● COX2 is found at sites of inflammation; will
feel pain and inflammation at particular area
Analgesic Anti Inflammatory Drug
How Pain is Felt
● Pain = protective mechanism
● Peripheral nerves send message to brain
● Pain receptors (nociceptors) detect nerve
tissue damage and send a message via the
Peripheral nerve going to the brain.
● Sends message to brain to act ie. arm
moves to remove source of pain like the bee
● Nociceptors found in skin, muscle, bone,
joints and viscera
● Body releases arachidonic acid …..
● Platelet aggregation - compilation of blood
● Arachidonic acid is a precursor in the
biosynthesis of essential substances for
inflammation
○ Precursor for the release of the
different inflammatory substances in
the body (cyclooxygenase)
● Cyclooxygenase is an enzyme that
produces prostaglandins and thromboxanes
● COX 1 inhibitors are nonselective (affect
everywhere)
● Cox 2- induced and inflamed tissue
● Prostaglandin = group of lipids at site of
tissue damage; important for temperature
homeostasis, gastric mucosal barrier
(Pinoprotektahan ang stomach from causing
inflammation), Uterine contractions,
inflammatory process
● Gastric mucosal barrier
● COX1- blocking platelet aggregation,
production of pain signals and
inflammatory process would take place
*Ang patient pwede magkaroon ng bleeding
tendencies*
Narcotics v. Opioid
● Narcotics - a drug that relieves pain and
induces drowsiness, stupor or insensibility
(commonly abuse, misused).
○ A drug or other substance that
affects mood or behavior
○ Morphine
● Opioid - opioid are a broad group of
pain-relieving drugs that work by interacting
with opioid receptors in your cells
○ They activate an area of nerve cells
in the brain and body called opioid
receptors that block pain signals
between brain and body
When the patient will take the medications, it
will be relieved
NON-OPIOID / NON NARCOTIC
Uses:
- Mild to moderate pain of the skeletal
muscle and joint
- Not addictive & are less potent (hindi ganon
ka lakas) than narcotic analgesics
* Potency - great effects of the drug
MOA:
- Act on peripheral nervous system at the pain
receptor sites by inhibiting prostaglandin
 synthesis (initiate inflammation kapag i block
ang response from prostaglandin then we
will not feel pain or there will be no
inflammation that will occur)
- Effective for dull, throbbing pain of HA,
dysmenorrhea, pain from inflammation
(muscle inflammation), minor abrasions
(bike then natumba then nasugat), muscular
pain and mild-moderate arthritis
- Most analgesics have an antipyretic effect
(ex. pt. Naka sakit, nagareklamo sakit ulo at
nalalagnat; gamitin narcotics para ma
address both ang HA at fever) alleviate pain.
Antipyretic Effect - Medication that lower down the
temperature of the patient
EG: aspirin, acetaminophen, ibuprofen (endorser:
alaxan has paracetamol with ibuprofen), naproxen
Endorsers of meds: Ibuprofen - Manny Pac,
Naproxen - Vice Ganda, Acetaminophen - John
Llyod
Aspirin
- A salicylate, oldest non narcotic analgesic
drug
- MOA: inhibit synthesis of prostaglandin.
- Primary effect: analgesic (antipyretics, anti
inflammatory, anti platelet)
- Antipyretics - lowers down
temperature
- Anti-inflammatory - hubag sa mga
lawas
- Anti platelet - pinalapalabnaw ang
dugo ni pt
- Not recommended due to bleeding
tendencies, diet modification;
recommended for antiplatelet
- CI: children < 12 y.o (Reye’s syndrome -
brain and liver damage)
Reye’s Syndrome - rare disorder that could
cause brain and liver damage
- DI:
- + warfarin, heparin, thrombolytics =
inc. bleeding
- Ibuprofen + insulin / OHA Oral
hypoglycemic agents (For pt w/
diabetes) = hypoglycemia
- SE: gastric irritation, excess bleeding might
occur during the first two days of
menstruation
- Nursing Responsibilities:
- take with food (gastric irritant)
- with glass of water
- monitor platelet bleeding time PT
(how fast clotting)
- discontinue 7 days prior to surgery
*Baka if i open ang body ni pt, hindi basta basta
magka coagulation magkaka massive bleeding si pt.
Acetaminophen (tylenol, tempra)
*same as paracetamol
- MOA: weakly inhibits prostaglandin
synthesis which decreases pain
sensation and heat
- Is safe effective analgesic & antipyretic
drug used for muscular aches & fever
caused by viral infections
- Causes no/litte gastric distress; does not
interfere with platelet aggregation, no
antiinflammatory effect
- CI: severe hepatic / renal disease,
alcoholism, hypersensitivity
- Di:
- + caffeine = inc. effect
- + oral contraceptive, anticholinergics
(blocks neurotransmitter) = dec.
effects
- SE/AE: hepatotoxicity (injury to the liver),
early symptoms of hepatic damage (N/V,
diarrhea, abdominal pain)
- Nursing Considerations:
1. If hepatotoxic si pt - Check liver
enzymes, self medication should not
alabe used or more than 10 days for
adults & 5 days for children
2. Keep out of children’s reach
3. Acetylcysteine (antidote)
acetaminophen toxicity *overdose
sa biogesic
4. No alcohol when pt. is on med
ASPIRIN ACETAMINOPHEN
- analgesic ( - Causes no/litte
antipyretics, gastric distress;
anti does not
inflammatory, interfere with
anti platelet) platelet
aggregation,
no
antiinflammator
y effect

NARCOTIC AND OPIOID ANALGESIC
*nakakahigh, elevate mood - drug abuse/addiction
MOA:
- binds to opiate receptors in the CNS,
reduces stimuli from sensory nerve end,
pain threshold is increased (mas matapang)
Uses:
- moderate to severe pain
- Suppresses pain muscles
- Suppresses respiratory & coughing by acting
on the respirator & cough centers in the
medulla of the brainstem
- Most opioid with exception to meperidine
(demerol) have an antitussive property
(known as cough suppressant)
- Have two isomers (molecule with same
molecular formula but differ in structure)
(e.g. levo & dextro)
- Levo isomers: produce an
analgesic effect only, can cause
physical dependence
- Dextro isomers : do not cause
physical dependence
- Both levo and dextro: posses an
antitussive response (cough suppressant)
CI: with respiratory dysfunction, head injuries,
increase ICP (increased intracranial pressure),
hepatic & renal disease, alcoholism
DI: + Alcohol, sedatives, hypnotics & other CNs
depressants = inc. CNS depression -can cause
drowsiness further usage of drug can cause
comatose
May increases ALT / AST (liver enzymes)
SE:
- N/V / nausea and vomiting (particularly in
ambulating patients)
- Constipation (less in demerol)
- Moderate decrease of BP
- Orthostatic hypotension (high dose)
- Antitussive effect (except demerol)
- CNS: drowsiness, dizziness, confusion,
sedation
*Pupil constriction - pinpoint pupil - sign of toxicity
- Normal pupil: 2-3 millimeters
- Less than 2-3 = toxicity
Ex.
- Codeine: not as potent as morphine
- Morphine sulfate: potent analgesics (can
depress respiration) effective against MI,
dyspnea - pulmonary edema, pre-op meds
*if pt has chest pain give morphine (pwede
siya sa pt with heart problem pero with
precautions)
- Meperidine (demorol): shorter duration of
action tha morphine, potency varies
according to dosage
Meperidine (Demerol)
- Most commonly used narcotic for alleviating
post-operative pain, no antitussive property
(alleviate pain but still allow the pt to cough
the phlegm)
Ex: pt galing sa surgical (any kind) bigyan ng
anesthesia si pt baba ang breathing ang lungs ay
hindi makapalabas ng secretion; deep breathing
exercise para di ma pool sa lungs; allows pt. To
cough out secretions in resp. Tract
- Ex: lung operation need daw ng maximum
lung expansion, we need to use demerol
para ma elevate ang pain and to allow
maximum lung expansion.
- Preferred in pregnancy (does not diminish
uterine contractions & causes less neonatal
respiratory depression
- Not prescribed for long term use
Withdrawal symptoms called abstinence syndrome
occurs 24-48 hours after last narcotic dose
(irritability, diaphoresis (pinapawisan ang px),
restlessness, muscle twitching, tachycardia,
hypertension)
- Ex: nasanay ang body sa morphine like
cancer tapos biglang tinanggal ang
morphine hahanapin ng katawan ang
morphine. Masyadong dependent ang body
sa narcotic dose
Nursing considerations:
- VS do not give if RR is < 10 cpm/min, BP <
90/70 mmHg
- Administer before pain reaches its peak
to maximize the effectiveness
- Should not taken with alcohol or sedative
→Lead to CNS depression
- Check urine output & bowel elimination -
causes constipation
- Assist pt. In ambulation
→ fall precaution
- Have naloxone (narcan) ready as antidote
→If nasobraan si pt ug morphine
- Do not abruptly withdraw medicine
→ magkaka abstinence syndrome
- Assess for toxicity due to overdose
 - Pupillary constriction
- Respiratory depression
- Decreased urine output
- Instruct about deep breathing & coughing
exercises especially in patent with altered
pulmonary function
Narcotic Antagonist
- Antidotes for overdoses of narcotic
analgesics
- Have high affinity to the opiate receptor site
than the narcotic being taken
- Blocks the receptor & displaces any narcotic
that would be at the receptor, thus inhibiting
the narcotic action]reverses respiratory
and CNS depression
- Eg; naloxone (narcan) - IM, IV
NSG: VS q5, q 15 q 30 until stable
Narcotic Addicted Person
- METHADONE: a narcotic but causes less
dependency that the narcotics it is replacing
→ narcotic parin siya but less
potent/dependency ang binibigay kay pt
- Helps the narcotic addicted person to
withdraw from narcotics without causing
withdrawal symptoms
- Given OD (longer half life)
Narcotic Agonist - Antagonist
- A narcotic antagonist is added to a narcotic
agonist to decrease narcotic abuse
→ to decrease narcotic abuse (hindi ganun
ka concentrated)
- EG: pentaxoncine (talwin), butophamol
tartrate (stadol), nalbuphine HCl (nubain),
buprenorphine (buprenex)
Anti-Inflammatory Drugs
Nonsteroidal Anti-Inflammatory
A. Salicylate (aspirin)
B. Nonsalicylates
Parachlorobenzoic acid
- Indomethacin (indocin)
- Sulindac
- Tolmetic
Pyrazolone derivatives
- Phenylbutazone
Propionic
- Ibuprofen (alaxan, advil)
- Naproxen (flanax)
- Ketoprofen (orudis)
Fenamates
- Meclofemanate (meclofen)
- Mefenamic acid (ponstan)
Oxicam
- Meloxicam (mobic)
Phenylacetic acid derivatives
- Diclofenac na (voltaren, cataflam)
Selective COX2 inhibitors
- celecoxib
MOA: inhibits the enzyme cyclooxygenase (COX) (if
na inhibit = no pain and no inflammatory
response) that is needed for the biosynthesis of
prostaglandin
Uses: reduce inflammatory process
-relieve pain
-reduce fever
CI: severe renal and hepatic disease, GI bleed,
hypersensitivity (aspirin: tinnitus, vertigo,
bronchospasm esp asthmatic)
SE: Gi irritation (blocking of the platelet), anorexia,
N/V, dizziness, confusion, hearing loss,
heartburn (blocking the cyclooxygenase = decrease
inhibition of the prostaglandin mawawala ang
mucosal barrier), drowsiness
AE: GI bleed, tinnitus, life threatening (BM
depression, hepatotoxicity, bronchospasm (constrict
airways), cardiac dysrhythmias)
Bone Marrow - problems with the levels of the
different cells in the body
DI:
+ Anticoagulants, antiplatelets,
thrombolytics = inc. GI bleed
NSG RESP:
- Take with meals
- Check hypersensitivity
- Monitor bleeding
- Avoid alcohol
- Inform client that it may take several weeks
to experience the desired effect of some
NSAIDs
- Direct client to inform the dentist or surgeon
before a procedure when taking ibuprofen or
other nsaids for a continuous period
Steroidal Anti-inflammatory
Corticosteroids
MOA: suppresses the inflammatory process; can
control inflammation by suppressing or preventing
many of the components of inflammatory process at
the injured site.
Uses:
Myocarditis, pericarditis, arthritis, tendonitis, bursitis
(sac between bone and muscle), ulcerative colitis (
colon inflammation, dermatitis (swollen
integumentary system)
*S for steroids
Swollen,
Suppress immune system
Sterility
Sugar will increase
Serum electrolytes
Slowly taper off
Sight
Truncal obesity
Major side effects
- Buffalo hump - accumulation of fat on the
back of the neck
- Moon face - rounded, puffy face
- Immunosuppressant effect - inability of the
immune system to respond to antigenic
stimulation
- Growth retardation
- Mood swing
- Acne (skin irritation)
- Truncal obesity
- Sterility - inability to conceive (pwede hindi
mabuntis si pt)
- Cardiac dysrhythmias - tachycardia most
common NSG consideration
- Inhibited CHON synthesis - Usually recommend for short term use
- Taper off slowly to prevent adrenal
Hypokalemia, hypocalcemia, hyperglycemia, insufficiency (adrenal gland not producing
hypernatremia , hypertension enough steroid hormone)
*high risk for cataract development - High CHON, potassium, calcium, low
Due to hyperglycemia. sodium intake
- Daily weight, report weight gain > 5 lbs
Moon Face - Check CBC, strengthen immune system
- Take with food
- Avoid vaccines with Attending Physician’s
approval

