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Pharmacology Bullet Review URINARY SYSTEM DIURETICS Thiazides Drug Names o Thiazides Prototypes Hydrochorothiazides Trichlormethiazide Methylclothiazide Hydroflumethiazide

azide Chlorothiazide (Diuril) Benthiazide Bendroflumethiazide o Thiazide-like Diuretics Chlorthalidone Metolazone Quinethazone Indapamide Special Indications o Hypocalcemia Pharmacodynamics o These drugs BLOCK the chloride pump o This will keep the Chloride and Sodium in the distal tubule to be excreted into the urine o Potassium is also flushed out!! Adverse Effects o Hyperglycemia o Hyperuricemia due to DECREASED uric acid secretion o Hypercalcemia due to DECREASED calcium excretion o Hypokalemia

Loop Diuretics Drug Names o Furosemide o Bumetanide o Torsemide o Ethacrynic acid o Hypercalcemia Pharmacodynamics o BLOCK the chloride pump in the ascending loop of Henle o SODIUM and CHLORIDE reabsorption is prevented o Potassium is also excreted together with Na and Cl Adverse Effects o Hypokalemia

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Ototoxicity- due to the electrolyte imbalances Hypocalcemia due to INCREASED calcium excretion Bicarbonate is lost in the urine

Potassium-Sparing Diuretics Drug Names o Spironolactone o Triamterene o Amiloride Special Indications o Congestive Heart Failure and using Digoxin Pharmacodynamics o Spironolactone is an ALDOSTERONE antagonist o Triamterene and Amiloride BLOCK potassium secretion in the distal tubule o Diuretic effect is achieved by the sodium loss to offset potassium retention Adverse effects o HYPERkalemia! Avoid high potassium foods: Fresh fruits and vegetables

Osmotic Diuretics Drug Names o Mannitol o Glycerin o Isosorbide o Urea Special Indications o Increased ICP o LITHIUM TOXICITY Pharmacodynamics o Mannitol is a sugar not well absorbed in the nephrons o There will be osmotic pull of water leading to diuresis Adverse Effects o Sudden hypovolemia o Important for the nurse to warm the solution to allow the crystals to DISSOLVE in the bottle!

Carbonic Anhydrase Inhibitors Drug Names o Acetazolamide o Methazolamide Special Indications o Mountain sickness o Menieres disease o Nephrolithiasis due to calcium stones Pharmacodynamics

Carbonic Anhydrase is an enzyme that forms sodium bicarbonate BLOCKING the enzyme results to slow movement of hydrogen and bicarbonate into the tubules o plus sodium is lost in the urine Adverse Effects o Metabolic ACIDOSIS happens when bicarbonate is lost o Hypokalemia o o

Nursing Process Assessment o Assess the REASON why the drug is given o The nurse must elicit history of allergy to the drugs Allergy to sulfonamides may contraindicate the use of thiazides o Assess fluid and electrolyte balance o Assess other conditions like gout, diabetes, pregnancy and lactation o Assess symptom of body weakness which may indicate hypokalemia Nursing Diagnosis o Fluid volume deficit related to diuretic effect o Potential for injury (ototoxocity, hypotension) o Alteration in urinary pattern Implementation o Administer IV drug slowly o Safety precaution for dizziness/hypotension o Provide potassium RICH foods for most diuretics, with the exception of spironolactone o Provide skin care, oral care and urinary care o Monitor DAILY WEIGHT- to evaluate the effectiveness of the therapy o ADMINISTER in the MORNING o Administer with FOOD o Monitor urine output, cardiac rhythm and serum electrolytes Evaluation o Effectiveness of therapy seen in weight loss, increased urine output, resolution of edema, decreased congestion and normal BP CENTRAL NERVOUS SYSTEM ANXIOLYTICS AND HYPNOTICS General Information These drugs are used to change the individuals responses to the environment. The medications that can prevent the feelings of tension and fear are called ANXIOLYTICS. Anti-anxiety drugs The drugs that can calm individuals making them unaware of the environment are called SEDATIVES. The drugs that can induce sleep are called HYPNOTICS.

Benzodiazepines The benzodiazepines are the most frequently used anxiolytic drugs. These agents prevent anxiety states without causing much sedation, with less physical dependence than other agents. Drug Names o Alprazolam (Xanax) o Chlordiazepoxide (Librium) o clonazepam clorazepate o Diazepam (Valium) o Others: estazolam, flurazepam, lorazepam, midazolam, oxazepam, quazepam, temazepam and triazolam Special Indications o Diazepam - Status epilepticus o Chlordiazepoxide - Alcohol withdrawal o Alprazolam - Panic attack Pharmacodynamics (Mechanism of Action) o These agents act on the Limbic system and the RAS (reticular activating system) to make the GABA ( Gamma- aminobutyric acid) more effective causing interference with neuron firing. o GABA is an inhibitory neurotransmitter. This will result to an anxiolytic effect at lower doses than required for sedation/hypnosis. Adverse Effects o CNS effects - sedation, drowsiness, depression, lethargy, blurred vision o GIT - dry mouth, constipation, nausea, vomiting o CV - Hypotension or hypertension, arrhythmias, palpitations, and respiratory difficulties. o Hematologic - blood dyscrasias and anemia o GU - urinary retention, hesitancy, loss of libido and sexual functions changes. Nursing Considerations: o Maintain patients on bed for at least 3 hours after drug administration. o Instruct to avoid hazardous activities like driving and machine operation. o Instruct to avoid consuming ALCOHOL while taking the drug. o Provide comfort measures to help patients tolerate drug effects- instruct to urinate before taking drug give high fiber foods use side-rails and assistance with ambulation. o Have available FLUMAZENIL as an antidote for benzodiazepine overdose.

Barbiturates These are also anxiolytics and hypnotics with a greater likelihood of producing sedation, with increase risk of addiction and dependence. Drug Names o Phenobarbital

Others: amobarbital, aprobarbital, butabarbital, mephobarbital, pentobarbital, secobarbital Indications o Relief of anxiety manifestations and insomnia o For sedation and pre-anesthesia o Seizures/epilepsy o The rapid acting barbiturates are also used for the treatment of acute manic reactions and status epilepticus Pharmacodynamics o They depress the motor output from the brain resulting to sedation, hypnosis and anesthesia, and if extreme, coma. Adverse Effects o CNS - CNS depression, somnolence, vertigo, lethargy, ataxia, paradoxical excitement, anxiety and hallucinations. o GIT - nausea, vomiting, constipation/diarrhea and epigastric pain o CVS - bradycardia, Hypotension and syncope. o Respiratory - serious hypoventilation, respiratory depression and laryngospasms o Others= hypersensitivity and Stevens- Johnson syndrome. Nursing Considerations o Provide stand-by life support facilities in cases of severe respiratory depression or hypersensitivity reaction. o Taper the drug gradually after long- term therapy to avoid withdrawal syndrome. o Provide comfort measures including small frequent meals, access to bathroom facilities, high-fiber foods, environmental control, safety precaution and skin care. o

CNS STIMULANTS General Information o These are drugs used to treat certain disorders like exogenous obesity, attention-deficit hyperactivity disorders (ADHD) and narcolepsy o What is unusual is the ability of the CNS stimulants to CALM hyperactive children, which allows them to focus on one activity for a longer period. Drug Names o Methylphenidate (Ritalin) - most commonly used for ADHD o Dextroamphetamine - a CNS stimulant that is used for short tem therapy for obesity. o Modafinil - used for narcolepsy o Pemoline - used for ADHD Pharmacodynamics o Acts to stimulate the cortical and reticular activating system (RAS) of the brain. This is by releasing neurotransmitters from the nerve cells leading to increased stimulation of the post-synaptic neurons. o The paradoxical effect of calming hyperexcitability through CNS stimulation seen in ADHD is believed to be related to the increased stimulation of an

IMMATURE Reticular Activating System leading to the ability to be more selective in response to incoming stimuli. Adverse Effects o CNS - nervousness, insomnia, dizziness, headache, and blurred vision o GIT - anorexia, nausea and weight loss o CVS - hypertension, tachycardia arrhythmias, and angina o Others - rashes, physical/psychological dependence. Nursing Considerations o The nurse must ensure that the drug is only given to the indicated conditions o Administer the drug before 6 pm to reduce the effect of insomnia o BEST given AFTER meals to prevent the effect of anorexia o Consult with school personnel to monitor the patient under therapy o Provide safety measures such as side-rails and assisted ambulation

ANTI-EPILEPTICS These agents, also called anticonvulsants, are used to treat epileptic conditions. Hydantoins, Barbiturates, benzodiazepines, Succinimides and many others are given to a specific type of seizure.

