Pharmacology chapter 42(p-1)

Lecture Notes for 2nd year students

A very large, diverse group of eukaryotic, thallus-forming microorganisms that requires an external
carbon source
Fungi

Another of the major groups of antifungal drugs; includes ketoconazole

Imidazoles

A term for fungal infection of the mouth

Thrush

One of the older antifungal drugs that acts by preventing susceptible fungi from reproducing
Griseofulvin

The drug of choice for many severe, sys-temic fungal infections; also, the oldest antifungal drug
Amphotericin B

An antifungal drug commonly used to treat candidal diaper rash

Nystatin

An infection caused by fungi

Mycosis

Multicellular fungi characterized by long, branching filaments called hyphae, which entwine to form a
mycelium
Molds

An infant has thrush. The nurse expects to administer which drug for the treatment of thrush?
Nystatin

During an infusion of amphotericin B, the nurse monitors for which adverse effects? (Select all that
apply.)
Nausea
Fever
Malaise
Chills

A patient calls the gynecologic clinic because she has begun to menstruate while taking vaginal cream
for a vaginal infection. She asks the nurse, "What should I do about taking this vaginal medicine right
now?" Which is the nurse's best response?
"It's okay to continue to take the medication."
A patient will be receiving a one-dose treatment for vaginal candidiasis. The nurse expects to
administer which drug?
Fluconazole

The nurse is administering an antifungal drug to a patient who has a severe systemic fungal infection.
Which drug is most appropriate for this patient?
Amphotericin B

In an effort to prevent the complications associated with intravenous infusion of antifungal drugs such
as amphotericin B, the nurse will administer them over which time frame?
2 to 6 hours

The nurse is administering a new order for ampho-tericin B and reviews the patient's current
medications. Which medications, if also ordered, may cause an interaction with the amphotericin B?
(Select all that apply.)
Digoxin, a cardiac glycoside
Hydrochlorothiazide, a thiazide diuretic

Amphotericin B would be contraindicated in which patients? (Select all that apply.)

One with severe bone marrow suppression
One with renal impairment

What is the MOST important action for the nurse to complete before administration of intravenous
(IV) amphotericin B?
Check for premedication prescriptions.

Which antifungal drug can be given intravenously to treat severe yeast infections as well as a one-
time oral dose to treat vaginal yeast infections?
Fluconazole (Diflucan)
Fluconazole is an antifungal drug that does not cause the major adverse effects of amphotericin
when given intravenously. It is also very effective against vaginal yeast infections, and a single dose
is often sufficient to treat vaginal infections.

A client visits the health care provider for treatment of tinea pedis (athlete's foot). Which medication
would the nurse MOST likely instruct the client to take to treat this condition?
Terbinafine (Lamisil)
Terbinafine (Lamisil) is classified as an allylamine antifungal drug and is currently the only drug in its
class. It is available in a topical cream, gel, and spray for treating superficial dermatologic infections,
including tinea pedis (athlete's foot), tinea cruris (jock itch), and tinea corporis (ringworm).

The nurse would question a prescription for voriconazole (Vfend) if the client was taking which
medication?
Quinidine
The nurse would question a prescription for quinidine because both voriconazole and quinidine are
metabolized by the cytochrome P-450 enzyme system. The drugs will compete for the limited
number of enzymes, and one of the drugs will end up accumulating.
The nurse has provided education to a client about fungal skin infections. Further client teaching is
necessary when the client includes which condition in the discussion of fungal skin infections?
Impetigo
Impetigo is a bacterial skin infection and would not be classified as a fungal skin infection. If the
client included this in the discussion, further teaching is needed. All other skin infections listed are
fungal and would be treated with antifungal medications.

What are important for the nurse to monitor in a client receiving an antifungal medication? (Select all
that apply.)
Blood urea nitrogen, Daily weights, Creatinine, Intake and output
Nursing interventions appropriate to clients receiving antifungal drugs vary depending on the
particular drug. However, it is important for the nurse to monitor all clients for indications of
possible medication-induced renal damage so that prompt interventions can occur to prevent
further dysfunction. Monitoring intake and output amounts, daily weights, and renal function tests
will help prevent such damage.

What conditions are considered contradictions for use of antifungal medications? (Select all that
apply.)
Pancreatic failure, Liver failure

What is the MOST common drug used to treat oral candidiasis?

