PART 1. REVIEW ON COMMON ABBREVIATIONS AND TERMINOLOGIES

AbbreviationsAbbreviations are widely used in writing

directions for administration of medications and to perform activities. Standard abbreviations should be used. However, sometimes non-standard abbreviations are used and, as it is w/ any doctor’s order, it is the nurse’s responsibility to interpret correctly. Clarify an order if there is any question

ABBREVIATIONS: medications administration route, time, medication dosage form, other abb.

Quiz 1. ½ crosswise yellow paper.Write the abbreviation for each definition.1. After meals ______2. As desired _______3. As needed _______4. At bedtime _______5. Before meals _____6. By mouth ______7. Every ____8. Everday _______9. Every hour ______10.Every other day ___11.Four times a day ___12.If necessary _______13.Immediately _______14.Three times a day ___15.Twice a day ______

(con’t)Write the meaning for each abbreviation.1. cc _______2. cm ______3. dr _______4. Gm, g, gm ____5. gr _______6. gtt ______7. kg ______8. L ________9. mg ______10.mEq _____11.ml _______12.oz _______13.T, tbsp ____14.t, tsp _____15.ss __________

MEDICAL TERMINOLOGIES- language of the health care industry- derived from Greek & Latin words- roots, prefixes, & suffixes

Root – foundation of a medical termex. arthro = joint

cardio = heart derm or dermato = skin gastro = stomach

cyano = bluish eosino = rosy erythro = red leuko = white melano = black xantho = yellow

Prefixes – word element or part that is added to the beginning of the word rootex. ante = before; forward

hemi = halfmulti = manyneo = newsub = under/below

Suffix – word element or part that is added to the end of the word root

- indicate whether the medical term is a noun or adjectiveex. –ac; -al; -ar; -ary = pertaining to; like

-ic; -iac = pertaining to-oid = like; resembling-ectomy = surgical removal; excision-itis = inflammation of-megaly – enlargement-pathy = disease

Quiz 1. Write the meaning of the listed word elements

Part 11.arthro _____2.gastro _____3.ante ______4.multi _______5.-oid _______6.-ic _____7.-megaly _____8.-pathy _______

Combining Roots, Prefixes, & Suffixes- basic way to create medical terms

1.cardiogastric – pertaining to the heart & stomach

2.gastromegaly – enlargement of the stomach3.gastrectomy – surgical removal of the

stomach4.gastroenterology – study of the stomach &

intestines

Singular & Plural Words -a -ae papilla pappillae -en -ina lumen lumina -ex; -ix -ices apex apices -is -es diagnosis diagnoses -is -ides epididymis

epididymides -nx -nges larynx

larynges -on -a ganglion ganglia -us -i bronchus bronchi -us -era viscus viscera -us -ora corpus corpora

Quiz 1. Part II.Correctly combine each root with the suffix to form a medical term. You must decide whether or not to use the combining form

Example: ROOT SUFFIX TERM arthro -megaly arthromegaly

ROOT SUFFIX TERM 1. arthro -itis ________________ 2. arthro -ectomy ________________ 3. arthro -pathy ________________ 4. dermato-itis ________________ 5. dermato -pathy ________________ 6. gastro -ic ________________ 7. gastro -ectomy ________________ 8. gastro -megaly ________________ 9. cardio -megaly ________________ 10. cardio -pathy ________________

Quiz 1. Part III.Write the plural form for the ff singular terms:

1. ampulla2. fornix3. foramen4. ovum5. phalanx6. testis7. thrombus

Working with Roots, Prefixes, & Suffixes

ROOT MEANINGPREFIX MEANINGarthro joint epi- above, uponcardio heart hemi- halfgastro stomach hypo- below;deficienthepato liver peri- aroundosteo bone poly- many

SUFFIX MEANING-algia pain-itis inflammation-megaly enlarged-pathy disease-plasty repair

Example: hemigastrectomyROOT: gastroPREFIX: hemi = halfSUFFIX: ectomy = surgical removalDEFINITION: surgical removal of half the

stomach

Building Medical Terms

Example:DEFINITION: inflammation of jointsBODY PART: jointsROOT: arthr/oSUFFIX: -itisPREFIX: noneMEDICAL TERM: arthritis

Exercise:

DEFINITION: disease of the heartBODY PART:ROOT:SUFFIX:PREFIX:MEDICAL TERM:

PART II. REVIEW ON MEASUREMENTS & CONVERSIONS

•Metric System-common system of drug

measurement-Liter, ml, or cc– for liquid volume-cc is a common measurement of vol.

that is equivalent to 1 ml of fluid-metric wt of a drug is stated in terms

of kilograms (kg), grams, mg, or mcg

-based on the decimal system

-units of measure are the gram (weight), the liter (volume), & the meter (length or ht.)

-based on units of 10 by dividing or multiplying

Ex. To change mg to gm, or ml to L, divide the number by 1,000:

250 mg = x g(move decimal pt 3 places to the left)

x = 0.25 g or 500 ml = x L= 0.5 L

To convert gm to mg or L to ml, multiply the number by 1,000:

0.005 g = x mg(move dp 3 places to the right)x = 5mg or0.725 L = x mlx = 725 ml

Apothecary & Household Systems-originated in England is based on the

wt of 1 gr of wheat-older systems of measurement-uses the minim (size of a drop of

water), fl. dr, fl. oz, pint, qt, & gal as the basic unit of liquid measure & the gr, lb, oz, dr as the basic unit of solid measure

-this system is much harder to use than the metric system & is rarely seen in most clinical settings

-uses Roman numeral; ex. 15 grains – gr xv

Household System-least accurate of 3 systems-this system uses the teaspoon as the

basic unit of fluid measure, others: gtt, tsp, tbsp, cup & glass

-pound as the basic unit of solid measure- in this system, 1 lb is equal to 16

ounces-household units for liquids are tsp &

tbsp- accurate medical dosing devices:

calibrated oral dosing syringes, oral droppers, cylindrical spoons, medication cups

Avoirdupois System-another older system that was very

popular when pharmacists routinely had to compound medications on their own

-uses ounces & grains, but measures differenlty than those of the apothecary & household systems

-seldom used by prescribers but may be used for bulk medications that come directly from the manufacturer

Other units:unit – reflects the biological activity of the drug in 1 mL of sol’nmEq – used to measure electrolytes (K,

Na, Cl, Ca, Fl)- refers to the ionic activity of the

drug in questionInternational units (IU) – sometimes used to measure certain vitamins or enzymes

- is unique because cannot be converted to another

measuring form

PART III-1. INTRODUCTION TO NURSING PHARMACOLOGY

INTRODUCTION TO DRUGSDrugs – are chemicals that are introduced into the body to cause some sort of change. The nurse is in a unique position regarding

drug therapy, because nursing responsibilities include the ff:

Administering drug Assessing drug effects Intervening to make the drug regimen more

tolerable Provide patient teaching about drugs and the

drug regimen

Pharmacology derived from 2 Greek words, pharmakon, w/c means “medicine,drug,” and logos, w/c means “study.” - is the study of the biological effects of chemicals(WHO) – “ Drug is any substance or product that is used or intended to be used to modify or explore physiological system or pathological states for the benefit of the recipient.”

Nurses deal with pharmacotherapeutics, or clinical pharmacology, the branch of pharmacology that uses drugs to treat, prevent, and diagnose disease

Clinical pharmacology addresses 2 key concerns: the drug’s effects on the body and the body’s response to the drug

Because a drug can have many effects, the nurse must know which ones may occur when a particular drug is administered.

Some drug effects are therapeutic or helpful but others are undesirable or potentially dangerous. These negative effects are called adverse effects

Pharmacotherapeutics – science of drug used to treat various illnesses and the responses of the individual. Factors that prevent drug actions and the need to alter drug dosage will be studied latter.

Clinical Pharmacology – helps generate data for optimum use of drugs. It includes pharmacodynamic and pharmacokinetic study of drugs in healthy volunteers and in patients to evaluate the efficacy and safety of a given drug in comparison with other forms of treatment and its adverse effects.

Pharmacy – science of compounding and dispensing drugs and preparing suitable dosage forms for administration. It includes identification, collection, isolation, purification, synthesis, quality control and standardization of medicinal substances.

Pharmaceutics – technological science of drug manufacture in large scale

Chemotherapy – is treatment of systemic infections, and malignancy by use of specific chemical agents (chemotherapeutic agents) that have selective toxicity for the infecting organism or malignant cells with minimal adverse effect or no effect on the host cells.

Drugs having only pharacodynamic effects on the recipient are designated as pharmacodynamic agents

Pharmacopoeia- an official code containing selected list of established drugs and preparations with a description of their physical properties, purity, and potency. It defines standards that these preparations must meet and their average doses for an adult.

Toxicology – study of adverse effects of both chemotherapeutic agents and pharmacodynamic agents, since the same agent could be a drug or poison depending on dosage used. It also includes the study of poisonous effects of drugs and other chemicals with an emphasis on prevention, detection, and treatment of poisoning.

*The following formulations of drugs should not be crushed or chewed

Enteric-coated tablets, w/c are designed to dissolve in intestine instead of stomach.

Sustained-release forms w/ abbreviations such as Dur (duration), SR (sustained-release), CR (controlled or continuous release), SA (sustained action), LA (long acting), and Contin (Continuous-release).

Trade names with ‘twice daily’ abbreviation (bid). Ex. Theobid or Cardabid

Liquid-containing capsules meant for oral use.

Scored tablets may be broken along the scored line but should not be crushed or chewed.

FORMS OF DRUG PREPARATIONS

SOURCES OF DRUGSNatural Sources

Minerals: kaolin, magnesium trisilicate, magnesium sulfate, and liquid paraffin.

Plant products: alkaloids, oils, glycosides, resins, gums, tannins, and antibacterial substances (ex. Chitosan): Ex. Reserpine, digitalis, digoxin, quinine, atropine, and morphine

Animal products: used to replace human chemicals that are not produced because of disease or genetic problems: thyroid extracts, heparin, gonadotrophins, and insulin for treating diabetes was obtained from cow and pig pancreas tissue

Products of Genetic Engineering- the process of altering DNA-permits

science to produce human insulin by altering Escherichia coli bacteria, making insulin a better product without some of the impurities that come with animal products

Drugs by recombinant DNA technology are vaccines for viral hepatitis and rabies, hormones such as human insulin, human growth hormones, etc.

Inorganic Compounds – salts of various elements have therapeutic effects in the human body

: aluminum, flouride, iron, goldAl – antacid, hyperphosphatemia, prevention of the formation of phosphate urinary stonesFl – prevention of dental cavities & osteoporososAu – tx of RAFe – tx of IDA - discovered accidentally when a cause-effect relationship was observed

Microorganisms: penicillin and other antibiotics

Synthetic – made artificially by chemical synthesis, esp. so as to resemble a natural product

Most of the drugs in present use aresynthetic, e.g., corticosteroids,sulfonamides, aspirin, etc.

Drug evaluation

FDA – ensure the safety and reliability of any drug approved in this country. For every 100,000 chemicals that are identified as being potential drugs, only about 5 end up being marketed

Phases of Drug Development1.Preclinical Trials – chemicals that may

have therapeutic value are tested on laboratory animals for 2 main purposes:- to determine whether they have the presumed effects in living tissue- evaluate any adverse effects- at the end of trial, some chemicals are discarded for the ff reasons:

The chemical lacks therapeutic activity Too toxic Highly teratogenic Safety margins are small , not useful in

clinical testing

2. Phase 1 studies – use human volunteers to test the drugs- more tightly controlled and are performed by specially trained clinical investigators- volunteers are fully informed of possible risks and may be padi for their participation- chemicals are dropped from the process for the ff reasons:

they lack therapeutic effect in humans Cause an unacceptable adverse effects Highly teratogenic Too toxic

3. Phase II studies – allow clinical investigators to try the drug in patients who have the disease that the drug is meant to treat.- performed at various sites across the country – in hospitals, clinics, & doctors’ offices – and are monitored by representatives of the pharmaceutical company studying the drug- at the end of phase II, may be removed from further investigation for the ff reasons:

Less effective than anticipated Too toxic when used with patients Produces unacceptable adverse effects Low benefit-to-risk ratio, meaning that the

therapeutic benefit it provides does not outweigh the risk of potential adverse effects that it causes

Is no more effective than other drugs already on the market, making the cost of continuedresearch and productionless attractive to the drug company

4. Phase III Studies – involve use of the drug in a vast clinical market- prescribers are informed of all the known reactions to the drug and precautions required for its safe use

Food and Drug Administration Approval- drugs that finished phase III studies are evaluated by the FDA- drug that receive FDA committee approval may be marketed- the entire dev’t and approval process can take 5-6 yrs. Resulting in a so-called drug lag in US

5. Phase IV Study- After a drug is approved, it enters a

phase of continual evaluation- Approved drug is given a brand

name, generic, and chemical namesDRUG NAMES:

Drugs in general have 3 categories or nomenclatures:

Chemical name is the one that describes the drug chemically.ex. L-thyroxine, T4

• Generic name is the non-proprietary name that is accepted by a competent scientific body. The generic name of newer drugs all over the world are uniform by an agreement through WHO

◦ also called as approved name or official name.

ex. levothyroxine sodium Brand name (Proprietary name) is

the name adopted by the particular manufacturing company. That means a given drug can have many propriety names.ex. Crocin in India, Tylenol in USA

Eltroxin, Levothyroid, Synthroid

Pregnancy CategoriesAs part of the standards for testing

and safety, the FDA requires that each new drug be assigned to a pregnancy category.

