Professional Documents
Culture Documents
By: Barbara O.
Instagram: @yournursingeducator
E-mail: yournursingeducator@gmail.com
*Disclaimer: This PDF was created by cross referencing several resources. It is not meant to replace your pharmacology lecture/study notes or drug guide book but is
instead a supplementary resource to aid in studying. While all attempts were made to ensure accuracy, there is no guarantee of validity or accuracy. The purchaser of
this guide assumes all responsibility for the use of this material.
Analgesics ………………………………………..………………………………………………………………………………. 16
Classifications
Therapeutic class: broad purpose of drug (e.g. antihypertensive is used for HTN)
Pharmacologic class: specific pharmacological approach within the therapeutic class (e.g. beta blocker, calcium channel
blocker, etc. are within the antihypertensive therapeutic class)
Generic name: actual name of the drug (e.g. amlodipine)
Trade name: the name that the drug is marketed under; several different ways to name the generic drug (e.g. Norvasc)
Routes of Administration
Enteral – through GI tract
1. Tablets/Capsules – some can be enteric coated (prevents digestion by stomach acids)
2. Sublingual/Buccal – drug goes directly into blood due to amount of blood vessels in this area
3. Nasogastric/Gastric (G-tube)
Topical – applied to intended site of action
1. Transdermal
2. Ophthalmic
3. Otic
4. Nasal
5. Respiratory – administered via inhalation
6. Vaginal or rectal – suppositories, ointments, creams, gels; for irritation or infection
Parenteral – involves needles penetrating skin
1. Intradermal – rapid absorption due to vasculature; local anaesthetics or allergy testing
2. Subcutaneous – insulin, heparin, vaccines; no more than 1 mL to be injected
3. Intramuscular – faster than ID or SC; proper landmarking needed; no more than 3 mL to be injected
4. Intravenous – very rapid onset; continuous infusion, intermittent infusion, IV push
Pharmacokinetics
Absorption → distribution → metabolism → excretion
1. Oral → Stomach/small intestine → Absorbed/Carried by Portal Vein/blood supply → Liver (Primary Site of
metabolism in body) → Two possibilities:
1. Systemic Circulation → Tissue (Heart/Brain/Muscle/Kidney)
2. Excretion (Biliary) (Gall bladder/Bile ducts) → small-large intestines → Excretion (feces)
2. Parenteral/ Other routes → Directly absorbed into Systemic Circulation → Two possibilities:
1. Systemic Circulation → Tissue (Heart/Brain/Muscle/Kidney)
2. Excretion (Biliary) (Gall bladder/Bile ducts) → small-large intestines → Excretion (feces)
Adverse Effects
Unintended & undesired responses from drugs
1. Side effects
• Secondary to main therapeutic effect of drug & are expected
• Often occur at normal doses & are often unavoidable
• Often due to poor specificity/selectivity of drug.
Autonomic nervous system (ANS) regulates involuntary functions including heart rate, respiratory rate, and
digestion by balancing sympathetic nervous system (SNS) and parasympathetic nervous system (PNS)
Cholinergic drugs
Promotes action of neurotransmitter acetylcholine (Ach) = increase in Ach
Stimulates PNS – rest & relaxation
1. Cholinergic agonist
• Mechanism of Action (MOA): stimulates cholinergic receptors (mimics action of Ach) → allows
body to ‘rest & relax’
• Produces these effects: salivation, bradycardia, dilated blood vessels, constriction of bronchioles,
increased GI activity, increased contraction of bladder muscles, and constriction of pupils
• Used for: weak bladder, abdominal distention, constriction of pupils/high eye pressure, and
hypofunction of salivary gland
• Side effects: nausea (N)/vomiting (V)/diarrhea (D), blurred vision, bradycardia, hypotension, SOB,
urinary frequency, increased salivation, diaphoresis, corneal clouding, abdo pain/cramps, and
flushing
• Rarely administered by IV/IM route due to immediate breakdown by cholinesterase and due to
potential of cholinergic crisis (extreme muscle weakness + possible paralysis of respiratory
muscles)
Cholinergic drugs
Drug Indication Nursing
Acetylcholine Constriction of pupil during ocular Instill into anterior chamber of eye
→ Miochol E surgery
Bethanechol Urinary retention Potential for influx infection if the sphincter
→ Urecholine doesn’t relax
Carbachol Glaucoma, inhibition of Instill to anterior chamber of eye.
→ Miostat perioperative intraocular pressure Contraindicated in inflammation of anterior
chamber
Pilocarpine Xerostomia (dry mouth) Inform pt that blurred vision can impair driving,
→ Isopto particularly @ night
Carpine, Pilocar
2. Anticholinesterase drugs
• MOA: normally, Ach is broken down by the enzyme acetylcholinesterase. By destroying this
enzyme, more Ach accumulates → allows body to ‘rest & relax’
• Used to: decrease eye pressure, increase bladder tone, improve peristalsis, promote contraction
in myasthenia gravis, diagnose myasthenia gravis, and temporarily improve dementia
• Side effects: arrhythmias, N/V/D, seizures, headache, anorexia, pruritius, urinary frequency,
induction of preterm labor, SOB
• Build-up of Ach can precipitate cholinergic crisis (S/S: abdo cramps, N/V/D, pupillary miosis,
hypotension, increased secretions/salivation/perspiration, bronchospasm, bradycardia)
• When quick effect is needed = use IV/IM route
Anticholinesterase drugs
Drug Indication Nursing
Donepezil Alzheimer’s Disease Important to take daily at same time (usually
→ Aricept before bed)
Anticholinergic drugs
Also known as cholinergic blockers
Interrupt PNS impulses; prevent Ach from stimulating cholinergic receptors = decrease in Ach
These drugs will do the OPPOSITE of above cholinergic drugs
• MOA: Competitively inhibits the action of Ach
• Used to: treat nausea, treat Parkinson’s, relax the GI and GU system, manage headaches, dilate the
lungs, dilate the eye, and increase heart rate
• Side effects: dry mouth, dry eyes, dry nasal passage, blurred vision, urinary hesitancy or retention,
constipation, tachycardia
• Contraindicated in: narrow angle glaucoma, hemorrhage, tachycardia, and myasthenia gravis
Anticholinergics
Drug Indications Nursing
Atropine Symptomatic sinus bradycardia Monitor ECG and heart rate (can cause
increased HR and ventricular ectopy). Also
monitor intake + output due to possible
retention
Ipratropium COPD, acute asthma exacerbation Administered via nebulizer or inhaler.
→ Atrovent If administered with other inhalers, administer
adrenergic bronchodilators first, followed by
ipratropium, then corticosteroids. Wait 5 min
between each
Scopolamine Nausea, vomiting, motion sickness Administered via transdermal patch, IV, IM, or
→ Scopace prophylaxis, chemotherapy induced N & V SC. Contraindicated in closed angle glaucoma
Glycopyrrolate Pre- and post- op reduction of saliva, drooling May increase GI lesions in patients taking oral
→ Robinul potassium chloride tablets. Monitor intake +
output – can cause retention
Benztropine Parkinsonism, drug-induced extrapyramidal PO dose to be taken with food. Therapeutic
→ Cogentin disorders (S/S: restlessness, rigidity, tremors, effects seen in 2-3 days. Frequent rinsing of
pill rolling, masklike face, shuffling gait, muscle mouth will decrease dryness.
spasms, twisting motions, difficulty speaking,
loss of balance)
Dicyclomine Irritable bowel syndrome (IBS) Administer 30 mins before meals and at
→ Bentyl bedtime. Monitor intake + output due to
possible retention. Monitor for drowsiness
Oxybutynin Overactive bladder (incontinence, frequency, Administered PO, transdermal patch, or
→ Ditropan urgency) transdermal gel. Contraindicated in glaucoma,
XL intestinal obstruction, and urinary retention
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Adrenergic drugs
Also called sympathomimetic drugs
Produce effects similar to SNS – fight or flight = increase in norepinephrine (NE)
• MOA: direct acting adrenergic = the drug directly stimulates adrenergic receptors. Indirect acting
adrenergic = drug stimulates the release of norepinephrine from nerve endings
• Receptor sites:
o Alpha1 adrenergic receptors = cause vasoconstriction, papillary dilation, closure of sphincter and
bladder
o Alpha2 adrenergic receptors = cause decreased SNS activity, reduced NE release, insulin release
o Beta1 adrenergic receptors = located in heart; cause increased HR and increased force of
contraction
o Beta2 adrenergic receptors = cause vasodilation, bronchodilation, increased release of glucagon
o Dopamine receptors
1. Catecholamines
• Primarily direct-acting adrenergics
• Produce these effects: constrict blood vessels, increase heart rate, increase blood pressure, and
dilate bronchi
• Catecholamines are positive inotropes (make heart contract more forcefully) and positive
chronotropes (make heart beat faster)
• These drugs aren’t taken PO due to quick destruction by digestive enzymes
• Side effects: dry mouth, N/V, CNS stimulation, appetite suppression, increased HR,
bronchodilation, decreased blood flow to GI, pupil dilation, increased glucose levels
• Contraindicated: uncorrected tachyarrhythmias
Catecholamines
Drug Indication Nursing
Dobutamine Cardiac decompensation, low cardiac Stimulates beta1 receptors. Administer drug
→ Dobutrex output into large vein; monitor site for inflammation
+ pain. Perform independent double check
Dopamine Hypotension, low cardiac output, poor Stimulates dopaminergic and beta1
perfusion of vital organs receptors. Administer drug into large vein;
Low dose: increases urine output + renal monitor site for inflammation + pain.
blood flow Perform independent double check.
