericidal Systemic infections of gram-positive cocci; syphilis, prophylaxis for rheumatic fever and bacterial endocarditis; staphylococcal infections, UTI, sore throat A/R: hypersensitivity; GI upset, nephritis, anemia, leukopenia and thrombocytopenia

EYE DRUGS Mydriatics & Cycloplegics Miotics MYDRIATICS & CYCLOPLEGICS Representative Drug: atropine (Isopto Atropine)

PENICILLIN Penicillin G Potassium (Pentids)-Probenicid (Benemid) may be given to increase blood levels of penicilin Ampicillin and Amoxicillin increased effectiveness against gram negative organisms. CEPHALOSPORINS (FIRST GENERATION) Representative Drug: Cefazolin Na (Ancef) Inhibits bacterial cell wall synthesis; bactericidal (same for all generations) Against gram positive cocci A/R: hypersensitivity, nephrotoxicity and hepatotoxicity; bone marrow depression Cross-allergy with penicillin Probenecid therapy CEPHALOSPORINS (SECOND GENERATION) Representative Drug: Cefoxitin Na (Mefoxin)

An anticholinergic that causes mydriasis (dilation) of the pupil ad cycloplegia which paralyses the lens and eye muscles. Used to facilitate eye cream and treat uveitis. Adverse reactions: photophobia, impaired distant vision, increased intraocular pressure, blurred vision, reduced lacrimation. MIOTICS Representative drugs: acetylcholine (Miochol) pilocarpine (Pilocar)

Cholinergic drug that causes miosis (contraction) of the pupil and contraction of the ciliary muscle of the eye. Decreases intraocular pressure in glaucoma and achieves miosis in cataract surgery. Adverse reactions:transient hypotension, decreased heart rate, blurred vision and difficulty focusing.

ANTIVIRAL AGENTS ACYCLOVIR (ZOVIRAX) Inhibits viral DNA replication. Does not cure nor prevent transmission of herpes infections but decreases the severity and duration of the infection. Indicated for herpes simplex 1 and 2, varicella and herpes zoster infection. Adverse reactions: crystalluria, phlebitis at injection site. (instruct client to increase fluid intake)

pain

Used against gram negative and gram positive bacteria A/R: is the same for all generations Lidocaine is used as diluent for IM injection to reduce the

CEPHALOSPORINS (THIRD GENERATION) Representative Drug: Cefotaxime (Claforan) Used in serious gram-negative and gram-positive infections such as neonatal meningitis and gonorrhea Protect IV solutions from light and do not mix with aminoglycosides-nephrotoxic.

ANTIVIRAL AGENTS ZIDOVUDINE (AZT, RETROVIR) Developed to control AIDS Safe for pregnant women Adverse reactions: leukocytopenia and anemia, hepatotoxic and nephrotoxic, dizziness ANTIMICROBIALS GENERAL INFORMATION ON ALL AGENTS AMINOGLYCOSIDES Representative drug: Gentamicin (Garamycin); MYCINS Suppresses protein synthesis in bacterial cell; bactericidal

ERYTHROMYCIN (E-MYCIN) Inhibits protein synthesis in bacterial cell; bacteriostatic Used in persons with allergy to penicillins; indicated for acne, streptococcal and staphylococcal infections A/R: GI irritation, allergic reactions, hepatitis, reversible hearing loss Do not give with acids TETRACYCLINES Representative drug: Tetracycline HCL (Achromycin V)

Inhibits bacterial cell wall synthesis; bacteriostatic and bactericidal; reduces fatty acids from triglycerides Used for acne vulgaris, gonorrhea and spirochetes

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A/R: photosensitivity, hepatotoxicity, avoid giving to pregnant and nursing women, and children under 3 years old (retards bone growth)

PYRAZINAMIDE A/R: increased uric acid causing gout or hepatitis Instruct client to increase oral fluids INTEGUMENTARY DRUGS ACNE PRODUCTS

CHLORAMPHENICOL (CHLOROMYCETIN) Inhibits protein synthesis; bacteriostatic and bactericidal Used against Haemophilus influenza meningitis, salmonella typhi-used only in severe infections where other antibiotics cant be used because A/R are aplastic anemia, and gray baby syndrome (seen in premature infant and children below 2 years..experiences vomiting, abdominal distention, irregular respirations and circulatory collapse.

Representative drug: Isotretinoin (Accutane) Treatment for severe cystic acne C/I: sun exposure, alcohol and pregnancy BURN PRODUCT Representative drug: Mafenide (Sulfamylon) Bacteriostatic, against gram negative and gram positive microorganism Apply 1/6 inch film directly to burn A/R: diffuses via devascularized areas; may precipitate metabolic acidosis manifested by hyperventilation, bone marrow depression and hemolytic anemia. BURN PRODUCT NITROFURAZONE (FURACIN)

SULFONAMIDES Representative Drug: Sulfisoxazole (Gantrisin) Prevents conversion of para-aminobenzoic acid (PABA) to folic acid which is needed for bacterial growth; bacteriostatic and bactericidal Used for UTIs, eye infections, otitis media, vaginitis A/R: Steven-Johnson syndrome (acute onset of fever, bullae on skin and ulcers on mucus membranes of lips, eyes, mouth, nasal passages and genitalia. Pneumonia and joint pains may occur; fever after 7-10 days after onset of therapy indicates hypersentivity or hemolytic anemia. Caution diabetics that drug may cause hypoglycemia; women on oral contraceptives need an alternative method of contraception.

