DISTRIBUTION METABOLISM plasma-protein binding, oral medicines, age, nutrition volume of distribution, and hormones barriers (blood

- brain and placental), obesity and receptor combination EXCRETION renal excretion, drugs affecting elimination of other drugs, blood concentration levels

II. GENERAL PRINCIPLES OF DRUG ADMINISTRATION & SAFETY GUIDELINES GIVING MEDICATIONS

General Principles of Drug Administration and Safety Guidelines Giving Medications

1. 2. 3. 4. 5.

Confirm client diagnosis and appropriateness of medicines Identify all concurrent medicines and any potential C/I and allergies Research drug compatibilities, action, purpose, route, C/I, S/E Calculate dosage accurately especially for pediatric clients Check for expiration date of medicines

General Principles of Drug Administration and Safety Guidelines Giving Medications

6. Confirm client’s identity 7. Provide client teachings 8. Stay with client until medicines is gone; do not leave at bedside 9. After giving medicines, leave client in position of comfort 10. Give medicines within 30 minutes of prescribed time

General Principles of Drug Administration and Safety Guidelines Giving Medications
11. To ensure safety do not give a medication that someone else prepared 12. Know the policies of your office regarding the administration of medication. 13. Give only the medication(s) that the physician has order in writing. Do not accept verbal order. 14. Check with the physician if you have any doubt about a medication or an order. 15. Avoid conversations or other distractions while drawing up and administering medication. It is important to remain attentive during this task.

General Principles of Drug Administration and Safety Guidelines Giving Medications

16. Work in quiet, well lighted area. 17. Check the label when taking the medication from the shelf, when pouring it, and when replacing it on the shelf. This is known as the “three checks” for safe medication administration. 18. Place the order and the medication side by side to compare its accuracy. 19. Check strengths of the medication (eg. 250 mg versus 500 mg) and the routes (eg. ophthalmic, otic, topical). 20. Read labels carefully. Do not scan labels or orders.

General Principles of Drug Administration and Safety Guidelines Giving Medications

21. Check the patient’s chart for allergies to components of the medication. 22. Check the medication’s expiration date. 23. Be alert for color changes, precipitation, odor, or any indication that the medication’s properties have changed (especially insulin, nitroglycerin & phenytoin). 24. Measure exactly; there should be no bubbles. 25. Have sharps containers as close to the area of use as possible.

General Principles of Drug Administration and Safety Guidelines Giving Medications
26. Put on gloves for all procedures that might result in contact with blood or body fluids. 27. Stay with the patient while oral medication is being taken. Watch for any reaction and record the patient’s response. 28. Never return a medication to the container. 29. Never recap, bend, or break a used needle. 30. Never give a medication poured or drawn up by someone else. 31. Never leave the medication cabinet unlocked when not in use. 32. Never give the keys of the medication cabinet to an unauthorized person. Limit access to the medication cabinet by limiting access to the cabinet keys.

Even if you are extremely careful, you may make an error when administering a medication. It is imperative that you report the error to the physician and that intervention measures start immediately. The error and all corrective actions must be documented thoroughly on the patient’s chart. An incident report must be completed for the error and filed in the patient’s chart as verification that all possible precautions were taken for the patient.
Errors made in charting medications must be corrected using a standard procedure. If you discover a charting error, mark it with one line. Then mark the correction above the error and sign it.

THERAPEUTIC SERUM MEDICATION LEVEL

Acetaminophen Carbamazepine Digoxin Gentamycin Lithium Magnesium SO4 Phenytoin Theophylline

10 – 20 ug/ml 5 – 12 ug/ml 5 – 2 ng/ml 5 – 10 ug/ml 5 – 1.3 mEq/L 4 – 7 mg/dl 10 – 20 ug/ml 10 – 20 ug/ml

Right Client Right Drug Right Dose Right Route Right Time Right Documentation Right Drug Preparation and Administration

IV. GENERAL CONSIDERATIONS FOR ORAL MEDICINES
1. Assess oral cavity and ability to swallow medicines 2. Enteric-coated medicines must not be crushed. Only scored tablets can be broken 3. Do not administer alcohol-based products like elixirs to alcohol dependent persons 4. Have patients swallow medicines except for sublingual and buccal route. Do not allow fluids 30 minutes after giving medicines. Give iron preparation using straw to prevent teeth staining. 5. When giving medicines via NGT, do not mix with food. Give before or after meals and flush tubing with 30 ml of H2O. Check for tube patency before giving medications.

V. GENERAL CONSIDERATIONS FOR PARENTERAL MEDICINES
•Select appropriate needle size and syringe for ID, SQ, IM ROUTES •Use tuberculin syringe for medicines less than 1 ml •Draw up air equal to amount of medicines needed •Inject air to vial to prevent negative pressure and aid in aspirating medicines •Ampule: place needle into ampule to draw medicines and use filter needle to avoid glass shards •Select and rotate sites avoiding bruised or tender areas •Insert needle quickly with bevel side up. Aspirate to check for blood except heparin. If blood is present, remove needle and start again. For giving IV medicines, blood return is desired •Apply gentle pressure after giving injections except for heparin and Z-track.

a. Use 25g to 27g, ½ to 1 inch needle b. Maximum volume of 1.5 ml c. Pinch skin to form SC fold and insert at 45 degrees in thigh or arm and 90 degrees in abdomen d. Possible sites: lateral aspect of upper arm, anterior thigh, abdomen…1 inch from umbilicus and scapular area
EXAMPLES: Heparin, Insulin, MMR, Enoxaparin (Lovenox)

a.

Use 26g to 27g, 1" needle on a 1 ml or tuberculin syringe (vol. approximately 0.1 ml) b. Insert needle at 10-15 angle with 1-2 mm depth with needle bevel upward c. When wheal appears, do not massage, mark d. Possible sites: ventral forearm, scapula, upper chest
EXAMPLES: BCG, PPD (Purified Protein Derivative)/ Mantoux test

a. Use 18 g to 23 g, 1-2 inch needle, maximum volume is 5ml b. Stretch skin taut c. Insert at 90 degrees angle. 45 degrees for infants and children d. Possible sites: gluteus medius (ventrogluteal and dorsogluteal, vastus lateralis (anterior thigh), rectus femoris (medial thigh) and deltoid e. For Z-track: 20-22 g, 2-3 inches long with a different needle to draw medicines; draw skin laterally with nondominant hand to ensure that medicines enter muscle; wait 10 sections before removing injection; do not massage to lock irritating substances in place EXAMPLES: Vit.K, Hep. B, DPT, Iron dextran (Z-track)

a. Check site for complications (redness, swelling, tenderness) b. Check blood return c. Prepare medicines according to manufacturer’s specifications d. Prepare tubing according to requirement: micro or macro tubing e. Change tubing and dress site every 24-72 days depending on hospital policy and label appropriately f. Never hang solutions more than 24 hours g. Use syringe infusers and infusion pumps EXAMPLES: vancomycin (Vancocin), amphoterecin B, cisplatin (Platinol), fluorouracil (5-FU), Oxytocin, Mannitol

a. Monitor the risk for fluid overload especially in patients with respiratory, cardiac, renal and liver diseases. Elderly clients and very young clients cannot tolerate excessive fluid volume b. Clients with CHF cannot tolerate solutions containing sodium c. Clients with diabetes mellitus does not typically receive dextrose (glucose) solutions d. Lactated Ringer’s Solution contain potassium and should not be given to clients with renal failure

A. INFECTION • LOCAL: redness, swelling and drainage at site • SYSTEMIC: fever, chills, HA, tachycardia, malaise The longer the site, the higher the risk At risk are HIV/Aids patients and those receiving chemotherapy Assess for the S/Sx of infection, maintain strict asepsis in IV site care, monitor WBC, check the integrity of solutions, change tubings and dressings q 24-72 hrs, prepare to obtain blood culture from venipuncture device

B. PHLEBITIS/THROMBOPHLEBITIS • PHLEBITIS: Redness, heat and tenderness at site, sluggish IV • THROMBOPHLEBITIS: Hard and cordlike vein Use IV cannula smaller than vein Avoid lower extremities and areas of flexion as the site