Category A: Adequate studies in pregnant women have not demonstrated a risk to the fetus in the first trimester of pregnancy, and there is no evidence of risk in later trimesters

Category B: Animal studies have not demonstrated a risk to the fetus but there are no adequate studies in pregnant women, or animal studies have shown an adverse effect, but adequate studies in pregnant women have not demonstrated a risk to the fetus during the first trimester of pregnancy, and there is no evidence of risk in later trimesters

Category C: animal studies have shown an adverse effect on the fetus but there are no adequate studies in humans; the benefits from the use of the drug in pregnant women may be acceptable despite its potential risks, or there are no animal reproduction studies and no adequate studies in humans

Category D: There is evidence of human fetal risk, but the potential benefits from the use of the drug in pregnant women may be acceptable despite its potential risks

Category X: Studies in animals or humans demonstrate fetal abnormalities or adverse reaction; reports indicate evidence of fetal risk. The risk of use in pregnant women clearly outweighs any possible benefit

*Regardless of the designated pregnancy category or presumed safety, no drug should be administered during pregnancy unless it is clearly needed

Controlled Substances controlled substances – drugs with abuse

potential eg., heroin, marijuana, LSD, narcotics, amphetamines, barbiturates

FDA studies the drugs and determines their abuse potential

PDEA enforces their controlGeneric Drugs

- are chemicals that are produced by companies that just manufacture drugs*why cheap? Because they do not have the research, the advertising, or sometimes, the quality control departments that pharmaceutical companies have

*the difference? Bioavailability of the drug- some prescribers however, specify that a drug prescription be “dispensed as written” (DAW) – that is, the brand-name product be used- the prescriber ensures the quality control and bioavailability expected with that drug- may be most important in drugs that have narrow safety margins such as Digoxin (Lanoxin), a heart drug and Warfarin (Coumadin), an anticoagulant- the initial cost may be higher but some prescribers believe that, in the long run, the cost to the patient will be less

Orphan Drugs-are drugs that have been discovered but

are not financially viable and therefore have not been “adopted” by any drug company

OTC Drugs-are products that are available without

prescription for self-treatment of a variety of complaintsDisadvantages:

Could mask the s/s underlying d’se, making dx difficult

Taking these drugs with prescription medications could result in drug interactions & interfere with drug therapy

Serious overdoses

Sources of Drug Information Drug doses Therapeutic and adverse effects Nursing-related implications

Package Inserts – chemical & study infoReference books • PDR is a compilation of the package insert info

from drugs• Drug Facts & Comparisons - provides a wide

range of info• AMA Drug Evaluations – contain detailed

monographs

• Lippincott’s Nursing Drug Guide (LNDG) – has drug monographs

Journals• Medical Letter – monthly review of new

drugs, drug classes, & specific tx protocolsInternet Information

PART III – A. DRUGS AND THE BODY

Pharmacodynamics – therapeutic effect or action (physiologic and biochemical effects) of drugs and their mechanism of action at molecular, cellular, and organ system levels.A drug can bring about physical or chemical change in the cell environment.Ex. 1. stool softeners that act by altering surface tension, and osmotic diuretics that alter osmosis.

Cell functions and process may be altered by drug interaction with drug receptors.Ex. Glucose transfer into cell is facilitated by insulin.

Agonist - Drug binding to receptor that brings about pharmacological action

Antagonist – prohibits pharmacological action

Drug Mode of Action Certain drugs work by interacting with

receptors, special sites on the surface of body cells. Drugs may bind to a specific receptor, possibly preventing naturally occurring chemicals from binding to the receptor. In so doing, if a drug enhances cell activity, it is called an agonist; if it blocks cell activity, it is called an antagonist.

Microsoft ® Encarta ® 2009. © 1993-2008 Microsoft Corporation. All rights reserved.

Local & systemic – (ex. Xylocaine plus epinephrine given SC) an agent given for its local effect but produces a systemic effect also.

Drug effect could be local (ex. Topical application of acyclovir for herpes simplex viral infection) that acts at the site of application

Systemic – affects more than one part of the body (ex. Novalgin given IM for pain at a distant place

Herpes Simplex Blisters Around Mouth Region One strain of the herpes simplex virus causes cold

sores (also known as fever blisters) in and around the mouth, lips, pharynx, nose, face, and ears. The causative agent remains in the cell bodies of facial nerves, causing repeated attacks of the blisters. No established therapy, beyond topical lotions for pain relief, has been developed.

Encarta Encyclopedia John Watney/Science Source/Photo Researchers, Inc. Microsoft ® Encarta ® 2009. © 1993-2008

Microsoft Corporation. All rights reserved.

Pharmacokinetics – study of how drugs are Absorbed, Distributed, Metabolized and excreted (ADME) from the body.•Absorption – refer to what happens to a drug from the time it is introduced to the body until it reaches the circulating fluids & tissues

Ex. Digoxin is absorbed orally to an extent of80%, transported through the blood where25% of it is bound to plasma proteins,distributed widely into all tissues with itseffect localized in the heart muscle, only asmall fraction is metabolized to its inactiveform in the liver, most of it is excreted bykidney in unchanged form, and it hasplasma half time (t ½) of about 40 hrs.

ROUTES OF ADMINISTRATIONThere are many ways to administer

drugs, and each method depends on the drug formulation, the expected action of the drug, and other clinically determined criteria. The most common methods of drug administration are oral and parenteral, w/c includes subcutaneous, intramuscular, and intravenous injections. Other methods include topical application to the skin or mucous membrane, inhalation into the respiratory tract, intra-articular injection into a joint activity, and intrathecal injection into the spinal column. Some drugs are also administered by rectum, by vagina, in the buccal pouch, and under the tongue (sublingual).

ORAL ADMINISTRATION-most commonly used route-convenient and simple, easy, safe,

economical-sometimes crushed or dispensed in

liquid form-may be swallowed or given by

nasogastric or gastrostomy tube - (-) slow absorption, may be

destroyed by digestive juices

Buccal-absorbed relatively slowly from the

mucous membranes of the mouth-placed in the cheek next to the

molars in either the upper or the lower jaw-troches and lozenges are forms-intended use is usually for local rather

than systemic effect

Sublingual-small tablets that dissolve quickly

under the tongue; absorbed through the mucous membranes of the mouth

-are not to be chewed or swallowed and must be allowed to dissolve completely before the patient eats or drinksex. NTG, Felpin (anti-hpn drug)

Rectal-inserted into the rectum-slow, irregular absorption

Nasogastric-delivered through a tube placed

through the nose & into the stomach-slow absorption; may be destroyed by

digestive juices

PARENTERAL ADMINISTRATION-any route of drug administration that

bypasses the gastrointestinal tractIntramuscular

-made into a muscle tissue-most frequently used sites: large

muscle masses such as vastus lateralis in the anterior thigh, gluteus maximus & gluteus medius in the buttocks & hip, & the deltoid in the upper arm

-drugs are readily and rapidly absorbed from IM sites because muscles have a good blood supply ex. AntibioticsSites: ventrogluteal, dorsogluteal, vastus lateralis, rectus femoris, deltoid site

Subcutaneuos Injection-made into the subcutaneous tissue or

the fatty layer of the skin, just below the dermis

-common sites are the outer aspect of the upper arm, the anterior thigh, & the abdomen

-absorbed more slowly from these sites than from IM sites because they contain a lesser blood supply

-ex. Insulin, hormones, local anestheticSites: Outer aspect of outer arm, Anterionr aspect of the thigh, abdomen, and scapular areas, Ventrogluteal areas, Dorsogluteal areas

Intravenous Injection-injected directly into a vein-action of drugs is very rapid, usually

within minutes-ex. Antibiotics, blood

Intradermal-injection into the dermis of the skin-ex. Vaccinations, tuberculosis &

allergy tests

Transdermal-through the skin; continuous

administration via patch or disk-hormones, NTG patch

Inhalation-applied topically but are absorbed

for a systemic effect-taken into the nose or mouth;

inhaled through face masks, nasal catheters, nebulizers, & positive-pressure breathing machines; absorbed into the bloodstream through the lungs

-ex. Asthma & anesthesia meds

TOPICAL ADMINISTRATION-used primarily for a local effect but

because the medication is applied to the skin or mucous membrane, the drug may be absorbed and have a systemic effect.

-may be in the form of creams, foams, gels, pastes, ointments, solutions, sprays & suppositories to the skin or to the mucous membranes lining the respiratory tract, vagina, rectum, or urethra

-eyedrops & eardrops are drugs given topically by the ophthalmic and ottic routes

INTRA-ARTICULAR ADMINISTRATION-directly injected into a joint, usually

by a physician-common ex: injection of the anti-

inflammatory agent cortisone into a knee or shoulder joint

INTRATHECAL ADMINISTRATION-only specially trained nurses, such

as nurse anesthetists & physicians administer drugs by this route directly into the spinal column

-some drugs are injected into the subarachnoid space (w/c contains the CSF) & others are injected into epidural space of the spinal cord.

Forms of Medications

• Distribution – involves the movement of a drug to the body’s tissuesFactors that affect distribution: tissues perfusion Hot/cold environment Drug’s lipid solubility Protein-binding BBB Placenta & breast milk

• Metabolism (biotransformation) – Liver Enzyme Systems – for

detoxification; hepatic cells are lined w/ enzymes

- increased activity in an enzyme system speeds the metabolism of the drug

Excretion – removal of a drug from the body

kidneys (), saliva, lungs, feces glomerular filtration – passage of water &

water-soluble components from the plasma into the renal tubule

considerations: kidney function & urine acidity

Half-Life - is the time it takes for the amount of

drug in the body to decrease to ½ of the peak level it previously achieved• Ex. If a pt. takes 20 mg of a drug w/ a half-life of 2 hrs., 10 mg of the drug will remain 2 hrs. after administration. 2 hrs. later, 5 mg will be left; in 2 more hrs., only 2.5 mg will remain• Consideration: absorption rate, distribution to the tissues, speed of biotransformation, excretion of drug

Factors Influencing Drug EffectsWhen administering a drug to a pt.,

the nurse must be aware that the human factor has a tremendous influence on what actually happens to a drug when it enters the body.

Factors Affecting the Body’s Response to a Drug•Weight – 150 lb.• Age – children – imature systems & older adults – fewer plasma proteins & less efficient perfusion, altered biotransformation or metabolism because of liver changes w/ age, & less effective excretion

• Gender – men – more vascular muscles- women – more fat cells, poss. of

pregnancy• Physiological factors – diurnal rhthym,

electrolyte balance, acid-base balance, hydration• Pathological factors – d’se, hepatic

dysfunction, renal dysfunction, GI dysfunction, vascular disorders, low bp• Genetic – lack enzyme systems necessary

for metabolizing a drug- overactive enzyme systems,

breaking down drugs very quickly- differing metabolisms &

enzymatic makeup

• Immunologic factors – allergy after exposure to its proteins, can develop antibodies to a drug

• Psychological factors – placebo effect, health beliefs, compliance

- pt’s attitude about a drug has been shown to have a real effect on how

that drug works• Environmental factors – temperature. Light,

noise- some drug effects are helped by a

quiet, cool, nonstimulating environment

Drug tolerance – because of increased biotransformation of the drug, increased resistance to its effects, or other pharmacokinetic factors

- ex. Morphine Cumulative effects – drug is taken in

successive doses at intervals that are shorter than recommended or body not able to eliminate drug properly

Drug-Drug interactions:• At the site of absorption – one drug

prevents or accelerates absorption of the other drug

- ex. Antibiotic tetracycline is not absorbed from the GI if there is a presence of Ca products

• During distribution – one drug competes for the potein binding site of another drug, so the 2nd drug cannot be transported to the reactive tissue

- ex. ASA competes with the drug methotrexate (Rheumatrex) for protein binding sites because ASA is more competitive for the sites, methotexate is bumped off resulting to increased toxicity to tissues

• During biotransformation – one drug stimulates or blocks the metabolism of the other drug

- Warfarin (coumadin) is biotransformed more quickly if it is taken at the same time as barbiturates, rifampin, etc. therefore higher doses will be needed

• During excretion – one drug competes for excretion w/ the other drug, leading to accumulation & toxic effects of one of the drugs

- ex. Digoxin (lanoxin) & quinidine (quinaglute)• At the site of action – one drug may be an

antagonist of the other drug or may cause effects opposite of the other drug, leading to no therapeutic effect

- ex. Anti-HPN drug taken w/ allergy drug that increases BP

• Drug-Food interactions – ex. Antibiotic tetracycline cannot be taken w/ iron & Ca products

• Drug-Laboraroy test interactions – some drugs may alter test results

- ex. Dalteparin (fragmin) may cause increased enzyme AST & ALT with no ijury to liver cells or hepatitis

Hx, PA,

PART III-B. TOXIC EFFECTS OF DRUGS• Adverse effects – undesired effects

- occur for many reasons: drug may have other effects on the

body besides the therapeutic effect pt. sensitivity to drug drug’s action on the body causes

other responses that are undesirable too much or too little taking

Drug Allergy – occurs when the body forms antibodies to a particular drug, causing an immune response when the person is re-exposed to the drug

4 classifications of drug allergy:•Anaphylactic reaction•Cytotoxic reaction•Serum-sickness reaction•Delayed allergic reaction

Drug-Induced tissue & organ damage• Dermatologic reactions

Assessment: hives, rash, severe: exfoliative dermatitis – rash, scaling fever, enlarged lymph nodes, enlarged liver, potentially fatal erythema multiforme exudativum (Stevens-Johnson Syndrome) char. by dark red papules on extremities often in rings or disk-shaped patches

Intervention: provide skin care, avoid rubbing, or tight rough clothing, harsh soaps, perfumed lotions, administer antihistamines. Topical corticosteroids, emollients as ordered

Stomatitisex. Fluorouracil (Adrucil)

antineoplastic agent causes mouth sores Assessment: gingivitis, glossitis, dysphagia, bad breath, pain in mouth & throat Intervention: provide mouth care w/ nonirritating solution, tolerated diet, antifungals, local anesthetics as ordered

•Superinfections – caused by the usually controlled organisms

Assessment: fever, diarrhea, black or hairy tongue, glossitis, mucous membrane lesions, vaginal discharge w/ or w/o itching

Intervention: frequent mouth care, skin care, small frequent meals, antifungal therapy, disc. Drug

•Blood dyscrasia – bone marrow suppression caused by drug effects

- occurs when drug that can cause cell death (antineoplastics, antibiotics) are used