Bactericidal Apply 1/6 inch film directly to burn A/R: contact dermatitis and rash BURN PRODUCT SILVER SUFADIAZENE (SILVADENE) Bactericidal against gm-postive and gm-negative org and Apply 1/6 inch film to burn A/R: leukopenia BURN PRODUCT SILVER NITRATE

VANCOMYCIN (VANCOCIN) Interferes with cell membrane activities; bacteriostatic and bactericidal Effective against gram-positive cocci like staphyloccoccus A/R: ototoxicity, nephrotoxicity, thrombophlebitis, redneck syndrome (flushing and hypotension from rapid IV infusion)

yeast

CIPROFLOXACIN (CIPRO) Inhibits DNA-gyrase (an enzyme needed for replication of bacterial DNA); bactericidal Used against gram-negative systemic/urinary infections; Pseudomonas infection A/R: nephrotoxic and hepatotoxic; anemia and leukopenia; crystalluria ANTI-TB DRUGS ISONIAZID (INH) Initial treatment against PTB; prophylaxis for high-risk

Antiseptic agaist gm-negative org Apply to dressing and not to wound or broken skin A/R: stains anything it comes into contact but discoloration is not permanent OPIOID ANALGESICS AND ANTAGONISTS Opioids natural or synthetic compounds that produce morphine-like effects Opiates drugs such as morphine and codeine obtained from the juice of the opium poppy plant STRONG AGONISTS Morphine a. major analgesic drug contained in crude opium b. absorption in the GIT is slow and erratic c. given IV, IM and subcutaneous Actions: analgesiarelief of pain without loss of consciousness relieves pain by raising the pain threshold at the spinal cord level alters brain perception of pain patient on morphine are still aware of the presence of pain but the sensation is not unpleasant 2. Europhia produce powerful sense of contentment and well being 3. Respiratory depression reduction of the sensitivity of respiratory centers to CO2 most common cause of death in acute opioid overdosage 4. Depression of cough reflex has an anti-tussive property

groups A/R: peripheral neuritis (give Vit B6 [Pyridoxine]); hepatitis (check liver enzymes frequently Taken on an empty stomach, avoid alcohol and interferes with Phenytoin (Dilantin) requiring lowering of INH dose ETHAMBUTOL (MYAMBUTOL) A/R: optic neuritis and loss of red-green color discrimination but its reversible RIFAMPICIN (RIFAMPIN) A/R: hepatitis, flu-like syndrome, may turn body fluids (urine, tears, saliva, etc) orange Interacts with anticoagulants, oral contractptives, methadone and corticosteroids. STREPTOMYCIN A/R: cranial nerve 8 damage (ringing and feeling of fullness in the ear); vestibular damage (dizziness and vertigo)

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5. Miosis pinpoint pupil 6. Emesis stimulates the CTZ causing vomiting 7. GIT decreases motility of the smooth muscle thus relieves diarrhea increases pressure in the biliary tract increases tone of the anal sphicter produces constipation 8. CVS no major effect on the BP or heart rate but large doses cause hypotension and bradycardia 9. CNS cerebral vessels dilate causing increase cerebrospinal fluid pressure 10. Histamine release urticaria, sweating and vasodilation 11. Lungs bronchoconstriction contraindicated in asthmatics 12. Hormonal actions: a. decrease testosterone and cortisol level b. increase antidiuretic hormone causing urinary retention Therapeutic uses: Relieves pain Treatment of diarrhea Relief of cough Adverse effects: Respiratory depression Sedation Constipation Nausea and vomiting Urinary retention Potential for addiction 2. meperidine (Demerol) -synthetic opioid -well absorbed from the GIT -most often administered IM -duration of action is 2-4 hours Actions: Cause respiratory depression IV administrationdecrease in peripheral resistanceincrease in peripheral blood flowincrease in cardiac rate Dilates cerebral vesselsincrease CSF pressurecontracts smooth muscles Impedes motilityconstipation Dilates the pupils Therapeutic uses: Analgesia for any type of severe pain Not clinically useful for cough and diarrhea Adverse effects: Large dosestremors, muscle twitching Severe hypotension can occur given post-op Can cause dependence 3. Fentanyl Chemically related to Meperidine Has 80x analgesic property of Morphine Used in anesthesia Rapid onset but short duration of action (15-30 mins) 4. Heroin Greater lipid solubilitycrosses the blood brain barrier more rapidly than Morphine Cause more exaggerated euphoria when the drug is injected Has no acceptable medical use MODERATE AGONIST Codeine Less potent than morphine Has higher oral efficacy Shows good anti-tussive activity at doses that do not cause analgesia Produce less euphoria Often used in combination with aspirin

NON-STEROIDAL ANTI-INFLAMMATORY DRUGS (NSAIDS) Superior to opioids in the management of pain associated with inflammation ASPIRIN MOST COMMONLY USED DRUG ANTIPYRETIC AND ANTI-INFLAMMATORY EFFECTS ARE DUE TO BLOCKADE OF PROSTAGLANDIN SYNTHESIS AT THE THERMOREGULATORY CENTERS IN THE HYPOTHALAMUS PREVENT SENSITIZATION OF PAIN RECEPTORS TO BOTH MECHANICAL AND CHEMICAL STIMULI Actions: Anti-inflammatory actions Analgesic action Antipyretic action Respiratory actionsrespiratory alkalosis (hyperventilation) GI effects increase gastric acid secretion epigastric distress, ulceration and hemorrhage

6. Effect on platelethas an anti-coagulant effect 7. Action on the kidneyretention of sodium and water causing edema and hyperkalemia Therapeutic uses: Antipyretic and analgesic Low dose of aspirindecrease incidence of TRANSIENT ISCHEMIC ATTACK and UNSTABLE ANGINA and CORONARY ARTERY THROMBOSIS, facilitates closure of PATENT DUCTUS ARTERIOSUS Chronic use of aspirin reduces the incidence of Colonic cancer Adverse effects: GIT a. epigastric distress, nausea and vomiting b. microscopic GI bleeding is almost universal in patients treated with aspirin c. should be taken with food and large volumes of fluids to diminish GI disturbances 2. Blood a. inhibition of platelet aggregation and prolonged bleeding time b. aspirin should not be taken for at least one week prior to surgery 3. Respiratory depression 4. hyperthermia--.when taken in toxic doses 5. Hypersensitivity reactionurticaria, bronchoconstriction 6. Reyes Syndromeoccurs when aspirin is given during viral infection common in children fulminating hepatitis with cerebral edema children should be given acetaminophen instead of aspirin 7. Salicylismdizziness, TINNITUS, difficulty hearing and confusion PROPIONIC ACID DERIVATIVES IBUPROFEN NAPROXEN KETOPROFEN Possess anti-inflammatory, analgesic and antipyretic effects Oral preparation Chronic treatment of rheumatoid and osteoarthritis Cause dyspepsia and bleeding INDOMETHACIN More potent than aspirin as an anti-inflammatory