C. INFILTRATION • Edema, pain and coolness at the site d/t seepage of IV fluid outside vein and into the interstitial space; • May or may not have blood return Caused when devise dislodged or perforates vein or when vein backs up pressure d/t venospasm Infiltrated if no backflow of blood upon lowering fluid container or after occluding the vein proximal to site and IV continues to flow Remove infiltrated IV, elevate extremity and apply cold or warm compress based on MD’s order

D. CIRCULATORY OVERLOAD • Increased BP, distended jugular veins, rapid breathing dyspnea, moist cough and crackles Use infusion pump esp. for clients at risk of overload and time tape If it occurs, KVO rate, elevate head of bed, assess for edema and inform MD If these occurs, remove and restart in opposite extremity apply warm and moist compress; inform doctor

E. AIR EMBOLISM • Increased BP, distended jugular veins, rapid breathing dyspnea, moist cough and crackles Occurs when air bolus enters vein through inadequately primed IV line, from loose connection, tubing change and IV removal If S/Sx occur, clamp the tubing, turn the patient on the left side with the head lowered (Trendelenburg position) to trap area in the right atrium, call MD right away

VI. CONSIDERATIONS IN GIVING OPTHALMIC MEDICINES
1. Have patient lie on back or sit with head turned to the affected side to facilitate gravitational flow. 2. Cleanse eyelids and eyelashes with sterile gauze pads soaked with physiologic saline. 3. Keep eye open by pulling down on cheekbone with thumb and pointer finger to expose lower conjunctiva. 4. Place the necessary drops near the outer canthus and away from cornea. 5. If using ointment, squeeze into lower conjunctiva and move from inner to outer canthus. Do not touch tip to the eye and twist tube to break medication stream.

VI. CONSIDERATIONS IN GIVING OPTHALMIC MEDICINES

6. Let patient blink 2-3 times 7. Press on nasolacrimal glands (to prevent systemic absortion, a perfect example is atropinr sulfate) 8. Wipe excess medicines starting from inner canthus 9. Droppers and ointments are for individual clients and never shared.

VII. CONSIDERATIONS IN GIVING OTIC MEDICINES
1. Clean outer ear using wet gauze pad. 2. Straighten ear canal: Pull pinna up and back for adults Pull pinna down and back for children under 3 3. Instill necessary number of drops along side of canal without touching ear with dropper. Maintain ear position until medicines has totally entered canal 4. Have client remain on side for 5-10 minutes to allow medicines to reach to reach inner ear.

VIII. CONSIDERATIONS IN GIVING TOPICAL MEDICINES
1. Cleanse area to remove old medicines using gauze with soap and warm water 2. Spread medication evenly and thinly wearing gloves if the skin is broken 3. When applying nitroglycerin ointment, take the client’s BP 5 minutes before and after application 4. Wash hands after applying to prevent self-absorption 5. For transderm patches, wear gloves to prevent self absorption and place in an area with little hair. Press down edges to secure patch

IX. CONSIDERATIONS IN GIVING VAGINAL MEDICINES
1. Let client void 2. Drape to provide privacy and wear gloves 3. Place client on bedpan in a dorsal recumbent position with hips and knees flexed 4. Cleanse perineum with warm, soapy water working from inner to outer

IX. CONSIDERATIONS IN GIVING VAGINAL MEDICINES
5. Moisten suppository with water-soluble lubricant 6. Separate labia and insert 2 inches…angled downward and backward 7. Provide pillow under buttocks and let patient remain in that position for 15-20 minutes (no sphincter to hold suppository in place) 8. Provide with pads

X. CONSIDERATIONS IN GIVING RECTAL MEDICINES
1. Check patient’s bowel function/ability to retain the enema or suppository 2. Store suppositories in the refrigerator 3. Provide privacy and position client left laterally 4. Don gloves and moisten suppository with water-soluble lubricant 5. Insert suppository tapered end 1st and insert 2 inches to pass the internal sphincter 6. Hold buttocks together. 7. Encourage patient to retain: Suppositories for 10-20 minutes Enema for 20-30 minutes

XI. NEUROLOGIC MEDICINES
Nervous System

CNS

PNS

Brain

Spinal Cord

Somatic

Automatic

Adrenergic 1. Alpha 2. Beta

Cholinergic

XI. NEUROLOGIC MEDICINES

1. ANALGESICS

A. Narcotic Analgesics
Actions: Combines with opiate receptors in CNS. Reduces stimuli from sensory nerve endings; pain threshold is increased. DON’T GIVE TO PATIENT’S WITH: Alcoholism, respiratory, renal or hepatic disease, increased intracranial pressure, severe heart disease. AVOID MIXING WITH THIS DRUGS: Alcohol and/ or CNS depressants, barbiturates, anxiolytics, any products with alcohol. MAOIs may result in a fatal reaction.

XI. NEUROLOGIC MEDICINES

1. ANALGESICS

A. Narcotic Analgesics
Interventions: Monitor RR, bowel sounds, VS, and pain for type location, intensity, and duration. Dilute and administer IV solution slowly to prevent CNS depression and possible cardiac arrest. Hold medication if respirations <12/min. with the adult or <20/min. with the child. Have Narcan available.
Education: No ambulating without assistance; no driving. Instruct to take before pain is too severe. Dependence on drug is not likely for short –term medical needs. Do not abruptly withdraw medication.

MAJOR SIDE EFFECTS OF NARCOTICS (this is according to prioritization): #1. Respiratory Depression (check the respiratory rate first!) #2. Orthostatic Hypotension (check the blood pressure before and after taking the drug) #3. Constipation decreases peristalsis)

MORPHINE-LIKE DERIVATIVES
Morphine (roxanol)- the best drug for MI NEVER GIVE TO PANCREATITIS AND CHOLELITHIASIS because it will contract the SPHINCTER of ODDI. = Codeine (Codeine SO4) & Hydrocodone (hycodan) COMMONLY USED AS AN ANTITUSSIVE (cough suppressant) = Levorphanol (Levodromoran)

MEPERIDINE-LIKE DERIVATIVES
• Meperidine (Demerol) never give to patients with increase ICP. It masks the symptoms of respiratory depression!

• Fentanyl (Sublimaze)

METHADONE-LIKE DERIVATIVES • Methadone( Dolophine) the #1 preferred drug of choice for heroin withdrawal. Propoxyphene (Darvon) contains aspirin NEVER give to hemorrhagic shock.

a. Others Narcotics: Code: morphone/ codone hydrocodone (Hycodan); hydromorphone (Dilaudid); oxycodone (Roxicodone); oxymorphone (Numorphan); Others: Dezocine (Dalgan); fentanyl (Sublimaze), levomethadyl (ORLAAM); levorphanol (Levo-Dromoran); remifentanil (Ultiva); sufentanil (Sufenta). Butorphanol Tartrate (Stadol), Nalbuphine, Pentazocine

b. Narcotic Antagonists (Antidote for Narcotic poisoning) • Naloxone (Narcan) • Naltrexone (Trexan, Revia) • Nalmefene (Revex)

c. Non-Steroidal Anti-Inflammatory

A. NSAIDS 1. ASA (Aspirin) – anti-platelet aggregator, antiinflammatory and analgesic

* the best drug for rheumatoid arthritis *always with meals (causes Peptic ulcer) *used in strokes and MI *ototoxic (early side effect: tinnitus and vertigo) *be careful in giving to individuals with Viral illness such as chicken pox because there is a risk for REYES SYNDROME (liver damage is evident) * avoid giving to individuals with bleeding tendencies and potential for blood dyscrasia such as thrombolytics , anticoagulants, ginko biloba, and phenytoin.

