Pharmacology

PHARMACOLOGY Pharmacology - most simply defined as study of drug. Fundamentals of Pharmacology 1. Pharmacokinetics - study of drug’s changes as it enters and passes through the body. a. absorption b. distribution c. biotransformation d. excretion 2. Pharmacodynamics - mechanism by which drugs produce changes in body tissue. a. desired effect - intended action of drugs b. adverse effect - harmful unintended reactions c. side effects – consequence reactions d. toxicity – the degree which something is poisonous digoxin = 0.5 – 2.0 ng/mL lithium = 0.5 – 1.5 mEq/L Safety and Efficacy Nursing Principles : 1. Always verify the Five Rights . a. the right medications b. the right client c. the right dosage d. the right form, route and technique e. the right time 2. Chart drug administration only after its been given, never before. 3. Never leave the medication on cart or tray unattended. 4. Chart observed therapeutic and adverse effects accurately and fully. 5. Check history for allergies and potential drug interactions before administering a newly ordered drug. 6. Inform the prescribing physician of any observed adverse effects; if cannot be located, inform the nursing supervisor 7. Question drug orders that are unclear, that appear to contain errors, or that have potential to harm. 8. Take the following actions if an error occurs : a. immediately notify the nursing supervisor, the prescribing physician, and the pharmacist. b. assess the client’s condition and provide any necessary care. 9. For postpartum women, advice to take drugs after breastfeeding. Administration of Drugs : Routes and Nursing considerations: 1. Enteral – oral, sublingual, rectal, gastric tubes

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- capsulated pill, sustained release and enteric coated should not be crushed. 2. Parenteral – IV, IM, SQ, ID, IT, IA, epidural. - vastus lateralis (safest site for IM) 3. Topical – skin, inhalants, mucus membrane. Eye medications : - administer eyedrops first then ointment. - use a separate bottle for each client. - instruct the client to tilt the head backward, open eyes and look up. - avoid contact of medication bottle to the eyeball. - place prescribed dose in the lower conjunctival sac. - instruct the client to press the inner canthus for 30-60 seconds. - instruct the client to close the eye gently. Ear drops - in infant and children younger than 3 y.o, pull pinna downward and backward. - in older children and adult, upward and backward. - direct the solution on the wall of the ear canal, not directly on the ear drum.

CLASSIFICATIONS OF DRUGS DRUGS AFFECTING THE CENTRAL AND AUTONOMIC SYSTEM Cholinergic Agents (Parasympathomemitics) Prototype : - synthetic acetylcholine, pilocarpine, carbachol, bethanecol (Urocholine), edrophonium (Tensilon), neostigmine (Prostigmine), pyridostigmine (Mestinon). Mechanism of action : - stimulates cholinergic receptors by mimicking acetylcholine or inhibition of enzyme cholinesterase. Indications : - glaucoma, urine retention, Myasthenia Gravis - antidote to neuromuscular blocking agents : tricyclic antidepressants and atropine Adverse effects : - blurring of vision, miosis - increase in salivation, intestinal cramps - bronchoconstriction, wheezing, DOB - hypotension and bradycardia Nursing considerations : 1. Warn & monitor clients of the side effects. 2. Have atropine available for use as antidote.

Cholinergic Blocking Agents (Parasympatholytics, Anticholinergics) Prototype : ______________________________________________________________

atropine, scopalamine (Triptone), dicyclomine (Bentyl), propantheline (Pro-Banthine). Mechanism of actions : - block the binding of acetylcholine in the receptors of parasympathetic nerves. Indications : - use preoperatively to dry up secretions. - treat spasticity of GI or urinary tract. - use for treatment of bradycardia, asthma, parkinsonism. - use for antidote in organophosphate poisoning. Adverse effects : - dry mouth , dilatation of pupils, tachycardia - urinary retention, ileus, heat stroke Nursing considerations : 1. Keep client’s in cool environment. 2. Watch out for signs of heatstroke and dehydration. 3. Encourage clients to increase fluid intake and use of sugarless gum/candy for dry mouth. 4. For GI spasticity, administer 30 minutes before meals and at bed time. -

Adrenergic Agents (Sympathomimetics) Prototype : - epinephrine, norepinephrine, ephedrine, dopamine, dobutamine, phenylephrine, terbutaline, albuterol, isoproterenol. Mechanism of actions : - stimulate alpha and beta adrenergic receptor directly or trigger the release of catecholamines indirectly causing sympathetic effects. Indications : - cardiopulmonary arrest, hypotension - COPD and asthma, nasal congestions - allergic reaction, anaphylactic shock Adverse effects : - restlessness, insomnia, tremors, nausea - palpitations, angina, tachycardia, HPN Nursing considerations : 1. Contraindicated in clients w/ hyperthyroidism, pheochromocytoma & cardiovascular disease. 2. Monitor vital signs and advice precautions. 3. Should be taken with food.