SONE - corticosteroids
Eg.
- Cortisone acetate
- Hydrocortisone
- Prednisone
- Fluticasone
- Dexamethasone
- betamethasone
- Budesonide( budecort)

Buffalo Hump
Anti- gout agents
Purines - essential for DNA synthesis, cell survival
Eg. nuts, organ meats, beer
Breakdown of purines = uric acid formation
Anti-gout agents usually inhibit the formation of uric
acid, which is derived from purines
Common drugs
Colchicine (nocovolchine)
- Anti Inflammatory
- Inhibits migration of leukocytes at inflamed
site
- Does not inhibit uric acid, does not promote
uric acid excretion
Probenecid (benemid)
- Uricosuric agent
- Increases rate of uric acid excretion by
inhibiting its reabsorption
- Should not be used in acute attack
Sulfinpyrazone (antirane)
- More potent than probenecid
Allopurinol (zyloprim)
- Uric acid inhibitor, not antiinflammatory
- Inhibits final step of uric acid biosynthesis
- Useful for client who do not respond well to
uricosurics
Uses:
Control acute inflammation of the attack
Increase excretion of uric acid
Decreases production of uric acid
Uses:
Gouty arthritis
Control uric acid production with antineoplastic drug
therapy
SE: kidney stone, N/V, diarrhea, HA, flushed skin,
rash metallic taste, drowsiness
AE: BMD (Bone Marrow Depression)
NSG resp.
- Fluid intake (at least 2L/day)
- Alkaline urine: milk, fruits except cranberries
(inc acidity), plums, prunes, most
vegetables, small amount of beef
- Alkaline urine = inc. solubility of uric acid
- Promote compliance, low purine foods: (high
) beer, wine, shellfish, legumes, gravy, organ
meat, salmon, sardines
- CBC (wbc to check for immunosuppression
or inflammation)
- Acetaminophen instead of ASA (aspirin) -
elevate uric acid
- Avoid large doses of vit C (ascorbic acid)
- Take with food
Respiratory Medications
Respiratory System Overview
● The major function of the respiratory system
is to exchange oxygen and carbon dioxide
between the body and the environment
● Passageways: nose, pharynx, larynx,
trachea, bronchi, bronchioles; constitute
conducting division
● Nasal cavity lined with ciliated mucous
membrane; mucus traps inhaled particles,
cilia drives debris-laden mucus toward the
throat to be swallowed
● Bacteria destroyed by lysozyme in mucus
● Additional protection by lymphocytes and
antibodies
● Three folds of tissue arising from wall of
nasal cavity: nasal conchae or turbinates
● Turbinates increase contact surface with
inhaled air, enabling the nose to rapidly
warm, moisten and cleanse it
● Roof of nasal cavity has olfactory nerve cells
in its lining; responsible for sense of smell
● 90* turn downwards towards pharynx is
another trap for large dust particles
● The pharynx houses several tonsils. These
immunocompetent tissues of the immune
system are well positioned to respond to
inhaled pathogens.
● Because aspiration of food or drink into the
lungs may potentially be life threatening,
there are mechanisms in place to prevent
this from happening. The opening of the
larynx is guarded by a tissue flap called the
epiglottis. During swallowing, the larynx is
pulled up and the epiglottis flips over,
directing food and drink to the esophagus.
More importantly, the vocal folds also close
to protect the airway.
● From the larynx, air passes to the trachea,
the windpipe, which then splits into two
primary bronchi, supplying the two lungs. In
the lungs, primary bronchi branch into
smaller and smaller bronchi and bronchioles,
forming the bronchial tree with millions of air
tubes, or airways. The airways have a layer
of smooth muscle in their wall which enables
them to constrict or dilate.
● The larynx, trachea and bronchial tree are
lined with ciliated columnar epithelium,
which produces mucus and functions as a
mucociliary escalator: the mucus traps
inhaled particles, while the cilia beating
moves the mucus up toward the throat,
where it is swallowed.
● The last component of the conducting
division, the terminal bronchioles, branch
into several respiratory bronchioles which
mark the beginning of the respiratory
division. The respiratory bronchioles end
with microscopic air sacs called the alveoli,
each of which is surrounded by blood
capillaries. The alveolar wall is composed
mainly of type I - thin squamous cells which
allow rapid gas diffusion. Inhaled oxygen
moves from the alveoli into the blood in the
capillaries, while carbon dioxide relocates
from the blood to the alveoli to be exhaled
out of the body. There is also a small
number of type II cuboidal cells secreting a
surfactant, whose function is to lower the
surface tension at the air-liquid interface and
prevent the alveolus from collapsing at the
end of each exhalation. The alveoli also
house a large number of macrophages,
ready to engulf any inhaled particles that
managed to get past previous barriers to the
lungs.
Understanding COPD
● COPD is a lung disease that makes it
difficult to breathe
● Long-term disease that gets worse over time
● Characterized by inflammation and severe
limitation of airflow in and out of lungs
● Chronic bronchitis and emphysema
● Common to have both CB and emphysema,
rare to have COPD and asthma
● Leading cause: cigarette smoking
● Long-term exposure to irritants:
second-hand smoke, air pollution, dust or
workplace fumes, biomass exposure (e.g
wood smoke)
● Genetic disorder: alpha-1 antitrypsin
deficiency
● Respiratory infections do not cause COPD
ie. influenza, pneumonia
● HOWEVER, respiratory infections can make
people with COPD very sick; therefore, keep
vaccinations up-to-date
● At first, symptoms are mild or none
● Signs and symptoms:
○ Shortness of breath
○ Wheezing
○ Chest tightness
○ Ongoing (chronic) cough w/ mucus
● As symptoms worsen, breathing needs more
energy
○ Difficulty with routine activities
○ Fatigue
○ Weight loss
○ Muscle loss
● Ranges: mild to moderate to severe
● In normal lungs, air travels down trachea
into bronchial tubes and into bronchioles into
the alveoli; air sacs should be flexible and
elastic, expand upon inhale and deflate upon
exhale
● In COPD, airways become thick and
inflamed, produce more mucus than usual,
leading to limited airflow
● In COPD, walls of the alveoli are damaged
and lose their elasticity; air gets trapped and
there are fewer alveoli to provide oxygen
into the blood
● COPD lungs do not deflate like normal
lungs; trapped air makes it harder to get
fresh air
● COPD is the 3rd leading cause of death in
the U.S; affects more than 13.5 million
Americans
● Predominantly diagnosed in men and
women older than 40 years of age
● COPD is more common in men
 ● More women die to COPD than men
● Rate of COPD continues to increase
worldwide due to smoking and worsening air
pollution
● While there is no cure for COPD, staying
active and taking steps to slow disease
progression can relieve the burden
● Self-management plan
○ Consult your healthcare provider
early
○ Seek diagnosis and intervention
therapies
○ Quit smoking
○ Pulmonary rehabilitation
○ Health diet and exercise
○ Maintain a positive outlook
Asthma
Asthma is a chronic respiratory condition where the
airways in the lungs are inflamed and narrowed
causing breathlessness, wheezing, chest tightness
and coughing. Symptoms come as recurrent
episodes known as asthmatic attacks most
commonly at night or early in the morning.
Pathology of asthma:
The lungs contain millions of air tubes or airways,
called bronchi and bronchioles, which bring air in
and out of the body. The airways have a layer of
smooth muscle in their wall which enables them to
constrict or dilate.
In people suffering from asthma these airways are
inflamed, narrowed and become more sensitive to
certain substances. Asthmatic attack, or
exacerbation, happens when the airways react to
these substances.
During an attack, the smooth muscle contracts,
squeezing the airways, making them even narrower;
mucus secretion is also increased which further
obstructs the airways.
Asthma is most commonly considered as an
inflammatory response disease where the body’s
immune system overreacts to certain environmental
agents. Causes of asthma are complex and not fully
understood but likely involve a combination of
genetic and environmental factors. Family history is
a known risk factor for asthma. There are at least
over twenty genes associated with asthma of which
many are involved in the immune system.
Triggers are factors that initiate the attack. Common
triggers include:
- allergens, such as pollen, animal fur, pet
dander, sulfites in preserved food..
- irritants, such as cigarette smoke, industrial
chemicals, dust, household chemicals,..
- medications, such as aspirin, beta
blockers,..
- physical activities, exercises.
There is no cure for asthma. The most effective way
to manage symptoms is to identify the triggers of
asthmatic attacks and avoid them.
There are two main classes of medication:
- Bronchodilators - substances that dilate
bronchi and bronchioles - are used as
short-term relief of symptoms.
- Inflammation moderators such as
corticosteroids are taken as long-term
treatments.
Asthma inhalers are used to deliver the medication
to the lungs.
A number of conditions tend to occur more
frequently in people with asthma and should be
taken into account when treating asthma:
- Allergies, such as eczema and hay fever.
These individuals are considered
hyper-allergic – they have a high tendency
to develop allergic reactions. The
combination of these conditions is known as
atopy or atopic syndrome. Immunotherapy
may be recommended for this group of
patients.
- Gastroesophageal reflux disease or GERD -
a condition in which stomach acid backs up
and damages the mucosal lining of the
esophagus. GERD may worsen asthma
symptoms and medications for asthma often
worsen GERD symptoms. Treating GERD
usually improves asthma and must be
included in an asthma treatment plan.
- Obstructive sleep apnea or OSA –
obstruction of the airway at the throat level
during sleep. Asthmatic patients are at
higher risks of developing OSA. The
mechanism of this association is largely
unknown.
- Sinusitis: inflammation of paranasal sinuses.
Sinusitis commonly worsens asthma
symptoms and makes treatments less
effective.
How to Properly Use a Nebulizer
● People with COPD or asthma often use a
nebulizer to take their medication in the form
of a mist that is inhaled into the lungs
● Nebulizers often used for patients who
struggle using inhalers because of health
issues or unable to inhale deeply enough for
other devices
● A nebulizer has five basic parts:
○ Medicine cup
○ Top piece or cap
○ mask/mouthpiece
○ Thin plastic tube
○ Compressor
● With clean hands, pour the medicine into the
medicine cup
● Attach the top piece to the medicine cup,
then attach the mouthpiece/mask. Then
connect the other end to the medicine cup
● Put the mask over your face, mouthpiece in
between the teeth and close lips tightly
around it
● Turn on compressor; hold nebulizer in
upright position to prevent spilling and
ensure correct distribution of medication
● Take normal regular breaths in through
mouth; continue until all medicine is gone
from the cup
Using a Metered Dose Inhaler
● Take off the inhaler cap and make sure the
mouthpiece and spray hole are clean
● Shake the inhaler 10-15 times
● Without the inhaler, inhale a deep breath
and breathe out all the way
● Hold the inhaler upright
● Put the inhaler in your mouth, above your
tongue and between your teeth
● Seal your lips around inhaler and breathe in
slowly
● Press down on the inhaler one time and
keep breathing in
● Hold breath for 5 - 10 seconds
● Open your mouth and breathe out slowly
What is Allergic Rhinitis?
● Inflammation of the nose caused by
allergens
● Allergens - anything harmless or neutral that
can be inhaled in the air by the nose that
can trigger excessive immune reaction ie.
pollen, dust
● In the immune system, allergens will
encounter mast cells with IgE antibodies,
allergens will bind to the antibodies which
will alert the mast cells
● In allergic rhinitis, the mast cell overreacts
and tells the surrounding cells to release
histamine
● Histamine causes inflammation and swelling
up, and leads to excessive mucus
production, resulting in nasal drip
● Excessive mucus will block two important
structure openings: nasolacrimal duct (sign:
watery eyes), eustachian tube (sign: stuffed
ears)
● Nerves in nasal cavity become irritated
which leads to sneezing
● Leads to difficulty breathing
● Allergic rhinitis can be diagnosed by looking
at patient history ie. seasonal rhinitis, skin
prick test, blood test ie. total eosinophil
count, total serum IgE levels, nasal smear
test
● Treatment
○ Avoid allergens ie. wear mask
○ Decrease inflammation
○ Antihistamines
○ Mast cell stabilizers
○ Immunotherapy via allergy shots
Drugs that Act on the Respiratory System
ANTITUSSIVES: Blocks cough reflex
DECONGESTANTS: Decrease blood flow to
the upper respiratory tract and
decrease the
over production of secretion
*PT WITH COMMON COLD
ANTIHISTAMINES: Block the release or
action of histamine
*(parang bouncer sa club)(makakati ang
lalamunan, ilong they can take
antihistamine)
EXPECTORANTS: Increase productive
cough to clear the airway, liquefy
secretions
MUCOLYTICS: breakdown the mucus
 *chlorpheniramine maleate - antihistamine
*paracetamol - analgesic, antipyretic

*drowsiness effect = for better sleep

*do not mix as they are the same med; misused
medications

COUGH

Irritant enters the airway

↓
Adhere to the mucus lining
↓
Cough centers send signal to the brain (medulla)
↓
Brain send signal to the muscle of the chest wall
*paracetamol - pt w/fever, body pain; antipyretic, and abdomen
analgesic ↓
*phenylephrine HCI(10mg) - nasal decongestant Cause person to take a deep breath and remove
*chlorphenamine maleate (2mg) - antihistamine trigger/ irritant
→kaya binibigyan ng bioflu because of the
component

COMMON COLD

Virus enters the body

↓
Attachment to soft and warm surfaces (nose,
throat, sinuses, airways)
↓
Immune system produces antibodies to destroy
virus
↓
Mucus is produced to trap virus
↓
Excess mucus production causes blocked nose
and airways