Hydantoins Drug Names o Phenytoin (Dilantin) Indication o These agents are utilized for general seizures because they can depress the central nervous system. o Tonic-clonic seizures and Status epilepticus o For the prevention of seizures in neurosurgery o For muscle relaxation Pharmacodynamics o These agents STABILIZE the nerve cell membrane throughout the brain reducing and limiting the excitability and conduction through nerve pathways. o They affect the entire brain and reduce the chance of sudden electrical outburst that causes seizures. Contraindications and Precautions Hydantoins o NOT given to pregnant patient because it can cause fetal hydantoin syndrome. Adverse effects o CNS effects- depression, confusion, drowsiness, lethargy, fatigue GIT- GI upset, constipation, dry mouth, GINGIVAL HYPERPLASIA , severe liver toxicity which are all related to cellular toxicity. o SKIN- hirsutism and coarsening of the facial skin o Bone Marrow depression Nursing Considerations o Administer the drug with food to alleviate GI irritation

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Discontinue the drug at any sign of hypersensitivity reaction, severe liver dysfunction and severe skin rashes. Provide meticulous mouth oral care Rule out pregnancy and advise women to use contraceptive measures to prevent pregnancy.

GASTRO-INTESTINAL SYSTEM ANTI-ULCER The H2 Blockers - tidines Drug Names o Cimetidine o Ranitidine o Famotidine o Nizatidine Indications o Short-term treatment of active duodenal ulcer or benign gastric ulcer o Treatment of hypersecretory conditions like the Zollinger-Ellison syndrome o Prevention of stress-induced ulcers and acute GI bleeding o Treatment of erosive GERD (reflux disease) o Relief of Symptoms of heart burn and acid indigestion Pharmacodynamics o The H2 blockers are antagonists at the receptors in the parietal cells of the stomach. o The blockage results to inhibition of the hormone gastrin. o There will be decreased production of gastric acid from the parietal cells. o Also, the chief cells will secrete less pepsinogen. Precautions and Contraindications o Any known allergy is a clear contraindication to the use of the agents. o Conditions such as pregnancy, lactation, renal dysfunction and hepatic dysfunction should warrant cautious use. o Nizatidine can be used in hepatic dysfunction. Adverse effects and adverse effects o GIT - diarrhea or constipation o CNS - Dizziness, headache, drowsiness, confusion and hallucination o Cardio - arrhythmias, HYPOTENSION (related to H2 receptor blockage in the heart) o Cimetidine - TREMORS, Gynecomastia and impotence in males Drug-drug Interactions o Cimetidine, Famotidine, Ranitidine are metabolized in the liver- they can cause slowing of excretion of other drugs leading to their increased concentration. o These drugs can interact with CIMETIDINE - anticoagulants, phenytoin, alcohol, antidepressants. Nursing considerations o Administer the drug WITH meals at BEDTIME to ensure therapeutic level o One hour after Antacids o Stress the importance of the continued use for the length of time prescribed o Monitor the cardiovascular status especially if the drugs are given IV

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Warn patient of the potential problems of increased drug concentration if the H2 blockers are used with other drugs or OTC drugs. Warn the patients taking cimetidine that drowsiness may pose a hazard if driving or operating delicate machines. Evaluate the effectiveness: Relief of symptoms of ulcer, heart burn and GERD

Antacids These are drugs or inorganic chemicals that have been used for years to neutralize acid in the stomach. Drug Names o Aluminum salts (hydroxide) o Calcium salts (carbonate) o Magnesium salts (milk of magnesia) o Sodium bicarbonate o Magaldrate (aluminum and magnesium combination) Indications o Symptomatic relief of upset stomach associated with hyperacidity o Hyperacidic conditions like peptic ulcer, gastritis, esophagitis and hiatal hernia o Special use of AMPHOGEL (aluminum hydroxide): to BIND phosphate Pharmacodynamics: o These agents act to neutralize the acidic pH in the stomach. o They do not affect the rate of gastric acid secretion. o The administration of antacid may cause an acid rebound. o Neutralizing the stomach content to an alkaline level stimulates gastrin production to cause an increase in acid production and return the stomach to its normal acidic state. Precautions o Known allergy is a clear contraindication. o Caution should be instituted if used in electrolyte imbalances, GI obstruction and renal dysfunction. o Sodium bicarbonate is rarely used because of potential systemic absorption Adverse Effects o GIT= rebound acidity; alkalosis may occur. o Calcium salts may lead to hypercalcemia o Magnesium salts can cause DIARRHEA o Aluminum salts may cause CONSTIPATION and hypophosphatemia by binding with phosphates in the GIT. o Fluid retention due to the high sodium content of the antacids. Nursing Considerations: o Administer the antacids apart from any other medications by ONE hour before or TWO hours after- to ensure adequate absorption of the other medications o Tell the patient to CHEW the tablet thoroughly before swallowing. Follow it with one glass of water o Regularly monitor for manifestations of acid-base imbalances as well as electrolyte imbalances Proton-pump Inhibitors (prazoles) Drug Names o Omeprazole o Lanisoprazole o Esomeprazole o Pantoprazole

Indications o Short-term treatment of active duodenal ulcers, GERD, erosive esophagitis and benign gastric ulcer. o Long-term- maintenance therapy for healing of erosive disorders. Pharmacodynamics o They act at specific secretory surface receptors to prevent the final step of acid production and thus decrease the level of acid in the stomach o The pump in the parietal cell is the H-K - the ATPase enzyme system on the secretory surface of the gastric parietal cells Adverse effects o CNS- dizziness, headache, asthenia (loss of strength), vertigo, insomnia, apathy o GIT- diarrhea, abdominal pain, nausea, vomiting, dry mouth and tongue atrophy o Respi- cough, stuffy nose, hoarseness and epistaxis. Nursing considerations: o Administer the drug BEFORE meals. Ensure that patient does not open, chew or crush the drug. o Provide safety measures if CNS dysfunction happens. o Arrange for a medical follow-up if symptoms are NOT resolved after 4-8 weeks of therapy.

The Mucosal Protectant This is given to protect the eroded ulcer sites in the GIT from further damage by acid and digestive enzymes Drug Name o Sucralfate Indications o Short and long term management of duodenal ulcer o NSAIDs induced gastritis o Prevention of stress ulcer o Treatment of oral and esophageal ulcers due to radiation, chemotherapy or sclerotherapy Pharmacodynamics o It forms an ulcer-adherent complex at duodenal ulcer sites, protecting the sites against acid, pepsin and bile. o This action prevents further breakdown of proteins in the area and promotes healing. Precautions o This agent should NOT be given to any person with known allergy to the drug, and to those patients with renal failure/dialysis because of build-up of aluminum may occur if used with aluminum containing products. Adverse Effects o GIT - CONSTIPATION, occasionally diarrhea, nausea, indigestion, gastric discomfort, and dry mouth may also occur o CNS - dizziness, drowsiness, vertigo o Others - rash and back pain Drug-drug interactions o If used with aluminum salts - high risk of accumulation of aluminum and toxicity.

If used with phenytoin, fluoroquinolones and penicillamines- decreased levels of these drugs when taken with sucralfate Nursing Considerations o Administer drug ON AN EMPTY stomach, 1 hour before meals , or 2 hour after meals and at BEDTIME o Monitor for side-effects like constipation and GI upset o Encourage intake of high-fiber foods and increased fluid intake o Administer antacids BETWEEN doses of sucralfate, NOT WITHIN 30 minutes of sucralfate dose o

Prostaglandin analogue Drug Name o Misoprostol Indications o NSAIDs-induced gastric ulcers and Duodenal ulcers unresponsive to H2 antagonists Pharmacodynamics o Being a prostaglandin analog, it inhibits gastric acid secretion to some degree o It INCREASES mucus production in the stomach lining. Precautions o This drug is CONTRAINDICATED during pregnancy because it is an abortifacient. o Women should be advised to have a negative pregnancy test within 2 weeks of beginning therapy and should begin the drug on the second or third day of the next menstrual cycle. o They should be instructed in the use of contraceptives during therapy. Adverse Effects o GIT - Nausea, diarrhea, abdominal pain, flatulence, vomiting, dyspepsia o GU effects - miscarriages, excessive uterine CRAMPING and bleeding, spotting, hypermenorrhea and menstrual disorders. Nursing Considerations o Administer to patients at risk for NSAIDs-induced ulcers during the full course of NSAIDs therapy o Administer four times daily with meals and at bedtime o Obtain pregnancy test within 2 weeks of beginning therapy. Begin the therapy on second or third day of menstrual period to ensure that the woman is not pregnant LAXATIVES Chemical Stimulant Cathartics o Drug Names Bisacodyl Castor oil Senna These agents DIRECTLY stimulate the nerve plexus in the intestinal wall The result is INCREASED movement or motility of the colon Mechanical Stimulant Cathartics LACTULOSE (Cephulac) Magnesium (citrate, hydroxide, sulfate) Psyllium o Pharmacodynamics