Assessment: fever, chills, sore throat, malaise, back pain, dark urine, dec. hct, (anemia), low platelet ct. (thrombocytopenia), low WBC ct. (leukopenia), pancytopenia

Intervention: monitor bld. counts, provide rest, protect from infection, injury, bleeding, disc. drug

• Toxicity - Liver injuryAssessment: fever, malaise, n/v, jaundice, change in color of urine or stools, abd. pain or colic, inc. liver enzymes, changes in

clotting factors (ex. PTT)Intervention: disc. Drug, notify physician, supportive measures (small frequent meal, skin care, cool env’t, rest

- Renal injury – Gentamycin cuses renal tox

A: elevated BUN, creatinine, dec. hct, electrolyte imbalances, fatigue, malaise, edema, irritability, skin rash

I: notify, disc. Drug, supportive measures (diet, fluid restrictions, positioning, skin care, electrolyte therapy, rest, controlled env’t)

- Poisoning – occurs when an overdose of a drug damages multiple body systems

• Alterations in glucose metabolism- Hypoglycemia – Glipizide (glucotrol),

glyburide (diabeta)

A: fatigue, drowsiness, hunger, anxiety, h/a, cold clammy skin, shaking, lack of coordination, inc HR, BP, numbness, tingling of mouth, tongue, lips, confusion, rapid shallow respirations, seizure, coma

I: restore glucose, skin care, env’t control, rest

- Hyperglycemia – ex. Ephedrine drug – bronchodilator & antiasthma to

relieve nasal congestionA: fatigue, polyuria, polydypsia, deep respirations (Kussmaul’s resp.),

restessness, polyphagia, nausea, hot or flushed skin, fruity odor of breath

I: insulin therapy controlled environment, mouth care

• Electrolyte imbalances- Hypokalemia – loop diureticsA: serum K conc <3.5 mEq/L,

weakness, numbness & tingling in the extremities, muscle cramps, NVD, dec bowel sounds, irregular pulse, weal pulse, orthostatic hpn, disorientation. In severe cases, paralytic ileus (absent bowel sounds, abd. Distention, & acute abdomen) may occur

I: replace serum K, monitor serum levels, safety precautions

- Hyperkalemia – K sparing diuretics, antineoplastic agentsA: serum K level >5.0 mEq/L, malaise, muscle cramps, diarrhea, numbness & tingling, slow HR, low BP, dec urine

output, DOBI: Na polystyrene sulfonate, safety

measures, monitor cardiac effects,

•Sensory effects- Ocular toxicity – drugs are

deposited into tiny arteriesinflammation & tissue damage

- chlorquine (aralen) x rheumatoid d’seretinal damage/blindness

A: blurring of vision, color vision changes, corneal damage, blindness

I: monitor pt’s vision for known oculotoxic drugs, consult w/ physician, disc. drug, monitor exposure to lights

- Auditory damage – ex. ASAA: dizziness, tinnitus, loss of balance, loss of hearingI: monitor perceptual losses or

changes, provide protective measures, consult w/ physician, supportive measures

•Neurological Effects- General CNS Effects –

Protection: BBB

- beta-blockers x hpn/angina cause feelings of anxiety, insomnia & nightmares A: confusion, delirium, insomnia, drowsiness, hyperreflexia/hyporreflexia, bizarre dreams, hallucinationsI: provide safety measures, avoid dangerous situations (driving, operating dangerous machinery), orient, provide support, consult physician

- Atropine-like (Cholinergic) Effects- Donepezil (Aricept) x

Alzheimer’s d’se, also cold & antihistamine drugsA: dry mouth, altered taste perception, dysphagia, heartburn, constipation, bloating, paralytic ileus, urinary hesitancy & retention, impotence, blurred vision, cycloplegia (loss of movement in eye muscles), photophobia, h/a, mental confusion, nasal congestion, palpitations, decreased sweating, dry skin

I: provide sugarless lozenges, mouth care to avoid dryness, have pt void

before taking drug, safety measures, avoid hot env’t, take protective measures from falling & dehydration

- Parkinson-like Syndrome – antipsychotic & neuroleptic drugs

A: lack of activity, akinesia, muscular tremors, drooling, changes in gait,

rigidity, extreme restlessness or jitters (akathisia), spasms (dyskinesia)

I: disc. Drug, small frequent meals, safety measures

- Neuroleptic Malignant Syndrome

– generalized syndrome that includes high fever; eg. general anesthetics

A: EPS sx (tardive dyskenisia, akinesia,akathesia, acute dystonia)

I: disc. drug, provide supportive care, safety precautions

• Teratogenecitydrugsdeveloping

tissues/embryo-->death/congenital defects

I: advise not to self-medicate, provide emotional & physical support

PART III-C. NURSING MANAGEMENTIntroductionNursing is a unique and complex science as well as a nurturing and caring art

- deals with the whole person including physical, emotional, intellectual, social, & spiritual aspects

- nurse needs to consider how a person responds to treatment, disease, and the changes in lifestyle that may be required

- nurse – key health care provider who is in the position to:•Assess the whole pt.•Administer therapy as well as medications•Teach pt. to cope w/ the therapy•Ensure favorable outcome of therapy•Evaluate effectiveness of therapy

The Nursing Process

Assessment – gathering informationNursing diagnosis – analyzing the information gathered to arrive at some conclusions

Interventions – actions undertaken to meet the pt’s needs, such as administration of drugs, education, & comfort measures

Evaluation – determining the effects of the interventions that were performed

In general, the nursing process - provides an effective method for handling all of the scientific & technical information as well as the unique emotional, social, & physical factors that each pt. brings to a given situation

- ensures that the pt. receives the best, most efficient, scientifically based, holistic care

Assessment – systematic, organized collection of data about the pt.

- include information about physical, intellectual, emotional, social, & environmental factors

- particular information that is needed varies w/ each drug, but the concepts involved are similar

- 2 key areas that need to be assessed: pt’s history & physical conditions

•Past History Chronic conditions – the presence of certain conditions (eg, renal d’se, heart d’se, diabetes, chronic lung d’se) may be contraindications the use of a drug. Or, these conditions may require that caution be used when administering a gertain drug or that the drug dosage be adjusted

Drug use – prescription drugs, OTC drugs, street drugs, alcohol, nicotine, alternative therapies, & caffeine may have an impact on a drug’s effect.

Allergies – past exposure to a drug or other allergens can provoke a future reaction or provide a caution for the use of a drug, food, or animal product- it is imp’t to describe the particular allergic reaction when noting a drug allergy. In some cases, the reaction is not an allergic response but an actual drug effect

Level of education – helps the nurse determine the level of explanation required & provides a basis for developing pt. education programs

Level of understaning of d’se & therapy – this information also helps the dev’t of educational information

Social supports – available support at home, also involves referral to appropriate community resources

Financial supports – the high cost of health care in general, & of medications in particular, should be considered when initiating drug therapy

Pattern of health care – knowing how a pt. seeks health care gives the nurse valuable information to include in the educational plan

- does this pt. seek ff. up care or does wait for emergency situation?

- does this pt. self-treat his complaints, or is brought to a health care provider?

Physical Assessment Weight – helps determine whether recommended drug dosage is appropriate.

- Because the recommended dosage typically is based on a 150-lb adult male, pts who are lighter or much heavier need a dosage adjustment

Age – children & older adults – require dosage adjustments based on the functional level of the liver & kidneys & the responsiveness of other organs

Physical parameters or known drug effects – provides baseline level

- Depends on d’se process being treated & on the expected therapeutic & adverse effects of the drug therapy

Ex. If a pt. is being treated for chronic pulmonary d’se, the respiratory status & reserve need to be assessed, especially if a drug is being given that has known effects on the respiratory tract

Nursing Diagnosis – a statement of the pt’s status from the nursing perspective

- directs appropiate nursing interventions

- shows actual or potential alterations in pt. function based on the assessment of the clinical situation

- Ex. Imbalanced Nutrition: Less or More Than Body Requirements

Impaired Physical Mobility Disturbed Body Image

Nursing Interventions- 3 types of interventions are

frequently involved in drug therapy: drug administration, provision of comfort measures, and pt./family education•Proper drug administration- there are 7 pts. to consider in the safe & effective administration of a drug:1. Drug2. Storage – refrigeration, protection from light

3. Route – check proper method of administering by that route4. Dosage – based on available drug form, the pt’s body wt. or surface area, or the pt’s kidney fxn

5. Preparation – know specific preparation before administering any drug - Ex. Oral drugs may need to

be shaken or crushed; - Parenteral drugs may need

to be reconstituted or diluted w/ specific solutions

- Topical drugs may require specific handling, such as use of gloves during administration or shaving of a body area before application

6. Timing – administration of one drug may require coordination w/ the administration of other drugs, foods, or physical parameters

- educate pt. to do this on his own7. Recording – document in accordance w/ the local requirements for recording medication administration

•Comfort Measures- nurses are in a unique position to help the pt. cope w/ the effects of drug therapy

Placebo effect – anticipation that a drug will be helpful has been proven to have tremendous impact on the actual success of drug therapy

- back rub, a kind word, positive approach may be as beneficial as the drug itself

•Managing Adverse Effects – decrease anticipated

adverse effects & promoting pt. safety – environmental control (temp., light), safety measures (avoid driving, avoid sun, using side rails), & physical comfort (skin care, laxatives, frequent meals) Lifestyle adjustment – ex. Pt. taking diuretics may have to rearrange their day so as to be near toilet facilities when the drug works

- pt. taking Monoamine oxidase inhibitors (MAOIs) must adjust their diet to prevent serious adverse effects from interaction of the drug w/ certain foods (tyramine-rich foods); eg.aged cheese, avocado, bean curd, bologna, chocolate, canned fish, dried & salted fish, pickled herring, caffeine, etc)

- in some cases, change in lifestyle can affect coping & compliance w/ the medical regimen

•Patient and Family Education - written information

- key elements that must be included in any drug education program are the ff:1. Name, dose & action of drug – to ensure safe & effective drug therapy & avoiding drug-drug interactions2. Timing of administration – teach pts. When to take the drug w/ respect to frequency, other drugs, & meals

3. Special storage & preparation instructions – some drugs

require particular handling procedures; inform pts. to carry out these requirements

4. Specific OTC drugs or alternative therapies to

avoid – causes unwanted & even dangerous drug-drug

interactions - prevent by explaining w/c

drugs or therapies should be avoided

5. Special comfort or safety measures

- teach pts. How to cope w/ anticipated adverse effects to ease anxiety & avoid noncompliance w/ drug therapy

- also educate pts. about the importance of ff-up tests or evaluation6. Safety measures – instruct all pts

to keep drugs out of the reach of children

- remind all pts to inform any health care provider they see about the drugs they are taking – this can prevent drug-drug interactions & misdiagnoses based on drug effects

7. Specific pts. about drug toxicity – give pts. a list of warning signs of drug toxicity

- advise to notify their health care provider if any of these effects occur

8. Specific warnings about drug discontinuation – some drugs w/ a small margin of safety & drugs w/ particular systemic effects cannot be stopped abruptly

- alert pts to inform their hcp immediately if they cannot do their medication for any reason (illness, financial constraints)

Evaluation– part of the continual

process of pt care that leads to changes in assessment, diagnosis, & intervention

- nsg intervention & education program

PART III – D. DOSAGE CALCULATIONS Review on conversions b/w systems of

measurement Converting b/w systems – ratio & proportion Calculating dosage – oral: solids,

oral/parenteral liquids, IV sol’ns Pediatric Considerations – Fried’s, Young’s &

Clark’s rule Quiz 3

Formula for Computation of Dosage

1.Oral Medications: Soliddesired dose

---------------- = quantity of drug stock dose

(D/S=Q)

2. Oral/Parenteral Medications: Liquiddesired dose

---------------- x dilution = quantity stock dose of drug

(D/S x Dil. = Q)

3. IV Fluid Ratea. gtts/min = vol. in cc x gtt factor

no. of hrs x 60 mins.b. cc/hr = vol. in cc

no. of hrs ORgtts/min x 4

c. duration in hrs = vol in cc cc/hr

4. Conversion of Temperaturea. C to F = (C x 1.8) + 32 (Note: 1.8 = 9/5)b. F to C = (F – 32)

1.8

5. Pediatric Dosagesa. Clark’s Rule

wt. in lbs. x ave. adult dose = child’s dose150 lbs.

b. Fried’s Ruleage in mos. x ave. adult dose = c.d. (age150 mos. <1 yr.)

c. Young’s Ruleage in yrs. x ave. adult dose = c.d. (age 1-age in yrs. + 12 12

yrs.)d. Surface Area Calculation

surface area in sq. m. x ave. adult dose = 1.73 child’s dose

Introduction to Cell Physiology

To understand the actions & the adverse effects caused by chemotherapeutic agents, it is important to understand the basic functioning of the cell.

Chemotherapeutic drugs are used to destroy both organisms that invade the body (b,v,p,p,i) & abnormal cells within the body (neoplasms or cancers). By keeping in mind the various properties of the cell, & cell processes, nurses may help determine interventions that increase the therapeutic effectiveness of a drug & limit the undesired adverse effects.