HISTAMINE RELEASE

*dextromethorphan (15mg) - antitussive Allergen enters the body

*phenylpropanolamine (25mg) - decongestant ↓
*paracetamol (325mg) - antipyretic, analgesic Immune system responds
Lower dose than bioflu ↓
WBC rush into bloodstream
↓
Histamine is released and binds to receptor sites
↓
Contraction of smooth muscles, having itchy eyes,
congestion, and swelling
 Antitussives
*ubo ng ubo pero walang plegm
● treatment of non productive cough
MOA:
- act directly on the medullary cough center of
the brain to depress the cough reflex
Example:
● codeine (generic only)
● guaifenesin (expectorant) & codeine
● hydrocodone bitartrate
● dextromethorphan (Benylin, Robitussin):
○ [cough suppressant], does not
cause respiratory depression,
neither cause physical dependence
nor tolerance
CI: head injury, CNS depression (if pt has CNS
depression it could cause respiratory depression)
Adverse effects:
- drying effect on the mucous membrane,
(nausea, constipation), increase respiratory
tract secretion, feelings of congestion,
drowsiness, sedation
*sympathomimetic effect
Other antitussives
MOA: directly act on respiratory tract
Example:
terpin hydrate ( generic only) – stimulates
secretory cells in the respiratory tract lining = more
copious secretion = buffers the irritation in the
respiratory tract wall that stimulate the cough
benzonatate (Tessalon) – acts as a local
anesthetic on the respiratory passages, lung, pleura,
blocking the effectiveness of stretch
receptors that stimulate cough reflex
CI: post op; asthma, emphysema,
Nursing Actions:
● Do not take longer than the recommended
● Further medical evaluation of cough
● Wait 15- 20 minutes after taking the syrup
before drinking any liquid - to let it sit on the
throat to sooth
● Other measures to relieve cough (humidity,
cool temperatures, fluids, topical
lozenges(strepsils - causes dry mouth))
Decongestants
● For common colds (viral infection), sinusitis,
allergic rhinitis (Hay fever- swelling of the
inside of the nose), otitis media
● Usually adrenergic or sympathomimetics
(local vasoconstriction = decrease blood flow
to the irritated and dilated capillary on the
mucous membranes lining the nasal
passages and sinus cavities
Rhinitis medicamentosa – a rebound
congestion that accompany frequent and
prolonged use of these drugs; will lead to more
congestion with prolonged use, body absorbs less of
therapeutic effect
TOPICAL NASAL DECONGESTANTS
- Sympathomimetic (inc. hr,bp, dilate the
vessels,---), immediate onset, less chance of
systemic effects, available in nasal spray
Example:
ephedrine (Kondon’s nasal),
oxymetazoline (Aftrin),
phenylephrine (Coricidin),
tetrahydrozoline (Tyzine),
xylometazoline (Otrivin)
CI: lesion or erosion on the mucous membrane,
HPN,
DM, thyroid disease, coronary disease
AE: local stinging and burning sensation, rebound
congestion ( longer than 3-5 days),
sympathomimetic effects ( increase pulse, BP
and urinary retention
DI:
+ cyclopropane/ halothane anesthesia = serious
cardiovascular effects
+ other sympathomimetics = toxic effect
+ other sympatholytics = non effective
TOPICAL NASAL STEROID DECONGESTANTS
● Directly block the effect of inflammation
● Takes several weeks to be really effective
and are more often used in cases of chronic
rhinitis and post nasal polyps removal
Example:
beclomethasone,
budesonide,
dexamethasone,
flunisolide,
Fluticasone [gargle after use to prevent fungal (itchy eyes, swelling, congestion, drippy
growth], nose)
triamcinolone - Have anti- cholinergic (it will dry the mouth
of the pt) and anti- pruritic effects
CI: acute infections (candida albicans infections), (nagkaroon ng rash)
airborne infection (chicken pox, measles)
pulmonary tuberculosis Example:
First generation – have greater anti- cholinergic
AE: same with topical + post nasal surgery or effect with resultant drowsiness (greater effect when
trauma = monitor closely for it suppresses causing drowsiness to the pt)
healing ● azatadine (Optimine)
● cetirizine ( Reactine)
ORAL DECONGESTANT ● diphenhydramine (Benadryl)
● Shrink the nasal mucous membrane by ● promethazine (Phenergan)
stimulating the alpha adrenergic receptors in
the nasal mucous membrane Second generation
● desloratadine (Clarinex)
Example: pseudoephedrine ● fexofenadine (Allegra)
● loratadine (Claritin)
CI: conditions exacerbated by sympathetic
activity CI: pregnancy & lactation, hepatic & renal
impairment, caution with cardiac arrhythmias
AE: rebound congestion, sympathetic effects (increase Q-T intervals)
( anxiety, tenseness, restlessness, tremors
arrhythmias, sweating, pallor) AE: drowsiness & sedation, drying of respiratory
and GI mucous membrane (skin eruption and
NURSING ACTIONS: itching), arrhythmias, dysuria, urinary hesitancy, GI
● Proper drug administration upset, nausea, thickening of mucous, difficulty
● Clear nasal passages before using coughing, tightening of the chest
● Tilt the head back when applying the drops
or spray NURSING ACTIONS:
● Keep it tilted back for a few seconds after ● Administer on an empty stomach
administration ● Response is individualized
● Not to use more than 5 days (topical), not ● Frequent mouth care (dry mouth nay lead
more than 7 days (PO), not more than 3 ● to anorexia & nausea)
weeks ( topical steroids), seek medical care ○ Sugarless candy
if s/sy persist ○ lozenges
● OTC, do not inadvertently combine drugs ● Take at bedtime or safety measures if taken
leading to overdosage during the day
● Provide safety measures ○ Do not drive
● Other measures to help relieve the ○ Do not operate dangerous
discomfort of congestion: machinery
○ Humidity ● Increase humidity
○ Fluids ○ Place pans of water throughout the
○ Cool environment house
○ Avoid smoke – filled areas ○ Avoid smoke filled area
● Peppermint may be used as nasal ○ Increase oral fluid intake
decongestant ● Void before each dose
● Skin care in case of allergic reactions
● Caution to avoid excessive dosage of other
Antihistamines
OTC
*histamine- produces immune response ● Avoid alcohol
It will be release for further infection
MOA:
Expectorants
- selectively block the effect of histamine – 1
receptor sites = decrease allergic response
● Use for dry, non productive cough
MOA:
- liquefy the lower respiratory tract secretions=
reducing viscosity = easier to cough out (or
expectorate it)
AE : N/A/V, HA, dizziness
EXAMPLE:
guaifenesin (Robitussin) - Enhances the output of
respiratory tract fluids by reducing adhesiveness and
surface tension of these fluids = easier movement of
less viscous secretions
terpin hydrate (generic) – iodine preparation, bitter
taste. Stimulates the glands of the respiratory tract to
increase the amount of fluid secreted
NURSING ACTIONS:
● Assess lung sounds, secretions (color -
green, yellow, white, consistency, amount),
know the underlying cause (bacteria, virus,
or allergy), should not be used for more than
one week, seek consultation if persistent
● Deep breathing and coughing exercises
● Increase oral fluid intake
● Small frequent meal
● Avoid driving or operating hazardous
machinery
● Avoid excessive use of OTC
Mucolytics
MOA:
- break down mucus in order to aid the high
risk respiratory patient in coughing out thick,
tenacious secretion
INDICATION:
● COPD
● Cystic fibrosis- genetic disorder that causes
mucus to build up, overproduction of mucus
● pneumonia
● Atelectasis
● Post tracheostomy
● Diagnostic bronchoscopy- flexible camera
for visualization
EXAMPLES:
1. acetylcysteine (Mucomyst) – PO
● Protects the liver from being damage during
episodes of acetaminophen toxicity
● Affects the mucoproteins in the respiratory
secretions by splitting apart disulfide bonds
that are responsible for holding the mucous
together
2. dornase alfa (Pulmozyme)
● Prepared by recombinant DNA techniques
that selectively breaks down respiratory tract
mucous by separating extracellular DNA of
proteins
● Long duration of action, store in refrigerator
& protect from light
CI: bronchospasm, peptic ulcer, esophageal varices
AE: GI upset, stomatitis, rhinorrhea, bronchospasm
NURSING ACTIONS:
● Assess lung sounds and respiratory status
● May be given through nebulization, IV, PO or
instilled in ET tube
● Avoid combining with other drugs in the
nebulizer
● Dilute with sterile water for injection
● Patients receiving by face mask should have
the residue wiped off the face mask and off
their face with plain water
● Use cautiously in adults or individuals with
severe respiratory insufficiency
● Administer PO mix with iced liquid, about 17
doses over a 4- day period of
acetaminophen overdose
*ex: If nag overdose ng tylenol antidote is
Acetylcysteine
CHEST PHYSIOTHERAPY:
INDICATIONS
● Increase production of secretions or thick,
sticky secretions
● With impaired removal of secretions
● Ineffective coughing
TECHNIQUES
● Postural drainage
● Percussion
● Vibration
Vibration: Hand is pressed firmly over the
appropriate segment of chest wall, and muscles
of upper arm and shoulder are tensed
(isometric contraction), done with flattened hands
FLAT
Percussion: Involves clapping with cupped hands in a chronic cough. Some call it a
on the chest wall “smoker’s” cough.

CUP HAND Bronchiectasis

- Chronic, irreversible dilation of the bronchi
and bronchioles

May be caused by the following:

➔ Pulmonary infections and obstruction in the
bronchus;
➔ aspiration of foreign bodies or any material
from the respiratory system;
Postural drainage: Uses gravity and various ➔ pressure from tumors,
Positions ➔ dilated blood vessels and
ex) pt has mucus on right side, lay pt on left side to ➔ enlarged lymph nodes.
drain
Asthma
Inflammatory disorder that involves the
hyperresponsiveness characterized by
bronchospasm, wheezing, mucus secretions
and dyspnea

DRUGS USED TO TREAT OBSTRUCTIVE

Nursing Considerations ● PULMONARY DISEASE:
● Perform 3 hours AC(before meals) or PC ● XANTHINES
(after meals) - to avoid for the risk to vomit ● SYMPATHOMIMETICS
● Bronchodilators 20 minutes prior ● ANTICHOLINERGICS
● Remove tight/ constricting clothing ● INHALED STEROID
● Each prescribed position for postural ● LEUKOTRIENE RECEPTOR
drainage = 3- 5 minutes ANTAGONISTS
● Place towel over the area percussed (approx ● SURFACTANTS
3 minutes during inspiration & expiration) - to ● MAST CELL STABILIZERS
lessen the impact
● Vibrate each area during exhalations of 4- 5
Xanthines
deep breaths
● POST PROCEDURE: comfortable position,
mouth care AKA: Methylxanthine Derivatives