Stimulating the local stretch receptors activating local defection reflex These agents are rapid-acting laxatives that INCREASE the GI motility by Increasing the fluids in the colonic material

Lubricants o Drug Names Docusate Glycerin Mineral oil o Pharmacodynamics Docusate increases the admixture of fat and water producing a softer stool Glycerin and Mineral oil forms a slippery coat on the colonic contents Indications o Short-term relief of Constipation o Prevention of straining in conditions like CHF, post-MI, post partum, post-op o Preparation for diagnostic examination o Removal of poison or toxins o Adjunct in anti-helminthic therapy o LACTULOSE decrease ammonia in patients with liver failure Contraindications o Ulcerative colitis o Diverticulitis o Appendicitis Adverse Effects o Diarrhea o Abdominal cramping o Fluid and electrolyte imbalance o Sympathetic reactions- sweating, palpitations, flushing and fainting o CATHARTIC dependence Nursing Considerations o Emphasize that it is use on a SHORT term basis o Provide comfort and safety measures like ready access to the bathroom, siderails o Administer with a full glass of water o Encourage fluid intake, high fiber diet and daily exercise o DO NOT administer if acute abdominal condition like appendicitis is present

ANTI-DIARRHEALS General Classifications o Local anti-motility Loperamide Directly inhibits the intestinal muscle activity to SLOW peristalsis o Local reflex inhibition Bismuth subsalicylate Locally coats the lining of the GIT to soothe irritation that may stimulate the reflex o Central action on the CNS Paregoric Opium derivatives Stops GIT spasm by CNS action Indications o Relief of symptoms of acute and chronic diarrhea o Reduction of fecal volume discharges from ileostomies

o Prevention and treatment of traveler's diarrhea Contraindications o Poisoning o Drug allergy o GI obstruction o Acute abdominal conditions Adverse Effects o Constipation o Nausea,vomiting o Abdominal distention and discomfort o TOXIC MEGACOLON Nursing Considerations o Monitor patient response within 48 hours. Discontinue drug use if no effect

EMETICS Drug Name o Ipecac Syrup Indications o To induce vomiting as a treatment for drug overdose and certain poisonings Pharmacodynamics o Ipecac syrup irritates the GI mucosa locally, resulting to stimulation of the vomiting center o It acts within 20 minutes Contraindications o Ingestion of CORROSIVE chemicals o Ingestion of petroleum products o Unconscious and convulsing patient Adverse Effects o Nausea o Mild CNS depression o CARDIOTOXICITY if large amounts are absorbed in the body Nursing Consideration o Administer to conscious patient only o Administer with a large amount of water o Vomiting should occur within 20 minutes of the first dose ANTI-EMETICS General Classifications o Phenothiazines Prochlorperazine, promethazine Pharmacodynamics Centrally block the vomiting center in the medulla o Non-phenothiazines Metoclopramide Pharmacodynamics Reduces the responsiveness of the nerve cell in the medulla o Anticholinergics and Antihistaminics Meclizine, buclizine Pharmacodynamics Block the transmission of the impulses to the medulla o Serotonin Receptor blockers setron Ondansetron Pharmacodynamics

Centrally and locally inhibits the serotonin receptors Miscellaneous Dronabinol, hydroxyzine Pharmacodynamics Act in the CNS , either in the medulla or in the cortex Indications o Phenothiazines - N/V associated with anesthesia, intractable hiccups o Non-phenothiazine - N/V associated with chemical stimulation o Anticholinergics - N/V associated with motion sickness o Serotonin-receptor Blockers - N/V associated with chemotherapy o Miscellaneous - N/V associated with chemotherapy Contraindications o Severe CNS depression o Severe liver dysfunction Adverse Effects o PHOTHOSENSITIVITY o Drowsiness, dizziness, weakness and tremors and DEHYDRATON o Phenothiazines - autonomic anti- cholinergic effects like dry mouth, nasal congestion and urinary retention Nursing Considerations o Emphasize that this is given on a short term basis o Monitor for dehydration and offer fluids o Provide mouth care and ice chips o Advise to change position slowly o Protect from sun exposure Sunscreens o ENDOCRINE SYSTEM

ANTI-DIURETIC HORMONES Action o Enhance re-absorption of water in the kidneys Indication o Used in Diabetes Insipidus Drug Names and Route o Desmopressin and Lypressin - intranasally o Pitressin - intramuscular Adverse-effects o Flushing and headache Water intoxication

THYROID MEDICATIONS Thyroid hormones Drug Names o Levothyroxine (Synthroid) o Liothyroxine (Cytomel) o Thyroid dessicated Liotrix (Thyrolar) Action o Increase the metabolic rate o Increase O2 consumption o Increase HR, RR, BP Adverse Effects

Nausea and Vomiting Signs of increased metabolism - tachycardia, hypertension, cardiac arrhythmias, anxiety, headache Nursing Considerations o Monitor weight and vital signs o Instruct client to take daily medication the same time each morning WITHOUT FOOD o Monitor blood tests to check the activity of thyroid o Advise to report palpitation, tachycardia, and chest pain o Instruct to avoid foods that inhibit thyroid secretions like cabbage, spinach and radishes o o

ANTI-Thyroid Medications Action o The thyroid becomes oversaturated with iodine and stop producing thyroid hormone o BLOCK the thyroid hormones and treat hyperthyroidism o Inhibit the synthesis of thyroid hormones Drug Names o Methimazole (Tapazole) o PTU (prophylthiouracil) o Iodine solution- SSKI and Lugols solution Used to decrease the vascularity of the thyroid (in preparation for thyroid surgery) Adverse Effects o AGRANULOCYTOSIS o GI complaints o N/V, drowsiness, lethargy o For Iodine solutions Iodism - metallic taste, burning in the mouth, sore teeth and gums, diarrhea, stomach upset Nursing Considerations o Monitor VS, T3 and T4, weight o The medications WITH MEALS to avoid gastric upset o Instruct to report SORE THROAT or unexplained FEVER o Monitor for signs of hypothyroidism. o Instruct not to stop abrupt o Use straw for Iodine solutions to prevent teeth staining

STEROIDS Drug Names o Cortisol o Cortisone o Betamethasone o Hydrocortisone o Dexamethasone - long acting Actions o Replaces the steroids in the body o Interfere with the release of inflammatory factors and immune responses o Corticosteroids are used topically and locally to achieve the desired antiinflammatory effects at a particular site

o Dexamethasone is used to induce the formation of lung surfactant Adverse Effects o CUSHING-LIKE effects Edema and Hypertension Hypokalemia Increased susceptibility to infection (immunosuppression) HYPERglycemia osteoporosis, growth retardation, peptic ulcer, cataract, mood changes, hirsutism, and fragile skin Nursing Considerations o Monitor VS, electrolytes, glucose o Monitor weight, edema and I/O o Encourage Potassium supplements o Protect patient from infection o Handle patient gently o Instruct to take meds WITH MEALS to prevent gastric ulcer formation o Caution the patient NOT to abruptly stop the drug o Drug is tapered to allow the adrenal gland to secrete endogenous hormones CARDIOVASCULAR SYSTEM

CARDIAC GLYCOSIDES Drug Name o Digoxin (Lanoxin) o Ouabain o Digitoxin (Crystodigin) Action o They increase the level of CALCIUM inside the cell by inhibiting the SodiumPotassium pump. o More calcium will accumulate inside the cell during cellular depolarization o Positive inotropic effect myocardium will contract forcefully Increased cardiac output Increased blood flow to the body organs like the kidney and liver o Negative chronotropic effect the heart rate is slowed due to decreased rate of cellular repolarization Bradycardia o Negative dromotropic effect Decreased conduction velocity through the AV node Indication o Treatment of congestive heart failure o Treatment of dysrhythmias like atrial flutter, atrial fibrillation and paroxysmal atrial tachycardia Contraindication o They are NOT given to patients with ventricular dysrhythmias, heart block or sick sinus syndrome, aortic stenosis, acute MI, electrolyte imbalances (HYPOKALEMIA, HYPOMAGNESEMIA and HYPERCALCEMIA) and renal failure (may cause accumulation of drug) Adverse Effects o CNS- Headache, weakness , seizures and drowsiness o CVS- arrhythmias o Digitalis toxicity