Medium dose: increases renal blood flow,
cardiac output, heart rate, and heart
contractility
High dose: increases BP, potential risk of
tachyarrhythmias
Epinephrine Cardiac arrest, hypotension due to septic Stimulates beta1 and beta2 receptor. Can
→ Adrenalin, shock, anaphylaxis, symptomatic cause paradoxical bronchospasm (wheezing)
Epi-Pen bradycardia, management of asthma and with overuse of inhaler. Teach pt using
COPD autoinjector about proper placement (into
2. Noncatecholamines
• Can be direct-acting, indirect-acing, or dual-acting
• Produce these effects: local or systemic vessel constriction, nasal/eye decongestion, dilation of
bronchi, and smooth muscle relaxation
• Can be taken orally, and have longer half life
• Contraindicated: Monoamine oxidase inhibitors (can cause severe hypertension), tricyclic
antidepressants (can cause hypertension + arrhythmias)
• Side effects: headache, irritability, trembling, seizures, hypertension, palpitations, tachycardia,
arrhythmias, flushing, angina
Noncatecholamines
Drug Indication Nursing
Phenylephrine Severe hypotension/shock Stimulates alpha receptors. Can cause severe
bradycardia + decreased cardiac output due
to increase in afterload
Albuterol Bronchospasm Stimulates beta2 receptor. Can cause
→ Ventolin paradoxical bronchospasm with excessive
inhaler use
Salmeterol Asthma prevention and maintenance, Stimulates beta2 receptor. Do not use to treat
→ Serevent COPD maintenance, prevention of exercise acute symptoms. Should only be used for
Diskus induced asthma patients not adequately controlled on other
asthma controller medications; long term use
can increase risk of asthma-related death
Terbutaline Bronchospasm, pre-term labor (this drug Stimulates beta2 receptor. Should not be
will stop contractions) used in pregnancy for the prevention of
prolonged treatment (48-72 hr) of preterm
labor
Nervous system = includes Central Nervous System (CNS) and Peripheral Nervous System (PNS)
• CNS = brain and spinal cord
• PNS = somatic and automatic nervous systems
Neuromuscular system = muscles of body (plus the nerves that supply these muscles)
Drugs include: skeletal muscle relaxants, neuromuscular blocking drugs, antiparkinsonian drugs, anticonvulsant
drugs, and antimigraine drugs
10
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Anticonvulsant Drugs
Seizure = disturbed electrical activity in brain
1. Partial/focal = part of brain is affected
• Simple: experience some elements of aura, some twitching (usually in 1 limb)
• Complex: experience some elements of aura. Often consists of repeated movements, some
altered consciousness, autonomic, sensory & motor signs, confusion after seizure
2. Generalized = involves all of brain
• Absence (petit mal): starring + transient loss of responsiveness and then retrograde amnesia (not
remembering what happened)
• Atonic: short episodes where patient suddenly falls
• Tonic-clonic (grand mal): may experience some elements of aura, then tonic phase (muscle
contraction) then clonic phase (repeated contraction & relaxation), usually followed by deep
sleep (postictal state). Also has retrograde amnesia
3. Special cases
• Febrile seizures: tonic-clonic seizure related to rapid rise in body temperature
• Myoclonic seizures: large jerky body movements due to uncontrollable skeletal muscle
contraction
• Status epilepticus: seizure is repeated or prolonged (life-threatening due to risk of hypoxia)
Medications for seizures will decrease neuron excitability
Observe and record intensity, duration, and location of seizure activity
1. Barbiturates
• For generalized tonic clonic seizures
• MOA: stimulates gamma-aminobutyric acid (GABA) neurotransmitter (an inhibitory
neurotransmitter), which then inhibits brain activity; this is what causes the drowsy/calming effects
• Side effects: drowsiness, tolerance, dependence, respiratory depression, GI effects
• Contraindication: liver or kidney disease
• Medications are not to be stopped abruptly as this can cause seizure activity
Barbiturates
Drug Indication Nursing
Phenobarbital Status epilepticus, seizures, sedation, Risk of toxicity increases when taken with CNS
→ Luminal hypnotic, insomnia depressants, valproic acid, chloramphenicol,
felbamate, cimetidine, or phenytoin
Therapeutic serum range: 15-40 mcg/mL
Primidone Seizures
→ Mysoline
2. Benzodiazepines
• For absence & myoclonic seizures
• MOA, side effects, and contraindications are same as above
• For IV injection, administer slowly to avoid bradycardia
• If there is an overdose on benzodiazepines = give flumazenil (Romazicon)
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3. Hydantoins (Phenytoin)
• For partial and tonic clonic seizures
• MOA: block Na+ influx = neurons are kept in absolute refractory for a longer time = less frequent
action potentials
• Side effects: dependence, respiratory depression, gingivitis, ataxia, dizziness, lethargy, alter vitamin K
metabolism, dysrhythmias, nystagmus
• Frequent bloodwork is needed to monitor drug levels
Hydantoins
Drug Indication Nursing
Phenytoin Seizures Risk of hypotension and arrhythmia – monitor BP
→ Dilantin and HR. Monitor for change in mood – there is a
risk of suicidal ideation
Therapeutic serum range: 10-20 mcg/mL
4. Phenytoin-like drugs
• For absence, tonic-clonic seizures, bipolar, and migraines
• MOA same as above
• Side effects: increased bleeding times, photosensitivity, hepatotoxic, pancreatitis
Phenytoin-like
Drug Indication Nursing
Valproic acid Seizures, bipolar mania, migraine Monitor for suicidal tendencies (especially early
→ Depakene prophylaxis on). Monitor for signs of pancreatitis (abdo
pain, N/V, anorexia). Monitor liver function
Carbamazepine Epilepsy, trigeminal neuralgia, bipolar Using an MAOI drug with carbamazepine may
→ Tegretol mania result in hyperpyrexia, hypertension, seizures,
and death
Therapeutic serum range: 3-14 mcg/mL
Zonisamide Seizures
→ Zonegran
5. Succinimides
• For absence seizures
• MOA: prevents Ca+2 entry through specialized T-type channels in thalamus = decreases neuron
excitability
• Side effects: anorexia, N/V, blood dyscrasia
Succinimides
Drug Indication Nursing
Ethosuximide Absence seizures Do not discontinue rapidly; abrupt withdrawal
→ Zarontin can cause absence seizure
Therapeutic serum range: 40-100 mcg/mL
13
1. Anticholinergic Drugs
• Also known as parasympatholytic drugs = inhibit action of Ach in parasympathetic nervous system
(PNS)
• MOA: inhibition of Ach at receptor sites = reduction of tremors; this category of drug reduces the
tremors + drooling but has minimal effect on the bradykinesia, rigidity, and balance abnormalities
• Side effects: anticholinergic effects = confusion, drowsiness, urine retention, blurred vision, N/V/C,
dry mouth/secretions, increased HR
• Contraindicated in: narrow angle glaucoma, BPH, GI obstructions, myasthenia gravis, dysrhythmias
• If discontinued abruptly, S/S of Parkinsonism can be intensified
Anticholinergic Drugs for Parkinson’s
Drug Indication Nursing
Benztropine Parkinsonism Reduces rigidity + tremors. Avoid driving due to
→ Cogentin side effect of drowsiness/dizziness
2. Dopaminergic Drugs
• These drugs increase effects of dopamine
• MOA: increase in neurotransmission of dopamine
• Side effects: too much dopamine = uncontrolled + involuntary movements, muscle twitching,
spasmodic winking, orthostatic hypotension
• Interact with: TCAs, MAOIs, antihypertensives, antipsychotics, anticonvulsants, antacids
• Contraindicated in: cardiac, kidney & liver disease, narrow angle glaucoma, history of seizures
Dopaminergic Drugs
Drug Indication Nursing
Carbidopa/Levodopa Parkinson Disease Avoid in narrow angle glaucoma. Avoid in pt
→ Sinemet taking MAOI (can cause hypertensive
reaction). Monitor for GI complications.
Divide total daily prescribed protein among
all meals (high protein diet interferes with
medication availability to CNS)
Amantadine Parkinson Disease, dyskinesia associated Avoid in narrow angle glaucoma and in
→ Osmolex with Parkinson Disease, drug-induced breastfeeding pts. Monitor for orthostatic
extrapyramidal symptoms hypotension and constipation
Selegiline Parkinson Disease Monitor for changes in behavior and
→ Eldepryl suicidal tendencies. Contraindicated in
concurrent use with SSRI or TCA
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Anti-Migraine Drugs
Migraine = unilateral headache pain (pounding/pulsating/throbbing), sometimes preceded by aura
Other S/S = light/sound sensitivity, N/V/C/D
Migraine is due to vasodilation or due to release of vasoactive + inflammatory substances from nerves in
trigeminal system
Treatment = abort migraine after it has started OR prevent one from starting
o Abortive medications = analgesics, NSAIDs, ergotamine, serotonin agonists
o Preventative medications = beta blockers, TCAs, valproic acid, and NSAIDs
1. Serotonin Agonists
• Treatment for moderate to severe migraines
• MOA: serotonin agonist = cause constriction + reduction of inflammation in trigeminal nerve =
provides relief
• Side effects: tingling, flushing, dizziness, weakness, somnolence, chest pain, dry mouth, N
• Contraindicated: ischemic heart disease, stroke, CAD
Serotonin Agonists
Drug Indication Nursing
Almotriptan, Eletriptan, Acute treatment of migraine Contraindicated in ischemic heart disease,
Frovatriptan, Naratriptan, attack with or without aura hypertension, or cerebrovascular syndrome.