Nystatin (Mycostatin)
Nystatin is an antifungal drug that is used for a variety of candidal infections. It is applied topically
as a cream, ointment, or powder. It is also available as a troche and an oral liquid or tablet.

The nurse needs to know that major adverse effects are MOST common by which drug?
Amphotericin B (Amphocin)
The major adverse effects caused by antifungal drugs are encountered most commonly in
conjunction with amphotericin B treatment. Drug interactions and hepatotoxicity are the primary
concerns in clients receiving other antifungal drugs, but the IV administration of amphotericin B is
associated with a multitude of adverse effects.

what are the 4 ways that vomiting is triggered

the brain, ear, emotions and stomach

what are the 2 areas of the brain where vomiting is triggered?

the vomiting center-digestive track, inner ear and CTZ muscarinic receptors
Chemoreceptor trigger zone- impulses from drugs, toxins, vestibular center in ear
dopamine 2 receptors
5 HT receptors

what is the pathway of the ear receptor that triggers vomiting?

vestibular cochlear nerve--vestibular nuclei--histamine 1 receptors and muscarinic receptors--CTZ---
vomiting center
what is the pathway of the stomach receptors that trigger vomiting
enterochromaffin cells---serotonin--5HT receptors in the vagus nerve--vomiting center

what emotions trigger vomiting and how are they triggered?

pain, smells, sights, anxiety
trigger the muscarinic receptors in the brain

what are some non-pharmacologic methods to treat nausea and vomiting?

weak tea, flat soda, gelatin, Gatorade, Pedialyte, toast, crackers, ginger etc.

what are Anti-Histamines and what are the associated drugs

a non-prescription antiemetic used to treat motion sickness/ block receptors in the inner ear
dimenhydrinate
cyclizine hydrochloride
meclizine hydrochloride
diphenhydramine hydrochloride

side effects of non prescription ANTI histamines

drowsiness, dry mouth, constipation, urinary retention, blurred vision

bismiuth subsalicylate(pepto bismal)

non-prescription antiemetic ; acts directly on the gastric mucosa; helps with upset stomach and
diarrhea

phosphorated carbohydrate solution (Emetrol) and what is it cautioned in?

non-prescription antiemetic; hyperosmolar carbohydrate
decreases smooth muscle contraction
cautioned in diabetes mellitus(raises BS)

what are prescription Anti-histamines/anticholinergics and what are some drugs

prescription antiemetics that treat motion sickness act primarily on the vomiting center; they also act
by decreasing stimulation of the CTZ and vestibular pathways
hydroxyzine
promethazine
scopolamine

what are some side effects of prescription anticholinergics and antihistamines

drowsiness, dry mouth, blurred vision, tachycardia, constipation

what do Dopamine antagonists do and what are the drugs

block dopamine receptors in the CTZ
phenothiazines, butyrophenones, benzodiazepines

what are some side effects of dopamine antagonists?

extra-pyramidal symptoms(shuffling gait, tremors, rigidity)
hypotension,
extrapyramidal syndrome

what are Phenothiazines used for and what are some side effects
-zine, used to treat nausea and vomiting resulting from surgery, anesthetics, chemotherapy, and
radiation sickness
SE- drowsiness, EPS, anticholinergic SE

What are butyrophenones used for and what are some SE?
-idol
used to treat postop nausea and vomiting and emesis associated with toxins, cancer chemo, and
radiation therapy
SE-EPS, hypotension

Benzodiazepines use and major side effect

lorazepam; used for control nausea and vomiting that may occur with cancer chemotherapy
major SE-sedation

How do serotonin antagonists work?

Serotonin antagonists suppress nausea and vomiting by blocking the serotonin (5-HT3) receptors in
the CTZ and blocking the afferent vagal nerve terminals in the upper GI tract

What are the serotonin antagonists and what are some side effects?
end in setron (odansetron)
SE-headache diarrhea, constipation dizziness

Glucocorticoids (Corticosteroids) medications and uses

Dexamethasone and methylprednisolone effective in suppressing emesis associated with cancer
chemotherapy.

cannabinoids uses and side effects

Dronabinol and Nabilone; alleviate nausea and vomiting resulting from cancer treatment.
side effects- depressed mood, drowsiness, dizziness, headaches hallucinations, paranoid reactions