Anorexia, nausea and vomiting, visual changes- YELLOW halo around an object, and palpitations or very slow heart rate Nursing Consideration o If taken with potassium-losing diuretics like furosemide can INCREASE the risk of toxicity and arrhythmias. Potassium replacement must be given o Administer the initial rapid digitalization and loading dose as ordered intravenously o Monitor the APICAL pulse rate for ONE full minute before administering the drug Withhold the drug if Less than 60 in adults Less than 90 in infants More than 110 in adults Retake pulse in one hour, if pulses remain abnormal, refer. o Administer intravenous drug VERY slow IV over 5 minutes to avoid arrhythmias. o Do NOT administer intramuscularly because it can cause severe pain o Check the dosage preparation and the level of digitalis in the blood. (Therapeutic level is 0.5 to 2.0 nanograms/mL) o Check the spelling of the drug- DIGOXIN is different from DIGITOXIN! o Provide comfort measures- small, frequent meals, adequate lighting, comfortable position, rest periods and safety precautions o Maintain emergency equipment and drugs Potassium salts, Lidocaine for arrhythmias, phenytoin for seizures, atropine for bradycardia. o Administer the drug without food if possible to avoid delayed absorption. o Weight patient daily to determine fluid retention o Advise the patient to report any of the following: Visual changes, rapid weight gain, unusually low heart rate, persistent nausea, vomiting and anorexia

ANTI-ANGINAL DRUGS Calcium-channel blockers Action o Decreases force of contraction leading to a decreased myocardial workload and demand o They can also produce vasodilation Beta-blockers Action o Decreases the heart rate Organic nitrates Drug Names o Nitroglycerin- A moderately volatile nitrate o Isosorbide Dinitrate (Isordil) or mononitrate o Amyl nitrate- an extremely volatile nitrate Action o Nitroglycerin relaxes the smooth muscles in the vascular system by its conversion to nitric oxide, a chemical mediator in the body that relaxes smooth muscles o Increased nitrates in the blood leads to increased formation of nitric oxide which leads to increased cGMP formation increased dephosphorylation of myosin causing vascular smooth muscle relaxation vasodilatation o Because significant first-pass hepatic effect, Nitroglycerin is given SUBLINGUALY, parenterally and topically

o The onset of action of nitroglycerin is more than 1 hour. Adverse Effects o TOLERANCE- the tolerance to the actions of nitrates develop rapidly. This can be managed by providing a day of abstinence. o CVS- postural Hypotension, facial flushing, tachycardia o HEADACHE is the most common effect of nitroglycerin. Nursing Considerations o Offer sips of water before giving sublingual nitroglycerin because dryness may inhibit drug absorption o Advise patient to remain supine or sit on a chair when taking the nitroglycerin for the first time. o Emphasize that he should change his position slowly or rise from bed slowly to avoid orthostatic Hypotension o Apply nitroglycerin ointment to the designated mark on paper NEVER USE her bare fingers because the drug can be absorbed, utilize gloves or tongue blades instead. The nurse should remove any excess ointment on the skin from the previous dose. The patch and the ointment should NOT be applied near the area for defibrillation because explosion and skin burns may result Apply nitroglycerin patch to an area with few hairs. Never touch the medication portion o Emphasize that tolerance to the nitroglycerin can occur o The dose may be repeated if pain is unrelieved within 5 minutes. o DO NOT give more than 3 tablets!!! o If chest pain persists for more than 15 minutes, hospital consult should be done immediately o If taking Sublingual Nitroglycerin, the patient should be instructed to place the tablet under the tongue for quick absorption. A burning sensation/biting/stinging sensation may indicate that the tablet is FRESH o Store the tablet in a dark container, keep it away from heat and direct sunlight to avoid lessening the potency o HEADACHES are common in the initial period of nitroglycerin therapy. Advise patient to take PARACETAMOL for relief o The nitroglycerin patch is applied once a day, usually in the morning. The sites should be rotated, in the chest, arms and thighs avoiding hairy areas.

DRUGS FOR SHOCK Dopamine Action o This is a sympathomimetic drug often used to treat Hypotension in shock states that are not caused by Hypovolemia o This drug is an immediate precursor of nor-epinephrine, occurs naturally in the CNS basal ganglia where it functions as a neurotransmitter. o The dose range is 1-20 micrograms/kg/min o It can activate the alpha and beta adrenergic receptor depending upon the concentration. o It stimulates receptors to cause cardiac stimulation and renal vasodilation. o At low dose (1-2 micrograms), dopamine DILATES the renal and mesenteric blood vessels producing an increase output (dopaminergic effect)

At moderate dose of 2-10 micrograms, dopamine enhance cardiac output by increasing heart rate (beta 1-adrenergic effect) and elevates blood pressure through peripheral vasoconstriction (alpha adrenergic effect) o At higher doses of more than 10 micrograms- vasoconstriction of all vessels will predominate that can lead to diminished tissue perfusion Adverse Effect o Tachycardia hypertension ectopic beats, angina, dysrhythmias, myocardial ischemia, nausea and vomiting. Nursing consideration o Check the IV site hourly for signs of drug infiltration of dopamine, which can cause tissue necrosis. Phentolamine should be infiltrated in multiple areas to reduce tissue damage. o Drug is effective if Urine output is increased and BP is increased o

ANTIHYPERTENSIVE Diuretics Furosemide Decreases blood volume Adverse Effect: Hypokalemia Beta-blocker Propranolol Blocks B1 receptor Adverse Effect: Bradycardia, hypoglycemia ACE (Angiotensin Converting Enzyme) Inhibitors pril Captopril ACE is the enzyme needed to convert Angiotensin I (A1) to Angiotensin II which is a strong vasoconstrictor Adverse Effect Cough ARB (Angiotensin Receptor Blockers) sartan Losartan, Telmisartan Prevents stimulation of angiotensin receptors Ca channel blockers Nifedipine Blocks Ca entry into cells in the heart causing it to slow down Adverse Effect - reflex tachycardia Vasodilators Nitroglycerin Dilates veins and arteries Adverse Effect - Headache and flushing Alpha receptor blockers Prazozin Blocks alpha receptors in blood vessel causing vasodilatation Adverse Effect - Urination Central alpha 2 receptor agonist Clonidine Fools the CNS into thinking that there is enough sympathetic hormones around the body thereby decreasing the secretion of sympathetic hormones

ANTICOAGULANTS Heparin Prevents formation of clots and extension of existing clots Antidote - Protamine sulfate Acts within minutes Monitor for aPTT Warfarin INHIBIT Vitamin-K dependent clotting factors anti-thrombin III in the blood (10,9,7,2) Antidote Vitamin K Acts within days Monitor for PT and INR ANTI-ANEMICS Iron preparations Drug Names o Ferrous gluconate o Ferrous fumarate o Ferrous sulfate Action o Iron is important for hemoglobin formation Adverse Effects o GIT- constipation (usually), diarrhea, vomiting, epigastric pain, gastric ulceration and darkening of stools o Other- dizziness o Liquid preparation can stain the teeth, and injectable iron can cause tissue discoloration Drug-Drug interaction o Milk containing foods, coffee, tea and eggs are NOT given with iron because they delay iron absorption. o Foods can impair iron absorption but they should be taken with iron to reduce GI discomfort. o Antacids and cimetidine- decrease iron absorption and effects o Tetracyclines combine with iron preparations and render the iron unabsorbable. Nursing Consideration o Advise clients to increase fluid intake and consume fiber rich foods if constipation becomes a problem. o DO NOT administer iron together with or within 1 hour of ingesting tetracyclines, antacids, milk and milk-containing products. o Instruct the patient to swallow the whole tablet and remain upright for 30 minutes to prevent esophageal corrosion from reflux. o It is best to offer citrus juices because the vitamin C content can increase iron absorption. o If increased absorption is necessary, administer IN BETWEEN meals with full glass of water or juice. o Administer iron preparations orally with foods to decrease GI discomfort. o Encourage the patient to eat iron-rich foods like liver, lean meat, egg yolk, dried beans, green leafy vegetables.

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To prevent undue alarm, instruct the patient that the stools may turn black or dark green. This is a harmless occurrence. Offer straw if giving liquid iron preparation to avoid staining the teeth. If injecting a parenteral iron preparation, inject DEEP IM utilizing the Z-track method to avoid leakage into the subcutaneous tissues and skin. Emphasize that the therapeutic effect of iron therapy may not be apparent until several weeks.