Rizatriptan, Suma triptan, Overuse of medication can lead to exacerbation
Zolmitriptan of headache. Do not use within 24 hrs of
another serotonin agonist
2. Ergotamine
• For abortion of migraine
• MOA: blocks inflammation + partially acts as serotonin agonist
• Side effects: N/V, numbness, tingling, muscle pain, weakness
Ergotamine
Drug Indication Nursing
Ergotamine Migraine, menopausal hot flashes Do not give with CYP3A4 inhibitor (e.g.
→ Ergomar erythromycin) – can lead to serious peripheral
ischemia due to high risk of vasospasm
15
2. Acetaminophen
• MOA: reduces pain + fever but does not affect inflammation or platelet function. Inhibits
prostaglandin synthesis to reduce pain and acts on hypothalamus to reduce heat
• Side effects: liver toxicity
Acetaminophen
Drug Indication Nursing
Acetaminophen Pain, fever Not to be given to pt with active liver disease.
→ Tylenol To minimize GI irritation, avoid alcohol when
taking medication
3. Nonselective NSAIDs
• Normally, inflammatory disorder produces/releases prostaglandins = causes pain
• MOA: inhibits prostaglandin synthesis by blocking COX-1 and COX-2 = decreased inflammation +
analgesic effect
o COX1 – prostaglandins in stomach lining; therefore produces GI side effects
o COX2 – prostaglandins that mediate inflammatory process
• Side effects: abdo pain + bleeding, diarrhea, N, ulcers, liver toxicity, drowsiness/confusion, tinnitus,
bladder infection, HTN
• Contraindicated for perioperative pain for CABG
• Take the drug with meals or milk to reduce GI side effects
Nonselective NSAIDs
Drug Indication Nursing
Indomethacin Inflammatory/rheumatoid disorders, Risk of MI and stroke. Elderly pts are at greater
→ Indocin tendonitis, gouty arthritis, pain risk of GI side effects.
16
4. Selective NSAIDs
• MOA: selectively blocks COX2 = decreases prostaglandin synthesis = decreases pain + inflammation
• Side effects: HTN, fluid retention, edema, dizziness, headache, GI ulcers (less than nonselective
NSAIDs)
Selective NSAIDs
Drug Indication Nursing
Celecoxib Acute pain, dysmenorrhea, ankylosing Risk of MI and stroke. Elderly pts are at greater
→ Celebrex spondylitis, OA, RA risk of GI side effects.
17
2. Opioid Antagonist
• MOA: Attach to opioid receptors but do NOT stimulate them = prevention of opioid effects
• Used to reverse effects of opioids
• MOA: drug blocks the receptor site = opioid receptor cannot attach = no opioid effects
• Side effects: HTN, palpitation, shortness of breath, anxiety, diarrhea, N/V, thirst, urinary frequency
Opioid Antagonist
Drug Indication Nursing
Naloxone Opioid overdose, reversal of respiratory Dilute 0.4mg ampule of naloxone in 10 mL of
→ Narcan depression NS and administer 0.5 mL (0.02 mg) by IV push
every 2 min. Monitor RR, rhythm, and depth;
HR, ECG, BP; and LOC frequently
18
Inotropic Drugs
Inotrope = increases force of heart contraction (positive inotrope)
These drugs can prevent remodeling of L or R ventricle (common in heart failure)
1. Cardiac glycosides
• Positive inotrope, negative chronotrope (decreases HR)
• MOA: inhibits Na/K activated ATP = increase in intracellular levels of Na and Ca = increase in Ca will
strengthen myocardial contraction. These drugs also act on CNS to increase vagal tone = slowing of
HR by slowing the SA and AV nodes
• Used for: atrial fibrillation (controls the HR from being too fast), atrial flutter, heart failure, and
supraventricular tachycardia (SVT)
• Side effects: N/V/D, abdo pain, confusion, vision changes, bradycardia, complete heart block
• Herbals like St. John’s wort and ginseng can increase digoxin levels = increased risk of digoxin toxicity
Cardiac Glycoside
Drug Indication Nursing
Digoxin Atrial fibrillation, heart failure Check HR before administration (ensure HR is
→ Lanoxin above 60 bpm). Monitor for bradycardia.
Monitor digoxin levels (digoxin has a narrow
therapeutic range)
2. Phosphodiesterase inhibitors
• Used for short term management of heart failure
• MOA: PDEI move Ca into cardiac cells = improve cardiac output by strengthening contractions. Also,
the drug relaxes smooth muscle = less vascular resistance and less amount of blood returning to
heart = decreased afterload + preload
• Side effects: arrhythmias, N/V, headache, chest pain, hypokalemia, increase in HR, hypotension
PDE Inhibitors
Drug Indication Nursing
Milrinone Heart failure (HF) Monitor ECG during infusion. Ensure that HR is
controlled in atrial fib before administration
because this drug can increase HR
Antiarrhythmic Drugs
Benefits vs risks need to be weighed because these drugs can worsen arrhythmias
4 classes: I, II, III, IV
1. Class I
• Used for: atrial and ventricular arrhythmias
• MOA: block Na channels = interfere with conduction of cardiac impulses = slows action potential
• Side effects: N/V/D, anorexia, arrhythmias (conduction delays; AV blocks), hypotension, bradycardia,
palpitations
19
2. Class II
• MOA: block beta adrenergic receptor sites in conduction system of heart = SA node is slowed down =
reduction of electrical impulses
• Strength of contractions are reduced = heart beats less forcefully (negative inotrope) = heart does
not need as much oxygen to work
• Side effects: arrhythmias, bradycardia, heart failure, hypotension, N/V/D, bronchospasm, fatigue
Class II Antiarrhythmics
Drug Indication Nursing
Propranolol HTN, migraine, angina, pheochromocytoma, Can exacerbate ischemic heart disease and
→ Inderal supraventricular arrhythmias, portal hypertension angina with abrupt withdrawal.
Contraindicated in asthma, COPD, severe
bradycardia, shock, and heart failure. If
giving via IV = constant ECG monitoring is
necessary. Monitor HR and BP
Esmolol Intraoperative tachycardia/HTN, SVT, Contraindicated in bradycardia, AV block,
→ Brevibloc hypertensive emergency heart failure
3. Class III
• Used for: ventricular arrhythmias
• MOA is not known; thought to delay repolarization & lengthen refractory period of action potential
• Side effects: hypotension, bradycardia, N, vision disturbance
Class III Antiarrhythmics
Drug Indication Nursing
Amiodarone Stable monomorphic or polymorphic ventricular Constant ECG monitoring needed.
→ Pacerone tachycardia, pulseless ventricular Contraindicated in AV block and
tachycardia/ventricular fibrillation bradycardia. Avoid during breastfeeding
Dofetilide Converting afib/flutter to sinus rhythm Continuous ECG monitoring needed.
→ Tikosyn Contraindicated in prolonged QT complex
and bradycardia. Grapefruit juice may
increase levels.
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5. Adenosine
• Used for acute treatment of SVT
• MOA: adenosine suppresses SA node = reduces HR. AV node is unable to conduct impulse from atria
to ventricles = temporary pause in rhythm
• Side effects: facial flushing, shortness of breath, dizziness, dyspnea, chest discomfort
Adenosine
Drug Indication Nursing
Adenosine SVT Contraindicated in AV block, sick sinus
syndrome, bradycardia. Used for
cardioversion. Monitor ECG continuously
Antianginal Drugs
Sign of angina = chest pain
These drugs work by increasing the O2 supply to the heart
1. Nitrates
• For acute angina
• Can be given sublingually, buccally, as tablets, aerosols, inhalation, transdermally, or via IV
• MOA: cause smooth muscle of veins and arteries to dilate = coronary arteries dilate = improvement
of O2 supply to myocardium. ALSO, the dilated blood vessels means there is less blood return to
heart = reduces preload = reduction of ventricular wall tension = reduces O2 requirements of heart
• Side effects: headache, hypotension, dizziness, and increased HR
• Have pt sit/lay when providing first dose
Nitrates
Drug Indication Nursing
Isosorbide dinitrate Angina pectoris Contraindicated in pts taking PDE-5 inhibitors
→ Isordil (e.g. sildenafil), shock, and hypotension
Nitroglycerin Angina pectoris, Contraindicated in pts taking PDE-5 inhibitors
(e.g. sildenafil), shock, and hypotension
2. Beta blockers
• For long term prevention of angina
• MOA: block beta receptor sites in heart = decreased HR, force of contraction, BP = lower O2 demand
21
Antihypertensive Drugs
HTN = elevation of systolic BP (SBP), diastolic BP (DBP), or both
1. Angiotensin-converting enzyme inhibitors (ACE inhibitors)
• Used for sodium + water retention and HTN
• MOA: inhibits ACE = prevents conversion of angiotensin I to angiotensin II (a potent vasoconstrictor)
= decreases peripheral arterial resistance and promotes excretion of aldosterone (normally
promotes Na and water retention) = decrease in BP + reduction of Na and water
• Side effects: headache, fatigue, dry cough, N/V, increased K+, elevation of BUN + Cre
22
3. Beta blockers
• Used to treat HTN (and ocular HTN) and angina
• MOA: blocks beta receptor sites in heart = decreased HR, force of contraction, BP = lower O2
demand
• Side effects: bradycardia, heart failure, arrhythmias (AV block), fainting, fluid retention, edema,
shock, N/V/D
• Assess apical pulse before administration; hold if <50 bpm
• Betaxolol, carteolol, and timolol are used for ocular HTN
23
5. Thiazides (hydrochlorothiazide)
• Used for: edema, HTN, diabetes insipidus
• MOA: reduce Na reabsorption by inhibiting Na+/Cl-cotransporter in the ascending loop of Henle =
prevent reabsorption of Na in kidneys = increased excretion of Na (and thus water). There is also an
increase in excretion of Cl, K, and bicarb
• Side effects: hypokalemia, hyperglycemia, hyperlipidemia, hyponatremia, hypercalcemia, low BP,
orthostatic hypotension
• Decreases responsiveness to oral hypoglycemics
Thiazide Diuretics
Drug Indication Nursing
Hydrochlorothiazide HTN, edema Contraindicated in anuria. Use cautiously in
→ HCTZ, microzide pts with DM, fluid/electrolyte imbalance,
gout, hypotension, SLE, kidney/liver disease.
