ROUTE OF ADMINISTRATION

>NASAL: drops & sprays

>INHALATION: dry powders & liquid sprays
>ORAL (including buccal and sublingual):
• Tablets
• Capsules
• Orally disintegrating tablets
• Buccal tablets
• Sublingual tablets
• Mini tablets
• Effervescent tablet
• Thin films
• Medicated gums
• Granules
• Troches
• Lozenges
• Solutions
• Suspension
• Emulsion
• Elixir
• Buccal sprays
>PARENTERAL

>OTIC: Topical
Intratympanic
Intracochlear
>OCULAR:
• Solutions
• Emulsions
• Suspension
• Ointments
• Contact lens
• Implants
• Inserts
 • Intravitreal

>TOPICAL/ TRANSDERMAL

• OINTMENTS
• CREAMS
• LOTION
• GEL
• SPRAYS
• PATCHES
>RECTAL/ VAGINAL

• SUPPOSITORY
• ENEMA
• TABLETS
• PESSARY
• GEL
• CREAM
• FOAM
• SPONGE
PHARMACOGENOMICS
-is the study of the role of the genome in drug response. Its name (pharmaco- + genomics) reflects its combining
of pharmacology and genomics.
-Pharmacogenomics analyzes how the genetic makeup of a patient affects their response to drugs.
-Pharmacogenomics also attempts to eliminate trial-and-error in prescribing, allowing physicians to take into consideration
their patient's genes, the functionality of these genes, and how this may affect the efficacy of the patient's current or future
treatments (and where applicable, provide an explanation for the failure of past treatments).

Three Phases of Drug Action

>pharmaceutic Phase- solid, Form liquid (Type of Medication)

Disintegration- breakdown of tablet into particles.

Dissolution- dissolving smaller particles in GI Fluid before absorption.
Rate limiting- Time for drugs to disintegrate and dissolve.

>Pharmacokinetic Phase- absorption, distribution, metabolism/ biotransformation, excretion (

effects of the body in drugs)
-process of drug movement to achieve drug action

Absorption- movement of drug particles from GI tract to body fluids.

Passive absorption -site to bloodstream
-determine how long it takes for a drug to take effect.
-does not require energy
Active absorption - requires a carrier such as enzyme or protein.
-energy is required
Pinocytosis- cell carry drug across their membrane.
Distribution- drugs from blood to site of action.
Volume of distribution - degree of distribution of drug into body compartments.
Metabolism - breakdown of drug
Biotransformation- body changes the chemical structure of a drug.
Metabolite- water soluble compound that can be easily excreted. liver- no. 1
organ to detoxify

Variations in metabolism
Pharmacogenetics- hereditary influence on drug response.
Circadiation rhythms- rate of drug absorption, hepatic clearance, half-life and duration of action
Excretion - drugs removed from the body
Kidneys- major organ for excretion.
>pharmacodynamics- drug action ( effects of the drugs in the body)
- study of the mechanism of drug action on living tissue
>RIGHT OF DRUG ADMINISTRATION (CDDTR)
-the right client
-the right drug
-the right dose
-the right time
-the right route

DRUG CALCULATIONS
𝑅𝐸𝑄𝑈𝐼𝑅𝐸𝐷 𝐷𝑂𝑆𝐸
TABLET: =
𝑆𝑇𝑂𝐶𝐾 𝐷𝑂𝑆𝐸
𝑅𝐸𝑄𝑈𝐼𝑅𝐸𝐷 𝐷𝑂𝑆𝐸 𝑆𝑇𝑂𝐶𝐾 𝑉𝑂𝐿𝑈𝑀𝐸
FLUID: 𝑥 =
𝑆𝑇𝑂𝐶𝐾 𝐷𝑂𝑆𝐸
𝑉𝑂𝐿𝑈𝑀𝐸 (𝑀𝐼) 𝑋 𝐷𝑅𝑂𝑃 𝐹𝐴𝐶𝑇𝑂𝑅 (𝐷𝑅𝑂𝑃𝑆/𝑀𝐼)
IV FLUID: =

ANTI-INFECTIVE AGENTS
>development of anti-infective therapy
• 1920s Paul Ehrlich worked on developing a synthetic chemical effective against infection-causing cells only.
Scientists discovered penicillin in a mold sample
• 1935 the sulfonamides were introduced
Mechanisms of Action
 1. Interfere with biosynthesis of the bacterial cell wall.
2. Prevent the cells of the invading organism front using substances essential to their growth and development
3. Interfere with steps involved in protein synthesis
4. Interfere with DNA synthesis
5. 5. Alter the permeability of the cell membrane to allow essential cellular components to leak out
Anti-infective activity:
• Anti-infectives carry in their effectiveness against invading organisms
• Some are selective: they are effective only for a small number of organisms
• Bactericidal: kill the cell
• Bacteriostatic: prevent reproduction of the cell
Mechanism of Anti-infective Agents

>Narrow spectrum of activity- effective against only a few microorganisms with a very specific metabolic pathway or
enzyme
>Broad spectrum of activity- useful in treating a wide variety of infections
PROBLEMS WITH TREATING INFECTIONS IN IMMUNOSUPPRESSED PATIENTS
-anti-infectives drugs cannot totally eliminate the pathogen without causing severe toxicity in the host
-patients do not have the immune response in place to deal with even a few invading organisms
Resistance – anti-infectives act on enzyme system or biological process; many microorganisms that do not act on a specific
system are not affected by the particular drug
ADVERSE REACTIONS TO ANTI-INFECTIVE THERAPY
1. Kidney damage
2. Gastrointestinal (GI) tract toxicity
3. Neurotoxicity
4. Hypersensitivity reactions
 5. Superinfections
Prophylaxis of Anti-infective Agents
People traveling to areas where malaria is endemic
Patients who are undergoing gastrointestinal or genitourinary surgery
Patients With known cardiac valve disease, valve replacement, and other conditions requiring invasive procedures.
ANTIBIOTICS
-defined as chemicals that inhibit specific bacteria
>Types of Antibiotics
1. Bacteriostatic- substance that prevent the growth of bacteria
2. Bactericidal-substances that kill bacteria directly
Signs of Infection
1. Fever
2. Lethargy
3. 3. Slow-wave sleep induction
4. 4. Classic signs of inflammation (redness, swelling, heat, and pain)
Goal of Antibiotic Therapy - decrease the population of the invading bacteria to a point where the human immune system
can effectively deal with the invaders.
Selecting Treatment
>Identification of the causative organism
>Based on the culture report, an antibiotic is chosen that is known to be effective at treating the invading organism
Bacteria Classification
1. Gram-positive - The cell wall retains a stain or resists decolorization with alcohol
2. Gram-negative - The cell wall loses a stain or is decolorized by alcohol
3. Aerobic - Depend on oxygen for survival
4. Anaerobic - Do not use oxygen Aminoglycosides - A group of powerful
>AMINOGLYCOSIDES- group of powerful antibiotics used to treat serious infections caused by gram-negative aerobic bacilli
*Bactericidal treatment of serious infections caused by susceptible bacteria
Adverse effects: ototoxicity and nephrotoxicity are the most significant
D-D interactions: diuretics and neuromuscular blockers
>CEPHALOSPORINS- similar to penicillin in structure and activity
Adverse effects: GI tract
D-D interactions: aminoglycosides, oral anticoagulants, and ETOH
>FLUOROQUINOLONES- new class of antibiotics with a broad spectrum of activity
Adverse effects: headache, dizziness, and GI upset
D-D interactions: antacids, quinidine, and theophylline
>MACROLIDES- antibiotics that interfere with protein synthesis in susceptible bacteria
Adverse effects: GI symptoms
D-D interactions: Digoxin, oral anticoagulants, theophylline, and corticosteroids
>LINCOSAMIDES- similar to macrolides but more toxic
Adverse effects: GI reactions
>MONOBACTAMS- unique structure with little cross-resistance
Adverse effects: GI and hepatic enzyme elevation
>PENICILLINS- first antibiotics introduced for clinical use
Adverse effects: GI effects
D-D interactions: tetracyclines and aminoglycosides
>SULFONAMIDES- drugs that inhibit folic acid synthesis
Adverse effects: GI symptoms and renal effects related to filtration of the drug
D-D interactions: cross sensitivity with thiazide diuretics: sulfonylureas
>TETRACYCLINES- developed as semisynthetic antibiotics based on the structure of common soil mold
Adverse effects: GI, skeletal: damage to bones and teeth
D-D interactions: penicillin G, oral contraceptive therapy, methoxyflurane, and digoxin
>ANRIMYCOBACTERIALS- contain pathogens causing tuberculosis and leprosy
Adverse effects: CNS effects GI irritation
D-D interactions: rifampin and INH can cause liver toxicity
Tuberculosis is a bacterial infection caused by Mycobacterium tuberculosis. –There are several treatment regimens
recommended in the United States for TB disease. TB treatment can take 4, 6, or 9 months depending on the regimen. TB
treatment regimens include

• 4-month Rifapentine-moxifloxacin TB Treatment Regimen

• 6- or 9-month RIPE TB Treatment Regimen

-Shorter regimens help patients’ complete treatment faster. Healthcare providers can choose the appropriate TB treatment
regimen based on drug-susceptibility results, coexisting medical conditions (e.g., HIV, diabetes), and potential for drug-drug
interactions.