Erythropoietin Drug Name o Epoetin alfa (Epogen) Action o This drug acts like the natural glycoprotein erythropoietin to stimulate the production of RBC in the bone marrow. Indication o It is also used in patients for blood transfusion to decrease the need for blood in surgical patients. o It is given SUBCUTANEOUSLY or INTRAVENOUSLY for the treatment of anemia associated with renal failure or for patients on dialysis. Adverse Effects o CVS- hypertension, edema and chest pain due to increase RBC number o GIT- nausea, vomiting and diarrhea o CNS- headache, fatigue, asthenia, dizziness and seizures- these are due to the cellular response to the glycoprotein. Nursing Consideration o Provide thorough health teaching: need for lifetime injection o Provide comfort measures like small frequent feedings and pain medications for headache. o Maintain seizure precaution on stand by as seizure can occur. o Determine periodically the level of hematocrit and iron stores during therapy. o If patient does not respond to the drug, reevaluate the cause of anemia. o Monitor the IV access line if given IV. o Do not mix with other solutions o Administer the drug SC or IV usually 3 times per week. PSYCHIATRIC MEDICATIONS Psychotrophic drugs - Drugs that can: Stimulate the release of neurotransmitters Block the receptor/activity of the neurotransmitter - like dopamine Stimulate the receptors in the CNS Prevents the breakdown of the neurotransmitters or the re-uptake mechanism ANTI-PSYCHOTICS/NEUROLEPTICS - Drugs used to treat PSYCHOSES Drug Names o Phenothiazines Chlorpromazine Thioridazine, Fluphenazine, Perphenazine o Butyrophenones Haloperidol, droperidol o Thioxanthines o Atypical drugs Clozapine, Olanzapine, Risperidone and quetiapine Action

Blockage of the DOPAMINE receptor in the CNS

Desired Effects o Reduced hallucination and illusions o CNS sedation and emotional slowing o Decreased ambivalence, reduced delusion o Reduced agitation resulting to calmness o Relief of emotional turmoil o Reduced flattening of affect Nursing Considerations o Sugarless gum, bed rest for Anticholinergic effects o Sunglasses, sunscreen, avoid sun for Photosensitivity o Change position slowly, lie prone for 1 hour after drug intake, monitor BP for Postural hypotension o Instruct to report sore throat and fever, monitor WBC for Agranulocytosis o Monitor EEG for Seizure Safety o No machine operation for Sedation o Extra-Pyramidal Syndrome Parkinsonism-Tremor, rigidity Dystonia- torticollis, face and tongue contraction and bradikinesia Akathisia - motor restlessness Neuroleptic Malignant syndrome - elevated temp, Notify physician, prepare to administer dantrolene Tardive Dyskinesia drooling, tongue movement and shuffling gait. This is irreversible Give anti- EPS drugs like Cogentin AUTONOMIC NERVOUS SYSTEM

SYMPATHETIC NERVOUS SYSTEM Adrenergic AGONISTS - SYMPATHOMIMETIC agents These drugs MIMIC the effects of the sympathetic nervous system Alpha and Beta agonists (non-selective) o Drug Names Epinephrine - drug of choice of anaphylaxis, Status asthmaticus Norepinephrine - used in shock Dobutamine - used in CHF Dopamine - used in shock Ephedrine- used in shock, asthma and rhinitis o Pharmacodynamics These agents stimulate ALL types of adrenergic receptors in the body by direct interaction or by releasing neurotransmitters from the nerve cells o Desirable Effects Pupillary dilatation Decreased intraocular pressure Increased blood pressure Vasoconstriction Bronchial DILATATION Increased myocardial contractility o Contraindications

Pheochromocytoma Tachyarrhythmias With halogenated anesthesia- increased sensitivity to adrenergic drugs o Adverse Effects CVS- hypertension, tachycardia, palpitations Respi- tachypnea GI- nausea, vomiting Others- sweating, headache, piloerection o Nursing Considerations Monitor patient response to the drug Emphasize to avoid the use with MAOIs and TCA Maintain phentolamine (alpha blocker) to manage extravasation of IV drug Alpha Agonists (Selective) o Phenylephrine - vasoconstricting drug, used topically to decrease the symptoms of rhinitis o Clonidine (alpha-2 specific) - for hypertension o Action These agents bind primarily to the alpha receptors in the body Clonidine - Stimulating the ALPHA-2 receptor causes decreased sympathetic outflow from the CNS/ decreased release of Norepinephrine o Adverse effects CNS- anxiety, depression, fatigue CVS- palpitations GI- nausea, vomiting and anorexia GU- oliguria, dysuria o Nursing considerations DO NOT discontinue drug abruptly to prevent rebound effect Maintain phentolamine if giving IV drug Provide comfort measures- rest, quiet environment, analgesics Beta Agonists (Selective) o ANTI-ASTHMA DRUGS isoproterenol (B1 and B2) salbutamol (Ventolin) B2 specific terol- albuterol, salmeterol, bitolterol Terbutaline and Ritrodrine also used to delay labor o Pharmacodynamics These agents bind to the BETA receptors (Mostly in the LUNGS) causing the sympathetic manifestations and effects o Adverse effects CNS- restlessness, headache, anxiety , tremors CVS- tachycardia, angina, palpitations GI- nausea, vomiting and anorexia Others- pupilary dilation, rash, sweating, pulmonary edema o Nursing considerations Monitor VS when giving the drug Remind mothers to lie on the left side during ritodrine administration Maintain a beta blocker on stand by Provide comfort- quiet environment, rest, analgesics. Prevent over-hydration to avoid pulmonary edema

Adrenergic ANTAGONISTS SYMPATHOLYTIC AGENTS

These drugs block the actions of the sympathetic nervous system Alpha blockers (selective) Drug Names Phentolamine used in pheochomocytoma Phenoxybenzamine used in pheochromocytoma zosin- prazosin, doxazosin, terazosin- these are alpha 1 blockers used to decrease blood pressure and to relax the urinary sphincter in BPH (Benign Prostatic Hypertrophy) o Pharmacodynamics - These agents have affinity for the ALPHA receptors Blocking the alpha receptors will cause: Vasodilation Sphincter relaxation in the bladder o Contraindications Myocardial infarction Allergy o Adverse Effects CVS- hypotension, reflex tachycardia, flushing CNS- dizziness, weakness, fatigue, drowsiness Others- nasal congestion, reddened eyes, priapism o Nursing considerations Monitor heart rate and BP Caution to change position slowly Advise to avoid hazardous activities Provide supportive measures like quiet environment, rest and analgesics The Beta blockers (selective) o These are agents used to treat cardiovascular problems- Hypertension, CHF, angina o Blocking beta receptor will cause decreased heart rate decreased BP o Drug Names The olols propranOLOL (both beta 1 and 2) atenOLOL esmOLOL metoprOLOL o Pharmacodynamics These agents block the beta receptors of the sympathetic system. The selective B1 antagonists block the B1 receptors, especially in the heart and the kidney o Indication To decrease BP in Hypertension To decrease cardiac workload in Angina and MI To terminate arrhythmias Cardiac tachyarrhythmias To cause vasoconstriction of the cranial vessels in Migraine headache To decrease the tachycardia HYPERTHYROIDISM o Contraindications Allergy Heart blocks Bradycardia COPD o

Adverse effects CVS- bradycardia, hypotension, heart block CNS- fatigue, dizziness, depression Respi- bronchospasm, pulmonary edema GI- nausea, vomiting, diarrhea, hypoglycemia GU- decreased libido, impotence, dysuria Nursing Considerations Change position slowly Avoidance of hazardous activities NOT to stop abruptly the drug intake Give with FOODS to improve absorption

PARASYMPATOTHETIC NERVOUS SYSTEM The Cholinergic Agonists - Parasympathomimetic agents Their action mimics the Parasympathetic nervous system These agents INCREASE the activity of acetylcholine receptors o DIRECTLY by occupying the receptor o INDIRECTLY by blocking the enzyme acetylcholinESTERASE - the enzyme that degrades acetylcholine (main neurotransmitter for parasympathetic nervous system) Direct acting cholinergic agonists Drug Names o BetaneCHOL, CarbaCHOL o Pilocarpine Indications o Post operative and post partum urinary retention and to treat neurogenic bladder o Relief of increased intraocular pressure of glaucoma by inducing miosis o The drugs INCREASE the bladder tone, RELAX the GI and urinary sphincters o The topical agent (pilocarpine) topically causes pupilary constriction to reduce IOP Contraindications o Bradycardia and Hypotension o Asthma Adverse effects o CVS- bradycardia, heart block, hypotension o GIT- nausea, vomiting, diarrhea, increased salivation, lacrimation o GUT- sense of urgency, sphincter relaxation o Others- increased sweating, headache, miosis (pupilary constriction) Nursing considerations o Administer on EMPTY stomach o Provide safety precautions- because of poor visual acuity o Promote cool environment, maintain access to the bathroom (urination) Indirect acting cholinergics (Acetylcholinesterase Inhibitors) Drug Names o Pyridostigmine Neostigmine Endrophonium (Tensilon) Pharmacodynamics o These agents REACT chemically with the enzyme - acetylcholinesterase