A. NSAIDS

2. Para – chlorobenzoic Acid (Indoles) Indomethacin (Indocin) Sulindac (Clinoril) Tolmetin (Tolectin)

3. Pyrazolone derivatives: Phenylbutazone (Butazolidin)

A. NSAIDS

Proprionic Acid Derivatives Ibuprofen (Motrin, Advil, Nuprin) Fenoprofen Calcium (Nalfon) Naproxen (Naprosyn) Flurbiprofen Sodium (Ansaid, Ocufen) Ketoprofen (Orudis) Oxaprozin (Daypro)

7.

Phenylacetic Acid Derivatives Ethodolac (Lodine) Diclofenac Sodium (Voltaren) Ketorolac tromethamine (Toradol)

A. NSAIDS

8.

COX-2 INHIBIOTORS Celecoxib (Celebrex) Meloxicaqm (Mobic) Rofecoxib (Vioxx)

9. Miscellaneous Analgesic Agents Acetaminophen (Tylenol) 1. Acetaminophen (Tylenol) *hepatotoxic ( monitor SGPT/ALT) *with food

ANXIOLYTICS/ANTI-ANXIETY

Another word: Sedatives/Hypnotics/Minor Tranquilizer For: Delirium, anti-anxiety, insomnia ACTION: Increases GABA (gamma amino butyric acid)
USES: Major Use

to reduce anxiety; also induce sedation, relax muscles, inhibit convulsion; Used in neuroses, psychosomatic disorders, functional psychiatric disorders. DO NOT modify psychotic behavior. Most commonly prescribed drugs in medicine
Greatest harm: When combined with ALCOHOL

ANXIOLYTICS/ANTI-ANXIETY

I. BENZODIAZEPINE
Code: ZEPAM / ZOLAM Action: Anticonvulsant, muscle relaxant & anxiolytic

Diazepam (Valium)* best for: Status epilepticus , the best for delirium tremens (alcohol & cocaine withdrawal

ANXIOLYTICS/ANTI-ANXIETY I. BENZODIAZEPINE

Estazolam (Prosom) Alprazolam (Xanax) Chlorazepate (Tranxene) Oxazepam (Serax)* The best in sundown syndrome (seen in Alzheimers) Advantage: Not hepatotoxic

ANXIOLYTICS/ANTI-ANXIETY I. BENZODIAZEPINE

Lorazepam (Ativan)* 2nd drug for sundown syndrome Triazolam (Halcion)* Anti-insomnia Temazepam (Restoril)* Anti-insomnia Flurazepam (Dalmane)* Anti-insomnia; do not stop abruptly  because of rebound grand mal seizure Midazolam (Dormicum)

Prazepam (Centrax)

ANXIOLYTICS/ANTI-ANXIETY I. BENZODIAZEPINE

Chlordiazepoxide (Librium)* 2nd drug of choice for delirium tremens Chlordiazepoxide (Librium), multivitamins, thiamine and folic acid help decrease withdrawal symptoms of alcohol withdrawal. Positive outcome of Librium in alcoholic depressed woman includes an observation that client can pick an object on floor w/ smooth coordination Clonazepam (Klonopin) Halazepam (Paxipam)

ANXIOLYTICS/ANTI-ANXIETY I. BENZODIAZEPINE

Side Effects #1: Vital sign to be monitored: Respiratory Rate due to its Lethal Side Effect; Respiratory Depression

1. Early Side effects  decrease LOC  Lethargic Late/Fatal side effects decrease RR  Respiratory Depression  RR below 12
Avoid strenuous activities Antidote for Benzodiazepine intoxication: FLUMAZENIL (ROMAZICON); an anxiolytic antagonist

ANXIOLYTICS/ANTI-ANXIETY

II. BARBITURATES
Action: Used as an anticonvulsant besides being a sedative
Code: TAL / AL

Secobarbital (seconal) Phenobarbital (luminal)* commonly used anticonvulsant barbiturate Methohexital (Brevital) Amobarbital (Amital) Methobarbital (Methalba)

ANXIOLYTICS/ANTI-ANXIETY

III. A TYPICAL ANXIOLYTICS
Meprobamate (Equanil, Milltown) Chloral Hydrate (Noctec) Hydroxyzine (Atarax, Iterax, Vistaril)* anti emetic & antihistamine Diphenhydramine (Benadryl)* Antiparkinsons, Antihistamine,and an Anxiolytic (addictive) Zolpidem (Ambien, Stillnox) sleeping aid Doxylamine (Unisom) sleeping aid Buspirone (Buspar)* will take 1 week before the effect could be seen

a. Barbiturates (given above) b. Benzodiazepines (given above) c. Hydantoins (code: toin) Phenytoin (Dilantin)  best anticonvulsant petit mal seizures for children SE: Gingival hyperplasia & pinkish urine, alopecia, hyperglycemia, Intervention: Massage the gums & use soft bristle toothbrush

Hydantoins

Adverse Effect: Blood dyscrasia- thrombocytopenia S/SX: Bleeding of the gums Lab test: Platelet count = 150,000-400,000; if ↓100,000-active bleeding Special Considerations: The only COMPATIBLE I.V. Solution for Phenytoin (dilantin) is NSS (Normal Saline Solution) • Ethotoin (Peganone) • Mephenetoin (Mesantoin)

d. Miscellaneous
e. Carbamazepine (Tegretol)  trigeminal neuralgia (tic douloureux) A/E: Agranulocytosis – S/Sx: Sore throat MgSO4 The best tocolytic for premature labor, also efficient as an anti-convulsant for Eclampsia or PIH. Early side effects: decrease deep tendon reflex and oliguria (renal failure). Fatal/Late Side Effect: Respiratory Depression (assess the RR if it is below 12 /min).
Valproic Acid (Depakene) therapeutic serum level: 40-100 mcg Adverse Reaction: Hepatotoxic (assess SGPT or ALT)

e.Succinimides (code: suximide) Ethosuximide (Zarantoin)

Methoximide (Celontin)
Phensuximide (Milontin)

ANTIPSYCHOTICS
Another word: Neuroleptic / Major Tranquilizers

USES: Schizophrenia, acute mania, depression and organic conditions; Non-psychiatric cases: Nausea and vomiting, pre-anesthesia, intractable hiccups.
Antipsychotics can only decrease the positive symptoms of schizophrenia, but not the negative symptom such as ambivalence. Action:↓ delusion, hallucinations, looseness of association to decrease levels of dopamine in the

ANTIPSYCHOTICS

I. PHENOTHIAZINE Code: AZINE Fluphenazine (Prolixin)* Acetophenazine (Tindal) Pherphenazine (Trilafon) Promazine (Sparine) Chlorpromazine (Thorazine)*#1 that causes photosensitivity/photophobia; Side effects: Causes also red orange urine. In liquid form is usually put in a chaser  Chaser: 60-100ml juice (prone or tomato); to prevent constipation & contact dermatitis; taken with straw (bite straw & sip)

ANTIPSYCHOTICS
MESORIDAZINE (SERENTIL) Thioridazine (Mellaril)* ceiling dose/day: 800 mg  Adverse Effect: Retinitis pigmentosa

Prochlorperazine (Compazine)* #1 commonly used anti emetic Trifluoperazine (Stelazine)

ANTIPSYCHOTICS
II. BUTYROPHENONES Code: PERIDOL Haloperidol (Haldol, Serenase)* #1 drug used for extreme violent behavior Instruct patient taking Haldol to wear sunscreen Droperidol (Inapsine) III. THIOXANTHENES Code: THIXENE Chlorprothixene (Taractan) Thiothixene (Navane)

ANTIPSYCHOTICS
IV. ATYPICAL ANTIPSYCHOTICS Code: DONE / ZAPINE or APINE Olanzapine (Zyprexia) Clozapine (Clozaril) #1 that causes Agranulocytosis & Blood Dyscrasia “I will need to monitor my blood level to continue my medication.” shows a correct understanding of a patient while taking Clozaril. Loxapine (Loxitane) Risperidone (Risperidone) #1 drug for Korsakoff’s psychosis Molindone (Moban) Aripiprazole (Abilify) newest antipsychotic drug

SIX COMMON ANTICHOLINERGIC SIDE EFFECTS OF ANTIPSYCHOTICS
(Anticholinergic effects are drug actions of antipsychotic drugs because they BLOCK MUSCARINIC CHOLINERGIC RECEPTORS) CODE: BUCO PanDan – anticholinergic S/Es