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Delay labor by suppressing uterine contractions Effective in treating patent ductus arteriosus MEFENAMIC CAUSE DIARRHEA

Inhibits premature uterine contractions

DICLOFENAC For long term treatment of rheumatoid arthritis, osteoarthritis Has an ophthalmic preparation Causes elevated liver enzymes KETOROLAC Oral route IM-for post operative pain Topical-allergic conjunctivitis ACETAMINOPHEN Inhibits prostaglandin synthesis Not affect platelet function Substitute for the analgesic and antipyretic effect of aspirin in patients with gastric complains Analgesic antipyretic of choice for children with viral infections Large doses hepatic necrosis; renal tubular necrosis Acetaminophen overdosage give N-acetylcysteine within 10 hours from overdose ANTI-ASTHMA A. BRONCHODILATORS Dilate the airways of the respiratory treerelaxation of the bronchial smooth muscle relief of dyspnea 1. Xanthine Bronchodilator (Theophylline) Dilate coronary and pulmonary vessels Cause diuresis Bronchodilatation Uses:

Adverse effects: Restlessness, anxiety, tremors, irritability Cardiac arrythmias, tachycardia, palpitations Nausea, vomiting, heart burn Sweating, pallor, flushing Contraindications and cautions: Hypersensitivity Hypertension Hyperthyroidism Laborinhibit labor Parenteral terbutalineaccelerates fetal heart beat, causing hypoglycemia in neonate Interventions: Maintain a beta blocker on standby in case arrythmias occur Do not exceed recommended dose Provide small, frequent meals if GI upset occurs Monitor for occurrence of side effects Beta 2 adrenergic agonists: albuterol (Proventil) terbutaline (Bricanyl, Brethine) salbutamol (Ventolin) salmetrol (Serevent) B. EPINEPHRINE Alpha adrenergic agonist Cardiac stimulant Bronchodilator Antiasthma, nasal decongestant Mediated by alpha and beta receptors in target organs Alpha effects: vasoconstriction, pupillary mydriasis Beta effects: positive inotropic and chonotropic effects on the heart; bronchodilatation, vasodilatation, uterine relaxation, decrease production of aqueous humor Indications: Epinephrine IV Cardiac arrest, anaphylactic shock Angioneurotic edema Acute asthmatic attacks not controlled by inhalation or subcutaneous injection b. Injection (subcutaneous) Relief from respiratory distress of bronchial asthma, COPD c. Aerosols and solutions for nebulization: temporary relief from acute attacks of asthma d. Topical nasal solution: temporary relief from: Nasal congestion caused by common colds, sinusitis and hay fever Adjunctive therapy in middle ear infections e. 0.25%-2% ophthalmic solutions open angle glaucoma f. 0.1% ophthalmic solution conjunctivitis, during surgery to control bleeding, produce mydriasis Adverse effects: anxiety, headache, palpitation in hypertensive patients Cardiac arrythmias Cerebral hemorrhagedue to rapid rise in BP Insomnia, tremors, sweating Nausea and vomiting

Relief and prevention of bronchial asthma COPD

Side effects: nausea, vomiting, diarrhea, insomnia Hyperglycemia, hypotension, cardiac arrythmias, tachycardia Palpitations, ventricular arrythmias, respiratory arrest Contraindications and cautions: Hypersensitivity to xanthines Peptic ulcer, active gastritis local irritation Cardiac arrythmias, acute myocardial injury, CHF Pregnancy & lactation Labor Increases risk of digitalis toxicity IV aminophylline or theophylline preparations should be administered slowly within 20 minutes: rapid administration cardiac arrythmias arrest Nursing Considerations: Take medications on an empty stomach Do not chew or crush enteric coated tablets Avoid excessive intake of coffee, tea, cocoa, cola, chocolates increase side effects Smoking influences effects of theophylline Report for occurrence of side effects 2. Beta 2 adrenergic agonist Acts on beta 2 adrenergic receptors to cause bronchodilation Relaxes pregnant uterus Uses:

Bronchial asthma COPD

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Contraindications: Allergic to ephedrine (derivative of epinephrine) Angle closure glaucoma Hypertension, thyroid storm Pregnancy Labor and delivery (accelerate fetal heart rate) Interventions: Protect parenteral solution from light Monitor urine output: initially renal blood vessels may be constricted urine formation Do not use nasal decongestant for longer than 3-5 years Closely monitor BP and cardiac response Provide additional comfort measures humidity, analgesics, positioning for patients with nasal congestion and asthma Monitor for occurrence of side effects C. GLUCOCORTICOIDS Inhaled Glucocorticoids Drug of choice in patients with moderate to severe asthma who require inhalation of B2 adrenergic agonists more than once daily Decrease airway inflammationreduce mucosal edema Reduces hyperresponsiveness of the airway smooth muscle to a variety of bronchoconstrictor stimuli: allergens, irritants, cold air and exercise Reduce bronchial reactivity 2. Systemic steroids For patients with severe exacerbation of asthma (status asthmaticus) IV methylprednisolone or oral prednisone 3. Spacers Large volume chamber attached to the metered dose inhaler decrease deposition of drug in the mouth Improve delivery of inhaled steroids Rinsing the mouth after inhalation decrease systemic absorption and decrease risk of oropharyngeal candidiasis Inhaled steroids: Budesonide Beclomethasone Flunisolide Triamcinolone Systemic steroids: Methylprednisolone Hydrocortisone Oral: Prednisone Dexamethasone Bethamethasone D. Cromolyn / Nedocromil Effective prophylactic anti-inflammatory agents Block precipitation of immediate and delayed asthmatic reactions Not useful in managing acute attacks Administered by inhalation or aerosolized solution Cromolyn effective in reducing symptoms of allergic rhinitis E. Cholinergic antagonists Block contraction of airway smooth muscle and mucus secretion Drug: Inhaled Ipratropium (slow in onset and nearly free of side effects) HISTAMINE AND ANTIHISTAMINES HISTAMINE Chemical mediator of allergy, inflammatory reactions, gastric acid secretion High amounts found in the lungs, skin, GIT Highest concentration in the mast cells and basophils Histamine release is brought about by: Destruction of cells as a result of cold, bee sting venoms Trauma Allergy/anaphylaxis HAS NO CLINICAL APPLICATIONS Receptors: H1 smooth muscle contraction, increase capillary permeability vasodilation H2 mediates/stimulates gastric acid secretion Effects of H1 receptors: Exocrine glands: increase production of nasal, bronchial mucus Bronchial smooth muscle: constrictions of bronchioles asthma Intestinal smooth muscle: intestinal cramps and diarrhea Nerve endings: cause pain and itch Effect of H2 receptors:

Stimulation of gastric acid secretion Effects mediated by both H1 & H2: Lowers BP reduce peripheral resistance (since there is vasodilation) (+) inotropic effects (increase contraction of the heart) Skin: Triple response Red spot Flush and flare Wheal formation ANTIHISTAMINES COMPLETELY BLOCK OR ANTAGONIZE ALL ACTIONS OF HISTAMINE EXCEPT OR THOSE MEDIATED BY H2 RECEPTORS. Therapeutic uses: Allergic conditions (H1 antagonists) Epinephrine drug of choice for systemic anaphylaxis Motion Sickness Scopolamine Dimenhydrinate Meclizine Diphenhydramine Insomnia Diphenhydramine (strong sedative effect First generation H1 blocker: Pass through the blood brain barrier Marked potential for producing sedation Cause increase in appetite and weight gain (Cyproheptadine) Brompheniramine maleate Cetirizine Diphenhydramine Clemastine Chlorpheniramine maleate Cyproheptadine Second generation H1 blocker: Does not pass the blood brain barrier No sedative effect Loratidine Astemazole Terfenadine Side effects: Drowsiness, fatigue Dizziness Blurring of vision Tremors Dry mouth weak anticholinergic effects Interventions: Monitor vital signs

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Administer with food Avoid alcohol and other CNS depressants potentiates the effect of antihistamines Instruct patient that taking medications for motion sickness should be done 30 minutes before taking any trip NEURO DRUGS ANTIMYASTHENIC MEDS Relieve muscle weakness associated with myasthenia gravis by blocking acetylcholine breakdown at the neuromuscular junction Drugs: 1.neostigmine bromide (Prostigmin), pyridostigmine bromide (Mestinon) are used to control myasthenic symptoms Take meds on timeMG impairs breathing and swallowing Take a.c for best absorption Meds for life and wear medic-alert bracelet 2. edrophonium chloride (Tensilon) is used to diagnose myasthenia gravis and differentiate cholinergic crisis (drug overdose) and myasthenic crisis (drug underdose) Prepare resuscitative equipment and antidote: ATROPINE SULFATE Dx as M.G. if client shows marked improvement in muscle tone within 30-60 seconds after injection lasting 4-5 minutes (POSITIVE TENSILON TEST) Dx as cholinergic crisis when muscle tone does not improve (NEGATIVE TENSILON TEST) ANTIPARKINSONIAN DRUGS RESTORES THE BALANCE OF NEUROTRANSMITTERS ACETYLCHOLINE AND DOPAMINE IN THE CNS CAUSING DECREASE SIGNS AND SYMPTOMS OF PARKINSONISM SUCH AS RIGIDITY, TREMORS, BRADYKINESIA, STOOPED FORWARD BEHAVIOR, SHUFFLING GAIT AND MASKED FACE Dopaminergic Meds Increases the amount of dopamine in the brain A/R: involuntary body movements, urinary retention, constipation, dizziness, orthostatic hypotension For levodopa, avoid Vit B6 and low protein food Not to take in alcohol and never to discontinue meds abruptly Urine and perspiration may be discolored and stain clothing but this is harmless Representative drugs: amantidine (Symmetrel) bromocriptine (Parlodel) carbidopa-levodopa (Sinemet) Anticholinergic Meds Block cholinergic receptors in the CNS, thereby suppressing acetylcholine activity A/R: blurred vision, dry mouth and secretions, urinary retention, constipation, restlessness and confusion Client to have a regular eye check up for increase IOP Avoid aspirin, caffeine, smoking and alcohol to decrease gastric acidity

Related drugs: carbamazepine (Tegretol) phenobarbital (Luminal) lorazepam (Ativan) BARBITURATES phenobarbital (Luminal)

used for tonic-clonic seizures and status epilepticus Also an adjunct to anesthesia A/R: drowsiness, dizziness, hypotension, respiratory depression and tolerance to meds BENZODIAZEPINES diazepam (Valium) Treat anxiety, status epilepticus and skeletal muscle spasms A/R: respiratory and cardiac depression, medication tolerance and dependency Related drugs: lorazepam (Ativan) chlorazepate (Tranxene) RENAL DRUGS URINARY TRACT ANTISEPTICS Nitrofurantoin ((Furadantin, Furalan, Macrobid) Inhibits the growth of bacteria in the urine Indicated for UTIs & do not achieve antibacterial effects in the blood or tissues Given with milk or meals to prevent GI distress A/R: pulmonary reactions like dyspnea, chest pain, chills, fever, cough and will resolve 2-4 days after treatment Imparts a harmless brown color to urine URINARY ANALGESICS Phenazopyridine HCL (Pyridium)