The acetylcholine breakdown is prevented so that the effect of acetylcholine is prolonged leading to increased muscle contraction o They are used IN myasthenia gravis Indication o Tacrine and Donepezil for Alzheimer's disease o Physostigmine, pyridostigmine, Neostigmine for Myasthenia gravis o Endrophonium (Tensilon) is fast acting mostly used for diagnosis of Myasthenia gravis Adverse effects o GI- nausea, vomiting, cramps, diarrhea, increased salivation, involuntary defection o CVS- bradycardia, heart block, hypotension o GU- urinary urgency o Others- blurred vision, miosis, headache, dizziness Nursing considerations o Administer IV drug slowly o Administer with foods BUT better BEFORE meals o Maintain atropine sulfate as antidote o Discontinue the drug if excessive salivation, diarrhea, vomiting become problematic o

The ANTI-cholinergics - Parasympatholytic These are drugs that BLOCK the effect of acetylcholine causing the effects of the sympathetic nervous system more prominent Drug Names o Atropine o dicyclomine glycopyrrolate o propantheline scopolamine Indications o Depresses salivation - Used as pre-op med o Decreases bronchial - Used as pre-op med secretions o Mydriasis (Pupilary dilation) - Used in cataract surgery o Cyclopledia - Used in cataract surgery o Inhibits vagal response - Used in BRADYCARDIA o Used in partly to control diarrhea o Used in Cholinergic and Reverses cholinergic Organophosphate poisoning toxicity o Scopolamine - Decreases nausea and vomiting associated Contraindications o Glaucoma o Bladder obstruction (like BPH) Adverse effects o CNS- blurred vision, pupil DILATION, photophobia, cycloplegia and increased Intraocular pressure o GI- dry mouth, constipation, bloatedness o CVS- tachycardia, palpitations o GU- urinary retention o Others- decreased sweating, flushing Nursing considerations o Instruct to void before administering the drug o Provide high-fiber diet and laxative o Advise to avoid hazardous activities o Provide increased fluids

Frequent mouth care ANTI-INFECTIVE AGENTS

Anti-infective agents are drugs that are designed to act selectively on foreign organisms that have invaded and infected the body Anti-infectives- range from antibiotics, antifungals, antiprotozoals, antihelmintics, antivirals and antimycobacterial General Mechanisms of Action of anti-infective o Some inhibit DNA synthesis o Some change the cell membrane permeability o Some inhibit protein synthesis o Some interfere with the biosynthesis of bacterial cell WALL Spectrum of Activity of Anti- infectives o Broad-spectrum anti-infectives affect many bacteria. o Narrow spectrum anti-infectives affect only a few bacterial types. Because narrow spectrum antibiotics are selective, they are more active against those single organisms than the broad spectrum antibiotics. o Anti-infectives that interfere with the ability of the cell to reproduce/replicate without killing them are called BACTERIOSTATIC drugs o Antibiotics that can aggressively cause bacterial death are called BACTERICIDAL. Common Adverse Reactions to Anti-infective Therapy o The most common adverse effects are due to the direct action of the drugs in the following organ system- Neuro, nephro and GI system 1. o Nephrotoxicity Antibiotics that are metabolized and excreted in the kidney most frequently cause kidney damage.. o Gastro-intestinal toxicity - Direct toxic effect to the cells of the GI tract can cause nausea, vomiting, stomach pain and diarrhea. Some drugs are toxic to liver cells and can cause hepatitis or liver failure o CNS toxicity - When drugs can pass through the brain barrier and accumulate in the nervous tissues, they can interfere with neuronal function. o Hypersensitivity - Most protein antibiotics can induce the bodys immune system to produce allergic responses. Drugs are considered foreign substances and when taken by the individual, it encounters the bodys immune cells. o Opportunistic infections that develop during the course of antibiotic therapy are called SUPERINFECTIONS.

PENICILLINS Narrow spectrum penicillins o Penicillin G Penicillin V Broad Spectrum Penicillins (aminopenicillin) o Amoxicillin Ampicillin Bacampicillin Penicillinase-resistant Penicillin (anti-staphyloccocal penicillins) o Cloxacillin Nafcillin Methicillin Dicloxacillin Oxacillin Extended-Spectrum penicillins (Anti-pseudomonal penicillins) o Carbenicillin Mezlocillin Piperacillin Ticacillin Beta-lactamase inhibitors o Beta-lactamase are enzymes produced by bacteria to neutralize penicillin o Beta-lactamase inhibitors are added to penicillin to protect the penicillin o Clavulanic acid Sulbactam Tazobactam

Structure of Penicillin o Penicillin is a beta-lactam drug, with a beta-lactam ring. The group of penicillins is called beta lactam antibiotics. Pharmacodynamcs o The penicillin and penicillinase-resistant penicillins produce BACTERICIDAL effects by interfering with the ability of susceptible bacteria from biosynthesizing the framework of the cell wall o The bacterium will have weakened cell wall, will swell and then burst from the osmotic pressure within the cell. Adverse Effects o Pain and inflammation on injection sites o Hypersensitivity reactions- rashes, pruritus, fever. These indicate mild allergic reaction. Wheezing and diarrhea may also occur. o Anaphylaxis can also happen leading to shock or death. It occurs in 5-10% of those receiving penicillins. o GI system effects- the major adverse effects of penicillin therapy involve the GIT. Nausea, vomiting, diarrhea, abdominal pain, glossitis, stomatitis, gastritis, sore mouth and furry tongue. Nursing Consideration o Administer the correct dosage and stress the importance of completing the full course and duration of therapy even though the patient experiences relief earlier in the treatment o Monitor the renal status and function regularly o Obtain culture and sensitivity testing results to check if penicillin is the drug of choice o Tell the patient to drink a lot of fluids and eat nutritious foods. o Advise to report difficulty of breathing, severe diarrhea, dizziness, weakness and vaginal itching. o Provide small frequent meals, frequent mouth care, ice chips or sugarless candy to suck if stomatitis and sore mouth occurs.

CEPHALOSPORINS First Generation cephalosporins- are largely effective against the same gram-positive organisms affected by penicillin o Cefadroxil Cefazolin Cephalexin Cephalotin Cephapirin Cephadrine Second generation cephalosporins- are effective against those strains as well as Haemophilus influenza, Entreobacter aerogenes and Nesseria sp. These drugs are less effective against gram positive bacteria o Cefaclor Cefamandole Cefonizind Cefotetan Cefoxitin Cefmetazole Cefprozil Cefuroxime Third Generation cephlosporins- are relatively weak against gram-positive bacteria but more potent against gram-negative bacteria, to include Serratia marcescens. o Cefnidir Cefixime Cefoperazone Cefotaxime Cefpodoxime Ceftazidime Ceftibuten Moxalact Fourth generation cephalosporins- are developed to fight against the resistant gramnegative bacteria o Cefepime Pharmacodynamics o The cephalosporins are primarily BACTERICIDAL. They interfere with the cellwall building ability of bacteria when they divide. They prevent the bacteria from biosynthesizing the framework of their cell wall. The weakened cell wall will swell and burst causing cell death.