CODE: BUCO PanDan – anticholinergic S/Es
1. Blurring of Vision - ↑ sympathetic reaction (don’t operate machinery); Mydriatic – pupil dilate  sympa  ↑ IOP  don’t use in glaucoma 2. Urinary Retention – Nursing Interventions: 1. Provide Privacy – give bed pan 2. Sounds of dripping water – faucet 3. Intermittent cold & warm compress

CODE: BUCO PanDan – anticholinergic S/Es

3. Constipation Nursing Interventions: 1. Prevent constipation ↑ fiber (residue) roughage, prune/pineapple/papaya juice/ fruits. 2. ↑ OFI 3. ↑exercise

CODE: BUCO PanDan – anticholinergic S/Es 4. Orthostatic Hypotension/Postural Hypotension Difference of BP 15-20 mm Hg above the diastole after sudden changing of position S/Sx: Pallor, dizziness Nursing consideration: Slowly change position Told patient to dangle feet first before standing

CODE: BUCO PanDan – anticholinergic S/Es 5. Pan Photosensitivity (photophobia) Nursing Intervention: 1. Use sun glasses, sun block, long sleeves or/and umbrella. Patients taking antipsychotic should be instructed to wear wide brimmed hat when going outside 6. Dan Dry mouth/ Xerostomia Prioritized Nursing Intervention: Give (1) ice chips, (2) chewing gum, (3) sips of water

ANTIDEPRESSANTS or THYMOLEPTICS

ANTIDEPRESSANTS or THYMOLEPTICS I. SELECTIVE SEROTONIN REUPTAKE INHIBITORS (SSRIs) Usually the FIRST LINE of drug. RATIONALE: FEWER SIDE EFFECTS Action: Balance Serotonin – gradual effect (usually 2 weeks) Effect: 2 wks.

ANTIDEPRESSANTS or THYMOLEPTICS
I. SELECTIVE SEROTONIN REUPTAKE INHIBITORS (SSRIs)

Code: XETINE/ODONE Fluoxetine HCl (Prozac) – causes too much dry mouth (xerostomia) Paroxetine HCl (Paxil) Trazodone (Desyrel)) – adverse effect: Priapism (prolonged use) Nefazodone (Serzone) Fluvoxamine (Luvox) Sertraline (Zoloft) – causes GI upset (diarrhea, insomnia): always with meals Venlafaxine (Effexor) Citalopram (Celexia)

COMMON SIDE EFFECTS:
1. Weight Loss 2. Insomnia (single am dose) Nursing Considerations: 1. For insomnia: a. Induce sleep thru: 1. Warm bath (systemic effect) 2. Warm milk/banana (active substance: tryptophan) 3. Massage b. Give meds in single AM dose Antidepressants are best taken after meals

ANTIDEPRESSANTS or THYMOLEPTICS
II. SECOND GENERATION TRICYCLIC ANTI DEPRESSANT

Action: Increases norepinephrine and/or serotonin levels in CNS by blocking their uptake by presynaptic neurons or it balances Serotonin & Epinephrine levels.

Effect: 2-4 wks.

ANTIDEPRESSANTS or THYMOLEPTICS
II. SECOND GENERATION TRICYCLIC ANTI DEPRESSANT

Code: PRAMINE/TRYPTILLINE Clomipramine HCl (Anaframil) #1 for OCD* Imipramine (Tofranil)* the best drug for enuresis Amitryptilline (Elavil) Protryphilline (Vivactil) Maprotilline (Ludiomil) Norpramine (Desipramine) #1 antidepressant for elderly depression. RATIONALE: Fewer anticholinergic S/E

ANTIDEPRESSANTS or THYMOLEPTICS
II. SECOND GENERATION TRICYCLIC ANTI DEPRESSANT

Code: PRAMINE/TRYPTILLINE
Nortryptilline (Pamelor, Aventyl) Trimipramine ( Surmontil) Buproprion (Wellbutrin) 400 mg/day*(ceiling dose) EXCESS INTAKE: Grand mal seizure Doxepine (Sinequan) Amoxapine (Asendin)

COMMON SIDE EFFECTS: 1. Sedation (best given at night) 2. Weight gain Nursing Consideration: 1. Give meds at night #1 adverse effect – cardiac dysrhythmias #1 screening test before taking TCA – ECG When a depressed client taking TCA shows no improvement in the symptoms, the nurse must anticipate the physician to discontinue TCA after two weeks and start on Parnate. Nursing intervention before giving the drug includes checking the BP to assess for orthostatic hypotension.

ANTIDEPRESSANTS or THYMOLEPTICS
III. MAOI – MONO AMINE OXIDESE INHIBITOR

ACTION: Psychomotor stimulator or psychic energizers; block oxidative deamination of naturally occurring monoamines (epinephrine, NOREPINEPHRINE, serotonin) → CNS stimulation Effect: 2 weeks CODE: PAMMANA Parnate (tranylcypromine) Marplan (Isocarboxacid) Mannerix (Moclobemide) *the newest MAOI Nardil (Phenelzine SO4)

ANTIDEPRESSANTS or THYMOLEPTICS
III. MAOI – MONO AMINE OXIDESE INHIBITOR

CONTAINDICATIONS: TYRAMINE + MAOI = HYPERTENSIVE CRISIS 1. Tyramine rich-food, high in Na & cholesterol Hypertensive Crisis 1. Aged cheese (except cottage cheese, cream cheese), Cheddar cheese and Swiss cheese are high in tyramine and should be avoided. 2. Canned foods such as sardines, soy sauce & catsup 3. Organ meats (chicken gizzard & liver) & Process foods (salami/bacon) ↑ Na 4. Red wine (alcohol)

ANTIDEPRESSANTS or THYMOLEPTICS
III. MAOI – MONO AMINE OXIDESE INHIBITOR

5. Soy sauce 6. Cheese burger 7. Banana, papaya, avocado, raisins (all over ripe fruits except apricot) 8. Yogurt, sour cream, margarine; 9. Mayonnaise 10. OTC decongestants 11. Pickled foods, Pickled herring 12. Other Foods contraindicated in MAOI therapy includes figs, bologna, chicken liver, meat tenderizer, , sausage, chocolate, licorice, yeast, sauerkrauts.

ANTIDEPRESSANTS or THYMOLEPTICS
III. MAOI – MONO AMINE OXIDESE INHIBITOR

Antidote for Hypertensive Crisis: CALCIUM CHANNEL BLOCKERS (-DIPINE) 1. Verapamil (Calan) 2. Phentolamine (Regitine)  also the #1drug for Pheochromocytoma (tumor in the medulla)

ANTICOAGULANTS

ANTICOAGULANTS

CODE: PARIN, RIN

Indication: to prevent clot formation. Used in MI, cardiac catheterization, pulmonary embolism.
Warfarin (Coumadin) Heparin , Enoxaparin (Lovenox), Ardeparin, Dalteparin

COMPARISON OF CHARACTERISTICS OF ANTICOAGULANT DRUGS
Heparin Onset of Action: Route of Administration: Duration of Action: Lab Test: Antidote: Immediate Parenteral Short (<4hrs) PTT or APTT Protamine SO4 Coumadin Slow (24-48hrs) Oral Long (approximately 2-5 days) PT Vitamin K or aquamephyton

Cost

Expensive

Inexpensive

1. WARFARIN
Action:  Interferes with the hepatic synthesis of vitamin K-clotting factors (II, VII, IX, and X)

Indication:
Undesirable Effects:

 Prevents or slow extension of a blood clot
 Anorexia, nausea, diarrhea; rash; bleeding, hematuria, thrombocytopenia, hemorrhage

Warnings:

 Pregnancy; hemorrhagic tendencies such as hemophilia, thromb-ocytopenia purpura, leukemia; peptic ulcer; cerebral vascular accident (CVA); severe renal.  DIC, Blood dyscrasia, liver & kidney diseases

Other Specific AVOID THE FOLLOWING !!!! Information H2 blockers , Aspirin, Phenytoin, Oral : Hypoglycemics & NSAIDS ( avoid HAPON!) Foods: Green leafy vegetables (Vitamin K) decrease Effectiveness (i.e. asparagus, cabbage, cauliflower, turnip greens, and other green leafy vegetables)  Drugs: decrease Effectiveness - Phenytoin Oral contraceptives, Rifampin,Estrogen (PORE). Increase Risk of bleeding with chamomile, garlic, ginger, ginkgo, and ginseng therapy. There are numerous interactions.