ADRENERGIC BLOCKING AGENTS Prototype : a. Alpha blockers - phentolamine (Regintine), phenoxybenzamine, prazosin (Minipress), reserpine (Serpasil), terazosin (Hytrin) - clonidine (Catapress), methyldopa (Aldomet) b. Beta blockers - atenolol (Tenormin), esmolol (Brevibloc), metoprolol (Lopressor), nadolol (Corgard), propanolol (Inderal), timolol ( Blocadren) Mechanism of actions : a. alpha blockers ______________________________________________________________

- inhibits action of a-receptors in vascular smooth muscle to cause vasodilatation. b. beta blockers - compete with epinephrine in b-receptors in heart, pulmonary airways, peripheral circulation and CNS. Indications : - Raynaud’s disease, hypertension, pheochromocytoma. - angina, arrhythmias, mitral valve prolapse, glaucoma Adverse effects : - orthostatic hypotension, bradycardia, CHF - depression, insomnia and vertigo - bronchospasm and dyspnea, nasal stuffiness, cold extremities Nursing considerations : 1. Administer oral alpha-blockers with milk to minimize GI side effects. 2. Administer oral beta-blockers before meals and at a.m. if insomnia occurs. 3. Check client’s apical pulse rate before drug administration, refer if below 60 bpm. 4. Hypotensive precautions. 5. Warn clients not to drive or operate dangerous machinery until he/she has adjusted to medications.

Skeletal Muscle Relaxants Agents Prototype : - methacarbamol (Robaxin), baclofen (Lioresal), dantrolene (Dantrium), metaxalone (Skelaxin), orphanedrine (Norgesic), chlorzoxazone Mechanism of actions: - depress CNS - inhibit calcium ion release in the muscle - enhance the inhibitory action of GABA (gamma-amino butyric acid) Indications : - for acute musculoskeletal pain - for muscle spasticity associated with multiple sclerosis, cerebral palsy, CVA, and spinal cord injury. Adverse effects : - hypotonia, ataxia, hypotension, drowsiness - blurred vision, bradycardia, depression, urine retention Nursing considerations : 1. Caution clients that mental alertness may be impaired. 2. Monitor neuromuscular status, bowel and bladder functions. 3. Inform clients that maximum benefit of baclofen is attained for 1-2 months. 4. Reduce baclofen dosage gradually because of associated withdrawal symptoms : Confusion, hallucinations, paranoia & rebound spasticity.

ANTICONVULSANTS ______________________________________________________________

Prototype : a. Hydantoins - phenytoin (Dilantin) b. Barbiturates - phenobarbital ( Luminal) c. Miscellaneous - carbamazepine (Tegretol), diazepam, clorazepate (Tranxene), valproic acid (Dapakene), ethosuximide (Zarontin). Mechanism of action : - treat seizures by depressing abnormal neuronal activity in motor cortex. Adverse effects : - sedation & drowsiness, gingival hyperplasia - diplopia, nystagmus, vertigo, dizziness - thrombocytopenia, aplastic anemia Nursing considerations : 1. Advise female clients to use contraceptives. 2. Inform clients taking phenytoin that harmless urine discoloration is common. 3. Warn clients with diabetes that hydantoins may increase blood sugar level and that valproic acid may produce a false positive result in urine ketone test. 4. Teach clients receiving carbamazepine to identify symptoms of bone marrow depressions. 5. Reassure that barbiturates are not addictive at a low dosage. 6. Avoid taking alcohol with barbiturates. 7. Administer IV phenytoin slowly to avoid cardiotoxicity. 8. Avoid mixing other drugs in same syringe with phenytoin.

ANTIPARKINSONIAN AGENTS

Prototype : a. Anticholinergic agents - trihexyphenidyl (Artane), benztropine (Congentin) b. Dopaminergic agents - Levodopa, carbidopa-levodopa (Sinemet), amantidine (Symmetrel), pergolide (Permax), selegiline (Eldepryl), bromocriptine. Mechanism of actions : a. anticholinergic agents - inhibit cerebral motor centers. b. dopaminergic agents - increasing dopamine concentrations or enhancing neurotransmitter functioning. Adverse effects of dopaminergic agents: a. levodopa – nausea, vomiting, anorexia, orthostatic hypotension, dark-colored urine and sweat b. amantidine – ankle edema, constipation c. bromocriptine – palpitations, tachycardia Nursing considerations : 1. Give dopaminergic agents after meals to reduce GI symptoms. ______________________________________________________________

2. Reassure client that levodopa may cause harmless darkening of urine and sweat. 3. Avoid taking Vit B6 (pyridoxine) with levodopa because it speed up metabolism. 4. Educate clients to minimize orthostatic hypotension. 5. Elevate leg to reduce ankle edema.

CENTRAL NERVOUS SYSTEM STIMULANTS Prototype : - amphetamines, methylphenidate (Ritalin) Mechanism of actions : - increase excitatory CNS neurotransmitter activity and blocks inhibitory impulses. Indications : - for obesity (amphetamines) - attention deficit hyperactivity disorders - narcolepsy - drug-induced respiratory depressions. Adverse effects : - nervousness, insomnia, restlessness - hypertension, tachycardia, headache - anorexia, dry mouth. Nursing considerations : 1. Should be given at morning. 2. Don’t stop amphetamine abruptly to avoid withdrawal symptoms. 3. Monitor blood pressure and pulse. 4. Ice chips or sugarless gum for dry mouth. 5. Watch out for growth retardation in children taking methylphenidate.