Malaria

• It is a disease characterized by a cycle of fever and chills transmitted through a bite of a female Anopheles mosquito.
Identified causes include Plasmodium falciparum, vivax, malariae, and ovale. Malaria is endemic in many parts of the
world.
• Sporozoites travel through bloodstream and become lodged in the liver and other tissues.
Antimalarials: are agents used to attack Plasmodium at various stages of its life cycle. Through this, it becomes possible
to prevent acute malarial reaction in individuals who have been infected by the parasite.
• These agents can be:
o schizonticidal (acting against the red-blood-cell phase of the life cycle),
o gametocytocidal (acting against the gametocytes),
o sporontocidal (acting against the parasites that are developing in the mosquito), or
o schizonts as prophylactic or antirelapse agent work against tissue t.
• Quinine (Qualaquine) was the first drug found to be effective in the treatment of malaria. Treatment of
chloroquine- resistant plasmodial infections
• Chloroquine (Aralen): Prevention and treatment of plasmodial malaria; treatment of extraintestinal amebiasis
• Halofantrine (Halfan): Treatment of plasmodial malaria in combination with other drugs
• Hydroxychloroquine (Plaquenil): Treatment of plasmodial malaria in combination with other drugs
(particularly primaquine)
• Mefloquine (Lariam): Prevention and treatment of plasmodial malaria in combination with other drugs
• Primaquine (generic): Prevention of relapses of Plasmodium vivax and Plasmodium malariae infections; Radical cure of
P. vivax malaria
• Pyrimethamine (Daraprim) : Prevention of plasmodial malaria in combination with other agents to suppress

Therapeutic Action of antimalarials is:

• Entering human red blood cells and changing the metabolic pathways necessary for the reproduction. Chloroquine,
the mainstay of treatment, in addition to this main mechanism, is directly toxic to parasites and decreases the ability
of the parasite to synthesize DNA.
• Interrupt plasmodial reproduction of protein synthesis
• Agents that do not appear to affect the sporozoites are used for prophylaxi

Contraindications: Known allergy, Liver disease, Alcoholism, Lactation

• Cautions: Retinal disease or damage, Psoriasis

Adverse Effects: Headache, Dizziness, Fever, Chills, Malaise, Nausea, Vomiting, Hepatic dysfunction

Drug-to-Drug Interactions
• Quinine derivatives and quinine create risk for cardiac toxicity
• Antifolate drugs with pyrimethamine can increase risk of bone marrow suppression

HIV/ AIDS
Signs & symptoms- Acute infection, persistent generalized lymphadenopathy, neurologic disease
Action- Reverse transcriptase inhibitors. Protease inhibitors, nucleosides, fusion inhibitors, locally active antiviral agents
Pharmacokinetics- Orally, IV metabolized in liver, excreted in urine, teratogenic except for saquinavir, orally or IV excreted;
urine, metabolized; liver, sub-q metabolized; liver, recycled; tissue, not absorbed systemically.
Contradictions- Pregnancy & lactation, Pregnancy & lactation, No true contraindication Allergy to drug
Adverse effect- Headache, nausea, vomiting, rash, fever, chills, diarrhea, HA, insomnia, dizziness, nausea, diarrhea, fever & rash
HA, dizziness, myalgia, nausea, vomiting & diarrhea Local burning, stinging & discomfort
D-D interaction- Pimozide, rifampin, triazolam, midazolam, & metabolic oral contraceptives
10 commonly prescribed HIV drugs:
1. Atripla (efavirenz + tenofovir + emtricitabine) combines an NNRTI and two NRTIs into one medication. The usual dose
is once daily on an empty stomach—one hour before or two hours after a meal. Dizziness, diarrhea and tiredness are
common side effects. Serious, life-threatening side effects are also possible, such as liver problems and a buildup of
lactic acid in the blood.
 2. Complera (rilpivirine + tenofovir + emtricitabine) combines an NNRTI and two NRTIs. The usual dose is once daily with
a meal. Strange dreams, trouble sleeping, depressed mood, headache, and digestive problems are common. Serious
liver problems and lactic acid buildup in the blood can occur.

3. Genvoya, Stribild (elvitegravir + cobicistat + tenofovir + emtricitabine) combines an INSTI, a pharmacokinetic booster,
and two NRTIs. You usually take it once a day with food. Headache, nausea, and diarrhea are common side effects.
Like Atripla and Complera, serious liver problems and lactic acid buildup in the blood are possible.

4. Isentress (raltegravir) is an INSTI you usually take twice a day. Nausea, headache, dizziness and fatigue are common
side effects. Although rare, muscle breakdown leading to kidney failure may occur.

5. Norvir (ritonavir) is a PI you usually take twice daily with meals. Digestive side effects are common, as are headache
and burning or tingling sensations. Norvir can also cause serious side effects and drug interactions. Tell your doctor
and your pharmacist about all of your medications.

6. Prezista (darunavir) is a PI you usually take with ritonavir either once or twice a day. Ritonavir acts as a
pharmacokinetic booster. Digestive problems, headache, and changes in body fat are common side effects. Severe
skin reactions and liver problems are also possible.

7. Tivicay (dolutegravir) is an INSTI you take once or twice a day. Headache, fatigue, sleep problems, and changes in
body fat are common side effects. Serious liver problems are also possible.

8. Triumeq (dolutegravir + abacavir + lamivudine) combines an INSTI and two NRTIs. The usual dose is once
daily. Headache, fatigue, sleep problems, and changes in body fat are common side effects. It is also possible to have
serious side effects, including a serious allergic reaction, liver problems, and a buildup of lactic acid in the blood.

9. Truvada (emtricitabine + tenofovir) combines two NRTIs. The usual dose is once daily. Abnormal dreams, trouble
sleeping, depressed mood, headache, and dizziness are common side effects. Like other NRTI combinations, liver
problems and lactic acidosis buildup in the blood is also possible.

10. Vemlidy, Viread (tenofovir) is an NRTI you usually take once a day. Digestive problems, fatigue, headache, depressed
mood, sleep problems, and changes in body fat are common side effects. Like other NRTIs, serious side effects are
possible, including liver problems and lactic acid buildup in the blood.

Complications of IV therapy may include:

• Damage to blood vessels
• Bleeding from the site of insertion
• Swelling in the area
• Inflammation of the veins if the IV is present for a long time
• Bruising at the site of insertion
• Infiltration
• Hematoma
• Air embolism
• Phlebitis
• Extravascular drug administration
• Intraarterial injection (more rare, but more threatening)
• Collapsed vein
• Infection
 • Swelling of the vein that causes a blood clot
CANCER: is a group of diseases involving abnormal cell growth with the potential to invade or spread to other parts of the
body.

Types of Cancer

• Carcinoma is a cancer that starts in the skin or the tissues that line other organs. These are most commonly
diagnosed cancers

• Sarcoma is a cancer of connective tissues such as bones, muscles, cartilage, and blood vessels.

• Leukemia is a cancer of bone marrow, which creates blood cells.

• Lymphoma and myeloma are cancers of the immune system.