Interventions:

A Warfarin’s antidote is Vitamin K (Aquamephytoin). Laboratory test is PT  Check all drugs for potential drug-drug interactions.

Education:

Evaluation of PT/INR will be required to regulate dosage. Report any unusual bleeding. Review a diet low in vitamin K. Wear a medical identification card or jewelry. No strenuous activities (skydiving, long distance running, football). Review bleeding protocol (i.e., electronic razors, soft toothbrushes, etc.)
Medical Alert: Always advise other providers (i.e., dentists, surgeon, etc.) of medication. No OTC medication without provider approval.

Evaluation:

PT will have a value of 1.5 to 2.5 times the control value in seconds; the INR will be 2-3. Normal PT is 9-11 seconds times 1.5 to 2.5 times the normal value. The client will have no signs or symptoms of bleeding.

2. HEPARIN SODIUM
Action:  Combines with antithrombin III to retard thrombin activity.  Low molecular-weight heparin blocks factor Xa, factor IIa.     Thrombosis Reduces risk of myocardial infraction (MI) CVA Clots associated with atrial fibrillation: pulmonary embolism

Indications:

Undesirable Effects: Other Specific Informatio:

 Hemorrhagic tendencies: hematuria, bleeding gums, frank hemorrhage  Risk of bleeding with chamomile, garlic, ginger, ginkgo, and ginseng therapy.

Interventions:

Monitor PTT (usually 1.5- 2.5 times control values) and platelet count. Monitor for signs of unusual bleeding (petechiae, hematuria. GI bleeding, gum bleeding). Initiate bleeding protocol measures (use electric razors, hold pressure for 5 minutes with venipunctures, soft toothbrushes). Monitor IV site carefully. Heparin has short half life, therefore, with discontinuation, PTT will usually return to baseline within 1-2 hours. Have protamine sulfate available as an antidote. *Monitor clotting time; normal is 8-15 minutes; maintain clotting time 15-20 minutes

Education:

Inject SQ into the abdomen with 25-28g at 90 degrees  angle; don’t aspirate or rub injection site  Explain bleeding protocol precautions.  Explain the need of several PTT evaluation.  Teach signs of unusual bleeding.  Avoid activities with risk of injury.  Caution with sharp utensils while cooking or eating.  Avoid salicylates or any OTC medication without approval from provider.  Wear identification that notes anticoagulant therapy.  Inform provider of therapy prior to surgical procedure.

Evaluation:

Heparin’s antidote is Protamine Sulfate. Laboratory test is aPTT. Normal PTT is 60-70 seconds Normal aPTT is 20-36 seconds times 1.5 to 2.5 times the normal value.

Drugs:

 Heparin Sodium (Hyperlin)  Low Molecular Weight Ardeparin (Normiflo); (Frafmin); Danaparoid Enoxaparin (Lovenox)

Heparins: Dalteparin (Organ);

THROMBOLYTIC MEDICINES

CODE: ASE / KINASE Example: Alteplase / Urokinase/ Streptokinase/ Reteplase/ Retavase Salteplase (Activase, t-PA tissue plasminogen activator); Abbokinase, Streptase, Kabikinase)

THROMBOLYTIC MEDICINES
Action: Binds with plasminogen causing conversion to plasmin which dissolves blood clots. Activates plasminogen which generates plasmin .  The best drug to DISSOLVE clot , such as pulmonary embolism & myocardial infarction

Indications:  Dissolves blood clots due to coronary artery thrombi, deep vein thrombosis, and pulmonary embolism. . Used 4-6 hrs after MI to restore blood flow, limit myocardial damage, and preserve left ventricular function.

THROMBOLYTIC MEDICINES
Warnings:  Active internal bleeding; recent CVA; aneurysm, hypertension; anticoagulant therapy; ulcerative colitis.  Severe allergic reactions to either anistreplase or streptokinase. Monitor for bleeding, hypotension & tachycardia .Handle clients minimally & let clients use electric razors & brush teeth gently.  Effects of drug disappear within a few hours after discontinuing but the systemic effect of coagulation and the risk of bleeding may persist for 24 hours.  Increase in risk for bleeding with heparin, oral anticoagulants, antiplatelet drugs and NSAIDs.

Other Specific Information:

THROMBOLYTIC MEDICINES
Interventions  Apply direct pressure over a puncture site for 20 – 30 minutes :  Monitor CBC especially hgb/hct, coagulation tests.  Evaluate bleeding at a sutured wound, arterial site, central line.  Monitor vital signs during and after infusion.  Monitor EKG for re-perfusion dysrhythmias.  Watch for unusual bleeding disturbance (GI, GU)  Initiate bleeding protocol measures for several hours (e.g., no venipunctures, repetitive manual blood pressure, or removal of IV lines or catheters). Antidote: Aminocaproic Acid (Amicar)

ANTIPLATELET: ASPIRIN
Action:  Platelet aggregation inhibitor; inhibitis platelet synthesis of thromboxane A2, a vasoconstrictor and inducer of platelet aggregation. This occurs at low doses and lasts for 8 days (life of the platelet).  TIAs, CVAs with a history of TIA due to fibrin platelet emboli.  Reduces risk of death from MI in clients with a history of infarction or unstable angina.  Allergy to salicylates or NSAIDs.  Bleeding disorders, renal or hepatic disorders, chickenpox, influenza (risk of Reye’s in syndrome in children), pregnancy, lactation.

Indications:

Warnings:

ANTIPLATELET: ASPIRIN
Warnings:  Allergy to salicylates or NSAIDs.  Bleeding disorders, renal or hepatic disorders, chickenpox, influenza (risk of Reye’s in syndrome in children), pregnancy, lactation.

Undesirable Effects:

 GI discomfort, bleeding, dizziness, tinnitus

Other Specific Information:

  Risk of bleeding with anticoagulants, thrombolytics   Risk of GI ulceration with alcohol, NSAIDs, phenylbutazone, steroids.

ANTIPLATELET: ASPIRIN
Interventions:  Monitor liver and renal function tests, CBC, clotting times, stool guaiac, blood drug levels, and vital signs.

Education:

 Instruct to take drug with food and a full glass of water.  Do not crush and do not chew sustained-release preparations.
COMMON DRUGS: Code: D CAT

Drugs:

Dipyridamole(persantine) Clopidogrel(plavix) Aspirin(ASA) Ticlopidine(Ticlid)

 Aspirin (Bayer, Bufferin, Ecotrin)  Other antiplatelet drugs are listed below, however, there are numerous differences between each drug : Abciximab (Reopro); Cilostazol (Pletal); Eptifibatide (Integrilin); Sulinpyrazone (Anturane); Tirofiban (Aggrastat)

CARDIOVASCULAR DRUGS

CARDIOVASCULAR DRUGS

ANTIHYPERTENSIVES CODE NAME: AAABCCD (short cut for anti-hypertensi

Angiotensin Converting Enzyme Inhibitor or Antagonist (ACE Inhibitor) Angiotensin II Receptor Blocker (ARBS) Alpha Adrenergic Blockers Beta Adrenergic Blockers Calcium Channel Blockers Central Acting Sympatholytics /Adrenergic Blockers Direct Acting Vasodilators Angiotensin Converting Enzyme Inhibitor or Antagonist (ACE Inhibitor)

Angiotensin Converting Enzyme Inhibitor or Antagonist (ACE Inhibitor) ACTION: prevent vasoconstriction by blocking angiotensin 1 to angiotensin 2 USE: hypertension, adjunctive therapy in CHF, PREVENTS SEVERE HEART FAILURE following M.I. in clients with IMPAIRED LEFT VENTRICULAR FUNCTION and prevents kidney failure in Type 2 Diabetes.