DRUGS AFFECTING MENTAL FUNCTIONING Sedatives, Hypnotics, and Anxiolytics Prototype : a. Benzodiazepines - diazepam (Valium), lorazipam (Ativan), alprazolam (Xanax), flurazepam (Dalmane) b. Barbiturates - amobarbital, phenobarbital, secobarbital c. Miscellaneous - chloral hydrate (Noctec), buspirone (Buspar), paraldehyde (Paral) Mechanism of actions : a. Benzodiazepines - increase the effect of inhibitory neuro transmitter GABA (gamma-amino butyric acid) b. Barbiturates and Miscellaneous agents - depress CNS Indications : - induce sleep, sedate and calm clients Adverse effects : - hangover-effect, dizziness, CNS depression - respiratory depression, drug-dependence Nursing considerations : ______________________________________________________________

1. Warn clients of injuries and falls. 2. Brief period of confusion and excitement upon waking up is common with benzodiazepines. 3. Warn clients not to discontinue medications abruptly without consulting a physician. 4. Avoid alcohol while taking these drugs. 6. Rotate and don’t shake the ampules of barbiturates. Don’t mix with other drugs. 7. Warn female clients that diazepam is associated with cleft lip.

ANTIDEPRESSANTS AND MOOD DISORDER DRUGS Prototype : a. Tricyclic antidepressants - amitriptyline (Elavil), protriptyline (Vivactil), - imipramine (Tofranil), desipramine b. MAO (monoamine oxidase inhibitors ) - isocarboxazid (Marplan), phenelzine (Nardil), tranylcypromine (Pernate) c. Second-generation antidepressants - fluoxetine (Prozac), trazodone (Desyrel) d. Lithium Mechanism of actions : a. Tricyclic antidepressants - increase receptor sensitivity to serotonin and/or norepinephrine. b. MAO inhibitors - inhibit the enzyme MAO that metabolize the neurotransmitters norepinephrine and serotonin. c. Second – generation antidepressants - inhibits the reuptake of serotonin. d. Lithium - increase serotonin & norepinephrine uptake Adverse effects : - dry mouth, blurred vision, urine retention, constipation (anticholinergic effects) - orthostatic hypotension, insomnia - hypertensive crisis (MAO) - dehydration (Lithium). Nursing considerations : 1. Caution client to rise slowly to reduce the effects of orthostatic hypotension. 2. Take antidepressant with food to enhance absorption 3. Explain to client that full response may take several weeks (2 weeks). 4. Assess client for constipation resulting from tricyclic antidepressant use. 5. Client taking MAO inhibitors should avoid tyramine-rich foods to avoid hypertensive crisis. - aged cheese, sour cream, yogurt, beer, wine, chocolate, soy sauce and yeast - pentholamine (Regintine) is the drug of choice for hypertensive crisis. ______________________________________________________________

6. Inform physician and withhold fluoxetine if client develop rashes. 7. Take lithium with food to reduce GI effects - > 1.5 mEq/L blood level may cause toxicity manifested by: confusion, lethargy, seizures,hyperreflexia. - maintain salt and adequate fluid intake - tremors may occur but it is temporary - monitor white blood cell count (increase).

ANTIPSYCHOTIC DRUGS (NEUROLEPTICS) Prototype : a. Phenothiazines - chlorpromazine (Thorazine), - trifluoperazine (Stelazine), - thioridazine (Mellaril) b. Other Agents - clozapine (Clozaril), haloperidol (Haldol) Mechanism of action : - block dopamine receptor in the limbic system, hypothalamus, and other regions of the brain. Adverse effects : - Extra pyramidal symptoms such as dystonia, pseudoparkinsonism, and an irreversible tardive dyskinesia as manifested by : a. lip smacking b. fine wormlike tongue movement c. involuntary movements of arms and leg. - Neuroleptic malignant syndrome a. fever, tachycardia, tachypnea, diaphoresis, cardiovascular collapse b. muscle rigidity, seizures. - orthostatic hypotension Nursing considerations : 1. Teach family members the signs of EPS and NMS, and report to physician immediately. 2. Normalization of symptoms may not occur for several weeks after beginning of therapy . 3. Avoid administering haloperidol intravenously 4. Watch out of neutropenia with clozapine. 5. Watch out for orthostatic hypotension and photosensitivity with phenothiazine. 6. Be sure that oral doses are swallowed, and not hoarded.

DRUGS USED IN PAIN

MANAGEMENT

General Anesthetics Prototype : a. Inhalation anesthetics - enflurane (Ethrane), halothane - isoflurane (Forane), nitrous oxide b. Injection anesthetics - fentanyl (Sublimaze), ketamine (Ketalar), thiopental Na (Penthotal), etomidate (Amidate) Mechanism of actions : ______________________________________________________________

- cause CNS depression, by producing loss of consciousness, unresponsiveness to pain stimuli, and muscle relaxation. Nursing considerations : 1. Instruct client NPO for 8 hours before administration. 2. Monitor cardio pulmonary depression and hypotension. 3. Monitor urinary retention. 4. Monitor body temperature - malignant hyperthermic crisis : dantrolene (antidote) 5. Avoid alcohol or CNS depressants for 24 hours after anesthesia. 6. In patient who received halothane, monitor signs of hepatic fatal side effects : - rash, fever, nausea, vomiting - jaundice and altered liver function.