• Melanoma are cancers that arise in the cells that make the pigment in the skin

Neoplasm Cancer—Mechanisms of Growth

a. Anaplasia : Cancerous cells lose cellular differentiation and organization and are unable to function normally

b. Autonomy : Cancerous cells grow without the usual homeostatic restrictions that regulate cell growth and control. This
allows the cells to form a tumor

c. Metastasis: Cancer cells travel from the place of origin to develop new tumors in other areas of the body

d. Angiogenesis : Abnormal cells release enzymes to generate blood vessels and supply oxygen and nutrients to the cells,
generating growth. Cancerous cells rob the host cells of energy and nutrients and block normal lymph

The Body’s Immune System Response to Cancerous Cells

• Can damage or destroy some neoplastic cells

• T cells recognize the abnormal cells and destroy them
• Antibodies form in response to parts of the abnormal cell protein
• Interferons and tissue necrosis factor (TNF) play a role in the body’s attempt to eliminate the abnormal cells Possible
Causes of Cancer
• Genetic predisposition
• Viral infection
• Constant irritation and cell turnover
• Stress
• Lifestyle factors
• Environmental factors

Goal of Cancer Treatment

• To destroy cancer cells using the following methods:
o Surgical removal
o Stimulation of the immune system to destroy them
o Radiation therapy to destroy them
o Drug therapy to kill them during various phases of the cell cycle
Mechanism of Action
• Functions at cellular level by interrupting cell life—modifies or interferes with DNA synthesis.
• Chemotherapeutic agents eradicate cells, both normal and malignant, that are in the process of cell reproduction.

A. Cell cycle–specific agents: antimetabolites and mitotic inhibitors.

• Act on the cell during a particular phase of reproduction.
• Most effective in tumors where a large number of cells are dividing.
• Divided doses produce greater cytotoxic effects (not all cells will be in the same phase at the same time).
• Antimetabolites.
a. Specific for the S phase—replaces building blocks of DNA so cell can’t divide.
b. Examples of antimetabolites: Trexall (methotrexate), Purinethol (6-mercaptopurine), Adrucil (5-fluorouracil),
Vidaza (azacitidine), Cytosar-U (cytarabine), Hydrea (hydroxyurea).
• Plant alkaloids.
a. Specific for the M phase—prevent cell division by destroying the mitotic spindle.
b. Examples of mitotic inhibitors: plant alkaloids—Oncovin (vincristine), Eldisine (vindesine), Velban (vinblastine),
Vumon (teniposide).

B. Cell cycle–nonspecific drugs: alkylating agents, antitumor antibiotics, and nitrosoureas.

• Act on cells during any phase of reproduction— some drugs will attack cells in the resting phase (not actively
dividing).
• Agents are dose dependent—the more drug given, the more cells destroyed.
• These drugs are more toxic to normal tissue because they are less selective.
• Alkylating agents
a. These drugs prevent cell division by damaging the DNA “ladder” structure and are effective in all phases of the
cell cycle.
b. Included in almost all chemotherapy regimens.
c. Examples of alkylating agents: Cytoxan (cyclophosphamide), Myleran (busulfan), Alkeran (melphalan [L-PAM]),
Thioplex (thiotepa), Platinol (cisplatin).
• Antitumor antibiotics.
a. These drugs attack DNA (they act like alkylating drugs) by slipping between the DNA strands and preventing
replication.
b. Examples of antitumor antibiotics: Adriamycin (doxorubicin), Cosmegen (dactinomycin).
• Nitrosoureas.
a. Alkylating agents that are stronger and have a greater ability to attack cells in the resting phase of cell growth.
b. These drugs can cross the blood–brain barrier.
c. Examples of nitrosoureas: Zanosar (streptozocin), semustine (methyl-CCNU), Gliadel (carmustine or BCNU),
azacitidine (chlorozotocin or DCNU).

C. Other miscellaneous agents (such as Matulane [procarbazine]) are used in the chemotherapy group, but their exact
mechanism of action is unknown.

D. Hormonal agents (estrogens, androgen, progestins) work in all cycles and are used in therapy to affect the hormonal
environment (Decadron [dexamethasone], DES, Halotestin [fluoxymesterone], Nolvadex [tamoxifen], Deltasone
[prednisone]).
• Affect the growth of hormone-dependent tumors.
• Steroids interfere with the synthesis of protein and alter cell metabolism (lymphomas and leukemias).
 • Antihormones (Nolvadex and Evista [Raloxifene]) block tumor growth by depriving the tumor of the
necessary hormones.

E. Combination chemotherapy.
• Most often administered in combination, which enhances the response rate: for example,
Adriamycin, Blenoxane (bleomycin), Velban, and dacarbazine (ABVD) used for Hodgkin’s
lymphoma.
• Studies at Stanford University now suggest ABVD and a fifth or sixth chemotherapy drug be combined
with Deltasone (for its antiinflammatory effect) for 3 months for Hodgkin’s disease.
• Cancer cells divide erratically on different schedules; thus drugs that are effective alone and have
different mechanisms of action can combine to destroy even more cells.
• Drugs used in combination for synergistic activity.
• Guidelines for drug administration are carefully planned and referred to as protocols or regimens.
a. Package inserts are based on single-agent therapy, so it is important to adhere to the ordered protocol.
b. Dosages of drugs are based on height and weight calculated as body surface area.

F. Other chemotherapeutic agents that do not fall into specific categories.

• Elspar (asparaginase)—an enzyme used to treat lymphocytic leukemia; Eulexin (flutamide)—antiandrogen
used to treat prostate cancer; and Taxol (paclitaxel)—used to treat ovarian, breast, and cell lung cancers.
• Chemotherapeutic drugs cause myelosuppression; nursing interventions include blood counts and
instituting precautions if blood count falls below normal, and assess for infection.

Goals of Treatment
A. The major goal is to cure the malignancy.
• Chemotherapy, as primary mode of treatment, may include curing certain malignancies such as
acute lymphocytic leukemia, Hodgkin’s disease, lymphosarcomas, Wilms’ tumor.
• Cure may also occur in combination with other modes of treatment, radiation, or surgery.
B. Control may be the goal when cure is not realistic; the aim is to extend survival and improve the quality of life.
C. Palliation may be the goal when neither cure nor control may be achieved; this goal is directed toward
client comfort.
VACCINES AND SERA

Biologicals—Actions
• Stimulate the production of antibodies
• Provide preformed antibodies to facilitate an immune reaction
• React specifically with the toxins produced by an invading pathogen

Types of Immunity
1. Active immunity : The body recognizes a foreign protein and begins producing antibodies to react with it
2. Passive immunity : Occurs when preformed antibodies are injected into the system and react with a specific
antigen

Immunization
• Definition
o The process of artificially stimulating active immunity
o Exposes the body to weakened or less toxic proteins associated with specific disease-causing organisms
• Goal
o To cause an immune response without having the patient suffer the full course of a disease

Childhood Vaccinations
• Diphtheria, pertussis, and tetanus
• Haemophilus B
• Hepatitis B and hepatitis A
• Chickenpox
• Polio
• Measles, mumps, and rubella

VACCINES
Indications
• Stimulate active immunity in people who are at risk
• The vaccine needed depends on the exposure the person will have to pathogens
• Vaccines are thought to provide lifelong immunity

Contraindications
• In the presence of immune deficiency
• During pregnancy
• Known allergies to any of the components of the vaccine
• Patients who receive immune globulin or who have received blood or blood products within the last 3 months
• Caution with history of febrile convulsions or cerebral injury, conditions in which high fever would be
dangerous, and during acute infection

Adverse Effects
• Fever
• Rash
• Malaise
• Chills
• Fretfulness
• Drowsiness
• Anorexia
• Vomiting
• Irritability
• Pain, redness, and swelling at the injection site
 Site of Action of Vaccines, Immune Sera, and Antitoxins

IMMUNE SERA
• Definition : Sera that contain antibodies to specific bacteria or viruses
• Types : Antitoxin and antivenom
o Immune sera have antibodies to specific toxins that might be released by invading pathogens, or to
venom from spider or snake bites

Immune Sera and Antitoxins

Indications
• Provide passive immunity to a specific antigen or disease
• Used as prophylaxis against specific disease after exposure
• May lessen the severity of a disease