Metoclopramide (Reglan)
controls post-op NV and used for chemo and radiation
SE- sedation, diarrhea, EPS

animetics nursing interventions

check vital signs, bowel sounds, assess for dehydration, inform to not consume alcohol, avoid
driving, avoid in pregnancy

What do emetics do?

they are used to induce vomiting
don't use if caustic substances ingested

what are some things that cause diarrhea?

infection, drugs, inflammation, spicy foods, malabsorption
nonpharmacologic diarrhea treatment
avoid milk products, avoid high fat foods, clear liquids, Gatorade, Pedialyte, IV fluids with
electrolytes

how do opiates work and what are the side effects?

decrease intestinal motility which decreases peristalsis
side effects- drowsiness, dizziness, confusion, hypotension dry mouth

opiate medications, CI, and general antidiarrheal nursing interventions

diphenoxylate with atropine
difenoxin with atrophine
loperamide
assess vital signs
CI in c diff, pts who ingested toxins glaucoma, liver disorders, or ulcerative colitis, can cause CNS
depression
assess bowel sounds
check for s/s of dehydration
check electrolytes

What do adsorbents do?

coats the wall of the GI tract and absorb bacteria or toxins that cause diarrhea

what are the adsorbent drugs and what do they do?

kaolin, bismuth subsalicylate and pectin-binds to and absorbs toxic bacteria
Psyllum- absorbs large amounts of fluid to form bulkier stools
lactobacillus- correct altered GI flora

Octreotide (Sandostatin)
somatostatin analog; treats severe diarrhea asst. w/ some cancers by inhibiting secretions and
enhancing absorption
given IM/IV
SE- nausea, diarrhea, abdominal pain, gallstones, cholestatic hepatitis

types of laxatives
Osmotic (saline)
Stimulant (irritants)
Bulk-forming
Emollient (stool softeners)
chloride channel activators

what are laxatives used for?

constipation, fecal impaction, immobile patients, children, bowel obstruction, pregnant patients

Osmotic (Saline) Laxatives

draws water into intestines, distends the bowel, and causes peristalsis; used for acute constipation,
bowel prep and purging toxins
continued use can cause electrolyte imbalances and dehydration
adequate renal function is needed to excrete magnesium
examples of osmotic laxatives
lactulose
magnesium hydroxide
magnesium citrate
sodium phosphates
polyethylene gycol with electrolytes

what are stimulant laxatives and what are some examples?

causes irritation to intestines causing peristalsis and evacuation; used for acute constipation and
bowel prep
very rapid acting and shouldn't be used regularly
Bisacodyl
castor oil
senna

How do bulk forming laxatives work?

water retained in stool, which increases bulk and stimulates peristalsis; used for a more chronic
safe laxative, IBS
give with a full glass of water

Types of bulk forming laxatives

polycarbophil
psyllium hydrophillic mucilloid
polyethylene glycol
methylcellulose

what do Chloride channel activators do and what is the drug?

increases fluid secretions which increases motility in chronic idiopathic constipation; IBS in women
with constipation and opioid induced constipation
lubiprostone

Emollient laxatives
prophylactic to draw water and fat into stool but dont stimulate peristalsis
onset of action: 24-48 hrs

Emollients (Stool Softeners) medications

mineral oil and docusate sodium(colace)
dont use on patients on fluid restrictions

what are the contraindications of chloride channel activators?

GI obstruction
chrons disease
diverticulosis
severe diarrhea

side effects of laxatives

flatulence, diarrhea, abdominal cramps, nausea, and vomiting
nursing interventions of laxatives
check fluid intake and output, monitor vital signs, encourage fiber intake
assess BUN and CR
increase water intake with stimulants
monitor bowel sounds
mix bulk forming laxatives in water
avoid overusing laxatives

How do peptic ulcers form?

when there is a hypersecretion of hydrochloric acid and pepsin, which erode the GI mucosal lining

what are some predisposing factors of ulcers

H.Pylori
mechanical factors
genetic factors
environmental factors
drugs
stress ulcer following a critical situation

GERD
inflammation of the esophageal mucosa caused by reflux of gastric acid content into the esophagus

non pharmacologic measures to treat peptic ulcers

avoid tobacco, avoid alcohol,
avoid hot spicy and greasy foods
dont take NSAIDS, including aspirin with food
sit upright during meals
dont eat before bedtime
wear loose fitting clothes

What are the 8 antiulcer drugs?