Indapamide HTN, edema Same as above
Metolazone HTN, edema Same as above. Avoid concurrent use with
→ Zaroxolyn lithium.
6. Loop diuretics
• Used for: hypercalcemia, hyperkalemia, pulmonary edema, CHF, HTN
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8. Adrenergic agents
• To reduce BP, drugs in this category will inhibit/block the following receptors (thus producing an
opposite effect)
• Alpha 1 – causes peripheral vasoconstriction
• Alpha 2 – causes reduced sympathetic response (*drug to help with BP will agonize this receptor)
• Beta 1 – causes increased HR, conduction & contractility
• Beta 2 – causes increased HR, bronchodilation
Adrenergic Agents
Drug Indication Nursing
Doxazosin HTN, BPH Alpha 1 antagonist = causes vasodilation. Side
→ Cardura effects: orthostatic hypotension, syncope, N/V,
hypothermia, dry mouth, tachycardia
Clonidine HTN, cancer pain, alcohol withdrawal, Alpha 2 agonist. Last choice for pts who don’t
→ Catapres restless legs syndrome, Tourette’s respond to other drugs. Reduces sympathetic
syndrome, menopausal flushing output but also increases Na & water retention
(usually given with diuretic). Side effects:
hypotension, dry mouth, edema
Atenolol, HTN, angina, post MI, SVT Beta 1 antagonist. Slows HR + reduces
metoprolol contractility = reduced cardiac output. Side
effects: bronchospasm, bradycardia,
hypotension. Contraindicated in bradycardia,
heart block, cardiogenic shock, COPD, asthma
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Anticholinergics
Competitively antagonize actions of Ach
Usually not used to treat asthma and COPD due to thickening of secretions, but, ipratropium is one drug in this
category that is used for COPD
Used in: pts with COPD to prevent wheezing, SOB, chest tightness, and cough
MOA: blocks PNS = inhibits muscarinic receptors = causes bronchodilation
Side effects: tachycardia, nervousness, N/V, dizziness, headache, paradoxical bronchospasm
Contraindicated in: benign prostatic hypertrophy, narrow angle glaucoma
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Corticosteroids
Used for: long term prevention of asthma attacks
MOA: inhibit production of cytokines, leukotrienes, and prostaglandins + promote recruitment of eosinophils
and inflammatory mediators = reduce inflammation
These drugs will not help in an acute asthma attack
Side effects: mouth irritation, oral candidiasis, upper respiratory tract infection, cough. Oral corticosteroids =
hyperglycemia, N/V, headache, growth suppression in children
Contraindicated in: active infection, hypertension, CHF
Pt’s with diabetes will need closer monitoring of blood glucose due to side effect of hyperglycemia
Anticholinergics for bronchodilation
Drug Indication Nursing
Beclomethasone Chronic asthma Contraindicated in primary treatment of status asthmaticus or
→ QVAR acute bronchospasm. Assess patients changing from systemic
corticosteroids to inhalation corticosteroids for signs of
adrenal insufficiency (anorexia, nausea, weakness, fatigue,
hypotension, hypoglycemia) during initial therapy + periods of
stress
Fluticasone Maintenance of asthma (not for Same as above
→ Flovent acute relief)
Prednisone Acute asthma, RA, advanced Contraindicated in untreated serious infections, varicella, and
pulmonary TB, autoimmune in administration of live or attenuated live vaccine. Monitor for
hepatitis Cushing syndrome and hyperglycemia. Prolonged use can
increase risk of infection
Leukotriene Modifiers
Used for: prevention of acute asthmatic episodes and long term control of mild asthma
Leukotrienes are pro-inflammatory and cause smooth muscle contraction
MOA: leukotriene receptors are blocked = smooth muscle relaxes + bronchodilation
Side effects: headache, dizziness, N/V, myalgia, cough
Contraindicated in: liver disease, active infections
Leukotriene Modifiers
Drug Indication Nursing
Montelukast Prophylaxis and maintenance of asthma, Not to be given during an acute asthma attack.
→ Singulair exercise-induced bronchospasm, allergic Monitor for behaviour that could indicate depression
rhinitis or suicidal thought.
Zafirlukast Chronic asthma treatment and Not to be given during an acute asthma attack.
→ Accolate prophylaxis Behavioural changes are reported. Use with warfarin
can result in increased INR
Expectorants
Used in cold and flu medications
MOA: Increases bronchial secretions = thins mucous = easier to cough up mucous = easier to clear the airway
Side effects: N/V/D, drowsiness, abdo pain, headache
Expectorants
Drug Indication Nursing
Guaifenesin Cough Notify MD if no improvement in >7 days.
→ Robitussin,
Mucinex
Antitussives
Used to relieve a dry + nonproductive cough
MOA: suppress cough reflex by direct action on cough center in medulla
Side effects: N/V/C, sedation, dizziness
Contraindicated in: COPD (it is important to cough in COPD)
Expectorants
Drug Indication Nursing
Hydrocodone bitartrate Cough Contraindicated in paralytic ileus, acute abdo conditions, and
→ Tussigon respiratory depression.
Dextromethorphan Cough Contraindicated in use with MAOI (can cause serotonin
→ Benylin, Buckley’s syndrome). Avoid OTC cough/cold medication while breast
feeding or to children <4 years.
Benzonatate Cough Risk of severe hypersensitivity reaction (bronchospasm,
→ Tessalon cardiovascular collapse). Keep away from children. Risk of
mental confusion/hallucinations.
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GI tract: mouth - pharynx - esophagus - cardiac sphincter - stomach - pyloric sphincter - duodenum - jejunum -
ileum - ascending - transverse - descending - sigmoid - rectum
Peptic ulcer disease (PUD): Acid irritates lining of the stomach or small intestine (SI)
Stomach produces mucous, SI produces bicarb = this protects the lining from acid
85% of cases of PUD are due to H. pylori = irritates epithelial cells and is toxic = lining becomes less able to
protect itself. If irritation is severe enough = bleeding occurs = manifested as blood and vomit, or as coffee
ground appearance.
Antiulcer Drugs
Used to eradicate H. pylori or restore balance between acid and pepsin secretions in GI mucosa
Patient teaching = elevate HOB, don’t lie down 1-2 hours after eating, decrease intake of fat; chocolate; citrus;
coffee; and alcohol, avoid smoking, take medications with water to avoid stomach irritation, exercise regularly
1. Systemic Antibiotics
• H. pylori is a gram -ve bacteria
• Eradicate bacteria = promote ulcer healing and decrease recurrence
• Usually combined with proton pump inhibitor or H2 antagonist
• Side effects: mild GI disturbance, abnormal taste, diarrhea
Systemic Antibiotics
Drug Indication Nursing
Amoxicillin ENT infections, GU tract infections, skin Monitor bowel function. Report diarrhea, abdo
→ Amoxil infections, lower respiratory tract cramping, fever, and bloody stools (can be sign of
infections, H. pylori, infective endocarditis c.diff)
Clarithromycin Acute exacerbation of chronic bronchitis, Concurrent use with pimozide can prolong the QT
→ Biaxin acute maxillary sinusitis, mycobacterial interval and increase risk of arrhythmias.
infection, PUD, pharyngitis, CAP, skin Contraindicated in co-administration with
infection, pertussis, endocarditis colchicine in patients with liver/kidney disease.
Increased risk of rhabdomyolysis with lovastatin
and simvastatin.
Metronidazole Anaerobic bacterial infections, STI, Possible carcinogenic effect. Contraindicated in 1st
→ Flagyl colorectal surgical infection, trimester patients with trichomoniasis.
trichomoniasis, Gardnerella infection, H. Superinfection may occur with prolonged use.
pylori infection, pelvic inflammatory Avoid alcohol while taking medication and for at
disease, Crohn disease least three days after discontinuation.
Tetracyclines Gram negative bacteria, specific bacterial Monitor bowel function. Report diarrhea, abdo
(e.g. infections, respiratory tract infections, cramping, fever, and bloody stools (can be sign of
doxycycline) STIs, periodontal disease, rosacea, c.diff). This is not the drug of choice for any staph
→ Vibramycin anthrax, malaria, infective endocarditis, infection. If given during last half of pregnancy or
cellulitis from MRSA in pediatric patients, it may cause yellow/brown
discoloration and softening of teeth and bones.
2. Antacids
• Used for: PUD and GERD
• Alkalines (calcium, magnesium, aluminum, sodium carbonates & hydroxides) that neutralize pH of
stomach
• MOA: neutralize acid in GI tract = allows peptic ulcers time to heal
• Pepsin (digestive enzyme) acts more effectively when acidity in stomach is higher. By reducing
acidity, pepsin is reduced.