Contraindications
• History of severe reaction to any immune sera
• Use with caution:
o Pregnancy
o Coagulation defects
o Previous exposure to the immune sera
o Rash
o Nausea
o Vomiting
o Chills
o Fever

• Allergic reaction
o Chest tightness, decreased blood pressure, and difficulty breathing
• Local reaction
o Swelling, tenderness, pain, and muscle stiffness at the injection site
ANTIPSYCHOTIC
● Referred as neuroleptics or major tranquilizers
● Use to treat schizophrenia & psychotic conditions
Classification of antipsychotic
Typical antipsychotic or first generation antipsychotic drugs- first developed in the 1950s, divided into two;
haldol (haloperidol) & thoraline (chlorpromazine)

Therapeutic action:
➢ Block dopamine receptors
➢ Prevent dopamine from stimulating postsynaptic neurons
Indication: for schizophrenia & manifestation of other psychotic disorders
- some antipsychotic are approved for treatment of bipolar disorder
atypical antipsychotic or 2nd generation antipsychotic drugs- approved in the 1990s, clozapine (clozaril),
risperidone (risperdal), olanzapine (zyperea) & quetiapine (seroquel)
❖ clozapine - categorize as the first atypical antipsychotic drug.
Indication: used for treatment of severely ill patients with schizophrenia but are unresponsive standard
drugs

>risperidone- commonly used for treatment of irritability and aggression in children & adolescence with
autism
Therapeutic action: block both dopamine & serotonin receptors

ANTIPSYCHOTIC DRUGS (Neuroleptics)

Prototype:
a. Phenothiazines
- chlorpromazine (Thorazine),
- thioridazine (Mellaril)
b. Other Agents
– olanzapine (Zyprexa) , haloperidol (Haldol)
Mechanism of action:
- block dopamine receptors in the limbic system, hypothalamus, and other regions of the brain. Adverse
effects:
- Extra pyramidal syndrome (or EPS) such as dystonia, pseudo parkinsonism, and an irreversible tardive
dyskinesia as manifested by:
a. lip smacking
b. fine wormlike tongue movement
c. involuntary movements of arms and leg
- Neuroleptic malignant syndrome (NMS)
a. fever, tachycardia, tachypnea, diaphoresis, cardiovascular collapse
b. muscle rigidity, seizures.
- Orthostatic hypotension Nursing considerations:
1. Teach family members the signs of EPS and NMS, and report to physician immediately
2. Normalization of symptoms may not occur for several weeks after beginning of therapy
3. Watch out for orthostatic hypotension and photosensitivity with phenothiazine.
4. Be sure that oral doses are swallowed, and not hoarded
ANXIOLYTICS
Therapeutic Actions
o Act in the limbic system and the RAS
o Make GABA more effective
o Cause interference with neurons firing
o Lower doses cause anxiolytic effects
o Higher doses cause sedation and hypnosis

Indications
o Anxiety disorders
o Alcohol withdrawal
o Hyperexcitability and agitation
o Preoperative relief of anxiety and tension

Pharmacokinetics
o Well absorbed from the GI tract
o Peak levels achieved in 30 minutes to 2 hours
o Lipid soluble and well distributed throughout the body
o Cross placenta
o Enter breast milk
o Metabolized in the liver
o Excretion is primarily in the urine
Contraindications & Cautions
o Allergy to benzodiazepines
o Psychosis
o Acute narrow angle glaucoma
o Shock
o Coma
o Acute alcohol intoxication
o Pregnancy
Adverse Effects
o Sedation
o Drowsiness
o Depression
o Lethargy
o Blurred vision
o Confusion
o Dry mouth
o Constipation
o Nausea
o Vomiting
o Hypotension
o Urinary retention
Drug-to-Drug Interactions
o Increase CNS depression when taken with alcohol
o Increase in effect when taken with cimetidine, oral contraceptives, or disulfiram
Decrease in effect if given with theophylline or ranitidine
Lithium Carbonate -is a medication used to treat bipolar disorder. It is important to take the medication as prescribed by
your healthcare provider, as taking too much of it can lead to Lithium toxicity .
Lithium toxicity is a life-threatening condition that can cause intestinal and neurological symptoms, and can also lead to
kidney damage
>The symptoms of lithium toxicity can vary based on the type of toxicity and the severity.
Early symptoms of acute lithium toxicity include gastrointestinal (GI) problems, like nausea, vomiting, diarrhea, and
abdominal pain.
If you have moderate to severe lithium toxicity, you’ll likely get neurological symptoms after the gastrointestinal
symptoms.
These include mental status changes that can range from mild confusion to delirium, uncontrolled shaking (tremors),
coordination and balance issues (ataxia), and muscle twitches (myoclonus)
MOOD STABILIZER - LITHIUM

Trade name: Eskalith, Lithane, Lithonate, Lithobid

Therapeutic action : treat bipolar manic-depressive psychosis, manic episodes

Alteration of ion transport in muscle and nerve cells: increase receptor sensitivity to serotonin.

• Alters sodium transport in nerve and muscle cells

• Inhibits the release of norepinephrine and dopamine- but not serotonin- from stimulated neurons
• Increases the intraneuronal stores of norepinephrine and dopamine slightly
• Decreases intraneuronal content of second messengers

Contraindications: Liver and renal disease, pregnancy, lactation, severe cardiovascular disease, severe dehydration, brain
tumor or damage, sodium depletion, children 12 years old and below.

Side effects: headache, lethargy, drowsiness, dizziness, tremors, slurred speech, dry mouth, anorexia, vomiting diarrhea,
polyuria, hypotension abdominal pain, muscle weakness and restlessness

Use of Antidepressant Agents Across the Lifespan

Adverse reaction : urinary incontinence, clonic movements, stupor, azotemia, leucocytosis, nephrotoxicity

o Cardiac dysrhythmias, circulatory collapse

Nursing responsibilities

o Observe for signs and symptoms of depression: mood changes, insomnia, apathy, or lack of interest in activities
o Monitor vital signs: orthostatic hypotension is common
o Monitor for suicidal tendencies when marked depression Is present.
o Evaluate client's urine output and body weight. Fluid volume deficit may occur as a result of polyuria.
o Observe client for fine and gross motor tremors and presence of slurred speech which are signs of adverse
reaction
o Check client's cardiac status. Loss of fluids and electrolytes may cause cardiac dysrhythmias
o Monitor for signs of lithium toxicity.
Monoamine oxidase inhibitors (MAOIs) -are a class of drugs that inhibit the activity of one or both monoamine
oxidase enzymes: monoamine oxidase A (MAO-A) and monoamine oxidase B (MAO-B). They are best known as
effective antidepressants, especially for treatment-resistant depression and atypical depression. They are also used to
treat panic disorder, social anxiety disorder, Parkinson's disease, and several other disorders.

> Monoamine Oxidase Inhibitors (MAOls)

o Isocarboxazid (Marplan): Used for patients who do not respond to or cannot take newer, safer antidepressants
o Phenelzine (Nardil): Used for some patients who do not respond to newer, safer antidepressants
o Tranylcypromine (Parnate): Used for adult outpatients with reactive depression

>Action: Irreversibly inhibit MAOs, allowing norepinephrine, serotonin, and dopamine to accumulate in the synaptic o
>Indication: Treatment of patients with depression who are unresponsive to or unable to take other antidepression
>Pharmacokinetics

o Absorbed from the Gl tract

o Peak in 2 to 3 hours
o Metabolized in the liver and excreted in the urine
o Cross placenta and enter breast milk

Contraindications: Known allergy, pheochromocytoma, CV disease, headaches, and renal or hepatic impairment

>Adverse reactions: Dizziness, excitement, nervousness, mania, hyperreflexia, tremors, confusion, abdominal agitation, liver
toxicity, nausea, vomiting, diarrhea or constipation, anorexia, weight gain, dry mouth, and abdominal pain

>Drug-to-drug interactions

o Other antidepressants: hypertensive crisis and coma

o Methyldopa: sympathomimetic effects increase
o Insulin or oral antidiabetic agents: additive hypoglycemia

> Food interactions : Tyramine or pressor amines: increase blood pressure

CNS STIMULANT (Drug to Drug Interactions)

o MAOIs: increased risk of adverse effects and increased toxicity

o Guanethidine: decreased in antihypertensive effects
o TCAs, phenytoin: increased drug levels