tranquilizers,
anticholinergic
antacids
H2 receptor blockers
proton pump inhibitors
mucosal coating agents
GI prostaglandins
prokinetic agents

tranquilizers
rarely used; reduced vagal nerve stimulation
side effects include edema, ataxia, confusion, EPS, agranulocytosis

what do Anticholinergics do and what are the side effects

decrease GI motility and secretions; take before meals
side effect: dry mucus membranes, constipation, urinary retention, drowsiness, dizziness, decreased
secretions
what do antacids do and what are some side effects?
neutralize stomach acid and reduce pepsin
don't take for more than 2 weeks
take other meds 1 hour before or 2 hours after
SE-chalky taste, diarrhea, constipation

caution in antacids
sodium bicarbonate
calcium carbonate
magnesium hydroxide
aluminum hydroxide

H2 receptor antagonists and when should you take it

-tidine (cimetidine)
suppresses amount of gastric acid secreted
used in GERD, PUD, hypersecretory secretions, heartburn, prevention of stress ulcers
take with first meal or immediately after

H2 receptor antagonists side effects and drug interactions

headache, dizziness, constipation, confusion, restlessness, gynecomastia(cimetidine)
antacids
oral anticoagulants
vitamin b12
minerals

what are Proton Pump Inhibitors and when are they best taken?
-prazole, long term and most effective medication to inhibit gastric acid secretions for patients with
GERD, peptic ulcer, prophylactic or burns
best taken 30 minutes before first meal of the day

side effects and risks of proton pump inhibitors

diarrhea, headache, abdominal pain, N/V more at risk of pneumonia and Cdiff and risk for fractures,
and risk for minerals and vitamin b12 deficiency

what is the pepsin inhibitor drug and how long should you take it and when?
Sucralfate (Carafate); coats ulcer from high acidic environment
taken up to 8 weeks, 4x a day ac and hs
antacids 30 minutes before or after

pepsin inhibitors 3 side effects

constipation, dry mouth, dizziness

what do gastrointestinal prostaglandins do, some CI and SE?

misoprostol; decreases the acidic environment and increases mucosa
prevents PUD
contraindicated in pregnancy
SE- diarrhea and abdominal cramps
what are the 3 types of drug cocktails to prevent H. pylori
PPI, clarithromycin, amoxicillin
PPI, clarithromycin, metronidazole
PPI, bismuth subsalicylate, metronidazole, tetracycline

what is normal blood glucose

60 to 100 fasting and up to 140 after eating

What is diabetes mellitus and what are some major symptoms?

deficient glucose metabolism
Type 1 is insulin dependent
Type 2 is insulin resistance
MS- polyuria, polydipsia and polyphagia

secondary diabetes
can be caused by medications like glucocorticoids, thiazide diuretics and epinephrine
pregnancy's
or illnesses like cystic fibrosis, pancreatic cancer and celiac disease

How does insulin work?

released by beta cells in pancreas; lowers blood glucose by facilitating uptake of glucose and coverts
to glycogen for future glucose needed in the liver and muscle

what are the types of insulin and what are some things to remember?
rapid-acting
short-acting
intermediate acting
long acting
combination
rotate sites to prevent lipodystrophy; changes required in times of stress; has to be administered
subcut (besides Humulin R)

rapid acting insulin onset/peak/duration and medications and food

insulin lispro insulin aspart, insulin glulisine
onset-5 to 15 min
peak- 30 min to 1 hour
duration- 2 to 4 hours
you want the meal in front of the patient as you administer

short acting insulin (clear) medication, peak/onset/duration

Humulin R and Novolin R
onset- 30 to 60 minutes
peak- 2 to 3 hours
duration- 3 to 4 hours

intermediate acting (cloudy) insulin onset peak and duration

insulin isophane (Humulin N, Novolin N)
onset- 2 to 4 hours
peak- 4 to 12 hours
duration- 18 to 24 hours

what are the 3 long acting insulins and what are their onset peak and duration
insulin glargine(peakless, onset 1 hr, duration 24 hrs, hs)
insulin detemir- similar to glargine but peak 8 hours
insulin degludec(duration 42 hours)

Combination insulin
composed of short and intermediate acting or rapid and intermediate acting
isophane NPH 70% regular 30%(Humulin 70/30)

insulin interactions with drugs

increased hypoglycemia with aspirin, oral anticoagulants, alcohol, oral hypoglycemics, beta blockers,
TCA, MAOIs, tetracyclines
increased chance of hyperglycemia with thiazides glucocorticoids, oral contraceptives', thyroid drugs,
smoking