The Cell

- basic structural unit of the body

Cell Nucleus- contains all the genetic material that

is necessary for cell reproduction & for regulation of cellular production of proteins

- “programmed” by the genes for the production of specific proteins that allow the cell to carry out its function, maintain cell homeostasis or stability, & promote cell division

- encapsulated by its own membrane- contains nucleolus & ribosomes, the site of protein synthesis in the cell- responsible for the formation of mRNA & tRNA

Cell Membrane- a thin barrier surrounding the cell, w/c separates ICF from the ECF- essential for cellular integrity & is equipped w/ many mechanisms for maintaining cell homeostasis- contains:

Lipoproteins - a structure in the cell

membrane w/c consists lipids (phospholipids, glycolipids, cholesterol) & proteins - keeps cytoplasm w/n the cell & regulating what can enter the cell - the freely moving nature of the membrane allows it to adjust to the changing shape of the cell

Receptor Sites - series of peripheral

lipoproteins w/ several functions embedded in the lipoprotein membrane

- reacts w/ specific chemicals outside the cell to stimulate a reaction w/n a cell

ex. Receptor sitereacts w/ hormone insulincauses activation of ATP w/n the cellalters cell’s permeability to glucose

- very imp’t in the functioning of neurons, muscle cells, endocrine glands, & other cell types

Identifying Markers- are surface antigens, or genetically determined identifying markers- provide the histocompatibility antigens or HLAs – identifies a cell as a “self-cell” & destroy non-self cells- can be changed in several ways: cell injury, viral invasion, age- if altered, the body’s immune system reacts to the change & can ignore it, allowing neoplasms to grow & develop; immune system may also attack the cell, leading to autoimmune disorders & chronic inflammatory conditions

Channels - pores w/n the cell

membrane made by proteins in the cell wall that allow passage of small substances in or out of the cell (Na, K, Ca, Cl, HCO3, H2O) - ex. Ca channel blockers prevent the movement of Ca into a cell through Ca channels

Cytoplasm- lies w/n the cell membrane, contains many organelles, is the site of activities of cellular metabolism & special cellular functions- inlcudes mitochondria, endoplasmic reticulum, free ribosomes, Golgi apparatus, & lysosomes

Mitochondria - rod-shaped power plants w/n

each cell that produce energy in the form of ATP, w/c allows the cell to function

- plentiful in very active cells (muscle cells)

- uses ATP to maintain homeostasis, produce proteins, & carry out specific functions

- if oxygen unavailable, lactic acid builds up as a byproduct of cellular respiration

- LA leaves the cell & is transported to the liver for conversion to glycogen & CO2

Endoplasmic Reticulum - fine network of channels that

are interconnected - undulating surface provides

large surface for chemical reactions w/n the cell

- contains granules w/ enzymes & ribosomes w/c produce protein

- production of proteins, non-proteins, hormones, & other substances & breakdown of toxic substances

Free Ribosomes - not bound to the surface of the endoplasmic ret.; free floating - produce proteins that are imp’t to the structure of the cell & some of the enzymes that are necessary for cellular activity

Golgi Apparatus - a series of flattened sacs - prepare hormones or other

substances for secretion - may produce lysosomes & store

other synthesized proteins & enzymes until they are needed

Lysosomes - membrane-covered organelles

that contain specific digestive enzymes that can break down proteins, nucleic acids, carbohydrates, & lipids

- responsible for digesting worn or damaged sections of a cell

Cell Properties

Endocytosis – pinocytosis – allow cells to absorb nutrients, enzymes, & other materials

Phagocytosis

Exocytosis – allows a substance to move in & out of the cell (eg, hormones, neurotransmitters, enzymes, other subs.

Homeostasis - main goal of a cell, means keeping the cytoplasm stable w/n the cell membrane - uses active & passive transport systems to achieve homeostasis - disposes waste products that could be toxic

Passive Transport- happens w/o using energy, occurs

across any semipermeable membrane3 types: Diffusion

- movement of a substance from a region of higher concentration to lower concentration

- the difference b/w the concentration of the substance in these regions is called concentration gradient

- the greater the conc. gradient, the faster the substance moves

- substances w/ negative charge move more freely than substances w/ a positive charge

- includes Na, K, Ca, Carbonate, O2, HCO3, & H2O Osmosis

- movement of water across a semi-permeable membrane from an area that is low in dissolved solutes to one that is high in dissolved solutes

- the diffusion of water across cell membrane from an area of high concentration to low concentration creates pressure on the cell membrane, called osmotic pressure

Osmosis The experiment shown above demonstrates the process of osmosis. Water flows through a semipermeable membrane into a sugar solution, diluting the solution. The sugar molecules cannot pass through the membrane, so the water outside remains pure.

- the greater the concentration of solutes in the sol’n to w/c the water is flowing, the higher the osmotic pressure

- a fluid that contains the same concentration of solutes as human plasma is called isotonic sol’n

- a fluid that contains a higher concentration of solutes than human plasma is a hypertonic sol’n, & draws water from cells

- a fluid that contains a lower concentration of solutes than human plasma does is hypotonic, loses water to cells

Facilitated Diffusion - sometimes a substance

cannot move freely on its own in or out of a cell

- such substance may attach to another molecule, called carrier, to be diffused, is known as facilitated diffusion does not require energy, just the presence of carrier

- carriers may be in the form of hormone, enzyme, or protein

Active Transport - sometimes a cell requires a

substance in greater concentration & must move substances against the concentration gradient, requiring them to use energy

- eg, sodium-potassium pump- cells use active transport to

maintain high level of K, & low level of Na,

- allowing the cell to maintain an electrical charge on the cell membrane w/c gives cells the electrical properties of excitation & conduction

- eg, cells in the kidney uses active transport to excrete drugs from the body as well as to maintain electrolyte & acid-base balances

Cell Cycle G0 Phase (resting phase) G1 Phase – extends from stimulation to the formation of DNA; synthesizes the subs. That are needed fr DNA formation

S Phase – actual synthesis of DNA G2 Phase – subs. production for manufacture of mitotic spindles

M Phase – cell splits to form 2 identical daughter cells (mitosis)

ANTI-INFECTIVE AGENTS- are drugs that are designed to act selectively on foreign organisms that have invaded & infected the body of a human host

BacitracinChloramphenicolMeropenemPolymyxin BSpectinomycinVancomycin

Mechanism of Action- Goal: interference w/ the normal function of the invading organism to prevent it from reproducing & to cause cell death w/o affecting host cells• Some interfere w/ biosynthesis of the bacterial cell wall • Prevent the cells of the invading organism from using substances essential for their growth & dev’t leading to inability to divide & eventually cell death (eg, sulfonamides, antimycobacterial, trimethoprim drugs

• Interfere w/ the steps involved in protein synthesis, a necessary function to maintain the cell & allow for cell division (eg, aminoglycosides, macrolides, & chloramphen.

• Interfere w/ DNA synthesis in the cell, leading to inability to divide & cell death (eg, fluoroquinolones)•Alter the permeability of the cell membrane to allow essential cellular components to leak out, causing cell death (eg, antibiotics, antifungals, & antiprotozoals

Anti-infective activity narrow (Spectinomycin – Trobicin) & broad spectrum activity

Bactericidal – anti-infective that is so active against the infective MO that they actually cause the death of the cells they affect

•Bacteriostatic – anti-infectives that are not as aggressive against invading MO; they interfere w/ the ability to reproduce or divide•Depends on the concentration of the drug that is present•Many of the adverse effects noted are associated w/ the aggressive properties of the drugs & their effect on the cells of the host as well as those of the pathogen

Human Immune Response- Goal: reduction of the population of the invading organism• Immune response – involves a complex interaction among chemical mediators, leukocytes, lymphocytes, antibodies, & released enzymes & chemicals• If functional, could eliminate pathogenic organisms• If immunocompromised for any reason (eg, malnutrition, age, AIDS, use of immunosuppressant drugs) – incapable of dealing effectively w/ the invading org.

Resistance- ability of bacteria to adapt to an antibiotic & produce cells that are no longer affected by a particular drug• Eg, Vancomycin (Vancocin, Vancoled) – given to pts. who are intolerant/allergic to penicillin/cephalosporins & pts. w/ staphylococcal infection that no longer respond to these drugs• Can be used orally or IV; for bacterial endocarditits•Highly toxic, reserved for very special situations

Can cause renal failure, ototoxicity, superinfections, “red man syndrome” char. by sudden & severe hypotension, fever, chills, paresthesias, erythema of neck & back

Acquiring Resistance- MO develop resistance in a

number of ways:

Producing an enzyme that deactivates the antimicrobial drug. Ex., some strains of bacteria that were once controlled by penicillin now produce an enzyme called penicillinase, w/c inactivates penicillin before it can affect the bacteria. This occurrence led to the development of new drugs that are resistant to penicillinase

• Changing cellular permeability to prevent the drug from entering the cell, or altering transport systems to exclude the drug from active transport into the cell

• Altering binding sites on the membranes or ribosomes, w/c then no longer accept the drug

• Producing a chemical that acts as an antagonist to the drug

Preventing Resistance• It’s imp’t to limit the use of

antimicrobial agents to the tx of specific pathogens known to be sensitive to the drug being used• Maintain a constant therapeutic

level to prevent the emergence of resistant microbes during times of low concentration

• Timing of doses & length of time of therapy

• Prescribing anti-infectives w/o knowing the causative organism promotes resistance

Treatment of Systemic Infections• Several factors should be

considered before beginning chemotherapeutic regimen

• Include identification of the correct pathogen & selection of a drug that is most likely to 1) cause the least cxs for that particular pt. &

• 2) be most effective against the pathogen involved

Identification of the Pathogen

•Culture of a tissue sample from the infected area, performed in the laboratory, where a swab of infected tissue is allowed to grow on an algar plate

•Straining techniques & microscopic exam to identify organism

•For parasitic sources of infection, stool exam for ova & parasites

•Microscopic exam is also used to detect fungal & protozoal infections

•Correct identification of CA is an imp’t 1st step in determining w/c anti-infective drug should be used

Sensitivity of the Pathogen• Sensitivity testing shows w/c drugs are capable of controlling the particular MO that have known resistant strains

Combination Therapy- may be effective in interfering with cellular structure in different areas or developmental phases; my be used for several reasons:

•Uses a smaller dosage of each drug leading to fewer adverse effects

•Some drugs are synergistic, w/c means they are more powerful when given in combination

•Many microbial infections are cause by more than one MO, & each pathogen may react to a different anti-infective agent

•Delay the emergence of resistant strains, eg, tx of TB, malaria, & some bacterial infections

Adverse Reactions to Anti-infective Therapy

•Kidney Damage- occurs more frequently w/

drugs that are metabolized by the kidney & then eliminated in the urine (eg, aminoglycosides)

- to prevent accumulation in the kidney, pts. should be well hydrated throughout the course

•GI Toxicity- many have direct toxic

effects on the cells lining the GIT, causing nausea, vomiting, stomach upset or diarrhea

- death of MO releases chemical/toxins in the body, stimulate CTZ in medulla, induces n/v

- some are toxic to the liver, causes hepatitis or liver failure (eg, cephalosporins)

- ex. Meropenem – inhibits bacterial cell wall synthesis; used to treat intra-abd. Infections & meningitis

•Neurotoxicity- Aminoglycoside collect in the

8th cranial nerve, that cause dizziness, vertigo, loss of hearing

- Chloroquine, used to treat malaria & some rheumatoid d/o accumulate in the retina & optic nerve can cause blindness

- others can cause dizziness, drowsiness, lethargy, changes in reflexes, & even hallucinations when they irritate specific nerve tissues

- ex. Polymyxin B (generic), an older antibiotic, uses a surfactant-like reaction to enter the cell membrane & disrupt it, leading to cell death in susceptible gram (-) bacteria

- can be toxic to the human host, leading to nephrotoxicity, neurotoxicity (facial flushing, dizziness, ataxia, paresthesias, & drowsiness), & drug fever & rashes

Hypersensitivity Reactions- it is imp’t to determine

what the allergic reaction was & when the pt. experienced it (after 1st use of drug, after yrs. of use)

- allergic reaction vs. adverse effect

Superinfections- destruction of the normal

flora opportunistic pathogens cause infections superinfections

- include vaginal or GI yeast infections by Proteus & pseudomonas

ANTIBIOTICS- are chemicals that inhibit bacteria

- bacteriostatic – prevents the growth of bacteria &

- bactericidal – those that kill bacteria directly

- can be both, depends upon drug concentration

- made in 3 ways: by living microorganisms, synthetic manufacture, & in some cases, genetic engineering

Major Classes of Antibiotics:1. Aminoglycosides, 2. Cephalosporins3. Fluoroquinolones4. Lincosamides5. Macrolides6. Monobactams7. Penicillin8. Penicillinase-resistant9. Sulfonamides10. Tetracycline11. Disease-specific antimicrobacterials –

anti- TB, & leprostatic drug

Bacteria & Antibiotics

• Invasion (routes)body becomes the host multiply/reproduceactivated immune responses/s (eg, fever, lethargy, signs of inflammation)

•Goal of therapy: decrease the population of bacteria – interferes w/ specific proteins & enzyme systems

•C&S to know w/c antibiotic the MO is most sensitive

◦Gram-positive bacteria – are those whose cell wall retains

a stain, known as gram’s stain, or resists decolorization w/ alcohol during C&S testing

- commonly associated w/ infections of the respiratory tract & soft tissues

- ex. Streptococcus pneumoniae

◦Gram-negative bacteria – are those whose cell walls lose a stain or are decolorized by alcohol- frequently ass. w/ infections of GU or GI tract- ex. Escherichia coli, a common cause of cystitis

◦Aerobic bacteria – depend on oxygen for survival, anaerobic bacteria (ass. w/ gangrene) do not use O2

◦Broad spectrum antibiotics – antibiotics that interfere w/

a biochemical reaction common to many organisms- has wide range of effects, therefore freq. ass. w/ adverse effects

Clinicians use drug w/ selective toxicity – ability to strike foreign cells w/ little or no effect on human cells

Consider contraindications like immunocompromised, have severe GI d’se, debilitated

◦Antibiotics are given in combination to promote synergy

Bacteria & Resistance to Antibiotics

Aminoglycosides- group of powerful antibiotics used to treat serious infections caused by gram (-) aerobic bacilli; bactericidal

amikacin (amikin), (P) gentamicin (garamycin), kanamycin (kantrex), neomycin (mycifradin), netilmicin (netromycin), streptomycin (generic), tobramycin (nebcin, tobrex)

Aminoglycosides

Aminoglycosides

- disrupts cell membrane- for tx of serious infections susceptible to penicillin when penicillin is contraindicated- can be used for C&S- rapidly absorbed via IM

Aminoglycosides

- crosses placenta & enters breast milk, use w/ caution esp. during pregnancy & lactation

Contraindications:Known allergyRenal or hepatic d’sePre-existing hearing loss

Active infection w/ herpes or mycobacterial infections

Myasthenia Gravis or parkinsonism

Lactating mothers

Aminoglycosides

Adverse EffectsCNS: ototoxicity leading to irreversible deafness, vestibular paralysis, confusion, depression, disorientation, numbness, tingling, weakness

Aminoglycosides

Renal toxicity – glomerulus Bone marrow depression leading to immune suppression superinfections, fever

GI: nvd, wt. loss, stomatitis, hepatic toxicity

Cardiac: palpitations, hypotension, HPN, hypersensitive reactions

Drug-Drug InteractionsDiuretic – the incidence of ototoxicity, nephrotoxicity, & neurotoxicity inc.