EXAMPLES: Captopril (Capoten)

ONE HOUR BEFORE MEALS Enalapril (Vasotec) Ramipril (Altace)
Side Effects: CHIT – B C: cough persistent H: Hyperkalemia and Hypoglycemia I: Impotence and Insomnia T: Taste decreases B: Bleeding

Angiotensin II Receptor Blocker (ARBS)
ACTION: blocks the binding of angiotensin II to the Angiotensin 1 , and also blocks the release of aldosterone resulting in a decrease BP. USE: Hypertension Code: SARTAN Examples: Losartan (Cozaar) Eprosartan (Teveten) Candesartan (Atacand) Side Effects: Upper Respiratory Infection (cough); Diarrhea Adverse Effect: Nephrotoxic / Hepatotoxic

ALPHA ADRENERGIC BLOCKERS
ACTION: blocks the alpha 1 adrenergic receptors resulting in vasodilation of arteries and veins, decreases peripheral resistance and relaxes smooth muscle of bladder and prostate. USE: Hypertension, Prazocin used in CHF and Doxazocin used in BPH. Code: ZOCIN
Examples: Doxazocin (Cardura) Prazocin (Minipress) Terazocin (Hytrin)

ALPHA ADRENERGIC BLOCKERS SIDE EFFECTS: SI – DUD Syncope Impotence Depression Urination Dry mouth ADVERSE EFFECTS: Nephrotoxicity

BETA ADRENERGIC BLOCKERS

ACTION: binds to beta 1 (cardiac) and beta 2 (lungs) adrenergic receptors sites that prevents the release of catecholamine.
USE: Angina, Hypertension, anxiety disorders, as a Group II anti dysrhythmias CODE: OLOL

BETA ADRENERGIC BLOCKERS
SIDE EFFECTS: P - BBNDAH Psychotic Features Bradycardia Bronchoconstriction Nightmares Depression Agranulocytosis Hypoglycemia

NEVER USED IN PATIENTS WITH COPD, CVA, CHF, HEPATIC DISEASE, GRAVES, and BRADYCARDIA

CALCIUM CHANNEL BLOCKERS ACTION: Decrease contractility (negative inotropic effect by relaxing the smooth muscle) and the workload of the heart thus decreasing the need for oxygen. It also causes coronary and peripheral vasodilation. USE: Group IV antidysrythmia, vasodilator and anti hypertensive drug.

CALCIUM CHANNEL BLOCKERS
CODE: DIPINE except Verapamil (Calan) and Diltiazem (Cardizem) SIDE EFFECTS: CAP Constipation AV block (therefore never give it to patients with CHF) Peripheral Edema ADVERSE EFFECTS: Hepatotoxic and Nephrotoxic

CENTRAL ACTING SYMPTHOLYTICS / ADNEGERNIC BLOCKERS
ACTION: Decreases the release of adrenergic hormones from the brain resulting in decrease peripheral vascular resistance and blood pressure.
MC G Methyldopa (Aldomet) Clonidine (Catapress) Guanabenz (Wytensin)

CENTRAL ACTING SYMPTHOLYTICS / ADNEGERNIC BLOCKERS SIDE EFFECTS: DIES Depression Impotence Edema (if more than 4 lbs/week) Sodium & Water retention ADVERSE EFFECT: Hepatotoxic

DIRECT ACTING VASODILATORS
ACTION: uses arterial vasodilatation

Nitroglycerin causes DECREASE LAV M
DECREASE Left Ventricular Workload DECREASE Arterial BP DECREASE Venous return DECREASE Myocardial O2 Consumption

DIRECT ACTING VASODILATORS
SIDE EFFECTS: HEN G Headaches (orthostatic Hypotension) Edema Nasal Congestion GI Bleeding Examples: D MANN Diazoxide (Hyperstat) Minoxidil (Lomiten) Apresoline (Hydralazine) Nitropruside (Nipride)

NITROGLYCERIN (Nitrobid, Nitrostat)

Action:

 Relaxes the vascular smooth system.  ↓ Myocardial demand for oxygen.  ↓ Left ventricular preload by dilating veins thus indirectly ↓ afterload.  Headache (most common), hypotension, postural hypotension, syncope, dizziness, weakness, reflex tachycardia, paradoxical bradycardia.  Sublingual: burning, tingling sensation in mouth.  Ointment erythematous, vesicular and pruritic lesions.

Undesirable Effects:

NITROGLYCERIN (Nitrobid, Nitrostat)
Interventions:  Record characteristics and precipitating factors of anginal pain.  Monitor BP and apical pulse before administration and periodically after dose.  Have client sit or lie down if taking drug for the first time.  Client must have continuing EKG monitoring for IV administration.  Cardioverter / defibrillator must not be discharged through paddle electrode overlying Nitro-Bid ointment or the Transderm-Nitro patch (may cause burns on client).  Assist with ambulating if dizzy.

NITROGLYCERIN (Nitrobid, Nitrostat)
Education:  Avoid alcohol.  Teach to recognize symptoms of hypotension.  Advise to make position changes slowly and to avoid prolonged standing.  Teach about the form of nitroglycerin prescribed.  Oral: Instruct to take on an empty stomach with a full glass of water. Do not chew tablet  Sublingual: Instruct to take at first sign of anginal pain. May be repeated every 5 minutes to a maximum of 3 doses. If the client doesn’t experience relief, advise to seek medical assistance immediately.  A stinging or biting sensation may indicate the tablet is fresh. With newer SL nitroglycerin, the biting sensation may not be present.  Protect drug from light moisture, and heat.  Instruct to apply Transderm-Nitro patch once a day, usually in the morning.  Rotation of sites is necessary.

NITROGLYCERIN (Nitrobid, Nitrostat)
Drugs:  Nitroglycerin intravenous (Nitro-Bid IV, Tridil)  Sublingual (Nitrostat)  Sustained-release (Nitroglyn, Nitrong, Nitro-Time)  Topical (Nitro-Bid, Nitrol, Nitrong, Nitrostat)  Transdermal (Deponit, Minitran, Nitro-Dur, Nitrodisc, Transderm-Nitro, Nitro-Derm)  Translingual (Nitrolingual)  Transmucosal (Nitrogard)

CARDIAC GLYCOSIDES

Code: Dig Example: Digoxin (lanoxin) Digitoxin (Crystodigin)

CARDIAC GLYCOSIDES
Action:  Inhibits the sodium-potassium ATPase, resulting in cardiac construction.  Effect: Positive Inotropic (increase Contraction of the heart) Negative Chronotropic (slows Cardiac ratedepresses SA node- bradycardia) Negative Dromotropic (slows conduction velocity)

Indication:

 THE BEST DRUG OF CHOICE FOR CHF  for CHF, atrial tachycardia, atrial fibrillation & atrial flutter.

CARDIAC GLYCOSIDES
Side Effects: 1st / Initial: Nausea & Vomiting(adult) Confusion(elderly) 2nd: Bradycardia 3rd: Hypokalemia (highest in K rich food is apricot and avocado, next is potato and raisins) Adverse Rxn/ Late: Yellow & Green Vision Special Consideration: Never give with FOOD. Check the pulse before & after giving. Compare the apical and the radial pulse in a FULL minute. Check the therapeutic serum level which is .5- 2 ng/ml Contraindicated: MI, heart blocks & PVC

CARDIAC GLYCOSIDES
Other Significant Information:  ↓ K; ↓ Mg”, and ↑ Ca “may be associated with digitalis toxicity.  Administer separately from antacids (1 to 2 hours apart).  Use cautiously with calcium channel blockers or beta blockers.  Monitor K+, Mg++, ECG, liver/renal function tests, drug level (therapeutic level 0.5-2.0 ng/ml. toxity is > 2.0 ng/mL).  Before each dose, assess apical pulse for full minute; record and report changes in rate or rhythm.  Withhold drug and contact provider if pulse is < 60/minute or > 100 (adults) or <1 10 minute (children) unless provider has outlined specific parameters.  Weigh daily, monitor I O, and signs has CHF.