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3. H2-receptor antagonist
• Used for: PUD and GERD
• In stomach, histamine binds to H2 receptors (on parietal cells) = stimulates acid secretion
• MOA: blocks H2 receptors = prevents stimulation for acid secretion
• Side effects: D, headaches, decreased liver function, loss of vitamin B12 absorption
H2 Receptor Antagonist
Drug Indication Nursing
Cimetidine Benign gastric ulcer, duodenal ulcer, This drug is an antiandrogen and may cause
→ Tagamet erosive GERD, heartburn feminization & sexual dysfunction in males
Ranitidine GERD, benign gastric ulcer, erosive If GERD is not improved after 6 weeks, switch to
→ Zantac esophagitis a PPI. Can lead to Vit B12 deficiency. Use
cautiously in renal/liver disease.
Famotidine Duodenal ulcer, benign gastric ulcer, Side effects include confusion, delirium,
→ Pepcid GERD, heartburn hallucinations, disorientation, agitation
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4. Stool softeners
• Used for: constipation
• MOA: surfactant lowers stool surface tension = water moves more easily into stool = stool is easier
to pass
• Side effects: diarrhea, throat irritation, abdo cramps
Stool Softeners
Drug Indication Nursing
Docusate Sodium Stool softener Can be given PO or PR. This med does not
→ Colace stimulate peristalsis. May take 3-5 days for a
result
5. Stimulant Laxatives
• Used for: constipation
• MOA: irritates bowel = promotes peristalsis + secretion of water into bowel = movement of feces
increases and softens
• Rapid effect (used as prep prior to surgery)
• Side effects: weakness, N, abdo cramps, mild inflammation of rectum
Stimulant Laxatives
Drug Indication Nursing
Bisacodyl Constipation Can be given PO or PR (enema or suppository).
→ Dulcolax Should only be used for short term therapy (no
longer than 1 week).
Senna Constipation, bowel preparation Contraindicated in GI obstruction, ulcerative
→ Senokot colitis, fecal impaction, and GI bleed
6. Osmotic Laxatives
• Used for constipation
• MOA: osmotically draws water into bowel
• Risk of dehydration
• Side effects: weakness, fatigue, abdo distention, N/V/D, electrolyte imbalance, weakness,
dehydration
Osmotic Laxatives
Drug Indication Nursing
Lactulose Constipation, portal systemic Contraindicated in impaction. Monitor for
→ Enulose encephalopathy electrolyte imbalance with long-term use. Avoid
using other laxatives concomitantly.
Glycerin Constipation Same as above.
→ Fleet glycerin
suppository
Polyethylene glycol Constipation, colonoscopy bowel Same as above.
→ PEG prep
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Diuretics
1. Thiazides (hydrochlorothiazide)
• Used for: edema, HTN, diabetes insipidus
• MOA: reduce Na reabsorption by inhibiting Na+/Cl- cotransporter in the ascending loop of Henle =
prevent reabsorption of Na in kidneys = increased excretion of Na (and thus water). There is also an
increase in excretion of Cl, K, and bicarb
• Side effects: hypokalemia, hyperglycemia, hyperlipidemia, hyponatremia, hypercalcemia, low BP,
orthostatic hypotension
• Decreases responsiveness to oral hypoglycemics
Thiazide Diuretics
Drug Indication Nursing
Hydrochlorothiazide HTN, edema Contraindicated in anuria. Use cautiously in
→ HCTZ, microzide pts with DM, fluid/electrolyte imbalance,
gout, hypotension, SLE, kidney/liver disease.
Indapamide HTN, edema Same as above
Metolazone HTN, edema Same as above. Avoid concurrent use with
→ Zaroxolyn lithium.
2. Loop diuretics
• Used for: hypercalcemia, hyperkalemia, pulmonary edema, CHF, HTN
• MOA: inhibits Na and Cl reabsorption in ascending loop of Henle = increases excretion of Na, Cl, and
water
• *very rapid effect
• Side effects: hyperglycemia, electrolyte imbalance, hypokalemia, hypovolemia, hypotension, ototoxic
Loop Diuretics
Drug Indication Nursing
Furosemide HTN, edema, acute pulmonary edema, If given in excess can cause severe diuresis +
→ Lasix increased ICP, hyperkalemia in ACLS water/electrolyte depletion. Contraindicated in
anuria. Use cautiously in pts with kidney/liver
disease. Risk of ototoxicity. Monitor BUN and
Cre
Bumetanide HTN, edema Same as above
→ Bimex
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Pregnancy Drugs
1. Oxytocic’s
• Used to: promote uterine contraction
• MOA: activates G-protein-coupled receptors that trigger increases in intracellular calcium levels in
uterine myofibrils = stimulates uterine smooth muscle = promotes uterine contractions
• Also has vasopressor and antidiuretic effects
• Oxytocin is contraindicated for contractions closer than two minutes apart
• Monitor pt’s for HTN
Oxytocic Drug
Drug Indication Nursing
Oxytocin Postpartum hemorrhage, labour induction, Monitor intrauterine pressure, FHR, maternal
→ Pitocin incomplete abortion BP + HR. Contraindicated in unfavorable fetal
positions, fetal distress, hypertonic uterus, and
in elective labor induction.
2. Tocolytic’s
• Used to: block uterine contractions
Tocolytic Drug
Drug Indication Nursing
Terbutaline Bronchospasm, pre-term labor Beta blocker. Monitor maternal HR and BP,
→ Brethaire frequency and duration of contractions, and
FHR. Maternal side effects include tachycardia,
palpitations, tremor, anxiety, and headache
Magnesium sulfate Hypomagnesemia, torsades de Monitor HR, BP, RR, and ECG frequently.
pointes, preterm labour Monitor newborn for hypotension,
hyporeflexia, and respiratory depression.
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Hematology system = plasma (liquid component of blood) and blood cells (RBC, WBC, platelets)
Hematinic Drugs
Aid in RBC production (which then also increases hgb = increases oxygen transportation)
Used for: microcytic and macrocytic anemia
1. Iron
• Treats the most common form of anemia = iron deficiency anemia
• Most important role of iron = production of hgb by increased erythropoiesis (production of RBC)
• Pregnant pt’s should take iron due to fetus using up the iron
• Iron absorption is reduced by: spinach, whole-grains, coffee, tea, eggs, and milk products
• Side effects: gastric irritation, constipation, dark stool
Iron Drugs
Drug Indication Nursing
Ferrous fumarate, ferrous Prevention/treatment of iron- Oral iron can decrease the absorption of
gluconate, ferrous sulfate deficiency anemia tetracyclines, fluoroquinolones, or
→ Feostat, Fergon, penicillamine.
Feosol Oral preparations are most effectively absorbed
if administered 1 hr before or 2 hr after meals
Iron sucrose, iron dextran Prevention/treatment of iron- Given via injection. Monitor BP and HR
→ Venofer, DexFerrum deficiency anemia frequently.
2. Vitamin B12
• Used to: treat pernicious anemia
• B12 is necessary for cell growth + replication and for maintenance of myelin in nervous system
o HCl acid and intrinsic factor from the parietal cells of gastric mucosa are necessary for
absorption of Vitamin B12
• Pernicious anemia = decreased gastric production of HCl acid + deficiency of intrinsic factor
• Side of effects of parenteral B12: itching, rash, hives, hypokalemia, polycythemia vera, heart failure,
pulmonary edema, anaphylaxis
• Assess pt for S/S of vitamin B12 deficiency (pallor; neuropathy; psychosis; red + inflamed tongue)
Vitamin B12 Drugs
Drug Indication Nursing
Cyanocobalamin, B12 deficiency, pernicious anemia Water soluble vitamin. Pt’s with small-bowel
hydroxocobalamin disease, malabsorption syndrome, or
→ Nascobal, gastric/ileal resections require parenteral, not
cyanokit PO, administration. With PO route, administer
med with meals to increase absorption.
3. Folic Acid
• Used to: treat megaloblastic anemia caused by folic acid deficiency
• Usually occurs in pediatric, pregnant, elderly, or alcoholic patients
• Folic acid is necessary in RBC production + growth
• Large doses of folic acid can counteract effects of anticonvulsants
• Side effects: erythema, itching, rash, anorexia, N, difficulty concentrating, irritability
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4. Epoetin Alfa
• Erythropoietin forms in kidneys when there is hypoxia + anemia; it stimulates erythropoiesis in bone
marrow (RBC production)
• These drugs are given to pts with decreased erythropoietin production
• Side effects: HTN is most common, headache, N/V/D, edema, fatigue, dizziness, chest pain, skin
reaction
Epoetin Alfa Drugs
Drug Indication Nursing
Epoetin Alfa Chronic kidney disease-associated Contraindicated in cancer pt’s whose anemia is
→ Epogen anemia, chemotherapy-related due to factors other than chemo and in pt’s with
anemia uncontrolled HTN. Additional heparin may be
needed to prevent blood clotting if the patient is
on dialysis.