Used to treat pain from UTI or irritation Usually given together with antibiotics A/R: nausea, headache, vertigo, urine will turn red or orange CHOLINERGIC bethanechol chloride (Duvoid, Urecholine)

Used to treat nonobstructive urinary retention Used to increase bladder tone and function A/R: hypotension, diarrhea, urinary urgency and bronchoconstriction ANTIDOTE: ATROPINE SULFATE ANTISPASMODICS oxybutynin chloride (Ditropan) Relaxes smooth muscles of urinary tract A/R: leukopenia, bradycardia, anxiety Propantheline bromide (Pro-banthine) decreases bladder muscle spasms A/R: palpitations, blurred vision, urinary hesitancy and urgency, dry mouth and constipation Never given in clients with glaucoma, obstructive uropathy and colitis

Representative drugs: benztropine mesylate (Cogentin) biperiden HCl (Akineton) trihexyphenidyl (Artane) ANTICONVULSANTS Representative drug: phenytoin (Dilantin)

Used to depress abnormal neuronal charges and prevent spread of seizures Also used to treat dyrhythmias A/R: GINGIVAL HYPERPLASIA reddened gums that bleed easily, alopecia, elevated blood gluicose, decreased WBC and platelet count

HEMATOPOIETIC GROWTH FACTOR EPOETIN ALFA (EPOGEN) Used to stimulate RBC Reverses anemia in chronic renal failure Initial effects seen in 1-2 weeks and hematocrit level reaches normal (30-33%) in 2-3 months Monitor CBC and BP for hypertensive side effects Caution in clients with uncontrolled hypertension, hypersensitivity to human albumin PREVENTING ORGAN REJECTION IMMUNOSUPPRESANT cyclosporine (Sandimmune)

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Used to prevent kidney transplant rejection by acting to suppress the action of T-lymphocytes Administered together with PREDNISONE A/R: nephrotoxicity, hirsutism (reversible) and infection Take with milk or orange juice, grapefruit juice increases drug level

plicamycin (Mithracin) A/R: prolongs bleeding timeavoid aspirin, anticoagulatns and antithrombolytics daunorubicin (Cerubidine) A/R: CHF and dysrhythmias bleomycin (Blenoxane) A/R: Pulmonary toxicity Doxorubicin (Adriamycin) & idarubicin (Idamycin) A/R: cardiotoxicity, dyspnea, hypotension, ECG changes & weight gain ANTIMETABOLITE MEDS HALT SYNTHESIS OF CELL PROTEIN; REPLACES PROTEIN NEEDED FOR DNA SYNTHESIS cytarabine HCL (ara-C, Cytosar-U) A/R: hepatotoxicity 5-Fluorouracil (5-FU, Adrucil) A/R: phototoxicity and cerebellar dysfunction 6-mercaptupurine (Purinethol) A/R: hepatotoxicity methotrexate (Folex) A/R: photosensitivity, hepatotoxicity, hematologic, GI and skin toxicity Given with leukovorin (folinic acid) VINCA ALKALOIDS Prevents mitosis causing cell death Vincristine S04 (Oncovin) A/R: neurotoxic (tingling and numbing of extremities) CARDIOVASCULAR DRUGS CARDIAC GLYCOSIDES Digoxin (Lanoxin) Increases force of myocardial contraction (positive inotropic effect). Decreases rate of conduction (negative chonotropic effect). Positive inotropic effect improves blood supply to vital organs and kidneys, providing a diuretic effect. Uses: CHF, atrial fibrillation, atrial flutter Adverse effects: Nausea, Anorexia, Vomiting, Diarrhea, Green or yellow tint halos, Hypokalemia (low serum potassium levels) CARDIAC GLYCOSIDES Interventions: Hold if apical rate is below 60 or greater than 120 bpm in adults, below 90 bpm in infants, below 70 bpm in children up to adolescence. Monitor serum potassium (n=3.5-5.0 mEq/L) Take dose the same time each day and do not skip or double up on dose. Daily weights Avoid high-sodium foods. Increase dietary intake of potassium. Separate digoxin from other pills in pillbox. ANTIANGINAL DRUGS Nitrates and Nitroglycerin (Nitrobid) Dilates the peripheral vascular smooth muscles of smaller vessels, which decreases cardiac preload and afterload leading to decreased myocardial oxygen needs. Given by many different routes of administration including PO, SL, Buccal, topical and transdermal Uses: treatment and prophylaxis of angina pectoris, HPN

CYTOTOXIC MED azathioprine (Imuran)

Suppresses immune response by inhibiting B and T lymphocytes Adjunct to cyclosporine A/R: neutropenia and thrombocytopenia ANTINEOPLASTIC MEDICATIONS Kill or inhibit the growth of neoplastic cells Effects of these medications are not limited to neoplastic cells but affect normal cells as well Agents are used in combination to increase therapeutic response May be combined with radiation and or surgery Routes of administration may vary; IV preferred Side effects of these meds are resultant from normal and rapidly dividing cells S/E: mucositis, alopecia, anorexia, nausea and vomiting, diarrhea, anemia, low WBC count, low platelet count, infertility

Monitor CBC and electrolyte count Initiate bleeding if thrombocytopenia occurs Monitor for signs of infection, ask visitors with URTI to wear masks Loss of appetite..due to bitter taste in the mouth For nausea and vomiting, administer anti-emetics Fluid hydration of at least 2 liters/day unless CI Administer allopurinol (Zyloprim) as rx Prepare drugs in an air-vented area wearing gloves, gown and masks Monitor insertion site for phlebitis or extravasation

Inform client about the potential loss of hair and will grow back after several months post-treatment. Inform that effects of infertility may be irreversible Instruct on oral hygiene, avoidance of crowded places, (-) use of aspirins and alcohol Consult with doctor regarding vaccinations ALKYLATING MEDICATIONS Affects the synthesis of DNA by causing cross linkaging of DNA to inhibit cell production A/R: gonadal suppression and hyperuricemia

cisplatin (Platinol) A/R: ototoxicity, tinnitus, hypokalemia, hypocalcemia, hypomagnesemia and nephrotoxicity Asses for dizziness, tinnitus, hearing loss, incoordination, numbness and tingling extremities Cyclophosphamide (Cytoxan)