Chronic Obstructive Pulmonary Disease Route: PO, IV

(COPD)
- Any process that limits airflow on expiration
COPD – group of chronic lung diseases
associated with persistent or recurrent
obstruction of airflow
Pulmonary Emphysema (pink puffers)
● The air sacs (alveoli) of the lungs are
enlarged and damaged, which reduces the
surface area for the exchange of oxygen and
carbon dioxide.
Chronic Bronchitis (blue bloaters)
● Chronic bronchitis is a condition when
repeated lung inflammation damages the
lungs. Chronic inflammation in the lungs
causes scarring of the airways and
excessive production of mucus that results
MOA: have direct effect on the smooth muscles
of the respiratory tract, both in the bronchi
and in the blood vessels through directly
affecting the mobilization of calcium within the
cell (stimulating prostaglandins resulting in
smooth muscle relaxation thus increasing the
vital capacity that has been impaired by
bronchospasm or air trapping
Inhibit release of slow-reacting substance of
anaphylaxis (SRSA) and histamine, decreasing
bronchial swelling and narrowing
Example:
● aminophylline
● caffeine
● dyphylline oxtriphylline
 ● theophylline
USES: bronchial asthma, bronchospasm
associated with COPD
CI: GI problems, coronary disease, respiratory
dysfunction, renal/ hepatic disease, alcoholism,
hyperthyroidism
AE: above therapeutic level: GI upset, irritability,
tachycardia, seizure, brain damage, death
DI:
+ nicotine = increase metabolism in the liver
+ smoking = dosage must be increased
NURSING ACTIONS:
● Caution if taken with coffee, cola, chocolate
and tea
● Monitor blood level for toxicity (therapeutic
level 10-20 ug/mL);
● first sign of toxicity = NAUSEA;
● late sign= TREMORS
● Instruct client as follows
● Be compliant with dosing, schedule and
blood work
● Do not crush or alter dosage form
● Take with milk or food if with GI upset
● Avoid smoking
Sympathomimetics
MOA: mimic the effects of the SNS at therapeutic
level = beta 2 selective agonist ( dilation of
bronchi with increased rate and depth of
respiration)
EXAMPLE
● epinephrine (Adrenaline)
● terbutaline sulfate (Brethine)
● salbutamol ( Ventolin)
● isoproterenol HCL ( Isuprel)
● isoetharine HCL ( Bronkosol)
● metaproterenol sulfate (Alupent)
CI: HPN, dysrhythmias, cardiac disease,
hyperthyroidism
AE: anxiety, tremors, HA, tachycardia, restlessness,
palpitations, rebound
bronchospasm, hyperglycemia, insomnia,
dysrhythmias, urinary retention
DI: + theophylline = increase cardiac effect
NURSING ACTIONS:
● Assess respiratory, cardiac status & ABG
● Instruct how to use inhaler or respiratory
apparatus at home
● Administer with meal if with GI upset
● Emphasize compliance with dosage and
schedule (minimal amount needed for the
shortest period necessary)
● Drug of choice vary with each individual
● For exercise induced asthma: take 30-60
minutes before exercising
Anticholinergic Bronchodilator
MOA: blocks the action of neurotransmitter
acetylcholine at vagal mediated receptor sites
EXAMPLE:
ipratropium bromide (Atrovent) – less
systemic effect
+ albuterol sulfate (Combivent) = more
effective and longer duration of action
AE: anticholinergic effects (dizziness, HA, fatigue,
nervousness, dry mouth, sore throat, palpitations,
and urinary retention
NURSING ACTIONS
● Adequate hydration
● Void before each use
● Safety measures
● Review use of inhalator with the patient
(caution not to exceed 12 inhalations in 24
hours)
● Small frequent meal & lozenges
Inhaled Steroids
MOA: decrease inflammatory response in the
airway
: promotion of beta 2 adrenergic receptor
activity
EXAMPLE:
● Inhaled: beclomethasone
● Tablet: triamcinolone, dexamethasone,
prednisone, prednisolone,
methylprednisolone
● IV: dexamethasone, hydrocortisone
CI: emergency, infection of respiratory system
AE: sore throat, hoarseness, coughing, dry
mouth, pharyngeal & laryngeal fungal infection
NURSING ACTIONS:
● Rapidly absorbed but tale 1-4 weeks to
reach effective level
● Do not administer to treat an acute asthma
attack or status asthmaticus
● Taper systemic steroid carefully
● Use decongestant drops before using the
inhaled steroids
● Rinse mouth after using inhaled steroid
● Monitor signs of respiratory infection
Leukotriene Receptor Antagonist
MOA: blocks receptors for the production of
leukotrienes D4 and E4 (components of SRSA):
Blocks:
● Neutrophil & eosinophil migration
● Neutrophil & monocyte aggregation
● Leukocyte adhesion
● Increased capillary permeability
● Smooth muscle contraction
EXAMPLE:
● Zafirlukast (Accolate)
● Montelukast (Singulair)
● zileuton (Zyflo)
CI: hepatic / renal impairment, pregnancy &
lactation
AE: HA, dizziness, myalgia, N/V, diarrhea, abdominal
pain, increase liver enzyme
NURSING ACTIONS:
● Oral granule packets should not be opened
until ready for use (max 15 min)
● If + aspirin hypersensitivity / NSAIDS =
bronchoconstriction
● Recommended for prevention
● Chewable tablets = swallowing whole -
altered absorption
● Take during evening = maximum
effectiveness
Lung Surfactant
*** neonates with RDS; birth wt</> 1350g with
evidence of lung immaturity
MOA: naturally occurring compounds of
lipoproteins containing lipids and opoproteins
that reduce the surface tension within the
alveoli = expansion of the alveoli for gas
exchange
EXAMPLE: (instilled into the trachea)
● beractant (Survanta)
● Calfactant (Infasurf)
● colfosceril (Exosurf Neonatal)
● Poractant (Curosurf)
AE: patent ductus arteriosus, hypotension,
intraventricular hemorrhage, pneumothorax,
hyperbilirubinemia, sepsis
NURSING ACTIONS
● Continuous monitoring
● Ensure: proper placement of ETT, bilateral
chest movement and sounds
● Suction before administration; do not suction
for 2 hours after administration
● Provide support and encouragement to
parents
● Continue other supportive measures related
to the immaturity of the infant
Mast Cell Stabilizer
MOA: prevents the release of inflammatory and
bronchoconstricting substances when mast cells
are stimulated to release these substances
because of irritation or presence of antigen
EXAMPLE:
● cromolyn – inhaled , may not reach its peak
effect for 1 week, pt>2 yo, maintenance
● nedocromil – prevent bronchospasm and
acute asthma attack; pt> 12 yo , more
effective
CI: hypersensitivity, pregnancy, lactation
AE: occasional (cromolyn) = swollen eyes, HA,
nausea, dry mucosa
● (nedocromil)= HA, dizziness, fatigue,
tearing, GI upset, cough
NURSING ACTIONS:
● Avoidance of dry and smoky environment,
humidifier, fluids
● Do not abruptly discontinue
● PO - administer before meal and at bedtime
● Safety precautions
Drugs for the GIT
Digestive System
● The human digestive system is very
complex and has evolved over millions of
years.
● It basically consists of the rectum, the large
and small intestine, the pancreas, the
stomach, also called gaster and ventriculus,
and the liver with the gallbladder. The
esophagus is also part of this system, as
well as various salivary glands near the
mouth. (eg. parotid, submandibular,
sublingual)
● First, the food is broken up in the mouth by
the teeth, and then mixed with saliva with
the help of the salivary glands.
● Saliva contains a digestive enzyme called
amylase that already begins to digest
carbohydrates in the mouth. It splits
carbohydrates into smaller units.
● The ball like mixture of food with saliva, also
known as bolus, is pushed into the throat by
the tongue and finally into the esophagus
which propels the bolus to the stomach.
● The esophageal lumen, that is the opening
inside the esophagus is very flexible which
allows boluses of different sizes to be
transported.
● The esophagus consists of several layers.
These layers occur throughout the
interdigestive tract. The two outer muscle
layers are responsible for peristalsis.
● Through these two muscles the bolus can be
transported from the mouth to the stomach,
even if the person is standing on his head.
● The stomach is often divided into six areas.
The stomach is composed of a similar
structure to the esophagus. It has a
longitudinal muscle layer on the outside.
● Underneath we can find circular muscle
fibers. In addition to this, there is an oblique
muscle layer overlaying the mucosa.
● On the inside, there are rugae that allow the
stomach to enlarge when food is consumed.
● The stomach wall contains gastric glands.
They produce mucus, which is able to
protect the stomach wall from secreted
gastric acid.
● Gastric acid is produced by simply smelling
or seeing food, but also spices, and the
stretching of the stomach causes the
secretion. That is, the release of gastric acid.
● About one to two liters of gastric juice are
produced per day. Since the esophagus
does not have a protective mucus layer, like
the stomach, stomach and esophagus are
separated by a sphincter. It relaxes when a
bolus is pushed from the esophagus, into
the stomach, and then contracts to prevent
acid and food from going back up.
● Gastric juice consists, among other things,
of hydrochloric acid, the enzyme pepsin, the
intrinsic factor, and lipase for the digestion of
fats.
● In addition to nutrients, food also contains
bacteria that damage the body.
● The components of hydrochloric acid are
able to destroy harmful bacteria. In addition,
hydrochloric acid converts pepsinogen also
released by the gastric glands into pepsin.
● Pepsin is able to break down proteins in the
stomach.
● For a vitamin B12 absorption in the small
intestine, the intrinsic factor is needed, which
is produced by the gastric glands.
● The vitamin must combine with an intrinsic
factor, then it can be absorbed later by the
small intestine.
● Vitamin B12 helps keep the body’s nerve
and blood cells healthy, and helps make
DNA. It also contains gastric lipase, an acid
resistant enzyme for fat digestion.
● In the stomach, gastric lipase splits a
triglyceride into a free fatty acid, and
diglyceride, whereby only the free fatty acid
can be absorbed by the body.
● More effective fat digestion takes place in
the small intestine.
● Through gastric juice and stomach
movements, which takes place
approximately every 20 seconds, the
individual boluses are mixed to a semi fluid
mass of partly digested food, the so-called
chyme.
● The chyme cannot enter the duodenum at
first because there is a sphincter at the
● The ileum continues into the large intestine
stomach exit.
in the right lower abdomen.
● The pyloric sphincter resembles the
● The duodenum and the jejunum have
esophageal sphincter. The pyloric sphincter
circular folds to increase the contact surface
opens only a few millimeters, so that larger
with the food.
pisces remain inside the stomach.
● These circular folds extend about one
● In the first section of the small intestine, the
centimeter into the lumen of the small
duodenum bile, and pancreatic secretions
intestine.
are mixed with the chyme via the ampulla of
● These folds are covered with small
vater.
finger-like projections called villi.
● Pancreatic juice contains numerous
● Villi increases the surface considerably. Villi
digestive proenzymes and enzymes.
are about one millimeter long.
● In order for them to do their job, a higher pH
● Each villus contains blood capillaries and a
value than that in the stomach is necessary.
lymphatic capillary called lacteal.. The
For this reason, pancreatic juice contains
nutrients are absorbed by the villus and
sodium hydrogen carbonate.
transferred to the blood capillaries.
● Hydrogen carbonate is able to neutralize the
● Some nutrients, such as glucose, do not
acid in the chyme and thus produce the
require a carrier. They are transported freely
optimum pH value of 7 or 8.
in the bloodstream.
● Pancreatic juice also contains proenzymes.
● Other nutrients, such as iron, require
It is only through enterokinase released by
transport proteins like transferrin.
the duodenum wall that the proenzyme
● Fats are transported by chylomicrons, which
trypsinogen and becomes tripsin, which can
are lipoproteins.
split proteins and activate other trypsinogen.
● The triglycerides to be transported are
● We also found alpha amylase, which we had
virtually enclosed in the lipoprotein.
already found in the mouth.
● Chylomicrons and triglycerides are then
● It now does the rest regarding the splitting of
transported through the lacteal of the villus.
carbohydrates which it converts into maltose
● Each villus is covered by even smaller
and isomaltose.
microvilli.
● Furthermore, pancreatic lipase is able to
● They multiply the intestinal surface
split triglycerides into two free fatty acids.
considerably.
● The gastric lipase, as we have seen before,
● The microvilli absorb nutrients and transport
can only produce one free fatty acid.
them to the inside.
● The pancreatic lipase can cleave
● The last part of the small intestine is the
triglycerides excellently because the bile
ileum. It does not have, unlike the
breaks the fats down into tiny droplets. This
duodenum and jejunum, circular folds.
is called emulsification.
● The ileum absorbs electrolytes, such as
● Numerous other enzymes are part of
calcium for building bones, hair, and teeth.
pancreatic juice.
Trace elements, such as zinc for sperm
● Bile is produced by the liver cells and
production, and the immune system,
transported to the gallbladder. The bile is
vitamins such as B12 for the formation and
stored in the gallbladder, and finally added to
maturation of red blood cells, and remaining
the food in the duodenum via the ampulla of
bile acid, which is transported back to the
vater. The pancreas also releases juice via
liver via the bloodstream.
the ampulla of vater.
● As with the esophagus, the food is
● The small intestine consists of three
transported by peristalsis. In contrast,
sections, duodenum, jejunum, and ileum.
 segmentation contractions serve to mix the
chyme.
● The large intestine is thicker than the small
intestine. It is about one meter long and
surrounds the small intestine. The small
intestine is connected to the large intestine
via the Bauhin’s valve.
● Bauhin’s valve opens when chyme is to pass
from the small intestine to the large intestine.
● The large intestine does not have any villi
like the small intestine because most
digestible substances have already been
absorbed in the small intestine.
● However, the large intestine has an
estimated 100 billion bacteria inside. They’re
important for many other tasks, such as the
production of vitamins, and the
decomposition of fiber for the body’s energy
production.
● Many of these bacteria are an important part
of the immune system by killing harmful
germs.
● Through peristalsis, the chyme
transported from the ascending colon to the
transverse colon to the descending colon.
On its ways through the large intestine,
water is removed from the chyme.
● Furthermore, mucus is added for proper
excretion of waste. Substances that cannot
be absorbed through the small intestine or
large intestine remain in the rectum and are
finally excreted through the anus.
Peptic Ulcer Disease
● A peptic ulcer is a roughened area or cavity
which is found in the stomach or small
bowel.
● Peptic ulcers can occur in the stomach or
the first part of the small bowel which is
called the duodenum.
● The stomach produces acid to break down
food.
● The stomach and duodenum have a layer of
mucus which protects it so the stomach
doesn’t damage it.
● A peptic ulcer occurs when the inside of the
stomach or small bowel is damaged by the
acid. It attacks the tissue causing a lesion or
ulcer to form the body’s usual mechanisms
which protect the tissue lining the stomach
and duodenum are not working properly.
● Peptic ulcers are usually about one to two
centimeters across, they look like large
mouth ulcers. Sometimes ulcers can erode
the stomach wall and cause it to bleed.
Rarely the ulcer may cause a hole to form,
this can cause severe pain and is a medical
emergency.
is
Gastroesophageal Reflux Disease (GERD)
● Gastroesophageal reflux disease or GERD
is a condition that causes the burning
sensation known as heartburn.
● When you swallow, food passes down your
throat and through your esophagus or food
tube to your stomach.
● A muscle called the lower esophageal
sphincter controls the opening between the
esophagus and stomach. This muscle
remains tightly closed except when you
swallow food.
● When the sphincter fails to close, the acid
containing contents of the stomach can
travel back up into the esophagus. This
backward movement is called reflux.
● When stomach acid enters the lower part of
the esophagus, it can produce a burning
sensation commonly referred to as
heartburn.
● Several factors might explain why this reflux
action occurs. The most important are the
following: the position of your body after
eating, an upright posture helps prevent
reflux, the size of the meal, smaller meals
reduce reflux, and the nature of the food you
eat and drink. Certain substances that
irritate the esophagus or weaken the
sphincter can cause reflux.
Constipation