Darbepoetin Alfa Same as above Same as above
→ Aranesp
Anticoagulant Drugs
These drugs reduce the ability of the blood to clot
Assess for S/S of bleeding or hemorrhage: bleeding gums, nosebleed, bruising, black tarry stools, hematuria
1. Heparin & Heparin Derivatives
• Used to: prevent clot formation
• Does not dissolve already formed clots
• MOA: drug activates antithrombin 3 = prevents formation of thrombin + fibrin
• Thrombin time and PTT are prolonged in pt taking heparin
• Low molecular weight heparin = used for DVT prevention
• Side effects: few side effects. Bleeding, bruising, hematoma
• PTT is maintained at 1.5-2x the normal
• Antidote for heparin is protamine sulfate
Heparin & Heparin Induced Derivatives
Drug Indication Nursing
Heparin DVT, PE, ACS, anticoagulation, High alert drug – can cause fatal hemorrhage.
catheter patency Contraindicated in uncontrolled active bleed
(except DIC). Heparin-induced thrombocytopenia
can occur. Monitor PTT
Dalteparin, Prevention of DVT and/or PE Low molecular weight heparin. Contraindicated
Enoxaparin in active bleed, history of heparin-induced
→ Fragmin, Lovenox thrombocytopenia, and in pt’s who had epidural
neuraxial anesthesia. Do not give via IM route.
2. Oral anticoagulants
• Main drug in this category = warfarin
• Rapid absorption, but effects are not seen for 36-48 hrs
• MOA: inhibits Vitamin K dependent activation of clotting factors
• Side effects: minor bleeding, bruising, hematoma
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3. Antiplatelets
• Used to: prevent arterial thromboembolism (used in pt’s at risk for MI, stroke, and arteriosclerosis)
• Absorbed quickly + reaches peak in 1-2 hours
• MOA: drug blocks synthesis of prostaglandin = prevents formation of platelet-aggregating substance,
thromboxane A2
• Side effects: bleeding is most common side effect. Others include stomach pain, heartburn, N/D/C
• Contraindicated in active bleeding
Antiplatelets
Drug Indication Nursing
Aspirin ACS, pain + fever, ischemic stroke, RA, Teach pt to avoid alcohol when taking aspirin – it
→ ASA OA, MI prophylaxis increases risk of GI bleed.
Clopidogrel ACS, MI, stroke, CAD Monitor patient for signs of thrombotic
→ Plavix thrombocytic purpura. Prolonged bleeding time
is expected – monitor CBC and platelet count.
Thrombolytic Drugs
These drugs dissolve existing clots
MOA: drug converts plasminogen to plasmin = dissolves thrombi + fibrinogen
These drugs are most effective when given within 6 hrs of onset of symptoms
Side effects: bleeding
Contraindicated in active bleed
Maintain bleeding precautions during administration
Thrombolytic Drugs
Drug Indication Nursing
Alteplase Acute MI, PE, acute ischemic stroke, Must be administered within 3-4.5 hr of onset of
→ TPA, alteplase peripheral artery occlusion, restoration ischemic stroke. Avoid IM injections on pt’s
of patency in clotted IV access taking alteplase.
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Insulin: pancreatic hormone that increases activity + production of glucose transporter, helps move glucose into
cells and out of blood, promotes storage of carbs, lipids & proteins
• Insulin decreases blood glucose levels
Glucagon: promotes conversion of stored carbs, lipids and proteins into glucose; releases glucose into blood
• Glucagon increases blood glucose levels
Type 1 Diabetes Mellitus:
• Due to genetic, immunologic factors
• Adequate amounts of insulin are not produced = pt requires insulin injections on a daily basis
• S/S: polyuria, polydipsia, polyphagia, hyperglycemia, glycosuria
Type 2 Diabetes Mellitus:
• Onset is usually during middle age
• Insulin is produced but not enough to compensate for hyperglycemia
• Treatment = diet, exercise, oral hypoglycemics, insulin
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3. Glucagon
• A hormone normally produced by alpha cells in the pancreas
• This drug raises blood glucose levels
• Used for: emergency treatment of severe hypoglycemia
• MOA: promotes glycogenolysis (conversion of glycogen into glucose), gluconeogenesis (formation of
glucose from fatty acids + protein), and lipolysis (release of fatty acids to be converted into glucose)
• Side effects: rarely any
Thyroid Drugs
1. Thyroid drugs
• Used to: treat hypothyroidism
• These drugs contain triiodothyronine (T3), thyroxine (T4), or both
• MOA: stimulates metabolism of all body tissue by accelerating rate of cellular oxidation
o Thyroid stimulates protein synthesis, gluconeogenesis, and increases glycogen storage
• Levothyroxine is the drug of choice
• Side effects: D, abdo cramps, weight loss, palpitations, HTN, headache, tremor, heat intolerance
Thyroid Drugs
Drug Indication Nursing
Levothyroxine Hypothyroidism, myxedema coma Contains T4. Not used for treatment of obesity.
→ Synthroid The dose needs to be properly titrated and
monitored. Monitor for tachyarrhythmias.
Thyroid USP Hypothyroidism Contains T3 and T4. Use cautiously in angina,
cardiovascular disease, and HTN.
2. Thyroid Antagonist
• Used to: treat hyperthyroidism
• MOA: blocks iodine’s ability to combine with tyrosine = prevents thyroid synthesis
• Side effects: granulocytopenia
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Antidepressant Drugs
S/S of depression: sleep disturbances, extreme fatigue, abnormal eating patterns, vague physical symptoms,
inability to focus attention, death-obsessed, avoiding personal interactions, lack of interest in sex/personal
appearance, delusions/hallucinations
1. SSRIs
• Used to: treat major depression, panic disorders, eating disorders, personality disorders, and anxiety
• Drug of choice for depression
• MOA: drug inhibits neuronal reuptake of serotonin = increase in serotonin levels
• Abrupt discontinuation can lead to SSRI discontinuation syndrome (S/S: lowered mood, lethargy,
irritability, paresthesia)
• Side effects: anxiety, insomnia, somnolence, palpitations, sexual dysfunction, orthostatic
hypotension, increased suicidal ideation
• Drug needs to be taken for 2-4 weeks for relief of symptoms to be seen
SSRI Drugs
Drug Indication Nursing
Citalopram Depression Do not administer to pt taking MAOI (increases
→ Celexa risk of serotonin syndrome). S/S of serotonin
syndrome: mental changes (agitation,
hallucinations, coma), autonomic instability
(tachycardia, labile BP, hyperthermia),
hyperreflexia, incoordination, and/or GI
symptoms (N/V/D). Monitor for suicidal ideation.
Use cautiously in pregnancy (risk of pulmonary
HTN of newborn)
Escitalopram Major depressive disorder, generalized Same as above.
→ Lexapro anxiety disorder, OCD, insomnia
secondary to panic disorder, PTSD
Fluoxetine Major depressive disorder, OCD, bulimia Same as above. Monitor for neuroleptic
→ Prozac nervosa, panic disorder, premenstrual malignant syndrome (S/S: fever, resp distress,
dysphoric disorder tachycardia, seizures, diaphoresis, arrhythmias,
HTN or hypotension, pallor, tiredness, muscle
stiffness, loss of bladder control)
Paroxetine Depression, OCD, panic disorder, social Same as above. Monitor for serotonin syndrome
→ Paxil phobia, generalized anxiety disorder, + neuroleptic malignant syndrome
PTSD, premenstrual dysphoric disorder,
menopausal vasomotor symptoms
Sertraline Major depressive disorder, OCD, panic Do not administer to pt taking MAOI (increases
→ Zoloft disorder, PTSD, social anxiety disorder, risk of serotonin syndrome). S/S of serotonin
premenstrual dysphoric disorder syndrome: mental changes (agitation,
hallucinations, coma), autonomic instability
(tachycardia, labile BP, hyperthermia),
hyperreflexia, incoordination, and/or GI
symptoms (N/V/D). Monitor for suicidal ideation.
Use cautiously in pregnancy (risk of pulmonary
HTN of newborn)
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Bipolar Drugs
Bipolar = cyclic episodes of mania & depression
Mania: due to excess excitatory neurotransmitters or deficit of inhibitory neurotransmitters (such as GABA)
In bipolar, pt has episodes of excessive catecholamine stimulation and diminished catecholamine stimulation
MOA: exact mechanism is unknown. Alters levels of NE, serotonin, and dopamine.
S/S of mania: insomnia, activity without fatigue, agitated, aggressive, overconfidence, seeking others, unusual
interest in sex, substance abuse, denial of problem
A pt on a severe salt-restricted diet is susceptible to lithium toxicity. Increased intake of Na+ may reduce the
therapeutic effects of lithium
Bipolar Drugs
Drug Indication Nursing
Lithium Bipolar disorder Take with plenty of water and after meals to
→ Eskalith, Lithobid minimize GI upset. Monitor lithium levels
(narrow therapeutic index); S/S of toxicity:
diarrhea, vomiting, tremor, drowsiness, muscle
weakness, and ataxia
Antipsychotic Drugs
These drugs control psychotic symptoms – delusions, hallucinations, thought disorder
Used for: schizophrenia, mania, and psychosis
S/S of schizophrenia: hallucinations, delusions, paranoia, indifference/detachment from surroundings,
deteriorating performance of basic skills, withdrawal from social interaction, strange communication
behaviours, irregular moods
• Positive symptoms = add on to normal behavior; hallucinations, delusions, disorganized
thought/communication
• Negative symptoms = subtract from normal behavior; lack of interest in daily activities, lack of
motivation, lack of responsiveness
1. Typical Antipsychotics
• Include phenothiazines and nonphenothiazines
• Block positive symptoms by antagonizing dopamine & serotonin
• Side effects: anticholinergic, sexual dysfunction, sedation, orthostatic hypotension, weight gain,
extrapyramidal effects (acute dystonia, akathisia, Parkinsonism, tardive dyskinesia), neuroleptic
malignant syndrome (fever, muscle rigidity, unstable BP, sweating, dyspnea)
• Contraindicated in: Parkinson’s, CNS depression, bone marrow depression, alcohol withdrawal
syndrome, Reye’s syndrome, COPD
Typical Antipsychotic Drugs
Drug Indication Nursing
Haloperidol Schizophrenia, psychosis, Tourette Monitor ECG and QT interval (risk of QT
→ Haldol disorder prolongation). Monitor for neuroleptic malignant
syndrome. Not to be used for dementia-related
46
2. Atypical Antipsychotics
• Blocks positive & negative symptoms by blocking dopamine, serotonin, ACh and alpha adrenergic
receptors (these drugs don’t block the receptors as much as the typical antipsychotics = less side
effects)
• Drug group of choice
• Side effects: weight gain, decreased libido, risk of type II diabetes due to altered glucose metabolism,
bone marrow depression, few motor (EPS) side effects
• Contraindicated in: epilepsy, leucopenia, CNS depression, hypotension
Atypical Antipsychotic Drugs
Drug Indication Nursing
Clozapine Schizophrenia, suicidal behaviour in Monitor for signs of myocarditis (fatigue,
→ Clozaril schizophrenia dyspnea, tachypnea, fever, chest pain,
palpitations, heart failure, ECG changes,
arrhythmias). This drug lowers the seizure
threshold (institute seizure precautions for pts
with hx of seizures). Monitor for neuroleptic
malignant syndrome. Monitor WBC and ANC
before and during treatment (stop the drug if
there is clozapine-induced neutropenia – can
lead to serious infection and death)
Olanzapine Schizophrenia, bipolar mania, agitation Not to be used in dementia-related psychosis.