Anesthetics, neuromuscular blockers, succinylcholine, citrate anticoagulated blood = inc. neuromuscular blockade w/ paralysis is possible

Nursing Consideration

1. Check C&S reports – ensure that this is the DOC for this pt.

2. Ensure that pt. receives full course of aminoglycosides as px – to inc. effectiveness & dec. risk for dev’t of

resistant strains of bacteria

3. Monitor site of infection & presenting s/s (fever, lethargy) throughout the drug therapy – failure of this s/s to resolve may indicate the need to reculture the site. Arrange to continue

drug therapy for at least 2 days after all s/s resolve

4. Monitor regularly for signs of nephrotoxicity, neurotoxicity, & BMS – for disc. of drug or dec. dosage

5. Provide for safety measures – to protect from CNS effects, such as confusion, disorientation, or numbness & tingling, occur

6. Provide small, frequent, meals, offer frequent mouth care, & offer ice chips or sugarless candy to suck –

to provide relief from stomatitis, etc, maintain nutrition, provide fluid

7. Ensure hydration – to minimize renal toxicity

8. Ensure that the pt. is instructed about the appropriate dosage regimen & possible adverse effects – to enhance pt. knowledge about drug therapy & promote compliance

Cephalosporins- (P) Cefaclor, cefadroxil, cefazolin, cefotaxime, ceftazidime, ceftriaxone, cefuroxime, cephalexin, etc.

1st – 4th generation 1st – effective against gram (+) bacteria & gram (-) bacteria PEcK

2nd - 1st gen + HEN = HENPEck; less effective against gram (+) bacteria

3rd – more potent against gram (-) bacillias well as Serratia marcescens (HENPEcKS)

4th – active against gram (+) & (-) organisms including cephalosporin-resistant staphylococci & P. aeruginosa

Indication- both bactericidal & bacteriostatic- cause bacteria to build weak

cell walls when dividing- well absorbed from GI, IM , & IV administration- for UTI, respi, skin, GU, bone

infections

Contraindications- allergies, RF

Adverse Effect - GI: NVD, anorexia, abd. Pain, flatulence (common)- CNS: h/a, dizziness, lethargy, paresthesias- nephrotoxicity, superinfections, phlebitis

Drug-Drug Interactions- cepha w/ amino = inc. nephrotoxicity- oral anticoagulants = inc. bleeding- alcohol for 72 hrs disc. Of the drug = disulfiram-like reactions (h/a, n/v, chest pain, vertigo, etc.)

Nursing Considerations: (same as amino)

1.Check C&S report2.Monitor RFT3.Ensure pt. receives full course4.Monitor site of infection & presenting s/s

5.Provide small, frequent meals; mouth care

6. Monitor for signs of superinfection

7. Monitor injection sites regularly

8. Initiate safety measures9. Instruct pt.

Fluoroquinolones- (P) ciprofloxacin, gatifloxacin, levofloxacin, lomefloxacin, moxifloxacin, norfloxacin, ofloxacin, sparfloxacin, trovafloxacin- Cipro – effective against a wide spectrum of gram- negative bacteria (eg. E. coli, K. pneumoniae, N. gonrrheae)

enter the bacterial cellinterferes w/ the DNA actioncell death

- not recommended for use in children <18y/o

- can cross the placenta, enter breast milk

Contraindications & Cautions•w/ allergy, pregnant, & lactating women•w/ renal dysfxn, seizures

Adverse Effects CNS: h/a, dizziness, insomnia, depression

GI: NVD, dry mouth,

IS: BMD Others: fever, rash, photosensitivity, skin reactions

avoid sun & UV light exposure, use sunscreen, protective clothing

Clinically Imp’t Drug-Drug Interactions- when used w/ iron salts, sucralfate, mineral supplements, or antacids, effect is decreased- if taken w/ drugs that inc. the QTc interval or cause “torsades de pointes” (quinidine, procainamide, amiodarone, sotalol, bepridil, erythromycin, terfenadine, astemizole, cisapride, pentamidine, tricyclics, phenothiazines), severe ot fatal cardiac reactions are possible

- Combined w/ theophylline, leads to inc. levels of theophylline

- if combined w/ NSAIDS, inc. risk of CNS stimulation. If used, monitor closely esp. those w/ hx of seizures or CNS problems

- Nursing Considerations (Same as above)

Macrolides

• Interfere w/ protein synthesis in susceptible bacteria•Azithromycin (zithromax), clarithromycin (biaxin), dirithromycin (dynabac), (P) erythromycin (E-Mycin, ERYC, etc.)

• DOC x Legionnaire’s d’se, infections caused by Corynebacterium diphtheriae, ureaplasma, syphillis, & other STI’s

Indications•Bactericidal/bacteriostatic binds to bacterial cell membrane & change protein fxnprevent cell division/cell death

• Indicated for acute infections caused by susceptible strains of S. pneumoniae, Mycoplasma pneumoniae, Listeria monocytogenes, & Legionella Pneumophila; group A B-hemolytic streptococci; PIDs; URTI; etc.

•May bre used for endocarditis before dental procedures in pts. w/ valvular heart d’se who are allergic to penicillin•Topical macrolides – tx of ocular infection, acne vulgaris, minor skin abrasions, etc.

Contraindications & Cautions•Pts. w/ known allergy •Ocular preps for viral, fungal, or mycobacterial infections of the eye – exacerbated by loss of bacteria of the normal flora•Pts. w/ hepatic dysfxn, renal d’se, lactating women – can cause diarrhea & superinfections to the infant, pregnant women – teratogenic

Adverse Effects•Few adverse effects•Most frequent – GI: abd. Cramping, anorexia, DV, & pseudomembranous colitis•Neuro: confusion, uncontrollable emotions•Hypersensitivity reactions ranging from rash to anaphylaxis, superinfections r/t loss of normal flora

Drug-Drug Interactions• Inc. serum levels of digoxin• Oral anticoagulants, theophyllines, carbamezipine, or corticosteroids – may require reduced dosage & careful monitoring

• Cycloserine (anti-TB/leprotic) – inc. risk of renal toxicity

Astemizole – may lead to cardiac arrhythmias

Drug-Food Interactions• Given on empty stomach 1hr or at least 2-3 hrs. after meals• Should be taken w/ full, 8oz. Glass of H2O

Lincosamides

•(P)clindamycin), lincomycin•Similar to Macrolides but more toxic•Clindamycin: Reserved for severe infections caused by the same strains of bacteria that are susceptible to macrolides

•Rapidly absorbed from the GI tract or from IM injections•Has a half-life of 2-3 hrs.; metabolized in the liver, excreted in the urine & feces•Caution w/ hepatic or renal impairment

◦Crosses placenta & enters breast milk◦Severe GI reactions

◦Available in parenteral, topical, vaginal form

◦Lincomycin: indicated for severe infections If pen & macrolides cannot be used

◦Rapidly absorbed from GI /IM injection

◦Metabolized in the liver, excreted in the urine & feces

◦Half-life: 5 hrs.◦Caution w/ hepatic & renal impairment◦Crosses placenta, enters breast milk•Severe GI reactions – pseudomembranous colitis•Careful monitoring of GI activity & fluid balance•Stop drug at first sign of severe bloody diarrhea

• Toxic effects: pain, skin infections, BMD

Monobactam antibiotics

•Aztreonam – only currently available for use•Structure is unique among anitbiotics•Little cross-resistance occurs

• Is efective against gram (-) enterobacteria & has no effect on gram (+)/anaerobic bacteria•Alternative for those allergic to pen & cepha•Absorbed well in IM•Peak levels: 1-1.5 hrs•Crosses placenta & enters breast milk

•Half-life: 1.5-2 & is excreted unchanged in the urine

Indications- disrupts bacterial cell wall synthesis, w/c promotes leakage of cellular contents & cell death in susceptible bacteria

- tx of UT, skin, intra-abdominal, gynecological infections, septicemia caused by susceptible bacteria ( E. coli, Enterobacter, Serratia, Proteus, Salmonella,et)- available for IV & IM use only

Contraindications & Cautions

•Allergy to Aztreonam•Caution to pts. w/ hx of acute allergic reaction to Pen or Cepha•w/ renal/hepatic dysfxn•Pregnant & lactating women

Adverse Effects

◦Local GI effects◦Hepatic enzyme elevations◦Inflammation, phlebitis, discomfort @ injection sites

◦Potential allergic response (anaphylaxis)

Nursing Considerations1.Hx of allergic reactios, liver/renal d’se

2.Pregnancy & lactation status3.PA 4.Obtain specimen for C & S5.Monitor temp.6.Abd. Exam & LFT & KFT to determine any needed alteration in dosage

Nursing Dx◦Acute pain r/t GI & local effects of drug

◦Deficient knowledge regarding drug therapy

◦Deficient fluid volume

Implementation1.Check C&S

2. Monitor hepatic & renal fxn tests

3. Ensure full course therapy4. Monitor for signs of infection5. Small, frequent meals as

tolerated, mouth care, ice chips or sugarless candy

6. Adequate fluids

7. Ensure ready access to bathroom8. Pt. Instruciton (route, S/E,)

Evaluation• Monitor pt. response to the drug• Monitor for AE – orientation &

affect, GI effects, local inflammation)

•Evaluate effectiveness of teaching plan (pt. can name the drug, dosage, poss. AE, & speciic measures to help avoid AE)•Monitor effectiveness of comfort, safety measures, compliance

PENICILLINS and PENICILLANSE-RESISTANT ANTIBIOTICS•First antibiotic introduced for clinical use•Sir Alexander Fleming – used Penicillin molds to produce the original penicillin in 1920s•Developed to decrease AE & modifies to act on resistant bacteria

•With prolonged use, bacteria synthesized enzyme penicillinase – counteract the effects of penicillins•Led to the dev’t of group of drugs w/ a resistance to penicillinase•C & S should always be performed

Indication•Bactericidal effect•Tx of streptococcal infections, inc. pharyngitis, tonsillitis, scarlet fever, & endocarditis; pneumococcal infections; staphylococcal infections; fusospirochetal; ratbite fever; diphtheria; anthrax; syphilis, uncx gonococcal infection

Pharmacokinetics

•Rapidly absorbed from GI, taken on empty stomach•Excreted unchanged in the urine,•Enters breast milk & cause diarrhea & adverse reactions to the baby

Contraindications & Cautions (same w/ other antibiotics)

•Gi tract, superinfections, pain & inflammation @ injection site, hypersensitivity reactions, anaphylaxis

Important Drug-Drug Interactions•Penicillin & penicillinase-resistant anitbiotics w/ tetracycline – decrese effect of Pen•w/ aminglycosides – inactivation of Amino

Nursing Considerations (same as other antibiotics)

Example of Penicillins

•Penicillin G Benzathine (Bicillin, Permapen)•Penicillin G Potassium (Pfizerpen)•Penicillin G Procaine (Crysticillin-AS)•Penicillin V (Beepen-VK)

Example of Extended Spectrum Penicillins

•Ampicillin (D-amp, omnipen)•Amoxicillin (P) (amoxil, trimox)•Carbenicillin (geocillin)•Mezlocillin (Mezlin)•Piperacillin (Pipracil)•Ticarcillin (ticar)

Penicillinase-resistant Antibiotics

•Cloxacillin (P) (Cloxapen, Tegapen)•Dicloxacillin (dyapen, Dycill)•Nafcillin (nafcil, nallpen)•Oxacillin (bactocill, prostaphillin)

SULFONAMIDES (sulfa drugs)

•Are drugs that inhibit Folic Acid synthesis w/c is necessary for the synthesis of purine & pyramidines, a precursor of RNA & DNA•Not used much anymore cause of emergence of new antibiotics & resistant bacterias

• Remain as inexpensive & effective tx for UTI & trachoma

Example of Sulfa drugs•Sulfadiazine – for susceptible bacteria; absorbed from GI; peak levels: 3-6 hrs.

•Sulfisoxazole – for broad-spectruminfection (STD’s, otitis media); absorbed from GI; PL: 2hrs., HL: 4-8hrs.•Sulfasalazine (Azulfidine) – a sullfapyridine carried by ASA; for ulcerative collitis, Crohn’s d’se, RA; absorbed from GI; PL: 2-6hrs.; HL: 5-10hrs.

•Cotrimoxazole (septra, bactrim) – combination drug containing sulfamethoxazole & trimethoprim; very effective for otitis media; absorbed from GI; PL: 2hrs.; HL: 7-12hrs.

Indications:•Trachoma, nocardiosis (causes pneumonias, brain abscess, & inflammation), UTI & STD’s

Pharmacokinetics•Absorbed form GIT, metabolized in the liver, excreted in the urine•Teratogenic; distributed into the breastmilk

Contraindications•Allergy to sulfonamide, sulfonylureas, thiazide diuretics•Pregnant – can cause birth defects (kernicterus)•Lactation – diarrhea, rash•Renal d’se or hx of kidney stone

Adverse Effects1.Same w/ others + renal effects like crystalluria, hematuria, & proteinuria to nephrotic syndrome & poss. toxic nephrosis

2.CNS, BMD, dermatologic effects

Drug-Drug Interactions•Antidiabetic agents (glyburide, glipizide); if needed, monitor pt. & dosage adjustment must be made•Cyclosporine – increased risk of nephrotoxicity

Nursing Considerations (same w/ others)

1.On empty stomach w/ water to promote adequate absorption of the drug

2.Discontinue if hypersensitivity occursmonitor CBC, U/A to check for adverse effects

3.Instruct pt.