ADHD MEDICATIONS

>AMPHETAMINES

➢ Names: Amphetamine (Adderall), Dextroamphetamine (Dexidrine), Methamphetamine (Desoxyn)

➢ Action: Stimulate release of neurotransmitters (dopamine andorepinephrinne) causing euphoria and alertness
➢ Indications: ADHD, narcolepsy
➢ Contraindications/Cautions: Symptomatic CV disease (The heat speeds up), Hyperthyroidism (increased HR/
everything), Agitated states (stress response), History of drug abuse
➢ Adverse Reactions/Side Effects: CNS: Restlessness, Insomnia CV: Tachycardia, Hypertension, Heart palpitations, GI:
Dry mouth, Anorexia, Weight loss, Diarrhea, Constipation, Endocrine: Impotence
➢ Nursing Responsibilities/Patient Teaching
o Monitor vital signs
o Monitor weight Offer fluids
o Provide reassurance
o Report extreme restlessness/insomnia
o Monitor for withdrawal
 o No caffeine
o Alternative therapies to help sleep

AMPHETAMINE LIKE DRUGS

• Names : Methylphenidate (Ritalin), Atomoxetine (Strattera), Modafinil (Provigil)

• Action: Produces CNS and respiratory stimulation with weak sympathomimetic activity
• Indications: ADHD (1st 2) (b/c this makes the person more alert), narcolepsy (#3)
• Contraindications/Cautions: Hyperexcitable states
• Adverse Reactions/Side Effects: Hyperactivity, Insomnia, Restlessness, Tremors, Anorexia, Sudden death
• Nursing Responsibility/Patient Teaching: Same as for amphetamines

Spinal anesthesia is a type of regional anesthesia that numbs the lower half of the body1. Some of the possible effects of
spinal anesthesia are:

• Back pain or muscle pain

• Chills caused by low body temperature
• Difficulty urinating
• Fatigue
• Headache, which can be severe if spinal fluid leaks out

>Spinal anesthesia, also known as spinal block, is a form of regional anesthesia that involves injecting a local anesthetic or
opioid into the subarachnoid space, generally through a fine needle, usually 9 cm (3.5 in) long. It is a safe and effective form
of anesthesia that can be used as an alternative to general anesthesia commonly in surgeries involving the lower extremities
and surgeries below the umbilicus .The local anesthetic with or without an opioid injected into the cerebrospinal fluid
provides locoregional anesthesia: true analgesia, motor, sensory and autonomic (sympathetic) blockade

1.The effects of spinal anesthesia can vary depending on the type of medication used and the dose administered. Some
common side effects include low blood pressure, nausea, difficulty breathing, and bleeding in the spine

2. In rare cases, major complications can result in more serious and permanent neurological damage and even death

Opioids -are substances that act on opioid receptors to produce morphine-like effects. Medically they are primarily used
for pain relief, including anesthesia. Other medical uses include suppression of diarrhea, replacement therapy for opioid use
disorder, reversing opioid overdose, and suppressing cough. Extremely potent opioids such as carfentanil are approved only
for veterinary use. Opioids are also frequently used non-medically for their euphoric effects or to prevent withdrawal.
Opioids can cause death and have been used for executions in the United States. Side effects of opioids may
include itchiness, sedation, nausea, respiratory depression, constipation, and euphoria. Long-term use can cause tolerance,
meaning that increased doses are required to achieve the same effect, and physical dependence, meaning that abruptly
discontinuing the drug leads to unpleasant withdrawal symptoms.

Pain- is mostly a subjective experience of unpleasant sensation and emotional experience. People respond to pain
differently because of cultural differences, learned experiences, and environmental stimuli.

• A-delta and C-fibers are two sensory nerves that respond to stimulation by generating nerve impulses that
produce pain sensations.

Acute vs. Chronic Pain

• Acute Pain - is caused by tissue injury. It is the type of pain which makes the person aware of the injury and leads him to
seek for care and education about the injury and how to take care for it.

• Chronic Pain - is a constant or intermittent pain that keeps occurring long past the time the area would be expected to
heal. This is the type that can interfere with activities of daily living.
Pain Classification According to Source

• Nociceptive Pain - caused by direct pain receptor stimulus

• Neuropathic Pain - caused by nerve injury
• Psychogenic Pain - associated with emotional, psychological, or behavioral stimuli

DRUGS USED IN PAIN MANAGEMENT ANALGESICS

Prototype:

a. Narcotic analgesics - codeine, meperidine (Demerol), morphine

b. Non – narcotic analgesics NSAIDs – aspirin (acetylsalicylic acid), ibuprofen (Motrin) paracetamol and acetaminophen
(Tylenol)

Mechanism of actions:

a. Narcotic analgesics - alter pain perception by binding to opioid receptors in CNS.

b. non-narcotic analgesics - relieve pain and fever by inhibiting the prostaglandin pathway.

Nursing considerations: 1. Monitor respiratory depression & hypotension in clients taking narcotic analgesics.

2. Injury and accident precautions in clients taking narcotic analgesic.

3. Warn clients about possibility of dependency, and do not discontinue narcotics abruptly in
narcotic-dependent clients.

4. Naloxone is the antidote for narcotic overdose.

5. Advice clients to take NSAIDs with food and monitor for bleeding complications.

6. Aspirin is contraindicated in clients below 18 years old with flu-like symptoms.

7. Monitor hearing loss in clients taking aspirin.

SEIZURE AND MANAGEMENT

Status epilepticus is a state in which seizures rapidly recur with no recovery between seizures. It is potentially the most
dangerous of seizures.

International Classification of Seizures categorized seizures based on symptoms and characteristics. The two main categories
include:

1. Generalized seizures: Begin in one area of the brain and rapidly spread throughout both hemispheres of the brain
2. Partial seizures or focal seizures: Begin and remain in one area of the brain

Generalized Seizures: These seizures are characterized by a massive electrical activity that begins in one area of the brain
and rapidly spread to both hemispheres. It is usually accompanied by loss of consciousness. It is further classified into five
types:

1. Tonic-clonic seizure(grand mal) : It involves involuntary muscle contraction (tonic) followed by relaxation appearing
as an aggressive spasm (clonic), loss of consciousness, and confusion and exhaustion in the early recovery period. N
2. Absence seizure (petit mal): It is an abrupt and brief (3-5 s) period of loss of consciousness common in children
Starting at age 3) but frequently disappears by puberty. This seizure does not usually involve muscle contractions.
3. Myoclonic seizure: It is characterized by short, sporadic periods of muscle contractions that last for several minutes.
It is relatively rare.
4. Febrile seizure: Self-limited seizure related to very high fevers and usually involves tonic-clonic seizures. This type
most frequently occurs in children.
 5. Jacksonian Seizures: Begins in one area of the brain and involve only one part of the body but this later on spread to
other parts until a generalized tonic-clonic seizure has developed.

Partial (Focal) Seizures: These are characterized by seizures that originate from one area of the brain which do not spread to
other parts. It can be further classified into two:

1. Simple Partial Seizure: It occurs in a single area of the brain and may involve a single muscle movement or
sensory alteration.
2. Complex Partial Seizure: It is a type which occurs by late teenage years and involves a series of reactions or
emotional changes and complex sensory changes (hallucinations, mental distortion, personality changes, loss of
consciousness, and loss of social inhibition). Motor changes may include involuntary urination, chewing
motions, and diarrhea.

Drugs for Treating Tonic-Clonic Seizures

1. Hydantoins
2. Barbiturates
3. Barbiturate-like drugs

Drugs for Treating Generalized Seizures

• Drugs used for treatment of generalized seizures exert their therapeutic effects by blocking channels in the cell
membrane or by altering their receptor sites. As a result, nerve membranes become stabilized. Their work involves •
the entire nervous system so sedation is an expected result.
• Drugs used to treat generalized seizures include hydantoins, barbiturates, barbiturate-like drugs, benzodiazepines,
and succinimides.
• Succinimides and drugs that modulate the inhibitory GABA are used to treat absence seizures

MYASTHENIA GRAVIS, is characterized by weakness and rapid fatigue of any of the muscles under your voluntary control
There cause of myasthenia gravis is a breakdown in the normal communication between nerves and muscles.