LOCAL AND TOPICAL ANESTHETIC Prototype : local : bupivacaine, lidocaine, tetracaine, procaine, mepivacaine, prilocaine topical : benzocaine, butacaine, dibucaine,lignocaine Mechanism of action : - block transmission of impulses across nerve cell membrane. Adverse effects : - cardiac dysrhythmias Nursing considerations : - lignocaine + prilocaine (EMLA cream) should be applied topically 60 minutes before procedure. - administer cautiously to the areas of large broken skin. - observe for fetal bradycardia in pregnant clients.

ANALGESICS Prototype : a. Narcotic analgesics - codeine, meperidine (Demerol) morphine, butorphanol (Stadol) nalbuphine (Nubain) b. Non – narcotic analgesic NSAIDs – aspirin (aminosalicylic acid), mefenamic acid (Ponstan), ibuprofen (Motrin), naproxen, ketoprofen (Orudis), ketorolac. paracetamol and acetaminophen (Tylenol) Mechanism of actions : a. Narcotic analgesics - alter pain perception by binding to opiod receptors in CNS. b. Non- narcotic analgesic - relieves pain and fever by inhibiting the prostaglandin pathway. Nursing considerations : 1. Monitor respiratory depression & hypotension in clients taking narcotic analgesic. 2. Injury and accident precautions in clients taking narcotic analgesic. 3. Warn clients about possibility of dependency,and do not discontinue narcotics ______________________________________________________________

abruptly in the narcotic-dependent clients. 4. Naloxone is antidote for narcotic overdose. 5. Advice clients to take NSAIDs with food and monitor bleeding complications. 6. Aspirin is contraindicated in clients below 18 years old with flu-like symptoms. 7. Monitor hearing loss in clients taking aspirin. 8. Monitor liver function in clients taking acetaminophen. 9. N-acetylcysteine is antidote for paracetamol overdose.

DRUGS AFFECTING THE CARDIOVASCULAR

SYSTEM

ANTICOAGULANTS Prototype : - Heparin (SQ and IV) Warfarin (Orally) Mechanism of actions : a. Heparin - prevents thrombin from converting fibrinogen to fibrin. b. Warfarin - suppress coagulation by acting as an antagonist of vitamin K after 4-5 days. Indications : - thrombosis, pulmonary embolism, myocardial infarction Adverse effect : - bleeding Nursing considerations : 1. HEPARIN sodium - if given SQ don’t aspirate or rub the injection site (above the scapula - best site). - therapeutic level 1.5-2.5 times normal PTT; normal PTT is 20-35 sec. = 50-85 sec. - antidote : (protamine sulfate) 2. WARFARIN sodium (coumadin) - warfarin is used for long-term .

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HEMOSTASIS : Bleeding/injury I Vasoconstriction Plasminogen I I Platelet aggregation Plasmin ( temporary plug) I I I Clotting factor activation -------------I I I I Intrinsic pathway (8,9,10,11,12) Extrinsic pathway (3,7,10) I (PTT ) (PT) Vit K dep. I I I I I Prothrombin activation I I I I Thrombin I I I Fibrinogen ------------Fibrin threads ------------- Fibrin split products (coagulation) ( Removed by liver & spleen )

- onset of action is 4-5 days. - therapeutic level is 1.5-2.5 times normal PT; normal PT = 9.6 -11.8 sec. = 25 - 30 sec. INR = 2 - 3 - should be taken at the same time of the day to maintain at therapeutic level. - reduce intake of green leafy vegetables. - antidote : Vitamin K ( Aquamephyton)

THROMBOLYTICS Prototype : Streptokinase, Urokinase Mechanism of actions : - activates plasminogen to generates plasmin (enzyme that dissolve clots). Indications : - use early in the course of MI (within 4-6 hours of the onset) Nursing considerations : - monitor bleeding - antidote : Aminocarpic acid Antiplatelet Medications Prototype: aspirin, Dipyridamole (Persantin) Clopidoigrel (Plavix), Ticlopidine Mechanism of action : - inhibit the aggregation of platelet thereby prolonging bleeding time. Indications : - used in the prophylaxis of long-term complication following M.I, coronary revascularization, and thrombotic CVA. Nursing considerations : ______________________________________________________________

- Monitor bleeding time ( NV = 1-9 mins) - Take the medication with food.

CARDIAC GLYCOSIDES Prototype: - digoxin (Lanoxin) and digitoxin (Crystodigin) Mechanism of actions : - increase intracellular calcium, which causes the heart muscle fibers to contract more efficiently, producing positive inotropic & negative chronotropic action. Indications : - use for CHF, atrial tachycardia and fibrillation Nursing considerations : - Monitor for toxicity as evidence by : nausea, vomiting, anorexia, halo vision, confusion, bradycardia and heart blocks . - Do not administer if pulse is less than 60 bpm. - Should be caution in patient with hypothyroidism and hypokalemia. - Antidote : Digi-bind - Phenytoin is the drug of choice to manage digitalis-induced arrhythmia. Nitrates Prototype : - isosorbide dinitrate (Isordil) - nitroglycerine (Deponit, Nitrostat) Mechanism of action : - produce vasodilatation including coronary artery. Indications : - angina pectoris, MI, peripheral arterial occlusive disease. Adverse effects: - headache, orthostatic hypotension . Nursing Considerations : 1. Transdermal patch - apply the patch to a hairless area using a new patch and different site each day. - remove the patch after 12-24 hours, allowing 10-12 hours “patch free” each day to prevent tolerance. 2. Sublingual medications : - note the BP before giving the medication. - offer sips of water before giving because dryness may inhibit absorption. - one tablet for pain and repeat every 5 mins. for a total of three doses; if not relieved after 15 mins., seek medical help. - stinging or burning sensation indicates that the tablet is fresh. - instruct patient not to swallow the pill - sustained release medications should be swallowed and not to be crush. - protect the pills from light.