Pharmacokinetics o Only a few cephalosporins are administered orally, most are administered parenterally. Their half- lives are short and they are excreted mainly in the urine Contraindications o The drugs are contraindicated in patients with known allergies to cephalosporins and penicillins Adverse Effects o GI system- Nausea, vomiting, diarrhea, anorexia, abdominal pain and flatulence are common effects o CNS headache, dizziness, lethargy and paresthesias have been reported. o Renal system - nephrotoxicity in individuals with pre-existing renal disease Drug-Drug interactions o Aminoglycosides - if given with cephalosporins may increase the risk of kidney toxicity o Anti-coagulants - may experience increased bleeding tendencies o ALCOHOL - many patients experience a disulfiram-like reactions when taken with some specific cephlosporins ( cefamandole, cefoperazone or moxalactam). The patient may experience flushing, headache, nausea, vomiting and muscular cramps. This may occur even up to 72 hours of cephalosporin discontinuance Nursing Considerations o Monitor renal function test prior to and periodically during therapy o Ensure that the patient receives the full course of cephalosporins as prescribed for the duration specified. Advise the patient to consume all the drugs even though signs/symptoms may resolve earlier in the course o Take medication with food if gastric irritation occurs. o AVOID alcoholic beverages for 72 hours after completing the drug o Take safety precaution in changing positions carefully, avoid driving and hazardous tasks, drink fluids liberally, report severe reactions to the drug

AMINOGLYCOSIDES Drug Names o Kanamycin o Netilmicin o Amikacin o Tobramycin o Gentamycin Pharmacodynamics o These are BACTERICIDAL. o They inhibit protein synthesis in susceptible strains of gram-negative bacteria, leading to loss of functional integrity of the bacterial cell membrane, which causes cell death Indications o These drugs are used to treat serious infections caused by gram-NEGATIVE bacteria. Contraindications o Known allergies to aminoglycosides, in patients with renal failure, hepatic disease, pre-existing hearing loss, myasthenia gravis, Parkinsons, pregnancy and lactation. Adverse Effects

CNS- irreversible deafness, vestibular paralysis, confusion, depression, disorietnation, numbness, tingling and weakness related to drug effects. o Kidney - renal toxicity, which may progress to renal failure caused by the direct toxicity of the aminoglycosides o Hema - bone marrow depression resulting from direct drug effect may lead to immune suppression and superinfection o GI system - nausea, vomiting, diarrhea, weight loss, stomatiits and hepatic toxicity. The effects are due to the direct GI irritation, loss of bacterial flora and toxicity to mucus membrane and liver as the drugs are metabolized o Cardiac - palpitaions, hypotension or hypertension o Skin effects - photosensitivity, purpura, rash, urticaria and exfoliative dermatitis Nursing Considerations o Ensure that the patient receives the correct dose and duration of treatment. o Auditory and CNS assessement must be done prior to thrapy o

MACROLIDES Drug Names o Erythromycin o Dirithromycin o Clarithromycin o Azithromycin Pharmacodynamics o The macrolides are primarily BACTERICIDAL and sometimes bacteriostatic. They exert their effect by binding to the bacterial cell ribosomes and changing or altering protein production/function. This will lead to impaired cell metabolism and division Pharmacokinetics o Erythromycin is destroyed by the gastric juice, which is why slats are added to stabilize the drug. Food does not interfere with the absorption of the macrolides Indications o These are indicated for the treatment of the following conditions: Steptococcal infection, Mycoplasma infection, Listeria infection and group A beta hemolytic strep infection Contraindications o Known allergy to any macrolide, because cross-sensitivity occurs. o Caution should be used in patients with hepatic dysfunction that could alter the metabolism of the drug; in lactating women because of drug excretion in breast milk and in pregnant women because potential adverse effects on the developing fetus. Adverse Effects o CNS - confusion, abnormal thinking and uncontrollable emotions o GI system- abdominal cramping, anorexia, diarrhea, vomiting and pseudomembranous colitis. HEPATOTOXICITY can occur if the drug is taken in high doses with other hepatotoxic drugs Nursing Considerations o Ensure that the patient receives the correct dose and duration of treatment. o The nurse obtains information about the status of the liver and kidney, skin and GI system.

LINCOSAMIDES Drug Names o Lincomycin o Clindamycin Action o These agents penetrate the cell membrane and bind to the ribosome in the bacterial cytoplasm to prevent the protein production o They are bactericidal and bacteriostatic depending on the dose Adverse Effects o GIT- GI irritation, nausea, vomiting and stomatitis

TETRACYCLINES Drug Names o Long acting tetracyclines Doxycycline, minocycline o Intermediate acting tetracyclines Emeclocycline, methacycline o Short-acting tetracyclines Tetracycline, oxytetracycline Action o The tetracyclines inhibit protein synthesis in susceptible bacteria leading to the inability of the bacteria to multiply o They are primarily BACTERIOSTATIC Contraindications and Precautions o Presence of known allergy to tetrayclines and the tartrazine dye o Not recommended for use in pregnancy and lactation because the drug can affect the bones and teeth, causing permanent discoloration and sometimes arrest of growth. o Avoided in children less than 8 (eight) years of age because of the potential damage to the bones and permanent discoloration of the teeth Adverse Reaction o Skin- photosensitivity and rash are expected o Musculoskletal - Tetracyclines have an affinity for teeth and bones; they accumulate there, leading to weakening of the bone/teeth and permanent staining and pitting o GI system - nausea, vomiting, diarrhea, abdominal pain, glossitis and dysphagia. Fatal hepatotoxicity related to tetracyclines irritating effect on the liver cells has been reported. Nursing Considerations o Dairy products can complex with tetracycline and render unabsorbable. Tetracyclines should then be given on an EMPTY stomach 1 hour before meals or 2-3 hours after any meal or other medications. o Oral contraceptives- if taken with tetracycline, will have decreased effectiveness. Nurse must advise alternative methods of contraception

FLUOROQUINOLONES Drug Names o Sparfloxacin o Levfofloxacin o norfloxacin o oxacillin

o ciprofloxacin o Nalidixic acid Pharmacodynamics o These agents enter the bacterial cell by diffusion through cell channel. Once inside they interfere with the action of DNA enzymes (DNA gyrase) necessary for the growth and reproduction of the bacteria. This will lead to cell death Therapeutic Use o These agents are indicated for the treatment of infections caused by susceptible strains of gram-negative bacteria including E. coli., Proteus, pseudomonas, Strep and Staph spp Contraindications and Precautions o Known drug allergy to these agents contraindicate their use. Pregnancy and lactation are also contraindications. o These agents are found to cause significant damage to the cartilages such that they are given cautiously to growing children and adolescents less than 18 years of age Adverse Effects o CNS- dizziness, insomnia, headache, and depression related to possible effects on the CNS membrane. o GI system- nausea, vomiting, diarrhea and dry mouth related to the direct effect on the GIT o Hema - bone marrow depression related to the direct effect of the drug on the cells of the bone marrow that rapidly turn over o effects- skin reactions, rash, fever and photosensitivity

SULFONAMIDES Drug Names o Sulfixoxazole o Sulfadiazine o Sulfamethoxazole o Sulfazalazine Pharmacodynamics o The sulfa drugs competitively block the para-amino benzoic acid to prevent the synthesis of folic acid in susceptible bacteria that synthesize their own folates for the production of RNA and DNA Therapeutic indications o The spectrum of activity includes the following bacteria- Chlamydia, Nocardia, Haemophilus, E, coli and Proteus. o Sulfa drugs are used to treat trachoma and brain abscess. Contraindications and precautions o These agents are contraindicated to patients with known allergy to sulfa drugs, sulfonylureas and thiazide diuretics because they share similar structures. o It is not recommended for use in pregnancy because it can cross the placenta and cause birth defects and kernicterus. o Lactating women who take these drugs will excrete them in the breast milk potentially causing kernicterus, diarrhea and rash in the newborn. Adverse Effects o GI system- nausea, vomiting, diarrhea, abdominal pain, anorexia, stomatitis and hepatic injury, which are all related to the direct irritation of the GIT and death of normal flora o Renal system- crystalluria, hematuria and proteinuria which can progress to a nephrotic syndrome.

CNS- headache, dizziness, vertigo, ataxia, convulsions and depression related to drug effects on the nerves o Dermatologic effects- photosensitivity and rash and hypersensitivity o Hema- bone marrow depression related to drug effects on the cells of the bone marrow that turn over rapidly Nursing Considerations o The nurse should also monitor the renal status. o CBC should be performed to establish a baseline data to monitor for adverse effects o

ANTIINFLAMMATORY AGENTS AND NONSTEROIDAL ANTIINFLAMMATORY DRUGS (NSAIDS) NSAIDs Action o Analgesia - treatment of headaches and pain Block the undesirable effects of prostaglandins, which cause headaches o Antipyretic - reduce fever Inhibit prostaglandin E2 within the area of the brain that controls temperature o Relief of inflammation Inhibit the leukotriene pathway, the prostaglandin pathway, or both Drug Names o Acetic Acid diclofenac sodium (Voltaren) diclofenac potassium (Cataflam) etodolac (Lodine) indomethacin (Indocin) sulindac (Clinoril) tolmetin (Tolectin) . o Carboxylic Acids Acetylated aspirin (ASA) choline magnesium salicylate (Trilisate) diflunisal (Dolobid) Nonacetylated salicylamide salsalate (Disalcid) sodium salicylate o Propionic Acids fenoprofen (Nalfon) flurbiprofen (Ansaid) ibuprofen (Motrin, others) ketoprofen (Orudis) ketorolac (Toradol) naproxen (Naprosyn) oxaprozin (Daypro) o Enolic acids phenylbutazone (Butazolidin) piroxicam (Feldene) Fenamic acids meclofenamic acid (Meclomen) mefenamic acid (Ponstel) Nonacidic compounds nabumetone (Relafen) o COX-2 Inhibitors celecoxib (Celebrex) rofecoxib (Vioxx) Indications o Relief of mild to moderate pain Acute gout Various bone, joint, and muscle pain Osteoarthritis Rheumatoid arthritis Juvenile rheumatoid arthritis Dysmenorrhea Fever o Salicylates (aspirin) More potent effect on platelet aggregation and thermal regulatory center in the brain analgesic antipyretic antiinflammatory Antithrombotic effect: used in the treatment of MI and other thromboembolic disorders o Phenylbutazone (Butazolidin) Greater effects on uric acid production and excretion, in addition to antiinflammatory effects More commonly used for treatment of gout Adverse Effects