Hypoglycemia (insulin reaction) signs and symptoms

headache, dizziness, confusion, slurred speech, tremors, tachycardia, seizures

how do you treat hypoglycemia

bs <60 and conscious patient, give fast acting sugar
bs <60 and unconscious patient, give D50 IV or glucagon subcut w/ OJ
repeat blood sugars every 15-20 minutes until stable

Hyperglycemia symptoms and how to treat

extreme thirst, dry mucous membranes, poor skin turgor, polyuria, fruity breath kussmaul
respirations
treat with fluids and insulin

other diabetic events

lipodystrophy, somogyi effect, dawn phenomenon, insulin shock, diabetic ketoacidosis

Nursing Interventions for insulin

monitor VS, glucose level, teach patient how to check blood glucose, how administer insulin, if patient
is NPO, dose reduction and holding, teach diet and exercise, rapid or fast acting-make sure food is in
room

how to prevent errors with insulin

match bottles with orders, have another nurse check, swirl to mix, inject air into vial first, no
aspiration, store in fridge,

what are some other methods of insulin administration

insulin pumps; insulin pen injectors, insulin jet injectors
sliding scale insulin
adjusted doses depending on blood glucose
done before eating and at bedtime
rapid or short acting insulin

how to store insulin

keep in fridge
remove from fridge 30 minutes before injection
avoid storing in sunlight or at high temperatures

first and second generation sulfonylureas

only used to treat type 2 diabetes and increases tissue response to insulin and decreases glucose
production

what are the first generation sulfonylureas medications?

short acting- tolbutamide
intermediate acting- tolazamide
long acting- chlorpropamide

second generation sulfonylureas

glimepiride
glipizide
these work more effectively and have a greater hypoglycemic potency so monitor for hypoglycemia

SE of sulfonylureas and cautions

GI distress(N/V/D)
dermatological responses
hypoglycemia
caution in ETOH(alcohol) because it causes disulfiram like reaction
contraindicated in type 1 diabetes

biguanide: Metformin action and side effects

decreases hepatic production of glucose from stored glycogen
decreases the absorption of glucose from the small intestine
SE- diarrhea, lactic acid, bitter taste
monitor renal function, avoid alcohol

alpha-glucosidase inhibitors
acarbose inhibits digestive enzyme in SI responsible for release of glucose in the diet

acarbose interventions
can combine with sulfonylureas, will not cause hypoglycemia when given alone
administer with first bite of food

thiazolidinediones
-glitazone
lowers glucose by decreasing hepatic glucose production and target cell response to insulin
thiazolidinediones side effects and cautions
headache, dizziness, blurred vision, weight gain, edema
CI in symptomatic heart disease class III and IV CHF

meglitinides action and nursing interventions

repaglinide stimulate beta cells to release insulin
short acting(less chance of hypoglycemia)
take with meals
CI- liver dysfunction

incretin modifiers (DPP 4 inhibitors)

-gliptin
increase level of incretin hormones, insulin secretion and glucagon secretion to reduce BS
no weight gain
teach families how to administer

SLT 2 inhibitors
-gliflozin
Dapagliflozin
blocks reabsorption of glucose in kidneys causing glucose to be eliminated through urine
no hypoglycemia
SE-UTI, yeast infection

Incretin Mimetics
-tide
enhance insulin secretion, suppress glucagon, slow gastric emptying and reduce food intake so good
with weight loss

incretin mimetics nursing interventions and SE

refrigerated injectable pen for subcut use
take within 60 min before breakfast and dinner
SE- headache, dizziness, jitteriness, GI distress

amylin analogue
Pramlintide acetate; improves post prandial glucose control in patients using insulin but unable to
maintain glucose control
vials; given before meals
for type 1 and type 2
SE- dizziness, anorexia, N/V fatigue

Hyperglycemic drugs- Glucagon

used to treat insulin induced hypoglycemia when other methods aren't available
parenteral routes
Onset- 5 to 20 min
teach families how to administer

hyperglycemic drugs-diazoxide
increases BS by inhibiting insulin release and stimulating epinephrine
treats chronic hypoglycemia due to hyperinsulinism caused by islet cell cancer/hyperplasia