• There is no cure for myasthenia gravis, but treatment can help relieve signs and symptoms - such as weakness breath of
arm or leg muscles, double vision, drooping eyelids, and difficulties with speech, chewing, swallowing and breathing

• Nursing management: Provide rest in-between nursing care interventions.

✓ Admin. Meds on time and evenly spaced intervals to prevent relapse.

✓ Make the most of energy peaks.
✓ Plan diet and food intake around ability to swallow.
✓ Stress needs for frequent rest periods.
✓ Establish resp. and neuro. Baseline.

• Medical Management

❖ Mestinon: Orally active cholinesterase inhibitor. Increases the amount of acetylcholine at the neuromuscular
junction. Enhances Communication between nerves and muscles.
❖ Corticosteroids- these inhibit the immune system
❖ Immunosuppressant's- to alter immune system. ( these can increase risk for infection) cyclosporine/mycophenolate
❖ Atropine: for bradycardia. This med will pick up the heart rate
❖ Tensilon: trade name for Edrophonium chloride. The tensilon test is an injection used to diagnose MG. Prolongs the
muscle stimulation and temporarily improves strengths, increased strength following an injection of tensilon
suggests a diagnosis of MG.

Muscle Spasm: A disturbance to the normal flow of information in the CNS caused by diseases, infections. toxins, and
injuries can lead to disturbances ranging from spasms to paralysis.
• results from violent and painful involuntary muscle contraction usually caused by muscle overstretching, joint wrenching,
and tendon or ligament tearing. When this happens, the injured area floods sensory impulses to the spinal cord and it
responds by eliciting intense muscle contraction. Pain from muscle spasms is due to lactic acid accumulation that occurs
when blood flow is cut off during contractions. Sensory impulses continue to flood and a vicious cycle of contraction
develops.

• What causes muscle spasms?

a) Insufficient stretching before physical activity.

b) Muscle fatigue.
c) Exercising in heated temperatures.
d) Dehydration.
e) Electrolyte imbalances in potassium, magnesium and calcium

• Muscle spasticity occurs when damaged neurons are within the CNS rather than the peripheral areas. The site of damage
makes this abnormality permanent. There is an interruption in the balance of excitatory and inhibitor influences within the
CNS which can lead to hypertonia (excessive muscle stimulation) and consequent contractures and structural changes. There
is now loss of coordinated muscle activity.

• Centrally acting muscle relaxants work in the CNS to interfere with reflexes that cause muscle spasms. They essentially
destroy or lyse spasms and are often referred to as spasmolytics.

• Other modalities of spasm and pain relief like rest, heat application, and physical therapy are used in addition to these
drugs.

• Therapeutic Action: The exact mechanism of action of skeletal muscle relaxants is not fully understood but it is thought
that it involves the participation of upper or spinal interneurons. It inhibits monosynaptic and polysynaptic spinal reflexes.
Other than that, it is a CNS depressant.

• Indications: Primary indication is relief of discomfort associated with acute, painful musculoskeletal conditions as adjunct
to rest, physical therapy, and other measures. Alleviation of signs and symptoms of spasticity, may be as use in spinal cord
injuries or spinal cord diseases.

• Contraindications and Cautions

➢ Allergy to centrally acting skeletal muscle relaxants. Prevent hypersensitivity reactions.

➢ Skeletal muscle spasms caused by rheumatic disorders. Do not benefit from these drugs
➢ History of epilepsy. CNS depression and imbalance caused by drugs may exacerbate seizure disorder.
➢ Cardiac dysfunction. Muscle function may be depressed.
➢ Condition marked by muscle weakness. Can be exacerbated by drugs.
➢ Hepatic, renal dysfunction. Interfere with drug metabolism and excretion.
➢ Baclofen is not indicated for treatment of spasticity that contributes to locomotion, upright function, or increased
function. Blocking this spasticity results in loss of these functions.

• Adverse Effects

o CNS: depression, drowsiness, fatigue, weakness, confusion, headache, insomnia.

o CV: hypotension, arrhythmias
o GI: nausea, dry mouth, anorexia, constipation.
o GU: urinary frequency, enuresis, urinary urgency
o Chlorzoxazone may turn urine into purple-red color.
o Tizanidine has been associated with liver toxicity and hypotension in some patients.
o Baclofen is tapered over 1-2 weeks to prevent development of psychoses and hallucinations.

Interactions: Other CNS depressants, alcohol: increased CNS depression

• Implementation with Rationale

o Provide additional spasm and pain relief like rest periods, heat application, NSAIDs as ordered, and positioning to
augment the effects of the drug at relieving the musculoskeletal discomfort.
o Discontinue drug at any sign of liver and renal dysfunction to prevent severe toxicity.
o Monitor respiratory status to evaluate adverse effects and arrange for appropriate dose adjustment or
discontinuation of the drug.
o Provide comfort measures to help patient tolerate drug effects. о Provide safety measures (e.g. adequate lighting,
raised side rails, etc.) to prevent injuries.
o Educate client on drug therapy to promote understanding and compliance.

Multiple Sclerosis (MS)- is a chronic autoimmune disease that affects the central nervous system (CNS)
The symptoms of MS can vary widely depending on the location and severity of the damage to the CNS.
Some common symptoms include fatigue, muscle weakness, difficulty with coordination and balance, vision problems, and
cognitive impairment.
There is no cure for MS, but there are several treatments available that can help manage symptoms and slow the
progression of the disease.
The treatment typically focuses on speeding recovery from attacks, reducing new radiographic and clinical relapses, slowing
the progression of the disease, and managing MS symptoms.
Some people have such mild symptoms that no treatment is necessary.
The diagnosis of MS often relies on ruling out other conditions that might produce similar signs and symptoms, known as a
differential diagnosis
There are no specific tests for MS.
Your doctor is likely to start with a thorough medical history and examination.
Blood tests may be done to help rule out other diseases with symptoms like MS.
Tests to check for specific biomarkers associated with MS are currently under development and may also aid in diagnosing
the disease.
A spinal tap can also help rule out infections and other conditions with symptoms like MS. MRI is often used to help
diagnose multiple sclerosis

ANTIPARKINSONIAN AGENTS

Prototype :

a. Anticholinergic agents - trihexyphenidyl (Artane), benztropine (Congentin)

b. Dopaminergic agents - Levodopa, carbidopa-levodopa (Sinemet), amantidine (Symmetrel)

Adverse effects of dopaminergic agents:

a. levodopa–nausea, vomiting, anorexia, orthostatic hypotension, dark-colored urine and sweat

b. amantidine – ankle edema, constipation

Nursing considerations:

1. Give dopaminergic agents after meals to reduce GI symptoms.

2. Reassure client that levodopa may cause harmless darkening of urine and sweat.

3. Avoid taking Vit B6 (pyridoxine) because it reverses effects of levodopa.

4. Change positions slowly to avoid orthostatic hypotension.

5. Elevate leg to reduce ankle edema.

PARKINSON'S DISEASE

• Parkinson's Disease is a chronic, progressive neurological disorder with rhythmic tremors as its initial manifestation. These
tremors lead to rigidity and weakness which interfere with the ability to maintain posture.

• Other manifestations include bradykinesia (extremely slowed movements), shuffling gait, drooling, and slow and slurred
speech. Cranial nerve affectations lead to a mask-like expression.

• It is important to note that Parkinson's does not affect the higher levels of cerebral cortex so intelligence and other brain
functions at the same level are intact.

• The actual cause of Parkinson's is not known but the manifestations are directly related to the damaged neurons in the
basal ganglia of the brain. Neuronal damage is thought to be caused by viral infections, head trauma, brain infections,
atherosclerosis, and drug and environmental exposures.

Parkinsonism - is referred to as the Parkinson's disease-like extrapyramidal symptoms which are associated to particular
drugs or brain injuries' adverse effects.

ADRENERGIC BLOCKING AGENTS

Prototype:

o Beta blockers (drug names end with “-olol”)

o Atenolol (Tenormin), metoprolol (Lopressor),
o Propanolol (Inderal),
o Timolol ( Blocadren)

Mechanism of actions :

- compete with epinephrine in b-receptors in heart, pulmonary airways, peripheral circulation and CNS.