● Visiting the bathroom is part of the daily
human experience. But, occasionally,
constipation strikes, a condition that causes
a backup in your digestive system.
● The food you eat can take several days to
exit your body. And, for many, constipation
can become chronic, meaning regularly
passing lumpy hard stools accompanied by
straining.
● What’s behind this unsettling phenomenon?
Constipation arises in the colon, also known
as the large intestine. This muscular organ is
split into four sections: the ascending,
transverse, descending, and sigmoid colon,
which connects with the rectum and anus.
● The small intestine delivers stool, consisting
of ingested food, bile, and digestive juices to
the large intestine.
● As the stool moves through the colon, the
organ siphons off most of the water it
contains, transforming it from liquid to solid.
The longer this transmission takes, the more
reabsorption occurs, resulting in increasingly
solid stool.
● Once it reaches the sigmoid colon, a final
bout of reabsorption occurs before it enters
the rectum, distending its walls and telling
the internal anal sphincter to relax.
● This is the point where you can usually
decide whether to physically expel or retain
the stool. That’s regulated by the pelvic floor
muscles, particularly the puborectalis and
external anal sphincter.
● The puborectalis forms a sling-like formation
around the rectum called the anorectal
angle. And when you voluntarily relax your
external anal sphincter, the stool is finally
expelled.
● When you’re constipated, however, a desire
to visit the bathroom isn’t enough to coax
your body into action.
● Usually, there’s two factors behind this
problem: the stool’s slow movement through
the colon and/or pelvic floor dysfunction.
● In the first, stool moves excessively slowly
through the intestines, causing
over-absorption of liquid, which makes the
stool dry and hard.
● With pelvic floor dysfunction, stool becomes
difficult to eliminate from the rectum because
of tightened pelvic floor muscles, or due to a
pelvic organ prolapse, usually through
childbirth or aging. Both of these problems
make the anorectal angle more acute and it
becomes difficult to expel waste.
● To identify constipation precisely,
researchers have developed metrics, such
as the Bristol Stool Chart. Most people who
look at that chart will be able to tell they’ve
experienced constipation before.
● When you’re on the toilet, you should ideally
be in a squatting position. With your buttocks
firmly on the toilet seat, you can elevate your
feet on a stool or chair and lean forward with
a straight back, which straightens the
anorectal angle and eases the passage of
waste.
● Going a day without a bowel movement isn’t
necessarily cause for alarm. But if you are
experiencing chronic constipation, simply
dietary and lifestyle changes, like fibrous
vegetables, regular exercise, abdominal
massage, and 6 to 8 cups of water per day
may help restore your daily trip to the toilet.
Diarrhea
● Diarrhea is the condition wherein frequent
passage of loose watery stool occurs.
● Diarrhea can be defined as absolute or
relative diarrhea.
● Absolute diarrhea is the occurrence of more
than 5 bowel movements a day. Relative
diarrhea is the unusual increase in bowel
movements in comparison to an individual’s
usual bowel habits.
● The types of diarrhea according to severity
are: acute diarrhea, chronic diarrhea.
● Acute diarrhea is a type of diarrhea that
usually lasts a day or two and heals on its
own. Acute diarrhea is commonly caused by
infection which can be viral, bacterial or
parasitic. Certain medications can also
cause diarrhea.
● Diarrhea that lasts for at least 4 weeks is
termed as chronic diarrhea. Chronic diarrhea
is commonly caused by a functional disorder
such as irritable bowel syndrome, infectious
diseases, an inflammatory bowel disease
such as Crohn’s disease, colon cancer, a
recent abdominal surgery, severe
constipation, carbohydrates or fats
 malabsorption, endocrine system
malfunction or abuse of laxative.
● Diarrhea usually starts with crampy
abdominal pain followed by frequent
passage of loose stool.
● Diarrhea with infectious origin, may also
experience such symptoms with addition of:
fever, loss of appetite, vomiting, weight loss
and dehydration.
● Complications of diarrhea can be:
dehydration, electrolyte imbalance, and
irritation of the anus.
● Diarrhea is usually treated with: frequent and
sufficient fluid intake, if necessary, oral
rehydration solutions, or in severe cases,
intravenous fluid administration to prevent
dehydration.
● For adults, medication such as anti-motility
medications can be used to relieve the
symptoms.
● However, in cases such as bloody diarrhea,
these medications are not advised. In that
case, antibiotics may be necessary, which
are prescribed by a physician.
● Furthermore, it is important to visit a
physician when you have severe diarrhea
after or during a visit to the tropics.
● Diarrhea is preventable and here are some
of the things you can do to avoid it: washing
your hands is by far the most effective way
of protecting yourself, not only from diarrhea
but from other diseases as well. Clean every
surface that will come in contact with your
food, do not drink unpasteurized milk or milk
products, avoid eating raw fruits and
vegetables, unless peeled or thoroughly
washed, do not eat meat or shellfish served
cold, and stay away from eating street food.
How to Give Suppository and Enema
● If the person you’re caring for has trouble
having a bowel movement, they may need
some extra help with medications like a
suppository or an enema and they may need
your help with it.
● A suppository is a bullet or a cone shaped
medication and an enema is usually a small
bottle of liquid medication. Both are given
rectally to help someone have a bowel
movement.
● You will also need a disposable absorbent
pad. Some water based jelly lubricant, and
some disposable gloves for you to wear. It’ll
be good to gather the supplies you’ll need to
help them clean up after a bowel movement
as well. (eg. basin with water, wash cloths,
wet wipes, hand sanitizer)
● Whether you are giving a suppository or an
enema, wash your hands and start with the
person you’re caring for lying in bed.
● Remove any clothing from their bottom half
but keep them covered as you can with a
sheet. Now, help them turn over onto their
left side. This helps the medication get into
the rectum easily. Next move is to move their
knee on top so it’s bent up, that will make it
easier for you to see. Tuck the disposable
absorbent pad under their hip and bottom so
if anything spills, the bed is protected.
● Put on your gloves and use the lubricant to
coat the tip of the enema or the entire
suppository with a generous amount of
lubricant. You can set it down on the side of
the disposable pad if you need it anytime.
● Use your non-dominant hand to separate the
buttocks cheeks of the person you’re caring
for. If you notice anything abnormal or any
bleeding contact their doctor before you give
the suppository or enema.
● Once you can see their anus, have them
take a deep breath to help them relax their
muscles. As they breathe out, you can insert
the suppository or the tip of the enema into
the rectum.
● If you’re using a suppository, push the
suppository into the rectum and use your
finger to push it in as far as you can go
comfortably. Then push it towards the side.
And, slowly remove your fingers.
● For an enema, once the tip is inserted,
squeeze the bottle to start the flow of the
fluid. Then roll the bottle up from the bottom
to make sure all the fluid goes in. Then,
slowly remove the bottle and throw it out.
● Now, you can remove your gloves and wash
your hands.
● If they can walk or stand, help them to the
washroom or help them use a bedside
commode.
● A suppository will usually take about 30
minutes to work and an enema may only
take five minutes.
● If they can’t stand, help them to sit on a
bedpan. Once they have a bowel movement,
help them get washed up and dressed
again.
● Giving someone a suppository or enema is
not difficult but it can feel awkward.

Drugs that Affect the Gastrointestinal Tract
Used to treat peptic ulcer disease and gastric
Hyperacidity
PEPTIC ULCER DISEASE - Break or
ulcerations in the protective mucosal lining of
the lower esophagus, stomach or duodenum
Non- Pharmacologic Measures:
● Avoid tobacco and alcohol
● Weight loss
● Avoid hot, spicy, greasy foods and caffeine
containing beverages
● Drugs like NSAIDs (ASA) / corticosteroids =
taken with food - decrease dosage
● Raise head of bed, do not eat before
bedtime, wear loose-fitting clothing
Antacids
MOA: neutralizes gastric acid secretions and
raises the gastric pH of the stomach
USES: reflux indigestion – esophageal irritation
and inflammation resulting from reflux of the
stomach contents into the esophagus
: PUD, ulcer prevention
DI: + digoxin / antibiotics = decrease absorption
SE:
● rebound hyperacidity (excessive amount of
acid in the stomach), GI disturbances (
constipation / diarrhea)
● Electrolyte imbalances
● Hypermagnesemia( hypotension, N/V, ECG
● changes)
● Hypophosphatemia (anorexia, malaise,
muscle weakness)
● Hypernatremia = water retention
● Systemic alkalosis
EXAMPLE: (systemic & non- systemic acting)
● aluminum hydroxide (Mylanta, Amphogel,
Novaluzid)
● magnesium hydroxide ( Milk of Magnesia,
simeco)
● calcium carbonate ( Alka – Mints, Tums)**
● sodium bicarbonate ( Alka – seltzer)**
● aluminum – magnesium complex (Maalox)
● magnesium hydroxide + aluminum hydroxide
● with simethicone (Maalox TC, Mylanta II)
Nursing Interventions:
● Assess effectiveness of medication
● Avoid other medicines that lowers gastric pH
or increases hyperacidity such as caffeine,
aspirin
● Take 1- 3 hours after eating & do not take
other medicines within 1-2 hours of taking
antacid; not at mealtime = slow gastric
emptying time = increase GI activity &
gastric secretions
● Drink 2-4 oz of water after antacid
● Shake liquid preparations well and followed
with water
● Instruct to inquire about interactions with any
new medication & OTC
● Inform clients that they may experience
better relief from liquids than tablets
● Monitor for constipation or diarrhea;
medication or dose may be changed
● Do not give milk products and vitamin D with
calcium carbonate = milk alkali syndrome
(alkalosis, hypercalcemia)
Histamine - 2 Receptior Antagonists
MOA: block the H2 receptors of the parietal cells
of the stomach, thus reducing gastric acid
secretion and concentration
USES: treatment ulcer, prevention of stress ulcer,
hyperacidity, patients on prolonged NPO / pre
operative, GI bleed
DI: + digoxin / anticoagulants = increases their
action
+ antacid = decrease effectiveness
SE: HA, confusion, nausea, diarrhea, abdominal
pain, anemia, severe bradycardia (IV
administration), constipation
EXAMPLE:
● cimetidine (Tagamet) famotidine (Pepcid)
● ranitidine (Zantac) nizatidine (Axid)
NURSING INTERVENTIONS:
● Administer before meals
● Reduced doses of drug are needed by older
adults
● Administer IV drug in 20 – 100mL solution
● Do not administer at the same time with
antacids, give an hour before or 2 hours
after
● Avoid smoking because it hampers the
effectiveness of the drug
 ● Drug induced impotence and gynecomastia
– reversible
● Relaxation technique
● Eat foods rich in Vit B12 to prevent
deficiency as a result of drug therapy
Anticholinergic Agents
AKA: anti – spasmodics
MOA: decreases acetylcholine by blocking the
cholinergic receptors
: reduces gastric acid secretion, decreases
smooth muscle motility and delays gastric
emptying time
**** stimulate gastric secretions = ulcerations
USES: adjunct therapy for PUD
: spasms and cramping associated with
irritable bowel syndrome
SE: tachycardia, urinary retention, dry mouth, HA,
constipation
EXAMPLE: Atropine sulfate, belladonna alkaloids,
hyoscyamine sulfate
NURSING RESPONSIBILITIES
● Monitor bowel elimination
● Take before meals
● Give antacids 2 hours after anticholinergic
Proton Pump Inhibitor
MOA: suppresses the final step of gastric acid
production by inhibiting hydrogen - potassium
ATPase enzyme
Inhibit up to 90% than H2 blockers
USES: short term treatment of erosive
esophagitis
: omeprazole – long term treatment of
duodenal ulcer
: treatment of H. pylori, active benign gastric
Ulcers
INTERACTIONS: may increase concentration o
oral anticoagulants, diazepam, phenytoin if with
Omeprazole
SE: headache, abdominal discomfort, dizziness,
flatulence, diarrhea
EXAMPLE: omeprazole (Losec), pantoprazole
(Pantoloc), esomeprazole (Nexium), lanzoprazole
(Prevacid)
NURSING INTERVENTIONS:
● Take before meals
● Regular medical check – up
Cryoprotective
AKA: Pepsin inhibitor / Mucosal Protective Drug
MOA: forms a barrier / coating at the ulcer site
EXAMPLE: sucralfate (Iselpin), rebamipide
(Mucosta)
SE: constipation ( not systemically absorb)
DI: may impede absorption of warfarin, phenytoin,
theophylline
NURSING INTERVENTIONS:
● Take before meals; as prescribed (4-8
weeks)
● Take one hour apart from antacid
● Digoxin: administer sucralfate at least 2
hours apart
Prostaglandin Analogue
MOA: decrease vagal activity
: inhibits gastric acid secretion & protects the
mucosa
: promotes secretion of sodium bicarbonate
and cytoprotection mucus
USE: PUD (peptic ulcer disease)
SE: diarrhea, abdominal pain
EXAMPLE: misoprostol (Cytotec)
NURSING RESPONSIBILITIES:
● Take with food
● No alcohol, NSAIDs, aspirin, smoking
● **** can cause uterine contractions
Anti-flatulents
MOA: aids in breaking up gas bubbles trapped in
the intestines; increases gastric emptying
USES: post operative patients, children with colic
SE: constipation, LBM (domperidone), dry mouth,
abdominal cramps
EXAMPLE:
● simethicone (Kremil-S, Simeco)
● domperidone (Motilium)
NURSING INTERVENTIONS:
● Increase oral fluid intake
● Manage constipation: high fiber (bran, grain,
fruits), ambulation
● Auscultate bowel sounds
● Avoid gas forming foods (apples, broccoli,
cabbage, coconuts, egg plant, milk, radish,
onions)
● Manage diarrhea
Antiemetics
MOA: used to control vomiting
SPECIFICALLY:
1. phenothiazines decrease the response to
chemoreceptor trigger zone (CTZ) by
inhibiting the dopaminergic receptors
- chlorpromazine (Thorazine)
- prochlorperazine maleate
(Compazine)
- promethazine
2. anti- histamines block the action of
acetylcholine in the brain to decrease
nausea and vomiting
- dimenhydramine (Dramamine)
- cyclizine HCL (Marezine)
- meclizine HCL (Bonamine)
- hydroxyzine pamoate (Vistaril)
- diphenhydramine HCL (Benadryl)
- promethazine (Phenergan)
3. Anti – cholinergics prevent motion sickness
by decreasing the GI motility and secretions
- scopolamine (Triptone)
- cannabinoids (active ingredients of
marijuana)
- dronabinol nabilone
4. Others : increases gastric emptying
- metoclopramide HCL (Plasil)
- trimethobenzamide HCL (Tigan)
USES: severe nausea, vomiting, before & after
chemotherapy, motion sickness
SE/ AE: - anticholinergic effects
- drowsiness (anti histamines)
- orthostatic hypotension
- extrapyramidal findings (phenothiazines):
- parkinson’s disease symptoms – tremors,
muscle rigidity, bradykinesia
- Hypersensitivity, photosensitivity
NURSING INTERVENTIONS
● Motion sickness: take 30 min- 1 hour before
the activity that causes nausea
● Caution the patient about sedative effects,
implement safety measures
● Give vistaril via Z- track route / deep IM
● Avoid alcohol
● Avoid use in pregnant women during 1st
trimester
● Increase OFI to prevent dehydration
Emetics
MOA: irritates the stomach and stimulates the
CTZ and vomiting center in the medulla
USES: overdose ; accidental poisoning
SE: toxicity, CNS depression (decrease RR and
BP), may be abused by bulimic patients, nausea,
diarrhea, GI upset
EXAMPLE: ipecac syrup, apomorphine HCL
NURSING INTERVENTIONS
● Have ipecac at home in case of accidental
poisoning, note expiration date
● Never administer to comatose or
semi-comatose patients
● Or accidentally ingest caustic substances
(ammonia, chlorine bleach, toilet cleaners or
battery acid)
● Can be very messy and may be difficult for a
child to ingest
● Administer 10 mL of ipecac followed by a
glass of water in children < 1 y.o.; 15 mL for
children > 1 y.o.; 15-30 mL followed by
several glasses of water for adults
● May repeat ipecac dose in 30 min if the first
dose does not produce emesis
● Never give with or after activated charcoal. If
needed, give before the activated charcoal,
activated charcoal is given via lavage if
emetics are ineffective
● Monitor VS especially RR because
apomorphine can cause respiratory
depression and hypotension