ANTI-ARRHYTHMIC DRUGS Class I (block Na channels) ______________________________________________________________

IA - quinidine, procainamide IB - lidocaine IC - flecainamide Class II (Beta-blockers) propanolol, esmolol Class III (block K channels) amiodarone, bretylium Class IV (block Ca channels) verapramil, diltiazem Nursing considerations : 1. Watch out for signs of CHF. 2. Have client weigh themselves and report weight gain. 3. Watch out for signs of lidocaine toxicity : - confusion and restlessness

ANTILIPEMICS Prototype : a. cholesterol-lowering agents - cholestyramine, colestipol, lovastatin b. triglyceride-lowering agents - gemfibrozil, clofibrate Mechanism of actions : - interfere with cholesterol synthesis as well as decreasing lipoprotein & triglyceride synthesis. Nursing considerations : - monitor liver functions while using statins. - prevent constipation, flatulence, cholelithiasis - encourage increase fluid and fiber intake.

ANTI – HYPERTENSIVE Angiotensin-Converting Enzyme (ACE) Inhibitors Prototype : captopril (Capoten), enalapril (Vasotec), quinapril, lisinopril Mechanism of actions : - prevent peripheral vasoconstriction by blocking conversion of angiotensin I to angiotensin II decreasing peripheral resistance. Adverse effect : - it cause hyperkalemia - induce chronic cough Nursing considerations : - not to discontinue medications because it can cause rebound hypertension. - avoid using K+ sparing diuretics.

CALCIUM-CHANNEL BLOCKERS Prototype : - Nifedipine (calcibloc, adalat), Amlodipine (norvasc), Felodipine (Plendil) Verapramil (Isoptin) Mechanism of action : - decrease cardiac contractility and the workload of the heart, thus decreasing the ______________________________________________________________

need for O2. - it also promote vasodilatation of the coronary and peripheral vessels. Indications : - hypertension, angina, arrhythmia Adverse effects : - bradycardia, hypotension, headache - reflex tachycardia, constipation Nursing considerations : - Administer between meals to enhance absorption. - Take client’s pulse rate before each dose, withhold if pulse is below 60 bpm. - Refer for signs of congestive heart failure.

DIURETICS - usually given at morning CARBONIC ANHYDRASE INHIBITORS - Acetazolimide (Diamox) - increase Na+, K+, & HCO3 secretion, along with it is H2O - metabolic acidosis OSMOTIC DIURETIC - Mannitol - Increase osmotic pressure of the glomerular filtrate. - hypotension THIAZIDE DIURETICS - hydrochlorothiazide - blocks Na and K reabsorption; reabsorb Ca - hypercalcemia LOOP DIURETICS - Furosemide (Lasix) - blocks Na, K, and Ca reabsorption - hypocalcemia POTASSIUM SPARING DIURETICS - Spironolactone (Aldactone) - excrete Na and water but it reabsorb K - hyperkalemia

RESPIRATORY MEDICATIONS Bronchodilators Prototype : Symphatomimetic Xanthines - albuterol, salbutamol - aminophylline - isoproterenol, salmeterol - theophylline - terbutaline Mechanism of actions: - sympathomimetic (b-receptor agonist) bronchodilators, dilate airways. - xanthine bronchodilators, stimulate CNS for respiration. ______________________________________________________________

Indications : - bronchospasm, asthma, bronchitis, COPD. Adverse effects : - palpitations and tachycardia - restlessness, nervousness, tremors - anorexia, nausea and vomiting, headache, dizziness. Nursing considerations : - Contraindicated hyperthyroidism, cardiac dysrhythmia, or uncontrolled seizure disorder. - Should be used with caution in patient with HPN and narrow-angle glaucoma.

GLUCOCORTICOIDS (CORTICOSTEROIDS) Prototype : - dexamethasone, budesonide, fluticasone, prednisone, beclomethasone. Mechanism of actions : - act as anti-inflammatory agents and reduce edema of the airways, as well as pulmonary edema. Adverse effects : - Cushing’s syndrome, neutropenia. osteoporosis Nursing considerations : - Take drugs at meal time or with food. - Eat foods high in potassium, low in sodium. - Instruct client to avoid individuals with RTI. - Instruct client not to stop medication abruptly, it should be tapered to prevent adrenal insufficiency - Avoid taking NSAID while taking steroids. - Take inhaled bronchodilators first before taking inhaled steroids, and rinse mouth after using.

MAST CELL STABILIZERS Prototype : cromolyn sodium (Intal) Mechanism of action : - stabilize mast cells that release histamine triggering asthmatic attacks. Nursing Consideration: - Should be given before asthmatic attacks. - Administer oral capsule at least 30 mins before meals for better absorption. - Drink a few sips of water before & after inhalation to prevent cough & unpleasant taste - Assess for lactose-intolerance.