A/R: gonadal suppression, hemorrhagic cystitis (s/sx: hematuria and dysuria) encourage 2-3 liters of fluids/day unless CI Encourage diet low in purine to alkalanize urine and lower blood uric acid level ANTITUMOR ANTIBIOTIC MEDS INTERFERE WITH DNA AND RIBONUCLEIC ACID SYNTHESIS

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A/E: headache, flushing, hypotension, dizziness, tachycardia ANTIANGINAL DRUGS Nursing Implications: No more than 3 tablets should be taken in a 15 minute period (one tablet every 5 minutes). If pain not relieved by 3 tablets over 15 minutes, could indicate an acute MI and physician should be notified. Sustained release tablets or capsules should be taken one hour before meals or two hours after meals. Nitroglycerin ointment should be applied to a hairless or shaved area to promote absorption. Wear gloves. Rise slowly to prevent hypotension. Do not drink alcohol. ANTIARRYTHMICS Quinidine (Quinaglute), Procainamide, Disopyramide Uses: arrythmias/dysrhythmias A/E: GI abnormalities, tinnitus, visual disturbances, dizziness, headache, hypotension, n&v, diarrhea. Take radial pulse before takiong. Report A/E if occurs.

ANTIARRYTHMICS Lidocaine (Xylocaine) Use: ventricular arrythmias A/E: drowsiness, CNS stimulation can develop leading to seizures; ventricular tachycardia, heart block, hypertension, bradycardia. Monitor ECG, VS and neuro status Use an infusion pump if given IV Do not mix with other drugs Deltoid is preferred for IM use. BETA BLOCKERS Propranolol (Inderal) Decreases heart rate, force of contraction, myocardial irritability Use: cardiac arrythmias, angina pectoris, HPN, prevention of migraine A/E: dizziness, drowsiness, insomnia, depression, bronchospasm, heart block, hypotension Take apical pulse before administering drug Related drugs: olol Esmolol, Nadolol, Pinolol, Timolol CARDIAC STIMULANTS Atropine sulfate Blocks vagal stimulation of the SA node in the heart, thus increasing heart rate. Uses: treatment of sinus bradycardia or asystole. ANTICOAGULANTS Heparin Blocks conversion of prothrombin to thrombin and fibrinogen to fibrin. Uses: prophylaxis and treatment of thrombosis and embolism, adjunct tx of coronary occlusion with acute MI Check partial thromboplastin time (PTT) (normal: 30-45 sec) if anticoagulated: 1.5-2x normal Safe for pregnant women Administered IV, and SQ (no IM!) Antidote: protamine sulfate ANTICOAGULANTS Warfarin sodium (Coumadin) Blocks prothrombin synthesis. Uses: prophylaxis treatment of thrombosis and embolism, adjunct tx of coronary occlusion Check prothrombin time (PT) (normal: 10-14 sec) if anticoagulated, 1.5-2x normal Can be given oral, IM and IV Not safe for pregnant use Antidote: Vitamin K THROMBOLYTIC DRUGS Streptokinase, Alteplase, Urokinase

Transforms plasminogen to plasmin which degrades fibrinogen, fibrin, clots and other plasma proteins. Uses: pulmonary emboli, coronary artery thrombosis, deep venous thrombosis, AV cannula occlusion When use in tx of an acute MI, start therapy within 6 hours of attack. Heparin is D/C before streptokinase is started. IM inj are contraindicated. Antidote: aminocaproic acid ANTILIPEMIC AGENTS Cholestyramine (Questran) Prevents the metabolism of cholesterol in the body USes: hyperlipidemia, partial biliary obstruction. A/E: constipation, nausea, and vomiting, deficiencies of Vit. A,D,E and K, rashes, headache, dizziness, syncope Monitor serum cholesteraol and triglycerides, long term use increases bleeding tendencies. Have Vit. K available. Take with water of preferred liquid and dissolve. Take before meals. Related drugs: colestipol (Colestid), Lovastatin (Mevachor), Lopid CENTRALLY ACTING ANTIHYPERTENSIVES Clonidine (Catapres) Blocks sympathetic nerve impulse in brain which causes decreased sympathetic outflow leading to decrease BP, heart rate and contractility Uses: moderate HPN A/E: orthostatic hypotension Related drug: methyldopa (Aldomet) ALPHA-ADRENERGIC RECEPTOR BLOCKER: Blocks alpha receptors in arterial smooth-muscle vasculature and mediates vasoconstriction. Uses: HPN caused by pheochromocytoma, in combination with thiazide diuretics A/E: postural hypotension, syncode Take with food to reduce dizziness, and light headedness. Report sexual difficulties Prazocin, Tamsulocin, Doxazocin ANGIOTENSIN-CONVERTING ENZYME (ACE) INHIBITOR Captopril (Capoten) Lowers BP by inhibiting angiotensin-converting ACE, which inhibits angiotensin II (potent vasoconstrictor) and indirectly reduces serum aldosterone levels. Uses: HPN, severe HPN in renal clients, CHF A/E: blood dyscracias, hyptonsion, proteinuria, hyperkalemia, loss of taste perception Monitor CBC, electrolytes and urinalysis. Use salt substitutes only if prescribed (many substiutes contain K) Related drugs: pril: enalapril, lisinopril DIRECT ACTING VASODILATORS Hydralazine (Apresoline) Direct relaxation of arteriolar smooth muscle causing vasodilation Use: HPN; hypertensive emergencies A/E: headache, dizziness, tachycardia, angina, palpitations Related Drugs: minoxidil- A/E: hirsutism; sodium nitroprusside administered in an infusion pump, container should be wrapped in foil to protect from light, monitor thiocyanate levels (cyanide toxicity) THIAZIDE DIURETICS Blocks sodium reabsorption in ascending tubule of kideny; water excreted with sodium, producing decreased blood volume. A/E: hyperuricemia, hyperglycemia, vomiting, headache, nausea, hypokalemia, hypotension Drugs: Chlorothiazide (Diuril), Hydrochlorothiazide (Hydro Diuril) LOOP DIURETICS Inhibit reabsorption of sodium and chloride at the proximal portion of ascending loop of Henle.