→ Zyprexa with schizophrenia and bipolar, bipolar Risk of severe sedation. Monitor for change in
depression mental status, and for neuroleptic malignant
syndrome
Risperidone Schizophrenia, bipolar disorder Not to be used in dementia-related psychosis.
→ Risperdal Monitor for suicidal ideation and neuroleptic
malignant syndrome.
Quetiapine Schizophrenia, bipolar disorder, major Same as above. Not to be used in pts under 10
→ Seroquel depressive disorder years.
Aripiprazole Schizophrenia, bipolar mania, major Not to be used in dementia-related psychosis.
→ Abilify depressive disorder Monitor for suicidal ideation.
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Dependence: unable to stop taking drug due to satisfaction/pleasure from taking drug → linked to dopamine
receptor stimulation in limbic system providing a sense of euphoria
Tolerance: higher dose needed to produce same response due to repeated exposure to drug
Withdrawal symptoms = opposite to the effects of the drug
CNS Depressants
Produce feeling of sedation/relaxation
1. Sedatives
• Used for: sleep disorders, epilepsy, anxiety
• Barbiturates and benzodiazepines
• MOA: stimulates GABA receptors, which then inhibits brain activity; this is what causes the
drowsy/calming effects
• Overdose = suppresses respiratory system
• Contraindications: airway obstruction, narrow angle glaucoma
• Benzodiazepines produce more mild effects while barbiturates have more intense effects
including dependence and potential for lethality
• Benzodiazepine antagonist = flumazenil
• Barbiturates antagonist = megimide
Barbiturates
Drug Indication Nursing
Phenobarbital Status epilepticus, seizures, sedation, Risk of toxicity increases when taken with CNS
→ Luminal hypnotic, insomnia depressants, valproic acid, chloramphenicol,
felbamate, cimetidine, or phenytoin
Primidone Seizures
→ Mysoline
Benzodiazepines
Drug Indication Nursing
Lorazepam Anxiety, status epilepticus, seizures Use with opioids can result in profound
→ Ativan sedation, respiratory depression, coma, and
death
Diazepam Anxiety, alcohol withdrawal, pre-op Use with opioids can result in profound
→ Valium sedation, seizure, muscle spasm, status sedation, respiratory depression, coma, and
epilepticus death. Do not use in pts with depressed
respirations or patients who recently received
respiratory depressants
2. Opioids
• Used for: pain, cough, diarrhea, and anesthesia support
• Sedation can occur after the initial “rush”: constricted pupils, respiratory depression, increased
pain tolerance, analgesia, tranquility, euphoria
• MOA: opioids bind to mu opioid receptors on neurons in nervous system + immune system;
produces these effects → pain relief, mood alteration (euphoria and decreased anxiety),
respiratory depression, decreased GI motility, cough suppression, pinpoint pupils (miosis), N/V,
pruritis
• During withdrawal you give = methadone (reduces withdrawal symptoms)
• When injected or inhaled, levels in the brain rise rapidly = causing a rush
49
Cannabinoids
• MOA: release of central biogenic amines including NE
• Side effects: dizziness, fatigue, slows motor activity, less coordination, paranoia, euphoria, food cravings,
red eyes due to dilated blood vessels
• Therapeutic effect: decreased pain and spasticity
• Active ingredient: delta 9 THC
Cannabinoids
Drug Indication Nursing
Cannabidiol Spasticity in multiple sclerosis, neuropathic Avoid alcohol use
→ Sativex pain in MS or advanced cancer patients
50
CNS Stimulants
• Increase in neurotransmitter NE; known as cognitive enhancers
• MOA: stimulates NE = increased CNS stimulation
• Side effects: increase in BP, increase in RR, reduced appetite, feelings of exhilaration, mental alertness,
dilates pupils, abdo pain, irritability, headache
CNS Stimulants
Drug Indication Nursing
Amphetamines Narcolepsy (excessive sleepiness), obesity, For narcolepsy, lowest dose should be
→ Evekeo, ADHD administered. Dextroamphetamine is used for
Adderall appetite suppression (obesity). Avoid
administration to pts taking MAOI (can result in
hypertensive crisis)
Cocaine Medical use: topical anesthesia When used recreationally: “high” is reached
quickly and more intensely. Can cause delirium,
hyperactivity, psychosis, arrhythmias,
hypertension, stroke, vasoconstriction
Methylphenidate ADHD, narcolepsy Focuses attention by promoting alertness. Used in
→ Ritalin children (less effective in adults). Monitor for
growth inhibition. Chronic abuse can lead to high
tolerance and dependence. Used as cognitive
enhancer in university.
Caffeine Fatigue, drowsiness, respiratory failure, Withdrawal symptoms include headaches, fatigue,
diuretic depression, impaired performance of skills. Used
as cognitive enhancer in university. Not to be given
to pts with anxiety, agitation, or tremors.
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Anti-Viral Drugs
1. Synthetic Nucleosides
• Used for: various viral syndromes including HSV and cytomegalovirus
• MOA: Interferes with DNA synthesis + inhibits viral multiplication
• Side effects: kidney injury, headache, N/V/D, hypersensitivity
• Monitor kidney and liver function
• Drugs in this category: acyclovir, famciclovir, ganciclovir, valacyclovir
2. Influenza A and syncytial virus drugs
• MOA: inhibits viral replication
• Side effects: confusion, depression, fatigue, insomnia, irritability, N, nervousness
• Drugs in this category: amantadine hydrochloride, ribavirin, rimantadine hydrochloride, oseltamivir
phosphate, zanamivir
3. Nucleoside reverse transcriptase inhibitors (NRTI)
• Used for: advanced HIV infections
• MOA: mimics thymidine = reverse transcriptase (RT) incorporates it into DNA strand = ends up being
non-functional = not incorporated into host DNA
• Side effects: headache, fever, dizziness, muscle pain, N/V/D
• Drugs in this category: zidovudine, didanosine, zalcitabine, abacavir sulfate, lamivudine, stavudine,
emtricitabine, tenofovir
4. Non-nucleoside reverse transcriptase inhibitors (NNRTI)
• Used in combination with other anti-vrials to treat HIV infection
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Vaccines
Expose our immune system to small amounts of antigens so that it can create a primary response.
1. Microbes that have been killed (organisms are intact but not alive/functional)
2. Attenuated microbes (weakened thus cannot produce disease) alive but cannot cause disease
3. Toxoids (modified bacterial toxins that do not have hazardous properties) pieces of protein or viruses
have been isolated and can be used to create a secondary response
Contraindications: allergies to egg products, fever, concurrent infections
Antihistamines
Primarily block the effects of an allergic reaction/type 1 hypersensitivity reaction
1. Histamine-1 receptor antagonists
• Used for: S/S of type 1 hypersensitivity (allergic rhinitis, allergic conjunctivitis, urticaria, angioedema)
• MOA: drug competes with histamine for the H1 effector cell sites (these cells cause S/S of allergic
reaction) = blocks histamine from its effects. The drug does not displace the histamine that’s already
bound to receptors
• The following are the effects of blocking H1 receptor sites:
o Blocking action of histamine on small blood vessels
o Decreasing arteriole dilation and tissue engorgement
o Reducing leakage of plasma proteins + fluids out of the capillaries = less edema
o Inhibiting smooth-muscle responses to histamine (blocking the constriction of bronchial, GI,
and vascular smooth muscle)
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Corticosteroids
These drugs suppress the immune response + reduce inflammation
1. Glucocorticoids
• Used for: adrenocortical insufficiency, anti-inflammatory, immunosuppressive, or antineoplastic
activity
• MOA: not entirely known, but these drugs suppress hypersensitivity + immune responses
• Side effects: these drugs affect almost every system; insomnia, increased water retention, increased
K+ excretion, suppressed immune response, peptic ulcers, impaired wound healing, HTN, increased
susceptibility to infx, DM, hyperlipidemia
• Do not administer live vaccines to pts on large corticosteroid dose
Glucocorticoid Drugs
Drug Indication Nursing
Beclomethasone Chronic asthma (puffer version), Do not use as a primary treatment for status
→ QVAR RediHaler (puffer), allergic rhinitis (intranasal version) asthmaticus or acute asthma attack.