ANTI-HISTAMINES (H-1 BLOCKERS) Protoytype : - Astemizole (Hismanal), Loratidine (Claritin), ______________________________________________________________

Brompheniramine (Dimetapp), Diphenhydramine (Benadryl), Cetirizine (Iterax), Celestamine (Tavist). Mechanism of action : - decrease nasopharyngeal secretions and decrease nasal itching by blocking histamine in H1-receptor. Indications : - common colds, rhinitis, nausea and vomiting, urticaria, allergies and as sleep aid. Nursing Considerations : - Administer with food and drink. - Given IM via Z-track method or orally. - Precautions in handling machine and driving while taking these drugs. - Ice chips or candy for dry mouth

ANTI-TUBERCULOSIS Prototype : First line - Isoniazid (INH) - Rifampicin (Rifadin) - Ethambutol - Pyrazinamide - Streptomycin

Second line - Cycloserine - Kanamycin - Ethonamide - Para-aminosalicylic acid

- active tuberculosis are treated with drug combination for 6-9 mos. - multidrug-resistant strain (MDR-TB) are medicated for 1 year up to 2 years - given before meals Isoniazid - should be given 1 hr before or 2 hrs after meals because food may delay absorption. - should be given at least 1 hr before antacids. - instruct to notify physician for signs of hepatoxicity (jaundice), and neurotoxicity numbness of extremities. - administer with Vitamin B6 to counteract the neurotoxic side effects. - avoid alcohol. Rifampicin - given on an empty stomach with 8 0z. of water, 1 hour before or 2 hours after meals and avoid taking antacids with medications. - hepatotoxic thus avoid alcohol. - instruct the client that urine, feces, sweat, and tears will be redorange in color. Pyrazinamide - given for 2 months. - increase serum uric acid and cause photosensitivity. ______________________________________________________________

Ethambutol - contraindicated in children under 13 years old. - obtain a baseline visual acuity because it can cause optic neuritis. - Instruct the client to notify the physician immediately if any visual problems occurs. Streptomycin - aminoglycoside antibiotic given IM. - nephrotoxic and ototoxic. - obtain baseline audiometric test and repeat every 1-2 months because the medications impairs the CN VIII.

DRUGS AFFECTING GASTROINTESTINAL SYSTEM Antacids Prototype : - aluminum/magnesium compounds (Maalox) - sodium bicarbonate (Alka-Seltzer) - calcium carbonate (Tums) - magnesium hydroxide (Milk of Magnesia). Mechanism of actions : - neutralize the stomach acidity. Adverse effects : - metabolic alkalosis, stone formation - electrolyte imbalance - diarrhea (magnesium), constipation (aluminum). Nursing considerations : - Give 1 hr after meals. - Avoid giving medications within 1-2 hrs of antacid administration (decreases absorption). - Take fluids to flush after intake of antacid suspensions. - Monitor for changes of bowel patterns.

HISTAMINE – 2 BLOCKERS Prototype : - cimetidine (Tagamet), ranitidine (Zantac), famotidine (Pepcid), nizatidine (Axid). Mechanism of action: - blocks H2 receptors in the stomach, reducing acid secretions. Nursing considerations : - Given before or with meals - Avoid giving other drugs with cimetidine - Gynecomastia may developed with chronic use of cimetidine.

Proton – Pump Inhibitors (PPI) Prototype : - omeprazole (Losec), Lansoprazole (Lanz), pantoprazole (Pantoloc). Mechanism of action : - inhibit the proton H+ to combine with Cl- toform hydrochloric acid. ______________________________________________________________

Nursing considerations : - Given before meals preferably at morning. Mucosal Barriers Prototype : - sucralfate (Carafate), misoprostol (Cytotec). Mechanism of action : - coats the mucosa to prevent ulcerations. Nursing consideration : - Given before meals. - Misoprostol is contraindicated for pregnants. - Sucralfate cause constipation. Anti-diarrheal Agents Prototype : - diphenoxylate (Lomotil), loperamide (Imodium), kaolin/pectin mixture (Kaopectate). Mechanism of actions : - decrease stomach motility and peristalsis. Nursing considerations : - Monitor for rebound constipation. - Be cautious taking if with infectious diarrhea. - Monitor atropine toxicity with diphenoxylate. - Clay, white or pale stool is common with kaopectate. Laxatives a. lactulose (Cephulac), Na biphosphate (Fleet enema) & magnesium salt (Milk of Magnesia) - retain fluid and distend intestine b. ducosate (Dialose) - emulsify fecal fat and water c. bisacodyl (Dulcolax) & senna (X-prep) - irritates intestinal mucosa and stimulate intestinal smooth muscles d. bulk-forming laxative (Metamucil) - increase fecal bulk and water content e. mineral oil - lubricates & prevent colon absorption

EMETICS Prototype : ipecac syrup, apomorphine Mechanism of actions : - induce vomiting through stimulation of vomiting center of medulla. Indications : - ingestion of poisonous or toxic substances. Nursing considerations : - Consult poison control center before induction of vomiting. - Administer ipecac syrup with large amount of fluid.