Laxatives / Cathartics
- To eliminate fecal matter
Laxatives: promote soft stools
Cathartics: promote soft watery stool with some
cramping
GROUPS:
1. Osmotic laxatives: pull water into the colon
and increases water in the feces to increase
bulk which stimulates peristalsis
- Hyperosmolar salts
- Saline products (composed of
sodium or magnesium)
- cephulac (Lactulose)
- Glycerin
- Sodium biphosphate
2. Contact laxatives/ stimulants/ irritants:
increase peristalsis by irritating the nerve
endings in the intestinal mucosa
- senna (Senokot)
- Bisacodyl (Dulcolax)
- Castor oil
3. Bulk forming: natural fibrous substance that
promote large, soft stools by absorbing
water into the intestine, increasing fecal bulk
and peristalsis; non absorbable agents
- psyllium (Metamucil)
4. Emollients/ stool softeners: lubricants to
prevent constipation, decrease straining
during defecation = lower surface tension
and promotes water accumulation in the
intestine and stool
- docusate sodium (Colace)
5. Lubricants: lessen irritation to hemorrhoids,
cause lipid pneumonia if accidentally
aspirated
- Mineral oil
SE: dehydration, electrolyte imbalance
(hypokalemia), abdominal cramps
NURSING INTERVENTIONS:
● Monitor for misuse of these drugs, can be a
habit forming, short term use (tone of bowel)
● Take drug within one hour of any other drug
● Monitor serum electrolytes
● Assess bowel elimination pattern:
discontinue if diarrhea persists, rectal
bleeding, cramping
● Do not give if obstruction is suspected
(abdominal pain with fever, nausea and
vomiting)
● Teach exercise and high fiber diet to
promote elimination
● Clients who should avoid straining may
benefit from a lubricant laxative
● Mineral oil enemas work well without
causing severe strain in clients who had a
recent heart attack and fecal impaction
● Mineral oil enemas also work well if saline is
contraindicated
● Bulk forming laxatives which come in
flavored and sugar free forms would be
mixed in 8- 10 oz of water or juice and drink
immediately followed by a full glass of water
● Take on an empty stomach
Anti-diarrheals
GROUPS:
1. adsorbents: removes toxins by binding wit
them and forms a coating over the mucosa
bismuth subsalicylate (Pepto- Bismol)
- Activated charcoal
- Kaolin
- Pectin
2. opiates: decrease intestinal motility
paregoric (camphorated opium tincture)
- codeine
- diphenoxylate HCL + atropine
sulfate (Lomotil)
- loperamide (Imodium)
3. Anticholinergic
- Alcoho l+ kaolin + pectin + paregoric =
parapectolin
- Scopolamine hydrobromide (Donnagel)
USES: short term diarrhea, irritable bowel
syndrome, overdose
SE: constipation; dizziness; OPIATES=abuse
potential, urinary retention, dry mouth, flushing
NURSING INTERVENTIONS:
● Know how to administer properly.
● Encourage clear liquids avoid fried foods or
milk products
● Instruct: relieve symptoms not cure the
disease
● Notify physician if diarrhea persists longer
than 48 hours or if abdominal pain occurs
● Assess elimination, dehydration
● Activated charcoal is a powder that must be
mixed with water during administration
● Monitor VS (opiates causes CNS
depression)
GASTROINTESTINAL STIMULANTS
MOA: stimulates motility of the upper GI tract and
increase the rate of gastric emptying without
stimulating gastric, biliary or pancreatic
secretions
USES: gastroesophageal reflux, treat urinary
retention & abdominal distention
CI: mechanical obstruction, perforation, GI
hemorrhage
SE/ AE: restlessness, drowsiness, dizziness,
insomnia, HA, N/V, salivation, decrease CR, BP,
increase lung secretion & LBM
EXAMPLE:
- bethanechol chloride (Urecholine)
- metoclopramide (Plasil)
- domperidone (motilium)
NURSING INTERVENTIONS:
● Administer 30 minutes before meal and at
bedtime
● Monitor pulse, BP when large doses are
taken because of the risk of hypotension
● Monitor I & O
Diabetic Medications
Diabetes and the Body
When you eat food that contains Carbohydrates, it's
broken down in the stomach and digestive system
into glucose, which is a type of sugar. We need
glucose from food because that's what gives us
energy.
Carbohydrate-containing foods are things like
starchy foods, sugary foods, milk, and some dairy
products and fruit. This glucose then moves into the
bloodstream and the body detects that the blood
glucose level is rising. In response to that the
pancreas, which is a little gland that sits just
underneath the stomach, starts to release a
hormone called insulin and it's insulin that helps our
body get the energy from the food we eat. The blood
stream then takes the glucose and the insulin to
every cell in our body that needs it.
To make this easier to understand let's look at
muscle cells, at the muscle cells it's insulin that
allows the glucose to get into the cells where it can
be used for energy. It's a bit like insulin is a key
unlocking the door to the cells so the glucose can
get in. That way, the blood glucose levels starts to
drop but the blood glucose level can be topped up at
any point by the liver releasing extra glucose that it
has stored. The blood glucose rises again, and
again, the pancreas produces more insulin to move
with that glucose through the bloodstream to the
muscle cells, open the doors and let the glucose in.
The body functions best with the blood glucose at an
optimum level. It doesn't like it if the blood glucose
rises too high. Normally there's a cycle within the
body which balances out the glucose and the insulin
level and this is achieved by the food you eat, the
pancreas and the liver. However in some people the
system doesn't work properly and they develop
diabetes. There are two main types of diabetes -
Type 1 and Type 2.
Type 1 diabetes
the body isn't making any insulin at all. This is
because of an autoimmune response whereby the
body has destroyed the insulin producing cells in the
pancreas. We don't entirely know why that happens
in some people and not in others.
Type 1 diabetes accounts for about 10 percent of all
cases. It's most often found in the under 40s and it's
by far the most common type of diabetes found in
childhood.
carbohydrate-containing food is turned into glucose
as normal. That glucose then moves into the
bloodstream. Normally the body would produce
insulin to let that glucose into the cells but because
of Type 1 diabetes there is no insulin being produced
so the glucose can't get into the body cells at all, so
the level of glucose in the blood rises and rises. The
body tries to lower the level of glucose, it tries to get
rid of the glucose through the kidneys. That's why
people who have undiagnosed Type 1 diabetes tend
to go to the toilet a lot to pass urine. As the kidneys
filter the glucose out of the blood, they also take a lot
of water with it so the person with diabetes will get
very thirsty. The urine contains a lot of glucose and
that creates an environment where it's quite easy for
bacteria to thrive so it's also quite common to get
thrush or genital itching. In the same way the blood
contains a high level of glucose as well so more
bacteria than usual will tend to breed in flesh wounds
and they might be slow to heal. Glucose can also
build up in the lens at the front of the eye causing the
liquid in the lens to become cloudy. That can mean
that some people with undiagnosed Type 1 diabetes
can have blurred vision.
Because the glucose can't get into the cells to be
used for energy, somebody who's got undiagnosed
Type 1 diabetes is going to start feeling very tired,
lethargic
and unable to go about their normal daily routine.
But the body still needs an energy source in order to
work properly so what it does is it starts to break
down its fat tools and that can lead to weight loss.
Main symptoms of Type 1 diabetes
1. going to the toilet a lot
2. thirst,
3. thrush or genital itching,
4. slow healing of wounds,
5. blurred vision tiredness
6. weight loss.
These symptoms generally happen quite quickly
often over a few weeks and come to be reversed
once the diabetes is treated with insulin.
Type 2 diabetes
accounts for about 90 percent of all cases in the
population. It's most common in the over 40 age
group in the white population and in the over 25 age
group in the South Asian population.
a little more complex because there are slightly more
processes at work. Either the body isn't producing
quite enough insulin or the insulin it is producing isn't
working properly. That can be due to being
overweight because a build up of fat can stop insulin
doing its job properly but it can also happen in
people of a healthy weight.
The carbohydrate-containing food is broken down
into glucose in the stomach and digestive system as
normal. That glucose then moves into the
bloodstream. The pancreas starts to produce insulin
which moves with the glucose through the
bloodstream to all the body cells which need glucose
for energy. However the glucose can't always get
into the cells because the locks to the cell doors
have become furred up with fat deposits. That
means that the insulin can't open the cell doors
properly. So the level of glucose in the blood
continues to rise. In response to this, the pancreas
produces even more insulin so the blood glucose
levels continue to rise and the insulin levels continue
to rise. This situation is further complicated by the
cells which are desperate for energy - sending out
emergency signals to the liver to release stored
glucose. The blood glucose level goes up and up
and the pancreas produces more and more insulin
until it can't cope anymore and eventually it can wear
out.
Symptoms of Type 2 diabetes
1. going to the toilet a lot
2. thirst
3. thrush or genital itching
4. slow healing of wounds
5. blurred vision
6. tiredness
7. weight loss in some people
-The symptoms for Type 2 diabetes come along very
slowly and some people don't have any symptoms at
all. So for that reason, people can live with Type 2
diabetes for up to 10 years before they realize that
they have it.
-Type 2 diabetes can be treated in a number of
different ways. Initially it may be sufficient to make
changes to the food you're eating and to take extra
physical activity or lose any weight that may be
appropriate. But Type 2 diabetes is a progressive
condition and most people will need some form of
medication to treat it
How to Check Blood Glucose Using Glucometer
1. Wash your hands
2. Gather your equipment. You will need your
meter, strips, lancing device, and a new
clean lancet (needle).
3. Insert the lancet (needle) into the chamber
of the lancing device, remove the protective
cover to expose the needle. Replace the cap
over the lancing device.
4. Check the expiry date on your strips. Insert
an unused strip into the meter, until the
meter “beeps” or the screen turns on.
5. Place the loaded lancing device against the
edge of your fingertip and push the button
until the needle is released
6. Wait 3 seconds, squeeze down your finger
until a drop of blood comes to the surface.
7. Snow plow the end of the strip into the drop
of blood until the meter either 'beeps' or
shows the count down on the screen.
8. Wait for the result and mark it down in your
log book.
9. Remove the cap from the lancing device and
pull out the lancet (needle). Discard the
lancet in a sharps container.
When the sharps container is full take it to your
pharmacy to be replaced. Do not put your lancets
(needles) in the garbage. Speak to your community
pharmacist to obtain a sharps container for disposal.
Continuous Glucose Monitoring
Continuous glucose monitoring automatically tracks
blood glucose levels, also called blood sugar,
throughout the day and night. You can see your
glucose level anytime at a glance. You can also
review how your glucose changes over a few hours
or days to see trends. Seeing glucose levels in real
time can help you make more informed decisions
throughout the day about how to balance your food,
physical activity, and medicines.
A CGM works through a tiny sensor inserted under
your skin, usually on your belly or arm. The sensor
measures your interstitial glucose level, which is the
glucose found in the fluid between the cells. The
sensor tests glucose every few minutes. A
transmitter wirelessly sends the information to a
monitor.
The monitor may be part of an insulin pump or a
separate device, which you might carry in a pocket
or purse. Some CGMs send information directly to a
smartphone or tablet. Several models are available
and are listed in the American Diabetes
Association’s product guide
Special Features of a CGM
CGMs are always on and recording glucose
levels—whether you’re showering, working,
exercising, or sleeping. Many CGMs have special
features that work with information from your glucose
readings:
● An alarm can sound when your glucose
level goes too low or too high.
● You can note your meals, physical
activity, and medicines in a CGM device,
too, alongside your glucose levels.
● You can download data to a computer or
smart device to more easily see your
glucose trends.
Some models can send information right away to a
second person’s smartphone—perhaps a parent,
partner, or caregiver. For example, if a child’s
glucose drops dangerously low overnight, the CGM
could be set to wake a parent in the next room.
Currently, one CGM model is approved for treatment
decisions, the Dexcom G5 Mobile. That means you
can make changes to your diabetes care plan based
on CGM results alone. With other models, you must
first confirm a CGM reading with a finger-stick blood
glucose test before you take insulin or treat
hypoglycemia.
Special Requirements Needed to Use a CGM
Twice a day, you may need to check the CGM itself.
You’ll test a drop of blood on a standard glucose
meter. The glucose reading should be similar on
both devices.
You’ll also need to replace the CGM sensor every 3
to 7 days, depending on the model.
For safety it’s important to take action when a CGM
alarm sounds about high or low blood glucose. You
should follow your treatment plan to bring your
glucose into the target range, or get help.
Who can use a CGM?
Most people who use CGMs have type 1 diabetes.
Research is underway to learn how CGMs might
help people with type 2 diabetes.
CGMs are approved for use by adults and children
with a doctor’s prescription. Some models may be
used for children as young as age 2. Your doctor
may recommend a CGM if you or your child:
● are on intensive insulin therapy, also
called tight blood sugar control
● have hypoglycemia unawareness
● often have high or low blood glucose
Your doctor may suggest using a CGM system all
the time or only for a few days to help adjust your
diabetes care plan.
What are the benefits of a CGM?
Compared with a standard blood glucose meter,
using a CGM system can help you
● better manage your glucose levels every
day
● have fewer low blood glucose
emergencies
● need fewer finger sticks
A graphic on the CGM screen shows whether your
glucose is rising or dropping—and how quickly—so
you can choose the best way to reach your target
glucose level.
Over time, good management of glucose greatly
helps people with diabetes stay healthy and prevent
complications of the disease. People who gain the
largest benefit from a CGM are those who use it
every day or nearly every day.
What are the limits of a CGM?
Researchers are working to make CGMs more
accurate and easier to use. But you still need a
finger-stick glucose test twice a day to check the
accuracy of your CGM against a standard blood
glucose meter.
With most CGM models, you can’t yet rely on the
CGM alone to make treatment decisions. For
example, before changing your insulin dose, you
must first confirm a CGM reading by doing a
finger-stick glucose test.
A CGM system is more expensive than using a
standard glucose meter. Check with your health
insurance plan or Medicare NIH external link to see
whether the costs will be covered.
How to Use Insulin Pen
When you're preparing to give yourself insulin, you
want to make sure that you place all the proper
supplies on a flat surface ready to go.
These supplies include:
1. insulin FlexPen, or whatever insulin pen you
may be using
2. your pen needles
3. an alcohol swab
4. sharps container, If you do not have a
sharps container, you can use a heavy
plastic container such as an old laundry
detergent bottle and write "used needles" on
the side with a permanent marker.
Steps
1. Before injecting yourself, wash your hands
with soap and water.
2. When your hands are dry, pull off the pen
cap from the insulin pen and set it aside.
3. Next, inspect the insulin through the viewing
window. Do not use the insulin if you notice
a change in color or if you notice things
floating in the insulin. By inspecting the
insulin pen, you will also be double checking
that you have the correct type of insulin. As I
mentioned already, for our example today,
I'm using the NovoLog FlexPen which has
been prefilled with insulin as part.
4. After inspecting the insulin pen, put it down
and open an alcohol swab.
5. Wipe the rubber stopper on the end of the
insulin pen with the swab. Allow the rubber
stopper to air dry completely. Do not blow on
the rubber stopper to dry it as this will
introduce germs from your mouth.
6. Next, pick up the pen needle and remove
the protective paper covering. Grasp the
base of the pen needle and carefully screw
the pen needle on to the insulin pen. Make
sure the pen needle is screwed on straight
and hand-tightened so that it pierces the
rubber stopper completely. Make sure you