Indications :

- Raynaud’s disease, hypertension, pheochromocytoma.

- angina, arrhythmias, mitral valve prolapse, glaucoma

Adverse effects :

- orthostatic hypotension, bradycardia, CHF

- depression, insomnia and vertigo

- bronchospasm and dyspnea, nasal stuffiness, cold extremities

Nursing considerations :

1. Administer oral beta-blockers before meals and at a.m. if insomnia occurs.

2. Check client’s apical pulse rate before drug administration, refer if below 60 bpm.

3. Change positions slowly to avoid orthostatic hypotension.

4. Warn clients not to drive or operate dangerous machinery until he/she has adjusted to medications.

ADRENERGIC AGENTS (Sympathomimetics)

Prototype: - epinephrine, phenylephrine, terbutaline, albuterol, isoproterenol.

Mechanism of actions: - stimulate alpha- and beta-adrenergic receptor directly or trigger the release of catecholamines
indirectly causing sympathetic effects.
Indications: - cardiopulmonary arrest, hypotension - COPD and asthma, nasal congestions - allergic reaction, anaphylactic
shock

Adverse effects: - restlessness, insomnia, tremors, nausea - palpitations, angina, tachycardia, HPN 12 Nursing considerations:
1. Contraindicated in client’s w/ hyperthyroidism, pheochromocytoma & cardiovascular disease.

2. Monitor vital signs and advice precautions

CHOLINERGIC BLOCKING AGENTS (Parasympatholytics, Anticholinergics)

Prototype: atropine

Mechanism of actions: - block the binding of acetylcholine in the receptors of parasympathetic nerves.

Indications:

- use preoperatively to dry up secretions.

- treat spasticity of GI or urinary tract.

- use for treatment of bradycardia, asthma, parkinsonism.

- use for antidote in organophosphate poisoning (insecticide)

Adverse effects: - dry mouth , dilatation of pupils, tachycardia

- urinary retention, ileus, heat stroke

Nursing considerations:

1. Keep clients in cool environment.

2. Watch out for signs of heatstroke and dehydration.

3. Encourage clients to increase fluid intake and use of sugarless gum/candy for dry mouth.

4. For GI spasticity, administer 30 minutes before meals and at bedtime.

CHOLINERGIC AGONISTS

• act at the same site as the neurotransmitter acetylcholine (ACh) and increase the activity of the ACh receptor
• These receptor sites are found throughout the body so their stimulation produces similar effects parasympathetic
nervous system is activated. Thus, they are also called as parasympathomimetics.
• Cholinergic agonists can either be direct- or indirect acting cholinergic agonists. Under indirectly-acting cholinergic
agonists, there are agents for Alzheimer's and Myasthenia Gravis.

ANTICHOLINERGICS

•are drugs that oppose the effects of acetylcholine. In essence, they also lyse and block the effects of parasympathetic
nervous system (PS) so they are also called as parasympatholytics. Atropine is currently the only widely used anticholinergic
drug. Other common examples include meclizine, scopolamine and ipratropium.

• Anticholinergics were once very widely used to decrease Gi activity and secretions. However, more specific and less toxic
drugs are available now and the utilization of this drug class is now limited.

• GI ulcers are basically erosions in the lining of the GIT caused by increased HCI production most commonly from H. pylori
infection. Patients with GI ulcers suffer from burning abdominal pain, nausea, and acid reflux.

Hypertension, or high blood pressure, is a condition where the force of blood against the walls of arteries is too high. It can
lead to serious health problems such as heart disease, stroke, and kidney failure if left untreated
The ABCs of hypertension are a set of guidelines that can help manage high blood pressure

Here’s what each letter stands for:

- A stand for Angiotensin-converting enzyme (ACE) inhibitors. These medications help relax blood vessels and lower
blood pressure 1.
- B stands for Beta-blockers. These medications reduce the heart rate and the amount of blood pumped by the heart,
which lowers blood pressure 2.
- C stands for Calcium channel blockers. These medications relax blood vessels and lower blood pressure by reducing
the amount of calcium that enters the heart muscle cells

THYROID AGENTS

Prototype: • Synthroid (levothyroxine)

Mechanism of action: - function as natural or synthetic hormones.

Nursing considerations:

- Taken in the morning.

- Caution with coronary artery disease.

- Monitor for signs of hyperthyroidism and refer for decreasing the dose

Hypothyroidism is a condition that results from decreased production of thyroid hormones. Symptoms of hypothyroidism
vary between individuals and they tend to develop slowly.

Commonly noted symptoms include:

- Fatigue
- Weight gain
- Increased blood cholesterol level
- Increased sensitivity to cold
- Constipation
- Dry skin
- Puffy face
- Hoarseness
- Muscle weakness, aches, tenderness, and stiffness
- Joint pain, stiffness, or swelling
- Irregular menstrual periods or amenorrhea
- Dry hair or hair loss

In order to diagnose hypothyroidism, certain laboratory tests may be recommended based on the symptoms. Thyroid
function tests (TFTs) are a blood test to measure the levels of thyroid hormone - T4 levels and also TSH and T3 levels. A
thyroid scan may also be conducted to check for abnormalities in the gland .

Synthetic thyroid hormones are prescribed to treat the condition. Hormone therapy involves synthetic thyroid hormone
(Levothyroxine) to regulate the body functions

Hyperthyroidism is a condition where the thyroid gland produces too much thyroid hormone. The diagnosis of
hyperthyroidism involves a complete medical history, physical examination, blood tests, and imaging tests. The treatment
options for hyperthyroidism primarily include reducing the production of hormones from the gland. Medications may be
prescribed to control some of the symptoms.
Methimazole is an antithyroid medication that stops hormone production, while propranolol is a beta-blocker that controls
rapid heartbeat, sweating, and pulse 12. In severe cases, if other treatments fail, surgical removal of a portion or all of the
thyroid gland may be recommended. Radioactive iodine therapy is another option that destroys cells that make hormone.

The symptoms of hyperthyroidism are various and can mimic other medical conditions. They include swollen thyroid gland,
prominent eyes, increased metabolic rate, irregular or rapid heartbeat, increased blood pressure, shaking hands, increased
sweating, hot flashes, irritability and restlessness, increased bowel movement, weight loss, weakness, difficulty sleeping,
brittle hair, hair loss, nausea and/or vomiting, irregular menstrual cycles or amenorrhea in women and breast development
in men. If untreated for a prolonged period it may lead to complications such as thyroid storm which is the release of large
amounts of thyroid hormone and sudden worsening of symptoms. It can also lead to loss of consciousness, shortness of
breath, very fast or highly irregular heartbeat, atrial fibrillation (a condition with irregularly beating heart), in turn increasing
the risk of stroke, osteoporosis or thin and weakened bones and eye problems which can lead to vision loss

>Medications known to interact with parathyroid hormone Note: Showing generic names only. Include all brand names and
combination drug names. alendronate calcipotriene topical calcitriol topical digitoxin digoxin

ANTIDIABETICS ORAL HYPOGLYCEMIC AGENTS (OHA)

1. Sulfonylureas 9

• stimulate insulin secretions and increase tissue sensitivity to insulin.

• First Generation: Chlorpropamide (Diabenase) - disulfiram precautions

• Second Generation: Glypizide, Glymepiride

2. Biguanides

• facilitates insulin action on the peripheral receptor site

• Metformin and Glucophage (Glucovance) - side effect is lactic acidosis

3. Alpha-glucosidase inhibitors

• delay carbohydrate absorption in the intestinal system

• Acarbose (Precose) – side effect is diarrhea

4. Thiazolinidine
• increase tissue sensitivity of insulin; e.g Rosiglitazone (Avandia) – already discontinued Nursing considerations: -
Effective only for type II DM - Contraindicated to pregnant & breastfeeding. - Given before meals - Monitor for signs
of hypoglycemia.