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A/E: similar to thiazides but intensity differs. Hypocalcemia, hearing loss Drug: Furosemide (Lasix), Bumetanide (Bumex) POTASSIUM-SPARING DIURETICS Antagonizes the effect of aldosterone on the tubular cells of the kidney; sodium excreted in exchange for potassium. A/E: hyperkalemia, gynecomastia, hirsutism, rashes, confusion Drug: Spironolactone (Aldactone) GASTROINTESTINAL MEDICATIONS ANTACIDS AND MUCOSAL PROTECTIVE MEDICATIONS Aluminum hydroxide gel (Amphojel) Alumunum carbonate gel (Basaljel) Bismuth subsalicylate (Pepto-Bismol) Calcium carbonate (Tums) Magnesium hydroxide (Milk of Magnesia) Misoprostol (Cytotec) Sucralfate (Carafate) ANTACIDS AND MUCOSAL PROTECTIVE MEDICATIONS React with gastric acid to produce neutral salts or salts of low acidity Used for peptic ulcer disease (PUD) and gastroesophageal reflux disease (GERD) Administered 7 times a day, 1 and 3 hours after each meal and at bedtime. To provide maximum benefit, treatment should elevate the gastric pH above 5 Antacids should be chewed thoroughly and followed with a glass of water or milk. SUCRALFATE (CARAFATE) Creates a protective barrier against acid and pepsin Administered orally and should be taken on an empty stomach Administer sucralfate at least 60 minutes apart from an antacid May cause constipation May impede absorption of: Warfarin sodium (Coumadin) Phenytoin (Dilantin) Theophylline Digoxin (Lanoxin) Some antibiotics NOTE: These should be administered at least 2 hours apart from these medications MISOPROSTOL (CYTOTEC) Used to prevent gastric ulcers caused by NSAIDS Suppresses secretion of gastric acid Administered with meals Causes diarrhea and abdominal pain C/I for use in pregnancy MAGNESIUM HYDROXIDE Referred to as Milk of Magnesia Most prominent side effect is diarrhea C/I in clients with intestinal obstruction, appendicitis or undiagnosed abdominal pain ALUMINUM HYDROXIDE (AMPHOJEL, ALU-CAP, DIALUME) Contains significant amounts of sodium Should be used cautiously in clients with hypertension and heart failure Side effect: constipation Can reduce phosphate absorption and thereby cause hypophosphatemia Can reduce the effects of: Tetracyclines Warfarin sodium (Coumadin) Digoxin (Lanoxin) SODIUM BICARBONATE Can cause systemic alkalosis in clients with renal impairment. Useful for treating acidosis and elevating urinary pH to promote excretion of acidic medications following overdose. HISTAMINE (H2) RECEPTOR ANTAGONISTS Cimetidine (Tagamet) Famotidine (Pepcid) Nizatidine (Axid) Ranitidine (Zantac) HISTAMINE (H2) RECEPTOR ANTAGONISTS Suppresses secretion of gastric acid These alleviate symptoms of heartburn and assist in preventing complications of peptic ulcer disease These prevent stress ulcers and reduce the recurrence of all ulcers. CIMETIDINE (TAGAMET) Administered orally, intramuscularly or intravenously Food reduces the rate of absorption Cimetidine and antacids should be administered at least 1 hour apart from each other May cause mental confusion, agitation, psychosis, depression, anxiety and disorientation Intravenous administration can cause hypotension and dysrhythmias If cimetidine is administered with warfarin sodium (Coumadin), phenytoin (Dilantin), theophylline, or lidocaine, the dosages of these medications should be reduced RANITIDINE (ZANTAC) Can be administered orally, intramuscularly or intravenously Does not penetrate the blood brain barrier as cimetidine does For IV injection, ranitidine should be diluted with 20 mL and adminsitered slowly over 5 minutes or more, or diluted in 100 mL and administered over 15 to 20 minutes PROTON PUMP INHIBITORS Esomeprazole (Nexium) Lansoprazole (Prevacid) Omeprazole (Prilosec) Pantoprazole (Protonix) Rabeprazole (Aciphex) PROTON PUMP INHIBITORS Suppress gastric acid secretion Proton pump inhibitors are used with active ulcer disease, erosive esophagitis, and pathological hypersecretory conditions Common side effects: headache, diarrhea, abdominal pain, and nausea GASTROINTESTINAL STIMULANTS Bethanechol chloride (Urecholine, Duvoid) Dexpanthenol (IIopan, Ilopan-Choline) Metoclopramide (Reglan) Neostigmine methylsulfate (Prostigmin) GASTROINTESTINAL STIMULANTS Stimulate motility of the upper gastrointestinal tract and increase the rate of gastric emptying without stimulating gastric, biliary or pancreatic secretions. Used for gastroesophageal reflux May cause restlessness, drowsiness, extrapyramidal reactions, dizziness, insomnia and headache Administered 30 minutes before meals and at bedtime. C/I: mechanical obstruction, perforation or gastrointestinal hemorrhage Can precipitate hypertensive crisis in clients with pheochromocytoma Metoclopramide (Reglan) can cause Parkinson-like reactions, and if this occurs, the medication is discontinued BILE ACID SEQUESTRANTS Cholestyramine (Questran, Prevalite) Colestipol (Colestid)

Used to treat pruritus associated with biliary disease

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Act by absorbing and combining with intestinal bile salts, which then are secreted in the feces, preventing intestinal reabsorption. May be used to treat hypercholesterolemia in adults. Should be used cautiously in clients with bowel obstruction or severe constipation because of the adverse gastrointestinal effects. Taste and palatability are often reasons for noncompliance and can be improved by the use of flavored products or mixing the medication with various juices.