TETRACYCLINES• Inhibits protein synthesis of susceptible bacteria•Available in oral & topical forms, including ophthalmic infections for tx of minor skin infections•Demeclocycline, doxycycline, minocycline, oxytetracycline, (P) tetracycline

Indication•Rickettsiae, M. pneumonia, H. influenza, H. ducreyi, etc.•Uncx GU infections, some protozoal infections

Contraindications•Allergy to tartrazine•caution w/ children <8 yrs. of age

•Pts. Who have fungal, mycobacterial, or viral ocular infections esp. the ophthalmic preps.

Adverse Effect•Glossitis, dysphagia, damage to teeth & bones•Anemia, intracranial HPN

Drug-Drug Interactions• If taken w/ pen G, pen G decreases• If used, dosage of pen is increased•Also w/ contraceptives•Methoxyflurane – inc. risk of nephrotoxicity•Digoxin – toxicity•Dec. absorption w/ Ca salts, bismuth salts, Fe, urinary alkalinizers, & charcoal

Drug-Food Interaction•Not absorbed effectively w/ food/dairy products•1 hr. before & 2-3 hrs. after a meal or other medcation

Nursing Consideration (same as sulfonamides)

ANTIMYCOBACTERIAL ANTIBIOTICS- cause TB & Leprosy- has the ability to hold a stain even in the presence of a “destaining” agent- because of this property, they are called “acid-fast” bacteria- takes several years before they can be eradicated

• Anti – TB drugs- affects lungs, GUT, bones, & the meninges

First line drugs:•(P) Isoniazid (Nydrazid) – affects the mycolic acid of the bacterium•Rifampin (Rifadin, Rimactane) – alters DNA & RNA activity in the bacterium

•Ethionamide (Trecator SC) – prevents cell division•Rifapentine (Priftin) - alters DNA & RNA activity, causing cell death

*If the d’se continues to progress because of the emergence of resistant strains

2nd line of drugs•Ethambutol (Myambutol) – inhibits cellular metabolism

•Pyrazinamide (generic) - both bactericidal & bacteriostatic

3rd line:•Capreomycin (Capastar) – idiopathic•Cycloserine (Seromycin) – inhibits cell wall synthesis & leads to cell death

• Leprostatic Drugs•(P) Dapsone•Clofazimine (Lapmrene)

Indication, Pharmacokinetics, & Contraindication/caution (same as w/ other antibiotics)

*if needed during pregnancy, combination of INH, ehtambutol, & rifampin is considered safest

Adverse Effects•CNS: neuritis, dizziness, h/a, malaise, drowsiness & hallucinations are often reported•GI: same•Discoloration of body fluids – urine, sweat, tears

Drug-Drug Interactions•Rifampin & INH – toxic to liver•Quinidine. Metoprolol, oral contraceptives – inc. metabolism & dec. effectiveness of drugs

New Class of Antibiotics•Ketolides – RI, given OD; Telithromycin (Ketek)

- for tx of CAP, acute bacterial exacerbations of chronic bronchitis & acute bacterial sinusitis

- given 800-mg oral dose•Ertapenem (Invanz) – CAP, skin infections

ANTIVIRALS acyclovir amantadine didanosine foscarnet ganciclovir idoxuridine ribavirin trifluridine vidarabine zidovudine

General Information & Action

- inhibit viral growth by inhibiting an enzyme within the viral cell, DNA polymerase- DNA synthesis is inhibited & the cell cannot replicate- Amantadine prevents virus from entering body cells

•Viruses – warts, common cold “flu”, chicken pox & measles•To carry on any metabolic processes, including replication, a virus must enter a cell •Interferons – tissue hormone that is released in response to viral invasion; blocks viral replication

Indication•Effective for a single class of virus•Acyclovir & Vidarabine – used in the tx of severe virus infections•Amantadine - prevention of Influenza A infections; Parkinson’s d’se because of its action on dopamine release in the EP tracts in the CNS

• Ganciclovir & Foscarnet – used to treat retinitis caused by CMV• CMV – common on patients whose natural immune process are depressed• Didanosine & Zidovudine – slow the progression of AIDS

• Idoxuridine & Trifluridine – currently used only for viral eye infections – herpes simplex• Ribavirin – used in tx of RSV infections in infants & young children

Contraindications• Hypersensitivity

•Zidovudine & Idoxuridine – can appear in breast milk therefore…

Adverse Reactions & Side Effects

•Vary greatly among the individual antiviral drugs•Some have life-threatening reactions

•Lightheadedness, dizziness, insomnia, nausea, orthostatic hypotension, urinary retention•NV, h/a, depression, rash, hair loss, •Rash, inflammation, burning at site of injection & topical application

Nursing Precautions

•Patients w/ renal & hepatic dysfxns should be monitored carefully•Safety among pregnant women & young children•Ribavirin – safety among adults

• Because drug is given by continuous aerosol administration – caution to pregnant nurses or of child-bearing age – avoid exposure to the drug

Interactions

• Varies among the individual antiviral drugs

ANTIFUNGALS•From annoying “athlete’s foot” to potentially fatal systemic infections•Caused by fungus called mycosis•Fungus – has a rigid cell wall made up of chitin & various polysaccharides & a cell membrane that contains ergosterol

• Candida can cause “thrush” on GIT & vagina

Systemic Antifungals- can be toxic to the host- culture of fungus is imp’t

• Amphotericin B (Fungizone, Albecet, Amphotec, AmBisome)

• Flucytosine (Ancoban)• Griseofulvin (Fulvicin, Grifulvin V, Grisactin, Gris-PEG)

•Nystatin (Mycostatin, Nilstat, Nystex)•Azoles – newer drug used to tx systemic fungal infections Ketoconazole (Nizoral), Fluconazole (Diflucan)

Indications•Acts on cell permeability of fungus leading to cell death & prevention of replication

Contraindications & Cautions•w/ known allergy•Pregnancy & lactation (exception to the terbinafine)•w/ renal/liver d’se

Adverse Effects•h/a, dizziness, fever, shaking, chills, malaise•NVD, dyspepsia, anorexia•Rash & pruritus

Drug-Drug Interactions•Pts. Who receive Amphotericin B should take neither nephrotoxic drugs nor corticosteroids•Cyclosporine, digoxin, oral hypoglycemics, & phenytoin = inc serum levels of azole family

• azole + lovastatin, simvastatin, astemizole, cisapride, triazolam, & midazolam = potentially severe CV events

Assessment: History & Patient Assessment- establishment of baseline dataHx of allergyHx of liver/renal dysfxnPregnant? Lactating?Culture of infected areaorientation & reflexesSkin color & lesionsRFT/LFT

Nursing Dx•Acute pain r/t GI, CNS, local effects of drug•Disturbed sensory perception r/t CNS effects•Deficient knowledge regarding drug therapy

Implementation•Arrange for appropriate C&S tests

•Administer entire course of the drug to get the full beneficial effects•Monitor IV sites to ensure that phlebitis does not occur•Monitor renal & hepatic fxn•Provide comfort & safety if CNS effects occur•Provide small, frequent meals•Provide pt. instruction

The patient should:•Follow appropriate dosage regimen•Take safety precautions – changing position slowly, avoiding driving & hazardous tasks if CNS effects occur•Take oral drug w/ meals & try small, frequent meals if GI upset is a problem

•Report to a health care provider any of the ff:

- sore throat- unusual bruising &

bleeding- yellowing of eyes or skin- severe n/v- severe local irritation w/

local application, w/c could indicate a sensitivity reaction & worsening of the infection

Evaluation•Monitor pt. response to the drug•Monitor for adverse effects•Evaluate effectiveness of the teaching plan•Monitor effectiveness of comfort & safety measures & compliance w/ the regimen

TOPICAL ANTIFUNGALS•Fungi that cause mycoses of the skin & mucos membranes are called dermatophytes• Includes tinea infections & candida infections•Fungizone, gentian violet, miconazole•Too toxic but effective in tx of local fungal infections

• Should not be used near open wounds• Can cause serious local irritation, burning & pain. Stop if this conditions occur

ANTIPROTOZOAL AGENTS•CA: amebiasis, gardiasis, & trichomoniasis•Malaria – p. falciparum, p. vivax, p. malariae, p. ovale•Ex. of drugs: quinine & chloroquine•Quinine – may lead to severe diarrhea & a condition called cinchonism (n/v, tinnitus, vertigo)

Action/Indications• Interrupt plasmodial reproduction of protein synthesis in the RBC stage of the life cycle

Contraindications•Known allergy•Liver d’se or alcoholism•Lactation•Caution w/ retinal d’se

•Psoriasis or porphyria (metabolism)•w/ damage to mucous membranes•w/ prolonged QTc interval, if using halofantrine

Adverse Effects•CNS: h/a, dizziness, fever, shaking, chills, malaise

• GI: n/v, dyspepsia, anorexia, liver toxicity• Skin: rash, pruritus, loss of hair ass. w/ changes in protein synthesis• Eye: possible blindness r/t retinal damage• Ototoxicity r/t add’l nerve damage• Cinchonism

Drug-Drug Interactions•Quinine + quinine derivatives =cardiac toxicity & convulsions•Halofantrine – increased risk for cardiac arrythmias & death if they take other drug that prolong the QTc interval•Fansidar – sulfadoxine +pyrimethamine – tx of p. falciparum when chloroquine resistance is suspected

Nursing Considerations (same w/ antifungals)

Other Protozoal Infections•Amebiasis – intestinal infection caused by entamoeba hystolytica, a.k.a. amebic dysentery•Leishmaniasis (skin d’se) – passed from sand flies

• Trypanosomiasis caused by typanosoma causing acute CNS inflammation that result to lethargy, prolonged sleep, even death (African sleeping sickness) transmitted by tsetse fly

• Trichonomiasis – caused by flagellated protozoans – trichomonas vaginalis – vaginits – reddened, inflamed vaginal mucosa, itching, burning, & yellowish-green discharge

•Gardiasis – caused by giardia lamblia from contaminated food/water, cause diarrhea, rotten egg-smelling stool, pale, mucous-filled stool, epigastric distress, wt. loss, malnourishment•Pneumocystis caranii pneumonia (PCP) – if pt. is immunosuppressed due to AIDS or ARC, etc.

Other Antiprotozoal Agents•Metronidazole (Flagyl, MetroGel, Noritate)- amebiasis, trichomoniasis, & gardiasis

- crosses placenta & enters fetal circulation, passes into breastmilk•Others: Pentamidine (Pentam 300, NebuPent); Atovaquone (Mepron)

Indication Inhibit DNA synthesis

Contraindications•Allergy, hypersensitivity, pregnancy•Caution w/ CNS d’se because of possible exacerbation•Hepatic d’se•Candidiasis – superinfection•Lactation

Adverse Effects•CNS: h/a, dizziness, ataxia, loss of coordination peripheral neuropathy•GI: NVD, unpleasant taste, cramps & changes in liver fxn•Superinfections

ANTIHELMINTIC AGENTS- about 1 B people have worms in their GIT or other tissues- common in tropical areas- helminths that most commonly infect humans are of 2 types: nematodes / roundworms & platyhelminths/flatworms

Intestine-Invading Worms- Involves the prevention of reinfection or spread of an existing infection•Nematodes or roundworms include pinworms, whipworms, threadworms, Ascaris, & hookworms•Pinworm – stay in the intestine, cause perianal itching, or occ. vag. itching

•Whipworms – attach to the wall of the colon; cause colic & bloody diarrhea when they inc. in #; may result in prolapse of the intestinal wall & anemia r/t bld. Loss•Threadworms – more pervasive; after burrowing, lay eggs, hatch into larvae that invade lungs, liver, & heart

- may result to death from pneumonia or from lung or liver abscesses•Ascaris – most prevalent helminthic infection; hatch in the small intestine to the lungs, cause cough, fever, & other signs of pulmonary infiltrate

- migrate back to the intestine, grow to adult size

- cause abdominal distention & pain

- severe case: intestinal obstruction by masses of worms can occur•Hookworms – attach to the small intestine & suck bld. from it; cause damage to the intestinal wall, cause severe anemia w/ lethargy, weakness, & fatigue

- malabsorption may occur; tx for anemia & fluid & electrolyte disturbances is an imp’t part of therapy

Platyhelminths: Cestodes•Flatworms include cestodes (tapeworms) – live in the human intestine & the flukes (schistosomes)

•Cestodes – segmented flatworms, may experience some abdominal discomfort & distention, wt. loss

- pts. Require psychological support when the worm comes out of their mouth, or nose w/c occur occasionally

Tissue-Invading Worm Infections•Trichinosis – ingestion of the encysted larvae of the roundworm, Trichinella spiralis, in undercooked pork

- deposited in intestinal mucosa, pass into bloodstream, throughout the body

- penetrate skeletal muscle, cause inflammatory reaction to cardiac muscle & brain

- can cause fatal pneumonia, heart failure, encephalitis• Filariasis – infection of the bld. & tissues; cause inflammation of lymphatic system lead to swelling of hands, feet, legs, arms, scrotum, breast - elephantiasis

•Schistosomiasis - infection by fluke carried by snail; larvae attach to the skin, burrow into the bloodstream & lymphatics

-Move into the lungs & liver, migrate into intestine & urinary bladder

-Lay eggs, expelled in feces & urine

-Pruritic rash/”swimmer’s itch”

- after 1-2 mos., may experience fever, chills, h/a, abdominal pain, diarrhea, blockage of bld. Flow leading to hepatomegaly / spleenomegaly & signs of CNS & cardiac ischemia

ANTIHELMINTICS

•Mebendazole (Vermox) – effective against pin, round, whip, & hookworms

- available in chewable tablet, in typical 3-day course, can be repeated in 3 wks. If needed

- few adverse effects

•Pyrantel (antiminth, pin-rid, pin-X, reese’s pinworm

- oral; effective against pin & roundworms; given as single dose

• Thiabendazole (mintezol)• Albendazole (albenza)• Ivermectin (stromectol

Indication- Interfere w/ metabolic processes in particular worms

Contraindications•Known allergy•Lactation•Pregnancy•Caution w/ renal/hepatic d’se, diarrhea, & malnourishment