Here are some common types of medications used to treat diabetes:

- Insulin: Insulin is a hormone that regulates blood sugar levels. It is used to treat type 1 diabetes and sometimes type
2 diabetes. Insulin is injected into the body using a needle and syringe, an insulin pen, or an insulin pump1.
- Oral hypoglycemic agents (OHAs): OHAs are medications that lower blood sugar levels in people with type 2
diabetes. They work by increasing insulin sensitivity, reducing glucose production in the liver, and increasing insulin
secretion from the pancreas.
- GLP-1 receptor agonists: GLP-1 receptor agonists are injectable medications that stimulate insulin secretion and
reduce glucagon secretion in people with type 2 diabetes. They also slow down gastric emptying and promote
satiety.
- DPP-4 inhibitors: DPP-4 inhibitors are oral medications that increase insulin secretion and reduce glucagon secretion
in people with type 2 diabetes.
- SGLT2 inhibitors: SGLT2 inhibitors are oral medications that lower blood sugar levels by increasing glucose excretion
in the urine.
 - Meglitinides: Meglitinides are oral medications that stimulate insulin secretion from the pancreas in people with
type 2 diabetes.
- Alpha-glucosidase inhibitors: Alpha-glucosidase inhibitors are oral medications that slow down carbohydrate
absorption in the small intestine, thereby reducing postprandial hyperglycemia.
- Thiazolidinediones: Thiazolidinediones are oral medications that increase insulin sensitivity in people with type 2
diabetes.
- Bile acid sequestrants: Bile acid sequestrants are oral medications that lower blood sugar levels by binding to bile
acids in the intestine, thereby reducing glucose production in the liver.
- Amylin analogs: Amylin analogs are injectable medications that reduce postprandial hyperglycemia by slowing down
gastric emptying and suppressing glucagon secretion

Heart failure is a chronic condition that requires lifelong management. To diagnose heart failure, your healthcare provider
examines you and asks questions about your symptoms and medical history. Your provider checks to see if you have risk
factors for heart failure, such as high blood pressure, coronary artery disease or diabetes. Tests that may be done to
diagnose heart failure may include blood tests, chest X-ray, electrocardiogram (ECG or EKG), echocardiogram, exercise tests
or stress tests, CT scan of the heart, heart MRI scan, coronary angiogram, and myocardial biopsy .

The treatment of CHF involves a combination of lifestyle changes, medications, and in some cases, surgery. The goal of
treatment is to improve symptoms and prolong life. Medications used to treat CHF include angiotensin-converting enzyme
inhibitors (ACE inhibitors), angiotensin II receptor blockers (ARBs), angiotensin-receptor neprilysin inhibitors (ARNIs), beta-
blockers, diuretics, aldosterone inhibitors, and other medications such as anticoagulants, statins, and vasodilators

Cholesterol medications, such as statins, have several effects:

- They lower blood cholesterol by reducing the amount of cholesterol produced by the liver.
- They lower "bad cholesterol" (LDL) levels.
- They lower triglyceride levels.
- They boost "good cholesterol" (HDL) levels.

It is important to follow a healthy diet and get enough exercise in addition to taking cholesterol medications. Statins are one
of the most commonly prescribed drugs in the U.S. and are known to lower a person's risk for stroke and heart attack

ANTICOAGULANTS

Prototype: - Heparin (SQ and IV) Warfarin (Orally)

Mechanism of actions:

a. Heparin - prevents thrombin from converting fibrinogen to fibrin.

b. Warfarin - suppress coagulation by acting as an antagonist of vitamin K after 4-5 days.

Indications: - thrombosis, pulmonary embolism, myocardial infarction

Adverse effect: - bleeding Nursing considerations:

1. HEPARIN sodium - test : PTT - antidote : (protamine sulfate)

2. WARFARIN sodium (coumadin) - test : INR - reduce intake of green leafy vegetables. - antidote : Vitamin K (
Aquamephyton)

DIURETICS - usually given at morning

Thiazides

- hydrochlorothiazide

- blocks Na and K reabsorption; reabsorb Ca

- hypercalcemia

Loop diuretics

- furosemide (Lasix)

- blocks Na, K, and Ca reabsorption

- hypocalcemia 6

Potassium sparing diuretics

- Spironolactone (Aldactone)

- excrete Na and water but it reabsorbs K

Codeine is an opioid pain reliever which is used to treat mild to moderately severe pain and to help reduce coughing.
Codeine is available as a single ingredient tablet and also available in multi-ingredients products combined with other pain-
relieving medicines or cold and flu medicines. Codeine can slow or stop your breathing, cause profound sedation, and may
be habit-forming. MISUSE OF THIS MEDICINE CAN CAUSE ADDICTION, OVERDOSE, OR DEATH, especially in a child or other
person using the medicine without a prescription. Codeine is not for use in anyone under 18 years old. Taking codeine
during pregnancy may cause life-threatening withdrawal symptoms in the newborn. Fatal side effects can occur if you use
codeine with alcohol, or with other drugs that cause drowsiness, sedation or slow your breathing.

BRONCHODILATORS

Prototype : Symphatomimetic Xanthines

- albuterol, salbutamol

- aminophylline

- isoproterenol, salmeterol

- theophylline

- terbutaline

Mechanism of actions:

> sympathomimetic (-receptor agonist) bronchodilators, dilate airways.

>xanthine bronchodilators, stimulate CNS for respiration.

Indications :

- bronchospasm, asthma, bronchitis, COPD.

Adverse effects :

- palpitations and tachycardia

- restlessness, nervousness, tremors

- anorexia, nausea and vomiting, headache, dizziness.

Nursing considerations:

- Contraindicated in hyperthyroidism, cardiac dysrhythmia, or uncontrolled seizure disorder.

- Should be used with caution in patients with HPN and narrow-angle glaucoma.
Gastric meds are medications that help treat, heal and protect against stomach acid problems123.Some common types of
gastric meds are1

- Proton pump inhibitors, such as esomeprazole, lansoprazole, omeprazole, or pantoprazole, that block stomach acid
production
- Histamine-2 (H2) blockers, such as cimetidine, ranitidine, or famotidine, that reduce stomach acid production
- Antacids, such as charcoal pills, that neutralize stomach acid and relieve heartburn and indigestion
- Alginates, that form a protective coating over the stomach lining
- Sucralfate, that helps heal ulcers and prevent bleeding

LAXATIVES

a. Osmotic : lactulose (Duphalac), Na biphosphate (Fleet enema) & magnesium salt (Milk of Magnesia)

- retain fluid and distend intestine

b. Fecal softeners : ducosate (Dialose)

- emulsify fecal fat and water

c. Stimulant : bisacodyl (Dulcolax) & senna (X-prep)

- irritates intestinal mucosa and stimulates intestinal smooth muscles

d. bulk-forming laxative (Metamucil)

- increase fecal bulk and water content

e. Emollient/Lubricant : mineral oil

- lubricates & prevent colon absorption

Aspirin (acetylsalicylic acid) has been widely used in the management of myocardial infarction (MI), commonly referred to as
a heart attack. When someone is experiencing a heart attack, the blood supply to a part of the heart muscle is blocked,
typically due to a blood clot in one of the coronary arteries. Aspirin plays a crucial role in the early treatment of MI for the
following reasons:

- Antiplatelet Effect: Aspirin is an antiplatelet medication, which means it helps prevent blood platelets from sticking
together and forming clots. In the context of MI, this can be especially important because it can help prevent or
minimize the size of the clot that is causing the heart attack.
- Clot Dissolution: Aspirin can also help break down the clot that is blocking a coronary artery, restoring blood flow to
the heart muscle. This can minimize the damage caused by the heart attack.
- Immediate Action: Aspirin can be administered quickly and easily, often through chewable tablets, in an emergency
situation. It is typically recommended that individuals who suspect they are having a heart attack chew and swallow
a full-strength (usually 325 mg) aspirin tablet to begin treatment while awaiting medical assistance.

It's essential to note that aspirin should be used as part of a comprehensive treatment plan for MI, including medical
intervention such as angioplasty and/or clot-dissolving medications like thrombolytics. After the initial administration of
aspirin, a healthcare professional will determine the most appropriate course of treatment.

However, not everyone should take aspirin in the event of a heart attack. It may not be suitable for individuals with certain
medical conditions or allergies, and it's essential to follow the guidance of healthcare professionals. If you or someone you
know is experiencing symptoms of a heart attack (such as chest pain, shortness of breath, and lightheadedness), seek
immediate medical attention by calling emergency services. They can provide the most appropriate care and medications.