Psyllium hydrophillic mucilloid (Metamucil)

Side effects: constipation, bloating, flatulence, nausea, fecal impaction, intestinal obstruction, exacerbation of hemorrhoids, hypoprothrombinemia, decreased vitamin absorption CHENODIOL (CHENIX) Medication for cholelithiasis Decreases cholesterol production, lowering content of bile, and thus facilitates dissolution of gallstones Can cause diarrhea and possibly hepatotoxicity Client should contact physician if abdominal pain, sudden right upper quadrant pain, nausea or vomiting occurs. Administer with food or milk Avoid aluminum-containing antacids LACTULOSE (CEPHULAC) Reduces ammonia levels Used to treat hepatic encephalopathy Lowers the colonic pH from 7 to 5; this acidification pulls ammonia into the bowel to be excreted in the feces, thus lowering the ammonia level Administered orally in the form of a syrup NEOMYCIN (MYCIFRADIN) Reduces the number of colonic bacteria that normally convert urea and amino acids into ammonia Administered orally or via nasogastric tube Used with caution in clients with kidney transplants PANCREATIC ENZYME REPLACEMENTS Pancreatin (Entozyme, Donnazyme) Pancrealipase (Pancrease, Viokase) -These medications are used to supplement or replace pancreatic enzymes. -Should be taken with meals or a snack (food helps to buffer the stomach acid) -A high-fiber diet may increase the efficacy of the medication -Side effects include abdominal cramps or pain, nausea and diarrhea -Products that contain calcium carbonate or magnesium hydroxide interfere with the action of the medication ANTIEMETICS Diphenidol hydrochloride (Vontrol) Dolasetron (Anzemet) Dronabinol (Marinol) Granisetron (Kytril) Hydroxyzine hydrochloride (Atarax) Hydroxyzine pamoate (Vistaril) Meclizine hydrochloride (Antivert) Prochlorperazine (Companzine) Metoclopramide (Reglan) Promethazine hydrochloride (Phenergan) Scopolamine transdermal (Transderm-Scop) Thiethylperazine maleate (Torecan) Trimethobenzamide hydrochloride (Tigan) ANTIEMETICS Medications used to control vomiting Monitor for drowsiness and protect the client from injury Monitor vital signs and intake and output. Limit odors in the clients room when the client is nauseated or vomiting Limit oral intake to clear fluids, when the client is nauseated or vomiting BULK FORMING LAXATIVES Calcium polycarbophil (FiberCon) Methylcellulose (Citrucel)

Absorb water into the feces and increase bulk to produce large and soft stools Contraindicated in bowel obstruction Side effects: GI disturbances, DHN, Electrolyte imbalance, Dependency with chronic use STIMULANT CATHARTICS Bisacodyl (Dulcolax) Cascara sagrada Castor oil Docusate sodium Senna concentrate (Senexon) Stimulate motility of large intestine Bisacodyl (Dulcolax): Do not administer within 60 minutes of an antacid or milk Castor Oil: Administer with juice; produces results in 6 to 12 hours SALINE CATHARTICS Senna (Senokot) Lactulose (Chronulac) Magnesium sulfate (epsom salts) Polyethylene glycol and electrolytes (GoLYTELY) Sodium Phosphates (Fleet enema, Phospho-Soda)
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Saline cathartics attract water into the large intestine to produce bulk Stimulate peristalsis Achieve results in 2 to 6 hours STOOL SOFTENERS Docusate calcium (Surfak) Docusate sodium (Colace)
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Inhibit absorption of water so fecal mass remains large and soft. Used to avoid straining LUBRICANTS Mineral Oil
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Act to soften the feces Ease the strain of passing stool Lessen irritation to hemorrhoids Mineral Oil can cause lipid pneumonia if accidentally Interferes with absorption of the fat soluble vitamins A,D,E, Codeine phosphate Loperamide hydrochloride (Imodium) Diphenoxylate hydrochloride with atropine (Lomotil)

aspirated
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and K OPIOIDS
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Decrease intestinal motility and peristalsis. When poisons, infections, or bacterial toxins are the cause of the bacteria, opioids worsen the condition by delaying the elimination of toxins. ABSORBENT ANTIDIARRHEALS Bismuth subsalicylate (Pepto-Bismol) Kaolin and pectin (Kapectolin) - Decrease intestinal motility and peristalsis ANTISPASMODIC Dicyclomine hydrochloride (Antispas, Bentyl) -Relax smooth muscle of the gastrointestinal tract -Side effects: * Constipation or diarrhea * Rash * Euphoria

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* Dizziness * Drowsiness * Headache * Nausea * Weakness ANTIFUNGALS AMPHOTERICIN B (FUNGIZONE) fungicidal, fungistatic Uses: candida infections, histoplasmosis A/E: febrile reactions, nausea, vomiting, nephrotoxicity, hypokalemia, blood dyscrasias ANTIFUNGALS Nystatin (Mycostatin) used to treat candida infections Griseofulvin used to treat ringworm infections Fluconazole used to treat candida infections Ketoconazole used to treat systemic fungal infections Terbinafine (Lamisil) used to treat onychomycosis ANTIDIABETIC AGENTS INSULIN Hormone that increases glucose transport across cell membranes; transforms glycogen into glucose, prevents breakdown of fats to fatty acids Uses: Type I DM, Type II DM, Diabetic pregnant women, Diabetic coma A/E: allergic reaction, hypoglycemia ANTIDIABETIC AGENTS Tolbutamide (Orinase) Lowers blood glucose concentrations by stimulating secretion of endogenous insulin from beta cells in the pancreas. Uses: Type II DM A/E: hypoglycemia, n&v, diarrhea, hemolytic anemia THE END