Interventions:

CARDIAC GLYCOSIDES
Education:  Teach to take pulse correctly and report if pulse is out of parameter.  Weigh every other day and record.  Restrict alcohol, sodium and smoking.  Eat food rich in potassium.  Wear medical alert tag. Emphasize importance of regular checkups.

Evaluation:  Normal sinus rhythm on ECG. Clinical improvement as evidenced by no S3, edema, etc.  Cardiomegaly decreased.
Antidote Antidote: Digibind Fab

ANTIHYPERTENSIVE

ANTIHYPERTENSIVE
STEP 1. Diuretic (1st step for younger clients with tachycardia and marked liability of BP) STEP 2. Beta-Blocking Agent Beta 1 Adrenergic (Cardioselective) Blocking Agents: Acetabulol (Sectral); Atenolol (Tenormin); Metoprolol (Betaloc) Beta 1 and 2 (Nonselective) Blocking Agents: Nadolol (Corgard), Pindolol (Visken), Propranolol (Inderal, Novopranol), Timolol Adrenergic Inhibiting Agent Clonidine, Methyldopa, Reserpine, Prazoline Usually diuretic added to prevent fluid retention STEP 3. Vasodilator Agent Hydralazine Added with adrenergic blocking agent and diuretic decrease workload STEP 4. Guanethedine, Minoxidil or Angiotensin Inhibitors Captopril or Analapril

ANTIDYSRHYTHMIC

ANTIDYSRHYTHMIC
GROUP 1 - Generally inhibit the fast sodium channel in cardiac muscle resulting in an increased refractory period

a.Disopyramide phosphate (Norpace); Procainimide HCl (Procan); Quinidine (Quinidex)
b.Lidocaine (Xylocaine) c. Flecainide

GROUP 2-Beta blockers that decrease stimulation of the heart •Beta 1 Selective Antagonists Cardiogenic Blockers; Block Beta 1 cardiac receptors Atelonol (Ternonim), Acebutolol Sectral, Metoprolol (Betaloc) •Beta 2 Selective Antagonists Mucolytics and Bronchodilators •Nonseletive Beta Adrenergic Blocking Agents; (Beta 1 and Beta 2 Blockers) Nadolol (Corgard); Oxyprenelol (Trasicor); Pindolol (Visken);

ANTIDYSRHYTHMIC

ANTIDYSRHYTHMIC
Group 3 - Generally do not affect depolarization but work by prolonging cardiac repolarization • Anti adrenergic; Positive inotropic action • Bretylium, Amiodarone HCl (Cordarone)

Group 4 • Calcium antagonist action - Depression of heart and smooth muscle contraction, decreased atomaticity and decreased conduction velocity • Verapamil

RESPIRATORY AGENTS

1. BRONCHODILATORS

Respiratory Agents

a. Breathing and Coughing Techniques: This will facilitate the removal of respiratory secretions and optimize oxygen exchange. b. Relation Techniques: Since anxiety may result in respiratory difficulty, review ways to alleviate anxiety such as music and relaxation techniques. c. Evaluate Heart Rate and BP: Teach client to monitor heart rate and BP since an undesirable effect of these medications may be tachycardia, cardiac arrthymias, and a change in blood pressure. (Beta2, Adrenergic Agonists can cause hypertension; methylxanthines can cause hypotension at theophylline levels > 30-35 mcg/ml.)

1. BRONCHODILATORS

Respiratory Agents

d. Arm Identification: Recommend clients having asthmatic attacks to wear an ID bracelet or tag. e. Tremors: Evaluate client for tremors from these medications. Have 8 or more glasses of fluids. Fluid will assist in decreasing the viscosity of the respiratory secretions.
f. Emphasize No Smoking: Encourage the client to stop smoking under medical supervision.

2. ANTIHISTAMINES
CODE: tadine, amine, ramine
Action: Indications:

Respiratory Agents

Blocks histamine at H, receptors Upper respiratory allergic disorders, anaphylactic reactions; blood transfusion reactions; acute urticaria; motion sickness. Allergies, acute asthmatic attack, respiratory disease, hepatic disorder, narrow-angle glaucoma, symptomatic prostatic hypertrophy, pregnancy, lactation. CODE: BUCO PD Blurring of Vision, Urinary Retention, Constipation, Orthostatic Hypotension, Photosensitivity & Dry Mouth

Warnings:

Side Effects:

2. ANTIHISTAMINES

Respiratory Agents

Interventions:  Monitor vital signs, intake and output. If secretions are thick, use a humidifier.

Education:

 Instruct client to take with food; drink minimum of 8 glasses of fluid per day.  Advise to do frequent mouth care; may use sugarless gum, lozenges, or candy.  Notify provider if confusion or other undesirable effects occur.  Instruct client not to drive or operate machinery if drowsiness occurs or until response to drug has been determined.  For prophylaxis of motion sickness, recommend taking 30-60 minutes before traveling. Avoid alcohol and other CNS depressants.

2. ANTIHISTAMINES
Drugs:

Respiratory Agents

Loratadine, Azatadine, Cyproheptadine, Cyproheptadine (Periactin), Diphenhydramine, Chlorpheniramine, Dexchlorpheniramine (Polaramine), Doxylamine, Phenylpropanolamine, Brompheniramine  Others: Azelastine (Astelin); Buclizine (Bucladin-S); Cetirizine (Zyrtec); Clemastine (Tavist); Cyclizine (Mazerine); Dimenhydrinate (Dramamine); Fexofenadine (Allegra); Hydroxyzine (Atarax, Vistaril); Loratidine (Claritin); Meclizine (Antivert); Promethazine (Phenergan); Tripelen-namine (PBZ)

3. BRONCHODILATOR
CODE: terol, terenol, phrine, phylline
Action:

Respiratory Agents

 Stimulates beta receptors in lung. Relaxes bronchial smooth muscle.  Increases vital capacity, decreases airway resistance.

Indications:  the best drug for COPD or CAL (chronic airflow limitation)  Asthma, bronchitis, emphysema, relief of bronchospasm occurring during anesthesia, exercised-induced bronchospasm.
Warnings:  Hypersensitivity, angina, tachycardia, cardiac arrhythmias, hypertension, cardiac disease, narrow-angle glaucoma, hepatic disease.

3. BRONCHODILATOR
Side effects:

Respiratory Agents

 Sympathetic Side Effects such as palpitation, tachycardia, restlessness, nervousness, Hyperglycemia, hypertension, cardiac dysrhythmias.  Caution with clients with glaucoma & HPN Special Consideration: Avoid Upperscaffeine, cola & tea. Be careful in giving bronchodilators with DIABETES (hypoglycemia). Remember that the therapeutic serum level of theophylline is 10-20mcg/ml. Theophylline when given intravenously should be given SLOWLY. If not sympathetic reactions will occur.

Other Specific Information:

3. BRONCHODILATOR
Interventions: Education:  Check for cardiac dysrhythmias.

Respiratory Agents

 Notify provider taking other medicines or if symptoms are not relieved. Watch our for status asthmaticus.  Demonstrate correct use of inhalers or nebulizers. Teach about metered-dose inhalers (MDI). When two puffs are needed, 1-3 minutes should lapse between two puffs. A spacer may be used to increase the delivery of the medication. Always prioritized using FIRST the bronchodilator before using steroids or another drug such as a mucolytic. * Avoid caffeine products Albuterol, Isoproterenol, Formoterol, Bitolterol, Levalbuterol, Epinephrine, Aminophylline,Theophylline, Oxtriphylline

Drugs:

4. STEROIDS
CODE: sone, one, solone
Action:

Respiratory Agents

 Synthesized by adrenal cortex.  Exhibits antiinflamatory properties suppress the normal immune response.  Increases carbohydrate, fat and protein metabolism.