do not over-tighten the pen needle as the
pen needle base is plastic and can crack.
7. Next, pull off the clear plastic outer needle
cap. You will see a second inner needle cap
still covering the needle. Remove the inner
plastic needle cap. Both plastic caps can be
disposed of in your regular household trash.
It is important to always use a new pen
needle for each injection to reduce the risk
of infection. Never reuse or share needles
with your family or friends.
8. Next, you will complete an air shot with the
insulin pen which should be done before
each injection. An air shot is sometimes
called "priming." Doing so removes any air
that is trapped in the needle.
9. Turn the dial up to two units. Hold your
insulin pen with the pen needle pointing
straight up and lightly tap the insulin pen
with your finger a few times to make sure
any air bubbles move to the top.
10. Next, press the push button all the way in.
The dial should return to zero. You should
see a drop of insulin appear at the tip of the
pen needle. If the drop does not appear,
repeat the process. This can be repeated up
to six times. If it still does not work, try using
a new pen needle. If that doesn't work, then
try a new insulin pen.
11. Next, select your insulin dose Check to
make sure the dial is set to zero, then turn
the dial selector to the desired number of
units. The pointer arrow should line up with
your desired dose. The dose can be
corrected up or down by turning the dial. For
example, if you were prescribed insulin 10
units before meals, you will dial up to 10 in
the pen window while making sure the arrow
lines up with the desired number of units. Be
careful not to press the push button while
selecting your dose or the insulin will come
out prematurely You will hear a click for each
unit you dial. It is not recommended that you
attempt to dose based on how many clicks
you hear as this may result in an incorrect
dose. Please note, towards the end of the
insulin pen use, you will not be able to dial
more than the number of units remaining in
the insulin pen.
12. Next, if your skin is not clean, use an alcohol
swab to clean the site before injection. If
you've just bathed, you may not need to
clean the area with alcohol. Remember,
alcohol can be very drying to your skin, so
you don't want to apply alcohol to your skin if
not needed. Insulin can be injected into
either your abdomen or stomach area,
buttocks, on the high hip upper outer area,
thigh, or upper arm. That is the back fattier
part of your upper arm and not the muscle
area. The needle you are using is thin and
may bend.
13. You may find that pinching your skin gently
before injection can prevent bruising and
decrease the chance of bending the needle.
It is recommended that you rotate to
different sites each time you use the insulin
pen. If you plan to be physically active right
after the injection, it is recommended to
rotate around your stomach area only rather
than to the arms, legs, or buttocks. Avoid
injecting insulin into any area of skin that
has pits, is thickened, or has lumps. Avoid
injecting where the skin is tender, bruised,
scaly, or hard. In addition, stay one to two
inches away from your belly button, scars, or
skin with open wounds. If you are injecting
more than one type of insulin, use different
injection sites as the insulins won't work as
intended if injected in the same site
together. For instance, give your basal or
long-acting insulin on the left side of your
stomach and then give your bolus or
rapid-acting insulin on the right side of your
stomach.
14. Insert the insulin pen into your skin straight
in and not angled. Again, if there is not
enough fatty tissue, pinch a one to two-inch
portion of skin in fat. Once the insulin pen
needle is inserted into your skin, keep it in
place and press the push button on the
insulin pen all the way in and maintain it until
the arrow next to the dial returns to zero.
15. Keep it pressed for a full six seconds after
the dial is at zero to make sure all the insulin
is injected.
16. Now you can remove the insulin pen. A small
drop of insulin may appear at the end of the
needle. This is normal and can be expected.
If a drop of blood appears on your skin after
you remove the insulin pen, press the
injection site lightly with a gauze pad.
17. Do not rub the area. Once the injection is
completed, do not recap the needle as this
can cause an accidental needle stick injury.
18. Remove the pen needle from the insulin pen
by grasping the sides of the plastic hub and
twisting.
19. Discard the pen needle into the sharps
container. Place the pen cap back on and
store the insulin pen in a safe location. Your
insulin pen can be stored at room
temperature below 86 degrees Fahrenheit
for up to 28 days away from heat or light. It
is recommended that you keep your unused
insulin pens in the refrigerator between 36 to
46 degrees Fahrenheit as the insulin pens
can be safely stored until the expiration date
on the label.
20. Never freeze insulin. When the insulin pen
has been completely used up, it will not
allow you to give any additional doses. At
that time, you can discard your insulin pen
with the pen needle removed into your
household trash.
21. The pen needles should always be placed
into a sharps container. You have
successfully given yourself a dose of insulin
using an insulin pen.
Insulin Administration
You will begin taking insulin by injecting it with a
needle into the subcutaneous tissue.
To determine when you should inject insulin, pay
attention to the times you check your blood sugar,
when you eat and what kind of insulin you are taking.
Check your blood sugar no more than thirty minutes
before you eat if you are taking rapid-acting insulin,
before meals give yourself the insulin, when you sit
down to eat if you are taking regular insulin before
meals give yourself the insulin no more than thirty
minutes before the meal, if you are taking
intermediate acting or long-acting insulin give
yourself the insulin at the same time each day.There
is no standard or typical dose of insulin your dose
will be the amount of insulin that you need in order to
keep your blood sugar and good control. Your doctor
will prescribe an insulin dose that is right for you.
The most common side effect of insulin is low blood
sugar or hypoglycemia. Low blood sugar happens
when the level of sugar in the blood falls below 70
milligrams per deciliter. Symptoms include:
1. Sleepiness
2. Shaking
 3. Sweating
4. Dizziness
5. Hunger
Be sure you know how to treat low blood sugar
before you start using insulin. An insulin injection
delivers medicine into the subcutaneous tissue,
which is the tissue between your skin and muscle.
Subcutaneous tissue which is also called sub Q is
found all over your body.
If the healthcare provider has chosen insulin
injections that are done with a syringe that is filled
from a bottle of insulin as the best option, here are
the steps you will take:
1. Select a clean dry work area. The supplies
you will need include the prescribed bottle of
insulin, an insulin syringe, alcohol wipes,
and a container for used equipment. You can
use a hard plastic container with a screw on
or tight lid or a commercial sharps container.
2. Begin by washing your hands. If the bottle of
insulin appears cloudy, roll the bottle in your
hands and turn it from side to side for one
full minute. You do not have to roll the bottle
if the insulin is completely clear. Do not
shake the bottle.
3. If opening a new bottle of insulin remove the
plastic cap and wipe the top of the bottle
with an alcohol wipe. If using a bottle of
insulin that has already been opened, you
will still need to wipe the top or rubber
stopper with an alcohol wipe.
4. Remove the caps from both the top and
bottom of the insulin syringe. You may need
to twist the cap to get it to come off more
easily.
5. Do not touch the needle.
6. Pull back on the plunger to the unit mark for
the insulin dose that has been ordered.
7. Put the bottle on the table, insert the needle
straight into the top of the bottle through the
rubber stopper, push the plunger down to
inject the air into the bottle, turn the bottle
upside down with a needle still in, it hold the
bottle at eye level make sure the tip of the
needle is in the insulin. Make sure not to
bend the needle when picking up the bottle.
8. Pull the plunger back to the unit mark for the
insulin dose ordered. If you see bubbles in
the syringe gently tap on the syringe so the
bubbles move to the top.
9. Push the syringe to release the bubbles
back into the bottle of insulin once again with
the needle in the insulin.
10. Pull the plunger back to the unit mark for
insulin dose that has been ordered. Check
that the dose is correct, set the syringe down
without letting the needle touch anything.
11. Since you will be injecting your insulin on a
regular basis, you need to know where on
your body to inject it. You will also need to
learn how to rotate or switch your injection
sites. Recommended injection sites include
the abdomen, front and side of the thighs,
upper and outer arms, and buttocks. Do not
inject near joints, the groin area, the navel,
the middle of the abdomen, or scar tissue. If
you use the same injection site over and
over again, you may get hardened areas
under your skin that keep the insulin from
working properly. Rotating your injection
sites will make your injections easier, safer
and more comfortable. Follow these
guidelines, ask your health care provider
which sites you should use.
12. The injection site is about two inches of skin.
Clean this area in a circular motion with an
alcohol wipe. Move the site of each injection
at least one and a half inches away from the
last spot where you injected it. Try to inject in
the same general area of your body at the
same time each day. Keep a record of which
injection sites you have used, every time you
give yourself an injection write down the
date, time and site. Please note depending
on which type of insulin you are taking,
absorption may be different for different
parts of the body. Talk to your healthcare
provider to learn more about the insulin you
are using and which sites work best.
13. Using the hand you write with, hold the
a. a syringe like a pen or a pencil with
the needle end down with your other
hand pinch about two to three
inches on both sides of the
cleanskin.
14. Insert the needle with a quick motion into the
pinched skin at a ninety degree angle. The
needle should go all the way into your skin.
15. Slowly push the plunger of the syringe until
all of the insulin is pushed out.
16. Stop pinching your skin and pull the needle
out you may bleed at the spot of the
injection.
17. If you notice bleeding, apply pressure with a
clean alcohol white or cotton ball. Cover the
injection site with a bandage if necessary,
drop the entire syringe and needle into your
container for sharps equipment.
18. Do not put the cap back on the needle. It's
important to remember that when storing
your insulin that you store unopened bottles
in the refrigerator. Unopened insulin that is
 stored in the refrigerator will be good until
the expiration date printed on the box. Write
the date on the bottle when you first open it,
store the bottle you are using at room
temperature, avoid temperatures that are too
hot or too cold, this can change how the
insulin works. Most insulin is good for 28
days once it's opened. Check with your
pharmacist or read the drug insert for exact
instructions. Always check your medicine
type and the expiration date printed on the
box before you leave the pharmacy. Do not
use insulin if it has lumps, is discolored or
has been frozen. Place used insulin syringes
and lancets for blood sugar testing in a hard
plastic or metal container with a screw on or
tight lid or a commercial sharps container.
Hyperglycemia VS. Hypoglycemia
What is Hyperglycemia?
Diabetes patients can get hyperglycemia or high
blood sugar. It is caused when the body does not:
1. Have enough insulin (Type 1)
2. Use insulin properly (Type 2)
Causes of hyperglycemia are:
1. Skipping or forgetting to take insulin
2. Consuming more carbohydrates
3. Stress
4. Illness
5. Exercising less than normal
6. The dawn phenomenon (early morning
surge in hormones)
Some early hyperglycemia symptoms are:
1. Blood sugar higher than 180 mg/dL
2. Increased thirst
3. Frequent urination
4. Headache
5. Lack of concentration
6. Tiredness
7. Prolonged hyperglycemia is a serious threat.
It can lead to:
1. Nerve damage
2. Blood vessel damage
3. Organ damage
There is also possibility of 2 life-threatening
conditions:
1. Ketoacidosis
It is the build-up of ketones in the blood.
Some symptoms are:
1. Fruity breath
2. Frequent urination
2. Hyperosmolar Hyperglycemic Nonketotic
Syndrome (HHNS):
Persistent high blood sugar (above 600
mg/dL) leads to it.
Some symptoms are:
1. Dry mouth
2. Frequent urination
3. Warm skin without sweat
Hyperglycemia treatment
Consult your doctor if you suspect hyperglycemia.
The doctor may recommend:
1. Exercise: Only if no ketones in the urine
2. Change eating habits
3. Change medication
Hyperglycemia vs hypoglycemia
Hypoglycemia refers to low blood sugar levels
(below 70 mg/dL). It should be treated immediately
with the 15-15 rule:
1. Consume 15g of fast-acting carbohydrate -
1tsp glucose or honey
2. Glucose should read above 70 mg/dL after
15 minutes
3. If not, repeat step 1 and 2
Go to a diabetologist soon mandatorily. Severe
hypoglycemia is a medical emergency, so call an
ambulance quickly. If hypoglycemia is not treated
immediately, it can lead to:
1. Loss of consciousness
2. Coma
3. Death
Anti Diabetic Drugs
INSULIN
- Transports and metabolizes glucose for
energy
- Stimulates storage of glucose in the liver
and muscles (glycogen) Signals the liver to
stop the release of glucose
- Enhances storage of dietary fat in adipose
tissue
- Accelerates transports of amino acids into
cells
MOA: primarily acts in the liver, muscle and
adipose by attaching to the receptors on cellular
membranes facilitating the passage of glucose,
potassium and magnesium
PC: B
Derived from: Animal / human
- pork ( one different amino acid)
- beef ( four different amino acids)
Route: subQ, IV, IM plasma glucose concentration
because of increase cortisol and
Types of Insulin growth hormone secretion
○ Manifestations: H/A,
Type Onset Peak Duration
lightheadedness, nervousness,
RAPID 5 min 0.5 - 1 hr 2 - 4 hrs tremors, excess perspiration, cold
ACTING clammy skin, tachycardia, slurred
Ex. Lispro speech, memory lapses, confusion,
(Humalog) seizure, blood glucose < 60 mg/dL
SHORT 0.5 - 1 hr 2 - 4 hrs 6 - 8 hrs
ACTING 2. Ketoacidosis (hyperglycemic reaction)
Ex. ● Inadequate amount of insulin
Regular ● Sugar cannot be metabolized, uses fatty
insulin, acids for energy
Humulin R ● Manifestations: extreme thirst, fruity breathe,
kussmaul breathing, rapid pulse, dry mucous
INTERME 1 - 2 hrs 6 - 12 hrs 18 - 24
membrane, poor skin turgor, blood glucose >
DIATE hrs
ACTING 250 mg/dL
Ex. NPH ● Storing Insulin:
(neutral ○ Avoid exposure to extreme
protamine temperature (should not be frozen or
hagedorn) kept in direct sunlight or a hot car)
, Humulin ○ Before injection should be at room
N, Lente
temperature (less irritating to tissue)
insulin
○ Unopened vials are refrigerated until
LONG 5 - 8 hrs 14 - 20 30 - 55 needed
ACTING hrs hrs ● Once insulin has been opened: - At room
Ex. temperature for one month - In the
Ultralente refrigerator for 3 months ( lose their strength
if otherwise)
COMBINA 0.5 - 15 4 - 8 hrs 22 - 24
TIONS min hrs ● Pre- filled syringes should be stored in a
refrigerator and should be used within 1- 2
Humulin - 0.5 - 6 hrs 20 - 24 weeks
70/30 hrs
(70% INSULIN PUMP
NPH, 30% - insulin is delivered from the device through a
regular)
plastic tube with a metal or plastic needle
Humalog - - - placed sub-q
75/25
(75% INSULIN JET INJECTORS
Lispro - Needleless
protamine, - delivered directly through the skin into the
25%
fatty tissue
lispro)
- delivered under high pressure (stinging,
pain, burning and bruising may occur)
S/E & A/D:
1. hypoglycemic or insulin shock Insulin Injection Sites:
● Somogyi effect – hypoglycemic conditions (2 Main area of injection: abdomen, arms (posterior
- 4AM) surface). thigh (anterior surface) and hips
○ Leads to Stimulate the release of
hormones (cortisol, glucagons, and Insulin injected in the abdomen may be
epinephrine) to increase blood absorbed more rapidly than the other sites
glucose lipolysis, gluconeogenesis, - Systemic rotation within one anatomical area
glycogenolysis is recommended to prevent lipodystrophy
○ Dawn phenomenon – requires
increase insulin dose in early Lipoatrophy – depression under the
morning hours due to increase skin surface; animal insulin
Lipohypertrophy – a raised lump of
knot on the skin surface
● Do not use the same site more than once in
a 2 – 3 week period
● Injections should be 1.5 inches apart within
the anatomical area
● Heat, massage and exercise of the injected
area can increase absorption rates =
hypoglycaemia
● Injection into the scar tissue may delay
absorption
b. intermediate acting: acetohexamide
(Dymelor), tolazamide (Tolinase)
c. long- acting: chlorpropamide (Diabinese)
A.2. Second Generation
- glimepiride ( Amaryl); glipizide (Glucotrol)
B. Non Sulfonylureas
B.1: Biguanides – decrease hepatic production of
glucose from stored glycogen
eg. Metformin