Adverse Effects•Abdominal discomfort, diarrhea, or pain•h/a & dizziness•Fever, shaking, chills, malaise•Rash, pruritus, loss of hair•Changes in protein synthesis to Steven-Johnson sydrome ass. w/ thiabendazole

Drug-Drug Interactions

•Theophylline + thiabendazole = increased levels of theophylline•Albendazole + dexamethasone/praziquantel/ cimetidine = increased toxicity of albendazole

Assessment•Screen for hx of allergy hepatic or renal dysfxn•Pregnancy, lactation•Physical assessment•Culture of stool for ova & parasite•Examine reflexes & muscle strength•Hepatic evaluation including LFT RFT

•Examine skin (lesion, color, temperature, & texture) & abdomen

Nursing Dx•Acute pain r/t GI, CNS, skin effects of drug•Disturbed personal identity r/t diagnosis & treatment•Deficient knowledge regarding drug therapy

Implementaiton•C & S•Administer complete course of drug; ensure chewable tabs are chewed•Take w/ food, avoid high-fat meals•Monitor hepatic & renal function before & periodically during tx

• Provide comfort & safety measures if CNS effects occur

• Provide oral hygiene & ready access to bathroom facilities

• Small, frequent nutrition, monitor nutritional status

• Ensure pt. instruction

The pt. should:• Take safety precaution – changing position slowly, avoid driving & hazardous tasks

◦Take drug w/ meals & try small, frequent meal if GI upset occur

◦Note importance of hand washing & hygiene measures

◦Report fever & severe diarrhea, or aggravation of condition, w/c could indicate a resistant strain or non-effective therapy to a health care provider

Evaluation•Monitor pt. response to the drug•Monitor for adverse effects (nutritional state, orientation & effect, skin color & lesions, hepatic & renal fxn, abdominal discomfort & pain•Evaluate effectiveness of teaching plan•Monitor compliance, comfort, & safety measures

ANTINEOPLASTIC AGENTS- use components of immune system instead of destroying cells directly- 2nd leading cause of death n US- genetically different cells divide passed to daughter cells tumor/neoplasm

- cancerous cells exhibit anaplasia

- anaplasia – loss of cellular differentiation & organization- metastasis

Alkylating Agents•Busulfan, Carboplatin, Chlorambucil, Cisplatin, Cyclophosphamide, Ifosfamide, Mechlorethamine, Thiotepa

Antimetabolites•Cytarabine, Fludarabine, Fluorouracil, Mercaptopurine, methotrexate

Antitumor Anitbiotics•Bleomycin, Dactinomycin, Daunorubicin, Doxorubicin

Hormonal Agents•Diethylstilbestrol, Leuprolide, Megestrol, Tamoxifen, Testosterone

Vinca Alkaloids•Vinblastine, Vincristine

Individual Agents•Asparaginase, Procarbazine

General Information & Action•Goal: Interruption or alteration of phase of the cell cycle•Classified as cell cycle specific/nonspecific•Cell cycle specific – agents that affect the cell during 1 phase of the cell life cycle; have their greatest activity during the S phase, blocking DNA synthesis

• Cell cycle nonspecific – those that exert their effects during >1 phase• Destroys normal cells as well as malignant cells• Adverse reactions – are most often a result of changes in normal cell growth• Cancer cells – rapidly dividing; drug affects them directly

• Also affects other body cells that normally reproduce rapidly: cells of GIT, hair follicles, bone marrow

General Use• For cure, control, or palliation (temporary relief of symptoms) of leukemias, lymphomas, solid tumors & preparation for BMT

•Some drugs (methotrexate) – used to treat RA•Often used in combination, to reduce risk drug of drug toxicity & increase therapeutic response•Also used for surgery & radiation•Adjuvant therapy – drugs given after removal of all known cancer present

Contraindications•Consumption of alcohol•Hypersensitivity•History of BMD

Adverse Reaction•BMD (myelosuppression)•Nausea, vomiting, anorexia, diarrhea•Alopecia

•Amenorrhea•Stomatitis, mucositis•Pneumonitis skin eruptions•Male impotency•Heart failure & resp. changes•Anaphylaxis•Metabolic alterations, neurotoxicity•Decreased kidney function•Paralytic ileus•Septic shock

Nursing Considerations1.Accurate identification of kind of cell involved in the neoplasm

2.Proper evaluation of the pt’s condition – ideally: no major infection, bleeding or other serious illness

3.Spills of chemo drugs should be cleaned up immediately by trained personnel

4. Follow special protective procedures for drug mixing, administration, disposal of equipment, unused drugs

5. Vesicant drugs that accidentally leak into surrounding tissues from IV site require immediate tx to prevent tissue damage

6. 24 hr. monitoring of reactions may be needed

NONNARCOTIC ANALGESICS/NONSTEROIDAL ANTI-INFLAMMATORY AGENTS Individual agents: acetaminophen, misoprostol, phenazopyridine

NSAIDs: ibuprofen, indomethacin, naproxen, piroxicam, sulindac

Salicylates: aspirin, choline magnesium trisalicylate, choline salicylate, salsalate

General Information & Action•Salicylates, salicylate-like & NSAIDs – inflammatory diseases (RA, DJD, lupus erythematosus, & scleroderma)•NSAIDs – have analgesic, anti-inflammatory, & antipyretic actions

•Analgesic/anti-inflammatory – inhibition of prostaglandin synthesis•Antipyretic – inhibition of both prostaglandin synthesis & vasodilation

Major Subgroups:•Acetaminophen – prostaglandin inhibition in CNS; peripheral & anti-inflammatory effects, minimal

•Misoprostol – synthetic prostaglandin, marketed as antiulcer

- Inhibit gastric acid secretion & thought to increase mucus production thereby protecting against adverse GI effects of prostaglandin inhibitors (ie. salicylates, NSAIDs); px concurrently w/ NSAID therapy

•NSAIDs – anti-prostaglandin agents – enhanced by inhibition of lysosomal enzyme release of substances causing inflammation•Salicylates – have antipyretic, analgesic, & anti-inflammatory properties

- cholin salicylate – only liquid salicylate available

- salsalate – converted to salicylate in the liver & has fewer GI adverse effects

General Use• To control mild to moderate pain, fever & inflammation (RA, OA)

• Acetaminophen – has no anti-inflammatory effect, useful only to reduce pain & fever

•Phenazopyridine (spasmolytic) – used only for pain r/t urinary tract•ASA, ibuprofen, & acetaminophen – are popular nonprescription drugs for h/a, mild to moderate pain•ASA & Aceta – found in many OTC drug combinations

Contraindications•Hypersensitivity - ASA•Acetaminophen – safe for use in pregnancy – occasionally•All salicylates are contraindicated in persons <21 y/o – Reye’s syndrome, a potentially fatal d’se involving brain & liver dysfunction

Adverse Effects•GI irritation & discomfort – NVD, abdominal pain, flatulence, GI bleeding & ulceration•Tinnitus, hearing loss, weakness, profuse sweating, slowed respiration & HR

Nursing Consideration1.Patients w/ hx of bleeding should be monitored closely – coz of prolonged bleeding time

2.Caution w/ severe CV, liver, or kidney d’se

3.w/ pregnant women4.w/ asthma or nasal polyps, allergy to ASA – higher risk for hypersensitivity

Drug-Drug Interactions•w/ narcotics – additive analgesic effect•w/ anticoagulants, some cephalosporins, plicamycin, thrombolytic agents, valproic acid – prolonged bleeding time

•Diuretics & other antihypertensive drugs may be diminished – fluid retention•w/ zidovudine – toxicity w/ acetaminophen•Large doses of Acetaminophen – can cause necrosis of liver•w/ corticosteroid + salicylates = GI ulceration & bleeding

•w/ phenytoin, sulfonlyureas, & sulfonamides = toxicity & shortened duration of action

ANXIOLYTIC/SEDATIVE/HYPNOTIC/MINOR TRANQUILIZER

A. Benzodiazepine – “lam”, “pam”• Diazepam (P)• Midazolam Hcl• Clonazepam• Alprazolam

Action- act in the limbic system & the RAS to make GABA more effective- for anxiety d/o, alcohol withdrawal, hyperexcitability & agitation

Contraindication• Allergy to any benzodiazepine

•Psychosis – exacerbated by sedation•Glaucoma, shock, coma, acute alcoholic intoxication•Pregnancy – cleft lip/palate, inguinal hernia, cardiac defects, microcephaly, or pyloric stenosis•Lactation•Caution w/ elderly/debilitated pts.

•Renal/hepatic dysfunction

Adverse Effects•CNS: sedation, drowsiness, lethargy, blurred vision, h/a, apathy, lightheadedness, confusion•GU: urinary retention, hesitancy, loss of libido, *do not stop abruptly

B. Barbiturates- general CNS depressant;

relief of s/s of anxiety, insomnia, seizure

C. Non-Barbiturate, Non-benzodiazepine• Buspirone (Buspar), Nabilone

(cesamet)*used for long term therapy; takes

3-6 wks. to take effect

ANTIDEPPRESSANT AGENTS- Obsessive-Compulsive disorder, Panic, PTSD, Premature Ejaculation

TCA (Tricyclic Antideppressant)•Elavil (Amitriptyline)•Tofranil (Imipramine Hcl)•Anafranil (Clomipramine Hcl)•Mellaril (Thioridazine Hcl)

SSRI (Selective Serotonin Reuptake Inhibitor)•Paxil (Paroxetine Hcl)•Prozac (Fluoxetine Hcl)•Zoloft (Sertraline Hcl)

MAOI (Monoamine Oxidase Inhibitor) – NO for tyrmaine•Pamoate•Nardil•Marplan

Nursing Consideration•Limit drug access if pt. is suicidal•Maintain 4-8 wks. Initial dosage reduce dosage if minor S/E occurs

ANTIPSYCHOTIC/ MAJOR TRANQUILIZERS/NEUROLEPTICS/DOPAMINE ANTAGONIST

A.Typical (old) – “zine”• Chlorpromazine (P)• Thorazine• HaldolB. Atypical (new) – after 1990 -

<effect on EPS (extrapyramidal system)

•Resperidone (Resperdal)•Clozapine (Clozaril); (P)•Olanzapin (Zyprexia)

Adverse Effect•Agranulocytosis•Photosensitivity•Orthostatic hypotension•Akathisia•Tardive dyskenisia•Dystonia

Antipsychotic – Antimanic•Lithium – Oskalith, Carbolith, Lithobid

CNS Stimulants- for tx of attention-deficit

d/o; narcolepsy•Dexymethylphenidate•Dextroamphetamine•Methylphenidate (Ritalin); (P)

ANTIEPILEPTIC AGENTS

Tonic-clonic (Grand Mal) Seizure

A.Hydantoins- Phenytoin (P)B.Barbiturates – Phenobarbital (P)

C.Benzodiazepines – diazepam (P)

Absence (Petit Mal) SeizureA.Succinimides – Ethosuximide (P)

B.Other drugs – Valproic acid (P); Acetazolamide

Partial (Focal) Seizure• Carbamezipine (P)

ANTIPARKINSONISMA. Dopaminergic (DA Agonist)

- Carbidopa (Sinemet)- Amantadine (Symmetrel)- Levodopa (Larodopa)

B. Anticholinergic - ABCs- A – Atropine So4, Artane, Akineton- Benadryl- Cogentin (Benztropine Mesylate

Action- to achieve balance b/w acetlycholine & dopamine (DA)

Contraindication•Anticholinergic – narrow-angle glaucoma, tachycardia, thyrotoxicosis•No for children <12 y/o•Levodopa – lactation

Adverse Reaction•Changes in BP & cardiac arrythmias•Levodopa - precipitates psychosis, melanoma, hemolytic anemia,•Anticholinergic – dry mouth, blurred vision, constipation, urinary retention

MUSCLE RELAXANTS•Centrally Acting – Baclofen, Carisoprodol, Cyclobenzaprine, Diazepam, Methocarbamol•Direct-acting Agents – dantrolene

Action- for muscle spasm, sprain, SCI, cerebral palsy

Contraindications•Hypersensitivity to drug or tartrazine (yellow food color)•pt. w/ glaucoma, gastric & intestinal obstruction, prostatic hypertrophy

Adverse Reaction•CNS depression – drowsiness, ataxia•Anticholinergic effects

•Blood – leukopenia, thrombocytopenia, agranulocytosis•Caution w/ seizure d/o•hepatotoxicity

NARCOTIC ANALGESIC

•Narcotic – codeine, hydrocodone, hydromorphone, meperidine, methadone, morphine, oxycodone, propoxyphene

•Mixed narcotic - agonist/antagonist

Action- interferes w/ pain receptors in nerve endings, change pain perception, or change pain reaction through responses in the autonomic & skeletal muscle

Contraindication•Hypersensitivity

• Narcotics – head injury, respiratory depression & shock

Adverse Reaction• CNS: euphoria or sedation, dizziness, resp. depression• GI: vomiting (CTZ), constipation• GU: urinary retention

• Morphine: biliary colic• CV: flushing, inc. HR, palpitations, hypotension, fainting

ALPHA-ADRENERGIC BLOCKING AGENTS•(alpha blockers) – block the effects of the catecholamines epinephrine & norepinephrine on alpha-adrenergic receptors in ANS•Prevents vasoconstriction caused by catecholamines•Primary site – smooth muscle of bld. vessel wall

•Causes relaxation of bld. vessel wall, increasing bld. flow• Inhibit effects of glands – sweat & salivary•Agents: phenoxybenzamine, phentolamine

Indication•Blood vessel spasm – Raynaud’s d’se

•HPN, sweating – adrenergic excess (pheochromocytoma, pt. taking MAOI, eats food w/ tyramine)

Contraindication• In any condition in w/c a sharp drop in BP is undesirable•Hypersensitivity, pregnancy, lactation