DRUGS AFFECTING THE

ENDOCRINE SYSTEM

THYROID AGENTS ______________________________________________________________

Prototype : - Proloid (thryroglobulin ) - Synthroid (levothyroxine) - Cytomel ( liothyronine). Mechanism of action : - function as natural or synthetic hormones. Nursing considerations : - Taken in the morning. - Caution with coronary artery disease. - Monitor for signs of hyperthyroidism and refer for decreasing the dose.

PARATHYROID AGENTS Prototype : a. calcitonin (Calcimar), etidronate (Didronel), b. calcitrol (Rocaltrol), calcifediol (Calcedrol) Mechanism of action : a. reduce bone resorption b. promotes calcium absorption Nursing considerations : - Monitor signs of calcium imbalance - Report for bone pains. - Remain sitting upright after taking etidronate.

Oral Hypoglycemic Agents (OHA) 1. Sulfonylureas - stimulate insulin secretions and increase tissue sensitivity to insulin. First Generation : Chlorpropamide (Diabenese) - disulfiram precautions Tolbutamide (Orinase) - congenital defect Second Generation : Glypizide, Glymepiride 2. Biguanides - facilitates insulin action on the peripheral receptor site. Metformin and Glucophage (Glucovance) - side effect is lactic acidosis 3. Alpha-glucosidase inhibitors ______________________________________________________________

- delay carbohydrate absorption in the intestinal system. Acarbose (Precose) – side effect is diarrhea 4. Thiazolinidine - increase tissue sensitivity of insulin. Rosiglitazone (Avandia) 5. Meglitinides - stimulate insulin release in pancreatic B-cells. Repaglinide (Prandin) Nursing considerations : - Effective only for type II DM. - Contraindicated to pregnant & breastfeeding. - Given before meals. - Monitor for signs of hypoglycemia.

Insulin Insulin

Onset

Peak

Duration

Immediate-acting 0.15h 0.5–1h 5 h (lispro) Short-acting 0.5-1 h 2-4 h 5-7h (regular, semilente) Intermediate-acting 1-3 h 6-12 h 18-24 h (NPH, lente) Long-acting 4-6h 10-30 h 24-36 h (ultralente) Mixed 0.5 h 4-8 h 25 h (regular 30%, NPH 70%) Nursing considerations : - Usually given before meals. - Roll the bottle in palm of hands, don’t shake. - Inject amount of air that is equal to each dose into the bottle – short acting last (clear). - Aspirate short acting first, then long or intermediate (cloudy). - Alcohol is recommended for cleansing bottle but not with skin. - Pinch skin, avoid I.M, don’t aspirate. - Rotate the injection site an inch a part. - Prefilled syringes are stored vertically, needle-up. - May increase dose during illnesses. - Used bottles stored in room temperature, unused bottle stored in refrigerator. - Monitor for acute hypoglycemia : a. 3-4 commercially prepared glucose tablet b. 4-6 ounce of fruit juice or regular soda c. 2-3 teaspoon or honey d. Glucagon 1 gm SQ or IM e. D50-50 IV.

ESTROGENS AND PROGESTINS Prototype : ______________________________________________________________

- conjugated estrogen (Premarin), estrone (Bestrone), estradiol (Estrace), diethylstilbestrol (DES). Indications : - prostate cancer, contraceptions - estrogen replacement Adverse effects : estrogen - endometrial CA, gallbladder disease, HPN, migraine, breast tenderness progesterone - altered menstrual flow, risk of thrombo embolism Nursing considerations : 1. Mix estrogen or progestins prior to IM administration by rolling vials between palms. 2. Monitor blood pressure 3. Teach patient how to perform BSE. 4. Regular follow-up examination is required to detect associated risk of acquiring CA

DRUGS AFFECTING LABOR and LACTATION Uterine Stimulating Agents Protoytpe : a. Oxytocin (Pitocin), ergonovine (Ergotrate), methylergonovine (methergine) b. carbopost (Prostin), dinoprostone (Prostin E2) Mechanism of actions : a. stimulates uterine smooth muscles b. ripening of cervix Adverse reactions : - fetal bradycardia (oxytocin), - hypertension (ergonovine), palpitations - allergic reactions (Prostaglandins)

Uterine Inhibiting Agents (Tocolytic) Prototype : - ritodrine (Yutopar), terbutaline (Brethine) Mechanism of actions : - relaxes the uterus by stimulating the B2- adrenergic receptors Adverse effects : - tremors, nausea, vomiting and tachycardia

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Lactation Suppressants Prototype : - bromocriptine (Parlodel) Mechanism of action : - decrease serum prolactin levels Adverse effects : - drowsiness, headache, nausea, palpitations