Gastrointestinal - dyspepsia, heartburn, epigastric distress, nausea, GI bleeding, mucosal lesions (erosions or ulcerations) o Renal - reductions in creatinine clearance acute tubular necrosis with renal failure o Cardiovascular - noncardiogenic pulmonary edema o Salicylate Toxicity Adults: tinnitus and hearing loss Children: hyperventilation and CNS effects Nursing Considerations o Before beginning therapy, assess for conditions that may be contraindications to therapy, especially: GI lesions or peptic ulcer disease Bleeding disorders o Salicylates are NOT to be given to children under age 12 because of the risk of Reyes syndrome. o Because these agents generally cause GI distress, they are often better tolerated if taken with food, milk or an antacid to avoid GI irritation. o BRONCHODILATORS AND OTHER RESPIRATORY AGENTS

Bronchodilators: Xanthine Derivatives Plant alkaloids: caffeine, theobromine, and theophylline Only theophylline is used as a bronchodilator Action o Increase levels of energy-producing cAMP (cyclic adenosine monophosphate) o This is done competitively inhibiting phosphodiesterase (PDE), the enzyme that breaks down Camp o Increased cAMP levels, smooth muscle relaxation, bronchodilation, and increased airflow Drug Effects o Cause bronchodilation by relaxing smooth muscles of the airways. o Result: relief of bronchospasm and greater airflow into and out of the lungs. o Also causes CNS stimulation. o Also causes cardiovascular stimulation: increased force of contraction and increased HR, resulting in increased cardiac output and increased blood flow to the kidneys (diuretic effect). Therapeutic Uses o Dilation of airways in asthmas, chronic bronchitis, and emphysema o Mild to moderate cases of asthma o Adjunct agent in the management of COPD o Adjunct therapy for the relief of pulmonary edema and paroxysmal nocturnal edema in left-sided heart failure Adverse Effects o Nausea, vomiting, anorexia o Gastroesophageal reflux during sleep o Sinus tachycardia, extrasystole, palpitations, ventricular dysrhythmias Bronchodilators: Beta-Agonists Sympathomimetics Used during acute phase of asthmatic attacks Quickly reduce airway constriction and restore normal airflow Stimulate beta2 adrenergic receptors throughout the lungs Beta-Agonists Three types

o o

o Action o Begins at the specific receptor stimulated o Ends with the dilation of the airways o Activation of beta2 receptors activate cAMP, which relaxes smooth muscles of the airway and results in bronchial dilation and increased airflow. Therapeutic Uses o Relief of bronchospasm, bronchial asthma, bronchitis, and other pulmonary disease. o Useful in treatment of acute attacks as well as prevention. o Used in hypotension and shock. o Used to produce uterine relaxation to prevent premature labor Adverse Effects o Alpha-Beta Beta1 and Beta2 Beta2 (epinephrine) (isoproterenol) (albuterol) insomnia cardiac stimulation hypotension restlessness tremor vascular headache anorexia anginal pain tremor cardiac stimulation vascular headache tremor vascular headache Nursing Considerations o Encourage patients to take measures that promote a generally good state of health in order to prevent, relieve, or decrease symptoms of COPD. o Avoid exposure to conditions that precipitate bronchospasms (allergens, smoking, stress, air pollutants) o Albuterol, if used too frequently, loses its beta2-specific actions at larger doses. As a result, beta1 receptors are stimulated, causing nausea, increased anxiety, palpitations, tremors, and increased heart rate.

Nonselective adrenergics Stimulate alpha1, beta1 (cardiac), and beta2 (respiratory) receptors. Example: epinephrine Nonselective beta-adrenergics Stimulate both beta1 and beta2 receptors. Example: isoproterenol (Isuprel) Selective beta2 drugs Stimulate only beta2 receptors. Example: albuterol

Anticholinergics: Action o Acetylcholine (ACh) causes bronchial constriction and narrowing of the airways. o Anticholinergics bind to the ACh receptors, preventing ACh from binding. o Result: bronchoconstriction is prevented, airways dilate. Ipratropium bromide (Atrovent) is the only anticholinergic used for respiratory disease. o Slow and prolonged action o Used to prevent bronchoconstriction NOT used for acute asthma exacerbations! Adverse Effects o Dry mouth or throat, gastrointestinal distress, headache Antileukotrienes - leukotriene receptor antagonists (LRTAs) Drug Names o Montelukast (Singulair) zafirlukast (Accolate) zileuton (Zyflo) Action o Leukotrienes are substances released when a trigger, such as cat hair or dust, starts a series of chemical reactions in the body. o Leukotrienes cause inflammation, bronchoconstriction, and mucus production. Result: coughing, wheezing, shortness of breath

Antileukotriene agents prevent leukotrienes from attaching to receptors on cells in the lungs and in circulation. o Inflammation in the lungs is blocked, and asthma symptoms are relieved. Drug Effects o Prevent smooth muscle contraction of the bronchial airways o Decrease mucus secretion o Prevent vascular permeability o Decrease neutrophil and leukocyte infiltration to the lungs, preventing inflammation Therapeutic Uses o Prophylaxis and chronic treatment of asthma in adults and children over age 12 o NOT meant for management of acute asthmatic attacks Adverse Effects o zileuton zafirlukas Headache, Dyspepsia, Nausea, Diarrhea, Dizziness, Liver dysfunction, Insomnia o montelukast has fewer side effects Nursing Considerations o Ensure that the drug is being used for chronic management of asthma, not acute asthma. o Teach the patient the purpose of the therapy. o Improvement should be seen in about 1 week. o Medications should be taken every night on a continuous schedule, even if symptoms improve. o

Corticosteroids Anti-inflammatory Used for CHRONIC asthma Do not relieve symptoms of acute asthmatic attacks Oral or inhaled forms - Inhaled forms reduce systemic effects May take several weeks before full effects are seen Action o Stabilize membranes of cells that release harmful bronchoconstricting substances. o These cells are leukocytes, or white blood cells. o Also increase responsiveness of bronchial smooth muscle to beta-adrenergic stimulation. Inhaled Corticosteroids o Beclomethasone dipropionate (Beclovent, Vanceril) o triamcinolone acetonide (Azmacort) o dexamethasone sodium phosphate (Decadron Phosphate Respihaler) flunisolide (AeroBid) Therapeutic Uses o Treatment of bronchospastic disorders that are not controlled by conventional bronchodilators. o NOT considered first-line agents for management of acute asthmatic attacks or status asthmaticus. Adverse Effects o Pharyngeal irritation o Coughing o Dry mouth o Oral fungal infections

Nursing Considerations o Teach patients to gargle and rinse the mouth with water afterward to prevent the development of oral fungal infections. o Abruptly discontinuing these medications can lead to serious problems. o If discontinuing, should be weaned for a period of 1 to 2 weeks, and only if recommended by physician. o REPORT any weight gain of more than 5 pounds a week or the occurrence of chest pain.

Mast Cell Stabilizers Drug Name o cromolyn (Nasalcrom, Intal) o nedocromil (Tilade) Pharmacodynamics o Indirect-acting agents that prevent the release of the various substances that cause bronchospasm o Stabilize the cell membranes of inflammatory cells (mast cells, monocytes, macrophages), thus preventing release of harmful cellular contents o No direct bronchodilator activity o Used prophylactically Therapeutic Uses o Adjuncts to the overall management of COPD o Used solely for prophylaxis, NOT for acute asthma attacks o Used to prevent exercise-induced bronchospasm o Used to prevent bronchospasm associated with exposure to known precipitating factors, such as cold, dry air or allergens Side Effects o Coughing, Taste changes, Sore throat, Dizziness, Rhinitis, Headache, Bronchospasm Nursing Considerations o For prophylactic use only o Contraindicated for acute exacerbations o Not recommended for children under age 5 o Therapeutic effects may not be seen for up to 4 weeks o Teach patients to gargle and rinse the mouth with water afterward to minimize irritation to the throat and oral mucosa