Beconase (intranasal) Monitor for vision change
Dexamethasone Inflammation, acute exacerbation Contraindicated in systemic fungal infx (can
→ Decadron of MS, cerebral edema, shock, exacerbate the infx)
asthma, dermatitis, allergic
rhinitis, altitude sickness,
Hydrocortisone Inflammation, status asthmaticus, Contraindicated in serious infx.
→ A-Hydrocort acute adrenal crisis, chronic renal
insufficiency
Methylprednisolone Allergy, acute exacerbation of MS Same as above. Avoid grapefruit juice.
→ Medrol
Prednisone Acute asthma, giant cell arteritis, Take with meal. High dose can cause
→ Deltasone idiopathic thrombocytopenic insomnia. Contraindicated in serious
purpura, RA, advanced TB, infection and varicella. Monitor for
autoimmune hepatitis hyperglycemia.
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Immunosuppressants
These drugs are used to prevent rejection of a transplant
MOA: Inhibit cell-mediated immune responses by different mechanisms
Do not administer this drug to a patient with an infection
Monitor for S/S of infection – WBC, fever, sputum, urine
Lifelong drug administration is needed to prevent transplant rejection
Side effects: bone marrow suppression, N/V, liver and kidney disease, infection, HTN, tachycardia, edema,
reduced WBC, weakness
Immunosuppressant Drugs
Drug Indication Nursing
Azathioprine Kidney transplant, RA, lupus nephritis, Not to be taken by pregnant/lactating pt. Long
→ Azasan Crohn disease, ulcerative colitis term use increases the risk of neoplasia
Cyclosporine Solid organ transplant, RA, psoriasis, ALS, Not to be taken by pregnant/lactating pt.
→ Neoral lung transplant Monitor for gingival hyperplasia, infx, and HTN.
Avoid grapefruit juice
Mycophenolate Kidney transplant, heart transplant, liver Not to be taken by pregnant/lactating pt. Assess
→ CellCept, Myfortic transplant for S/S of progressive multifocal
leukoencephalopathy (hemiparesis, apathy,
confusion, cognitive deficiency, ataxia)
Tacrolimus Kidney transplant, heart transplant, liver Risk of serious infx/malignancies including
→ Prograf transplant lymphoma and skin malignancies
Uricosurics
Increased uric acid in blood = gout
Normally, uric acid is excreted by the kidneys
MOA: reduce reabsorption of uric acid @ proximal convoluted tubule of kidney = increased excretion of uric
acid in urine = reduced uric acid levels
Side effects: headache, anorexia, N/V, GI pain, indigestion
Uricosuric Drugs
Drug Indication Nursing
Probenecid Gout, pelvic inflammatory disease, Should not be given during an acute gouty attack (this
→ Benemid gonorrhea drug will actually prolong the inflammation) – give
colchicine instead. Monitor kidney function. Give drug
with milk, food, or antacid to minimize GI distress
Allopurinol Gout, antineoplastic-induced Helps prevent acute gout attacks. Continue taking
→ Zyloprim, Aloprim hyperuricemia allopurinol along with an NSAID or colchicine during
an acute attack of gout
Colchicine Acute gout Co-administration with CY3A4 inhibitor can increase
→ Colcrys levels of toxicity (need to decrease the colchicine
dose). Do not give to liver/kidney disease pt
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Electrolyte Replacement
Electrolyte (EL) = element that carries an electric charge when dissolved in water; helps maintain homeostasis
1. Potassium (K+)
• Primary intracellular EL
• Body can’t store K+, so it needs to be ingested daily (if not, then K+ replacement is necessary)
• K+ is necessary for proper nerve function, muscle function, tissue growth + repair, and maintenance
of acid-base balance
• Hypokalemia is common in: V/D, NG suction, excessive urination, kidney disease, burns, excessive
antidiuretic hormone, laxative abuse, starvation
• Monitor K+ levels; S/S of hyperkalemia: abdo cramp, N/D, tall T waves, hypotension, muscle
weakness
• When giving IV K+, always dilute; never give as in IV bolus or IM injection
• Give PO K+ with or after meals to minimize GI effects
2. Calcium (Ca2+)
• 99% of Ca is stored in bone
• Function of Ca: nerve and muscle excitability; function of heart, kidney, lungs; blood coagulation;
neurotransmitter; bone + tooth formation
• Ca is helpful in treating magnesium intoxication and helps strengthen myocardial tissue after
defibrillation or poor response to epinephrine
• Hypocalcemia is common in: tetany, cardiac arrest, vitamin D deficiency, parathyroid surgery,
alkalosis
• Monitor Ca levels; S/S of hypercalcemia: drowsiness, lethargy, muscle weakness, headache, C, ECG
changes (short QT), heart block
• When giving PO calcium, don’t take with foods that interfere with absorption (e.g. spinach, rhubarb,
whole grain cereal, fresh fruit + vegetables)
3. Magnesium (Mg+)
• Function of Mg: transmits nerve impulses to muscle, activates enzymes for carb + protein
metabolism, stimulates parathyroid secretion, aids in cell metabolism
• Used to prevent deficiency, control seizures, treat/prevent preeclampsia, and treat ventricular
arrhythmias
• Hypomagnesemia is common in: malabsorption, chronic D, prolonged diuretic use, NG suction,
hyperaldosteronism, hypoparathyroidism, excessive release of adrenocortical hormones
• Mg taken with digoxin = can lead to heart block
• Monitor Mg levels; S/S of hypermagnesemia: hypotension, circulatory collapse, flushing, depressed
reflexes, respiratory paralysis
• Administering IV Mg too quickly can lead to cardiac arrest
4. Sodium (Na+)
• Major cation in extracellular fluid
• Function of Na: maintains osmotic pressure, acid-base balance, water balance; aids in nerve
conduction and neuromuscular function; aids in glandular secretion
• Hyponatremia is seen in: anorexia, excessive GI loss, excessive perspiration, overuse of diuretics,
trauma, SIADH
• To replace Na, sodium chloride IV is usually given
• Side effects: pulmonary edema, hypernatremia, and K+ loss
• S/S of pulmonary edema = SOB, cough, anxiety, wheezing, pallor
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Prefix, root, suffix Drug category Prefix, root, suffix Drug category
-afil (e.g. sildenafil) Phosphodiesterase -asone (e.g. Corticosteroid
inhibitor betamethasone)
-bital (e.g. phenobarbital) Barbiturate -caine (e.g. lidocaine) Local anesthetic
Cef- (e.g. cefaclor) Cephalosporin ABX -cillin (e.g. amoxicillin) Penicillin antibiotic
Cort (e.g. hydrocortisone) Corticosteroid -cycline (e.g. doxycycline) Tetracycline ABX
-dipine (e.g. amlodipine) Calcium channel blocker -dronate (e.g. Bone resorption inhibitor
alendronate)
-eprazole (e.g. Proton pump inhibitor -fenac (e.g. diclofenac) NSAID
omeprazole)
-floxacin (.e.g. Quinolone ABX -gliptin (e.g. sitagliptin) Antidiabetic
ciprofloxacin)
-mysin (e.g. ABX -olol (e.g. metoprolol) Beta blocker
azithromycin)
-olone (e.g. Corticosteroid -onide (e.g. budesonide) Corticosteroid
prednisolone)
-oprazole (e.g. Proton pump inhibitor -parin (e.g. Dalteparin) Anticoagulant
pantoprazole)
-phylline (e.g. Bronchodilator -pramine (e.g. Tricyclic antidepressant
theophylline) clomipramine)
Pred- (e.g. prednisone) Corticosteroid -pril (e.g. ramipril) ACE inhibitor
-profen (e.g. ibuprofen) NSAID -sartan (e.g. candesartan) Angiotensin 2 receptor
antagonist
-setron (e.g. ondasetron) Serotonin receptor -statin (e.g. atorvastatin) HMG-CoA reductase
antagonist inhibitor (statin)
-tadine (e.g. loratadine) Antihistamine -terol (e.g. albuterol) Beta agonist;
bronchodilator
-vir (e.g. acyclovir) Antiviral -zepam (e.g. lorazepam) Benzodiazepine
-zolam (e.g. midazolam) Benzodiazepine -zosin (e.g. prazosin) Alpha blocker
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E.g. Metoprolol (Lopressor), 25 mg PO, is ordered. Metoprolol is available as 50 mg tablets. How many tablets would the
nurse administer?
25 mg/50 mg x 1 tablet = 0.5 tablets
Infusion Time
Total Volume
mL/hr
E.g. Infuse 1 L of NS at 125 mL/hr. How many hours total will the infusion run for?
1000 mL/125 mL per hour = 8 hours
mL/hr
Total Volume (mL)
Total Time (hr)
E.g. Infuse 250 mL over the next 120 minutes by infusion pump
250 mL/2 hrs = 125 mL/hr
E.g. Calculate the IV flow rate for 1200 mL of NS to be infused in 6 hours. The infusion set is calibrated for a drop factor
of 15 gtts/mL
1200 mL x 15gtt per mL /360 min = 50 drops per minute
= x (mL/min, mL/hr)
E.g. Give patient 500 mg of dopamine in 250 mL of D5W to infuse at 20 mg/hr. Calculate the flow rate in mL/hr.
20 mg per hr/500mg x 250 mL = 10 mL/hr
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