DRUGS FOR TREATING INFECTION Antibacterial Agents 1. Cell wall inhibitors a. penicillins - pen G, amoxicillin, cloxacillin b. cephalosphorins - cephalexin, cefaclor c. glycopeptide - vancomycin 2. Protein synthesis inhibitors a. aminoglycosides - amikacin, gentamycin b. macrolide - erythromycins, roxithromycin c. lincosamides - clindamycins d. chloramphenicol, tetracyclines 3. Antimetabolites - blocks folic acid synthesis a. Sulfonamides - cotrimoxazole 4. DNA synthesis inhibitors a. quinolones - ciprofloxacin, ofloxacin b. metronidazole Adverse effects : 1. Aminoglycoside - nephrotoxicity & ototoxicity 2. Sulfonamides - Steven-Johnson’s syndrome, photosynsetivity 3. Quinolones - insomnia 4. Tetracyclines - bone problems 5. Chloramphenicol - Gray syndrome, bone marrow depression 6. Erythromycin - hepatitis Nursing considerations : 1. Collect appropriate specimen for C & S before starting antibiotics. 2. Check client’s history of allergies. 3. Avoid administering erythromycin and quinolones with food. 4. Pregnant precautions. 5. Report for diarrhea - pseudomembranous colitis (clindamycin) 6. Monitor adverse effects. Antiviral Agents Prototype : - acyclovir (Zovirax), ganciclovir (Cytovene), vidarabine (Vira-A), amantidine (Symmetrel), ribavirin (Virazole), zidovidine (Retrovir). Mechanism of actions : - inhibits virus specific enzymes involve in DNA synthesis. They only control the growth of virus but it does not cure. Adverse effects : - granulocytopenia, thrombocytopenia, nausea, nervousness, headache, nephrotoxicity. ______________________________________________________________

Nursing consideration : - Pregnant and breastfeeding precautions. - Administer IV antivirals to avoid crystallization in renal tubules. - Give ribavirin only with aerosol generator. - Monitor CBC and creatinine level. - Refer for signs of bleeding. - Take amantidine after meals. Antifungal Agents Prototype : - amphotericin B (Fungisone), nystatin, fluconazole (Diflucan), ketoconazole (Nizoral). Mechanism of actions : - inhibit the synthesis of fungal sterol. Adverse effects : - nephrotoxicity and neurotoxicity - bone marrow depression - chills, fever, joint pains, abdominal pain and headache. Nursing considerations : - Dilute amphotericin B with sterile water solution not with electrolyte solution. - Tell clients that fever, chills, GI upset, joint and muscle pain will subside as amphotericin B continues. - With oral candidiasis, let nystatin tablet dissolve in mouth rather than swallowing it. - Refrain ketoconazole with antacids. - Report for signs of bleeding, infection & fatigue.

ANTIPARASITIC AGENTS Prototype : a. Antimalarial - chlroquine, mefloquine, primaquine, quinine, pyrimethamine b. Antiamebiasis - metronidazole (Flagyl), iodoquinol, furozolidone (Furoxone). Mechanism of actions : a. antimalarial – alters protozoal DNA, depleting folates, & reducing nucleic acid production b. antiamoeba – block protein synthesis. Nursing considerations : 1. Administer anti-malarial drugs with food. 2. Take seizure precautions while administering antimalarial drugs. 3. Refer cinchonism during quinine treatment: - tinnitus, headache, vertigo, fever, and visual changes. 4. Inform clients that iodoquinol falsify thyroid function test for up to 6 months.

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ANTIHELMINTIC Prototype : - mebendazole (Vermox), thiabendazole, niclosamide (Niclocide), piperazine (Antepar), praziquantel (Biltricide). Mechanism of actions : - paralyze larva and adult helmints by acting on parasite microtubules. Adverse effects : - GI upset, urinary odor (thiabendazole) - headache, dizziness, fatigue Nursing considerations : 1. Treat all the family members for nematodes infection to prevent recurrence. 2. Praziquantel must swallowed rapidly because of its bitter taste to avoid gagging. 3. Other antihelmintics should be chewed.

ANTI-NEOPLASTIC DRUGS General considerations : - kills or inhibit the reproduction of neoplasmic cells but as well as normal cells. - it could be cell cycle phase specific or cell cycle non-specific. - preferably given through IV route. Prototype : 1. Alkylating Agents - inhibits cell production by causing cross linking of DNA a. Busulfan – hyperuricemia b. Chlorambucil – gonadal suppression c. Cisplatin – ototoxicity and nephrotoxicity d. Cyclophosphamide – hemorrhagic cystitis. 2. Antitumor Antibiotic Agents - interfere in DNA and RNA synthesis a. Plicamycin – affects bleeding time b. Doxurubicin – cardiotoxicity c. Bleomycin – pulmonary toxicity. 3. Antimetabolites - replace normal proteins required for DNA synthesis by inhibiting the S phase a. Cytarabine – hepatotoxicity b. 5-flourouracil – phototoxicity reaction and cerebellar dysfunctions c. 6-marcaptopurine – hyperuricemia d. Methotrexate – photosensitivity - given with leucoverin to lessen its toxicity. 4. Mitotic Inhibitors (Vinca Alkaloids) - prevent mitosis acting on the M phase causing cell death a. Vincristine sulfate – neurotoxicity, numbness 5. Hormonal Medications and Enzymes ______________________________________________________________

- block the normal hormones in hormone sensitive tumors a. Tamoxifen citrate – visual problems – elevate cholesterol & triglycerides level b. Diethylstilbestrol – impotence and gynecomastia in men. Side Effects: stomatitis - bland diet, avoid strong mouthwash - soft tooth brush, ice chips diarrhea, nausea and vomiting - anti-emetic, replace fluids and electrolytes alopecia - reassure that it is temporary - encourage o wear wigs, hats and head scarf skin pigmentation - inform that it is only temporary tumor lysis syndrome - hyperuricemia & hyperkalemia - force fluids infection - notify physician if WBC is