Administering Insulin: B.2: Alpha – Glucosidase Inhibitor – inhibit

● To prevent dosage errors, be certain that digestive enzyme in the small intestine responsible
there is concentration noted on the vial with for the release of glucose from complex CHO in the
the calibration of units in the insulin syringe, diet
the usual concentration is U 100 ( 100 units eg: acarbose; miglitol
per mL)
● Before use, role not shake (to avoid C. Meglitinides – stimulate beta cells to release
bubbles) the insulin bottle to ensure that the insulin
insulin and the ingredients are mixed well eg: repaglinide ; nateglinide
otherwise an inaccurate dose will be drawn
● Pre- filled syringes should be kept flat or with D. Incretin Modifier – increase level of incretin
needle in an upright position to avoid hormones, increase insulin secretion, decrease
clogging of the needle glucagon secretion. eg: sitagliptin phosphate
● Inject air into the insulin bottle (a vacuum
makes it difficult to draw up insulin)
● It is recommended to draw up regular insulin
Anti-Tubercular Drugs
(short acting) first, regular insulin may be
mixed with other insulin
● Insulin zinc suspensions may be mixed only TUBERCULOSIS- caused by ACID-FAST
with each other and regular, not with other BACILLUS.
types ● Mycobacterium tuberculosis; transmitted
● Administer a mixed dose of insulin within 5- through droplets dispersed in the AIR
10 minutes of preparation; after this time the through coughing/sneezing;
regular insulin bind with the NPH insulin and ● Have an outer coat of MYCOLIC acid that
its action is reduced protects them from many disinfectants
● Aspiration is not generally recommended allows them to survive.
with self injection insulin
● Administer insulin at a 45- 90 degree angle
● Regular insulin is the only type of insulin 1st LINE Mechanism of Side effects
which can be administered IV DRUGS Action

Oral Antidiabetic Drugs Rifampicin >alters DNA & Orange colored

AKA: Oral hypoglycemic drugs RNA activity in urine/body fluids;
the bacterium
Indication: DM type 2
(bacteriostatic) Hepatotoxic

A. Sulfonylureas >BEST taken on

- stimulate pancreatic beta cells to secrete EMPTY
more insulin; increase the insulin receptors; STOMACH
increasing the ability of the cells to bind (gastric irritation)
insulin for glucose metabolism >PROTECT from
light
A.1. First Generation Isoniazid (a.k.a. >inhibits cell wall Peripheral
a. short- acting: tolbutamide (Orinase) -INH) synthesis neuropathy
 (bactericidal) and Pyridoxine B6 (Discontinue)
>blocks PYRIDOXINE 100-200 mg daily
pyridoxine (B6) 10-50mg also for tx; 10mg for
which is used for prescribed to prevention)
intracellular avoid peripheral 2.GI intolerance
enzyme neuropathy 3.Mild skin
production; reactions

>TAKE BEFORE Pyrazinamide 1.Arthralgia due to

MEALS hyperuricemia
(give aspirin or
Pyrazinamide Both; rapidly Hepatotoxic NSAID)
(PZA) bacteriostatic & 2.Mild skin
slowly Ototoxic reactions
bactericidal
>NAVDA GI Photosensitivity Ethambutol None 1.Impairment of
upset - take w/ visual acuity &
food Hyperuricemia color vision due
>PROTECT from to optic neuritis
light (Discontinue &
refer to
Ethambutol Inhibits cellular Nephrotoxicity ophthalmologist)
metabolism
(bacteriostatic) Visual Streptomycin 1.Pain in the 1.Hearing
disturbances injection site impairment,
>Not to be given (optic neuritis- (apply warm ringing of ear,
to children 6 yrs/< affects RED & compress. Rotate and dizziness
(can’t reliably GREEN sites) due to damage
monitor vision) discrimination) of the 8th CN
(Discontinue)
Streptomycin First drug to treat Ototoxicity- 2.Oliguria or
TB tinnitus & hearing albuminuria due
impairment may to renal disorder
occur 3.Severe skin
rash due to
hypersensitivity

DRUGS MINOR MAJOR

ADVERSE ADVERSE
RXNS/MGT RXNS/MGT 2nd LINE DRUGS

Rifampicin 1.GI intolerance 1.Thrombocytop

(Give at enia, Anemia, ● Second line drugs are the TB drugs that are
bedtime/with Shock used for the treatment of drug resistant TB.
small meals) (Discontinue ● 2nd Line drugs Examples:
2.Orange-colored drugs & refer) Para-aminosalicylic acid, kanamycin,
urine (reassure 2.Oliguria or cycloserine, capreomycin
pt.) Albuminuria
Discoloration of (Discontinue &
body fluids- stain refer)
clothing, contact 3.Jaundice DRUG COMBINATION
lens
3.Flu-like
symptoms (give ● Myrin-P= (Etham + Rifam + INH + PZA)
antipyretics) ● Combipak= (Rifam + INH + PZA)
4.Mild skin ● Rambutol= (Rifam + Etham)
reactions (give
anti-histamines)

Isoniazid 1.Burning 1.Jaundice due NURSING CARE

sensation in the to Hepatitis
feet due to (Discontinue)
peripheral 2.Psychosis &
neuropathy (Give Convulsion
 ● Determine history, exposure, PPD (Purified
Protein Derivative) tuberculin test & reaction,
CXR (Chest X-Ray) and any allergies
● Medical history- CI = severe hepatic
diseases; check liver enzyme values,
bilirubin, BUN, S. creatinine
● Evaluate Signs and symptoms of peripheral
neuropathy
● Assess hearing changes – Ototoxicity
(adverse effect to streptomycin)
● INH – 1 hr ac or 2 hrs pc – FOOD decreases
absorption rate
● Give pyridoxine (Vit B6) prevent peripheral
neuropathy
● Collect sputum specimens for AFB (Acid
Fast Bacillus), 3 consecutive AM specimen
● EYE exam (INH & Ethambutol) – visual
disturbances
● Take drugs as prescribed
● Not to take with antacids – decreases
absorption
● Avoid alcohol – increased risk of
hepatotoxicity;
● Avoid direct sunlight & decreased risk of
photosensitivity
● RIFAMPICIN – urine, feces, saliva, sputum,
sweat, tears – harmless red-orange color;
● Contact lens –may be permanently stained
● Take lots of fluids
● Use barrier contraceptives – OCP may not
be effective

LUNGS

(INTERVENTIONS for the undesirable effects of

INH)

● Liver enzymes- must be monitored

● Use cautiously with renal dysfunction
● No alcohol
● Give pyridoxine
● Should take on empty stomach/screen vision