Indications:  Adrenal replacement therapy, immunosuppressant and increases fat & carbohydrate metabolism  Antiinflammatory, immunosuppressant dermatological disorders  Replacement in adrenal cortical insufficiency.

4. STEROIDS
Undesirable Effects:

Respiratory Agents Code name: GO CHAT!!! G.I. upset, Osteoporosis, Cushing like symptoms & Calcium is decrease, High glucose & Sodium, Addisonian Crisis (if abruptly withdrawn) , Tachycardia .  Initial Side Effect: Hyperglycemia  Late Side Effect: Immunocompromised  Always with food may cause Peptic Ulcer, monitor BP for Hypertension, do not abruptly discontinue the drug ,may cause Addisonian Crisis, Moon Face, Cushing like Symptoms  Monitor VS, BP, weight, blood glucose, electrolytes, EKG, and TB skin test results.

Other Specific Information:

Interventions:

4. STEROIDS
Education:

Respiratory Agents
 Special Considerations: Always With Food. Gradually Taper. Do not receive vaccination .High Calcium diet & Vitamin D. Steroids mask the symptoms of Infection. Avoid Potassium wasting diuretics – it increases HYPOKALEMIA. Anticoagulants decrease the effects of Steroids.  Instruct to administer oral drugs with food or milk early in the morning, withdraw medication slowly or taper off gradually under medical supervision.  Follow-up visits and lab tests are essential.  Avoid infection.  Wounds may heal slowly.  Do not receive vaccination.  Do not take aspirin or any medication without consulting provider.  Discuss a diet low in sodium, high in vitamin D, protein and potassium.  Avoid sun light on treated area.  Recommend wearing a medical alert tag.

4. STEROIDS
Drugs: 

Respiratory Agents

 

CODE: SONE, ONE, SOLONE Common Medications: (Baby) Bethamethasone (Celestone) usually given to premature infants, to increase Lung maturity), Dexamethasone (Decadron), Prednisone(Deltasone), Hydrocortisone (Solu-cortef), Prednisolone (Prelone), Triamcinolone (Azmacort, Kenalog, Nasacort-O) Topical: Alclometasone (Acolvate); Amcinonide (Cylocort); Clobetasol (Ternovate); Cortisone (Cortone-O); Desoride (Tridesilone); Desoximetasone (Topicort); IM, IV, OP, IN, IH); Fluocinolone (Synalar, Synemol); Flurandrenolide (Cordran); Fluocasone (Cutivate, Flonase-IN); Halcmonide (Halog); Halobetasol (Ultravate); Hydrocortisone (Cort-Dome, Cortef, Hydrocortone, Solu-Cortef – mO, IM, IV, SubQ, R); Mometasone (Elocon); ; Prednicarbate (Dermatop); Inhalation, intranasal: Beclomethasone (Beclovent, Vanceril, Benconase, Vancenase); Budesonide (Rhinocort-IN only); Flunisolide (Aerobid, Nasalide);; Oral; Fludrocortisone (Florinef); Methylprednisolone (Medrol, Solu-Medrol – IM, IV); Prednisolone (Delta-Cortef, Hydeltra, Hydeltrasol – IM, IV, Il, IA); Prednisone (Deltasone, Meticorten, Orasone). Ophthalmic: Fluorometholone (FML); Nmexolone (Vexol).

GIT MEDICINES

1. ANTACIDS AND MUCOSAL PROTECTIVES

GIT Medicines

react with gastric acid to produce neutral salts or salts of low acidity inactivate pepsin and enhance mucosal protection but do not coat ulcer to protect from acid & pepsin

used for patients with PUD & GRF (gastroesophageal reflex disease)
antacid tablets should be chewed and followed with glass of H2O or milk administer 1 hour – 2 hours apart from other meds to minimize the chance of drug interactions

1. ANTACIDS AND MUCOSAL PROTECTIVES
 Sucralfate (Carafate) CODE: Sucralfate (S for STOMACH EMPTY!) Carafate (CONSTIPATION IS THE SIDE EFFECT!)

GIT Medicines

creates a protective barrier against acid & pepsin given po & on an empty stomach A/R: constipation, impede absorption of warfarin Na,phenytoin, theophylline, digoxin & some antibiotics… Administer 2 hours apart from these meds

1. ANTACIDS AND MUCOSAL PROTECTIVES
 Magnesium Hydroxide (Milk of Magnesia)

GIT Medicines

rapid acting & A/R is diarrhea usually combined with aluminum hydroxide to counter diarrhea

1. ANTACIDS AND MUCOSAL PROTECTIVES
 Alumni Hydroxide (Amphoiel, Alu-Cap)

GIT Medicines

slow acting & A/R: constipation
with significant Na content…caution in clients with HPN & Heart failure; reduce effect of tetracyclines, warfarin Na & digoxin reduce phosphate absorption (USED IN CRF- Chronic Renal Failure)

1. ANTACIDS AND MUCOSAL PROTECTIVES
 Sodium Bicarbonate

GIT Medicines

rapid onset

A/R: liberates CO2 & increases intraabdominal pressure causing flatulence, caution in clients with HPN & heart failure, systemic alkalosis in clients with renal failure
 Calcium Carbonate (Tums)

rapid acting & A/R: constipation

2. H2 BLOCKERS

GIT Medicines

•suppress secretion of gastric acid •indicated for PUD & heart burn & for GRF ( gastro esophageal reflux disease)

CODE: TIDINE Cimetidine (Tagamet) Ranitidine (Zantac) Famotidine (Pepcid)

2. H2 BLOCKERS cimetidine (Tagamet)
*taken on an empty stomach

GIT Medicines

*administered 1 hour apart from antacids
*crosses the blood-brain barrier & may cause mental confusion, agitation, anxiety & disorientation

*dosages of these meds are reduced when taken together: warfarin Na, phenytoin, theophyllin & lidocaine
ranitidine (Zantac) *not affected by food *S/E are uncommon & does not cross blood-brain barrier

3. PANCREATIC ENZYME REPLACEMENT
CODE: PREFIX is PANCREA Pancreatin (Creon) Pancrelipase (Cotazym, Viokase, Pancrease)

GIT Medicines

*used to supplement pancreatic enzymes *taken with meals or snacks

*interacts with calcium carbonate & magnesium hydroxide

4. MEDICINES FOR HEPATIC ENCEHALOPATHY

GIT Medicines

LACTULOSE (CEPHULAC) *reduces the ammonia level *given p.o. in the form of a syrup *improves CHON tolerance in clients with advanced liver cirrhosis *lowers colonic pH from 7 to 5; acidification pulls ammonia into the bowel to be excreted in the feces thus decreasing the ammonia level NEOMYCIN (MYCIFRADIN) *reduces the number of colonic bacteria that normally convert urea & amino acids into ammonia *given p.o. or via NGT *used with caution in clients with kidney impairment

5. LAXATIVES

GIT Medicines

BULK FORMING LAXATIVES psyllium hydrophillic mucilloid (Metamucil) *absorbs water into the feces & increase bulk to form large and soft stools *C/I bowel obstruction *A/R: dehydration, electrolyte imbalance & dependent

STOOL SOFTENERS docusate calcium (Surfak), docusate sodium (Colace) *inhibit the absorption of H2O so fecal mass remains large & soft *used to avoid straining *Commonly used in CVA, MI, post op head surgeries, glaucoma and post op eye injuries so as to decrease straining and chances of complications.

5. LAXATIVES LUBRICANTS Mineral oil *soften stools, ease strain of passing stools; lessen the rritation of hemorrhoids *interferes with absorption of fat-soluble vitamins A, D, E, K

GIT Medicines

*Never use in pregnant women, may trigger premature labor

6. STIMULANTS CATHARTICS

GIT Medicines

biscodyl (Dulcolax): give 1 hour before/after antacids & milk cascara (Castor Oil): effect 2-6 hours; give with juice *stimulate motility of large intestine SALINE CATHARTICS Glycerin suppositories (Senokot); Mg hydroxide *Attract H2O to large intestine to produce bulk, stimulate peristalsis & effect begins in 2-6 hours