Adverse Reaction•Orthostatic hypotension, circulatory failure•Dizziness, weakness, fainting•Tachycardia esp. to pts. w/ heart d’se•GI irritation, NVD

Nursing Consideration•Pts. w/ severe cerebral or coronary arteirosclerosis, gastritis, ulcer – stimulate motility & contractility

Drug-Drug Interactions•antiHPN, block effects of adrenergic drugs (phenylephrine, ephedrine) – used as OTC decongestants

BETA-ADRENERGIC BLOCKING AGENTS

•Atenolol, metoprolol, nadolol, propranolol, timolol•2 types of beta-adrenergic receptors – beta-1 & beta-2

Action•Beta-1 – increased contractility (+ inotropic effect), HR (+ chronotropic effect), & AV conduction (+ dromotropic effect)•Beta-2 – located in smooth muscle of bronchi, bld. vessel, & uterus – cause bronchodilation, vasodilation, relaxation of uterus

•Blocks beta-1 & beta-2 receptor stimulation – slows HR, dec. in myocardial contractility, CO, BP

Indication•For angina pectoris, HPN, tachyarrhythmias, pheochromocytoma, prevention of MI & migrane h/a

•Timolol – used for glaucoma•Useful for symptoms of hyperthyroidism•Propranolol – only betablocker for hypertrophic subaortic stenosis – causes angina, palpitations, syncope; control tremors

Contraindication•CHF, heart block, bradycardia caused by arrhthymias•w/ asthma, COPD, any conidtion involving acute bronchospasm

Adverse Reaction•CV reactions•Dizziness, fatigue, weakness, depression insomnia

•Raynaud’s phenomena*do not withdraw abruptly (sympathomimetic (adrenergic symptoms)

Drug-Drug Interaction•w/ cardiac glycosides, Ca channel blockers, GA quinidine – may exaggerate bradycardia & cardiac depression

•Antidiabetic drugs (insulin) – prolonged hypoglycemia•HPN drugs, phenothiazines, & nitrates•Bronchodilators, catecholamines (epi, norepi, DA)•Cimetidine, oral contraceptives, furosemide, or hydralzine•Thyroid prep. – dec. effect

CALCIUM CHANNEL BLOCKERS- Diltiazem, felodipine, nicardipine, nifedipine, verapamil

Action•Contraction of the heart muscle, & tone of blood vessels

•Decrease the ability of Ca to enter the cells of myocardium & smooth muscle of peripheral blood vessels•Dilate coronary arteries & help prevent coronary artery spasm•Decrease force of contraction, slows AV conduction, reduces HR

Indication•Angina pectoris, HPN, coronary artery spasm•Tx of menstrual cramps, premature labor

Contraindication•Hypersensitivity•Bradycardia, 2nd & 3rd-degree heart block, or severe CHF (Diltiazem & Verapamil)

Adverse Reaction•CV: Hypotension, changes in HR, cardiac arrhythmias•GI: nausea, constipation•CNS: dizziness, h/a•CHF s/s: SOB, dyspnea, peripheral edema

Drug-Drug Interactions•w/ B-adrenergic blockers, quinidine, carbamezipine•Phenobarbital, phenytoin, cardiac glycoside

GENERAL & LOCAL ANESTHETIC AGENTS

General – are CNS depressants used to produce loss of pain sensation & consciousness•Barbiturates:methohexital, thiopental (P)

•Non-barbiturate: droperidol, etomidate, ketamine,

midazolam (P), propofol•Gases: cyclopropane,

ethylene, nitrous oxide (P)•Volatile liquids: desflurane,

enflurane, halothane (P)

Local Anesthetics – used to cause loss of pain

sensation & feeling in a designated part of a body without the systemic effects ass. w/ severe CNS depression•Esters: benzocaine (P), butamben, procaine•Amine: Bupivacaine, lidocaine(P)

NEUROMUSCULAR JUNCTION BLOCKING AGENTS

Non-depolarizing Neuromuscular blockers – acts as antagonists to Ach at the NMJ & prevent depolarization of muscle cells•Atracurium, tubocurarine (P), vecoronium

Depolarizing neuromuscular blocker – acts as ACH agonist causing stimulation of the muscle cells & then preventing it from repolarizing•succinylcholine

*Both of these types cause paralysis/loss of muscular function, for performance of SP or facilitation of MV

Indication- adjunct to GA, facilitate mechanical intubation, facilitate ECT

ADRENERGIC AGENTS (Sypmathomimetic drugs)

•Dobutamine, dopamine (P), epinephrine, norepinephrine, terbutaline, albuterol

Indication• increases HR, bronchodilation, vasoconstriction, glycogenolysis,

shock, bronchospasm, asthma

Contraindication•pheochromocytoma, tachyarrhythmias, ventricular fibrillation, PVD,

Adverse EffectSNS: arrhythmia, HPN, palpitation, angina, dyspnea, N/V, h/a, sweating, piloerection

Drug-Drug Interactions• Increased effects of TCAs & MAOI

CHOLINERGIC AGENTS•Direct-Acting Cholinergic Agonists

- Bethanecol (P), pilocarpine

• Indirect-Acting Cholinergic Agonists

- donepezil (P), edrophonium, neostigmine,

pyridostigmine (P)

Are chemicals that act at the same site as the neurotransmitter acetylcholine (Ach)

Found in PNS – stimulation of these sites produces a response similar to what is seen when the PNS is activated

Referred to as parasympathomimetic drugs

Action•slows HR, vasodilation, bronchoconstriction, inc. secretion from bronchial mucus, inc. GI activity, inc. bladder tone, pupil constriction

ADRENOCORTICAL AGENTS

Glucocorticoids – anti-inflammatory & immunosuppressive effect; affect K, NA, &

h2o levels•betamethasone, prednisolone (P)

Mineralocorticoids – inc. NA reabsorption, inc. K &

Hexcretion, renal

insufficiency,hypotension•hydrocortisone, fludrocortisone (P)

THYROID & PARATHYROID AGENTS

Thyroid Hormones – hypothyroidism (myxedemcoma); inc. metabolic rate, prevention of goiters, mngt. of thyroid Ca• levothyroxine (P) (Synthroid)

Antithyroid Agents– acute thyrotoxicosis; to block thyroid function in

radiation emergencies•propylthiouracil (PTU), radioactive idodide (I 131), K iodide

Antihypocalcemic Agents - • calcitrol (P)

Antihypercalcemic - Paget’s d’se, osteoporosis

•(Biphosphonates) alendronate (P), calcitonins, gallium

ANTIDIABETIC AGENTSParenteral Antidiabetic• insulin

Oral AntidiabeticSulfonylureas: 1st generation•Chlorpropamide (P)•Talbutamide

Sulfonylureas: 2nd generation•Glipizide•Glyburide (P)

Nonsulfonylureas•acarbose (P)•metformin,

Glucose-elevating agent•glucagon, diazoxide

DRUGS AFFECTING FEMALE REPRODUCTIVE SYSTEM

Progestins - Includes female hormone progesterone

Eg. Levonorgestrel (P); estradiol (P)

Fertility drugs – stimulate the female reproductive system

Eg. Clomiphene

Oxytocics – stimulate uterine contractions & assist labor

Eg. Oxytocin (P) Abortifacients – used to induce abortion

Eg. Dinoprostone (P); Carboprost

Tocolytics – used to relax gravid uterus to polong pregnancy

Eg. Ritodrine (Yutopar) (P)

DRUGS AFFECTING THE MALE REPRODUCTIVE SYSTEM

ANDROGEN – more anabolic effects rather than androgenic (male sexual characteristic); improve penile dysfunction; hypogonadism (underdeveloped testes); tx of breast CaEg. Testosterone (P); Danazol

Anabolic steroids – stanozolol (P); oxymetholone

Drugs for treating Penile Dysfunction – sildenafil (P); alprostadil

DRUGS ACTING ON THE CARDIOVASCULAR SYSTEM• Drugs affecting Blood Pressure• Cardiotonic Agents• Antiarrhthmic Agents• Antianginal Agents• Lipid-lowering Agents• Drugs Affecting Blood Coagulation• Drugs Used to Treat Anemias

Drugs Affecting BP (ABCD)A – Angiotensin-Converting Enzyme Inhibitors (ACE) – “pril”; stops the phase of RAS •Benazepril, enalapril, capropril (P)

A – Angiotensin II Receptor Blockers•Losartan (P), telmisartan

Betablocker

Ca Channel BlockersDiureticsOthers: Vasodilators•hydralazine; NitroprussideGanglionic Blocker•mecamylamineAntihypotensive agent•midodrine

Action- prevent conversion of AI to AII, a powerful vasoconstrictor & stimulator of aldosterone release- conjunction w/ digoxin & diuretics to tx CHF & left ventricle dysfunction

Contraindication•Allergy to ACE inhibitors• Impaired renal function•Pregnancy & lactation•Caution w/ CHF & salt/volume depletion

Adverse Effects•Tachycardia, chest pain, CHF, cardiac arrhythmias

•GI irritation, ulcers, constipation, liver injury•Proetinuria, RF•Rash, alopecia, dermatitis, photosensitivity

Drug-Drug Interaction•w/ Allopurinol

Drug-Food•Empty stomach

CARDIOTONIC AGENTS

Cardiac Glycoside•Digoxin (P) (Lanoxin)

Phosphodiesterase Inhibtors• Inamrinone (P)

Digoxin Antidote•Digoxin Immune Fab

Action & Indication- increase intracellular Ca & allow more Ca to enter myocardial cells during depolarization causing: + inotropic effect (inc. force of myocardial contraction

- Increased cardiac output& renal perfusion

- Slow HR owing to slowing of cellular repolarization (- chronotropic effect)

- Decreased conduction velocity through AV node

Contraindication & Caution•Allergy w/ digitalis preparation•Vent. tach./vent. fib.

• Heart block; MI• Pregnant & lactating

ANTIARRHYTHMIC AGENTS

Class Ia – stabliize cell membrane by binding to Na channels; Ventricular A.•quinidine (P); procainamide

Contraindication•Allergy•bradycardia/heart block •CHF; hypotension, shock

• lactation; electrolyte disturbances; renal/hepatic dysfunction; pregnancy

Adverse Effects•CNS: dizziness, drowsiness, fatigue, twitching, mouth numbness, slurred speech, vision changes, tremors•GI: change in taste, n/v

• CV: hypotension, vasodialtion, cardiac arrest• RS: resp. depression• Others: rash, hypersensitivity, loss of hair, BMD

Class Ib – Antiarrhythmics• lidocaine (P) Class Ic Antiarrhythmics• flecainide

Class II Antiarrhythmics•propranolol (P)

Class III Antiarrhythmics•amiodarone; bretyllium (P); sotalol

Class IV Antiarrhythmics•diltiazem (P); verapamil

Other: •adenosine; digoxin

ANTIANGINAL AGENTS

Nitrates – direct relaxation of smooth muscle, reduces myocardial workload; for prevention & tx of angina pectoris

• Isosorbide mononitrate•Nitrogylcerin (NTG) (P)

Contraindication•Allergy to nitrates•Severe anemia•Head trauma/cerebral hemorrhage•Pregnancy/Lactation•hepatic/renal d’se•Caution w/ hypotension, conditions limiting CO (eg. tamponade)

Adverse Effects•CNS: h/a, dizziness, weakness•GI: n/v, incontinence•CV: hypotension, tachycardia, angina•Skin: flushing, pallor, sweating, increased perspiration

B-blockers – block B-adrenergic receptors & vasoconstriction•metoprolol•Nadolol•Propranolol

Ca-Channel Blockers – prevent movement of Ca into cardiac & smooth muscle cell

•Amlodipine•Bepridil•Diltiazem (P)

LIPID-LOWERING AGENTS/ANTILIPEMICS

Bile acid sequestrant•Cholestyramine (P) –

HMG-CoA Reducatse Inhibitors- block formation of cellular cholesterol, leading to decrease in serum cholesterol

•Lovastatin (Mevacor) (P) •Simvastatin (Zocor)•Other: clofibrate, niacin, HRT

Contraindication•Allergy w/ statins or fungal byproducts or compounds•Active liver d’se•Pregnancy/lactation• Impaired endocrine function

Adverse EffectsGI: flatulence, abdominal pain, cramps, n/v, constipation, acute liver failure

CNS: h/a, dizziness, blurred vision, insomnia, fatigue, cataract dev’t

MS: RhabdomyolysisES: ARF

DRUGS AFFECTING BLOOD COAGULATION

Antiplatelet drugs – inhibit platelet adhesion & aggregation by blocking receptor sites on platelet membrane •Aspirin (P)•Clopidogrel (Plavix)

Contraindication•Allergy to specific drug•Pregnancy, lactation•Presence of known bleeding disorder•Recent surgery•Closed head injuries

Adverse effects•Bleeding•Skin rash

Anticoagulants – interferes clotting process; tx of thromboembolic disorders (eg. atrial fib., MI, pulmonary embolus, stroke)

Antithrombin•Heparin (P)•Warfarin

Low-Molecular-Weight Heparins – inhibit thrombus & clot formation by blocking clotting factors•Enoxaparin (P)

Anticoagulant Adjunctive Therapy•Protamine sulfate•Vitamin K

Contraindication•Known allergy to drugs

w/ hemorrhagic disorders•Recent trauma, spinal punture•GI ulcers recent sx•Caution w/ CHF, thyrotoxicosis, psychosis

Hemorheologic agent•Pentoxifylline

Thrombolytic agents – breaks down fibrin threads & dissolves clot•Alteplase•Reteplase•Streptokinase(P)•Urokinase

Drugs used to control bleeding – replacement factors that are genetically missing; prevent blood loss, treat bleeding episodes •Antihemophilic agent•Antihemophilic factor(P)•Factor IX complex

Contraindication•Allergy to mouse proteins•Liver d’se – factor IX•Lactation/pregnancy

Adverse Effects•Risk w/ use of blood products•h/a, flushing, chills, fever, lethargy

• n/v, stinging, itching, burning at site of injection

Systemic Hemostatic Agents•Aminocapoic acid (P)•Aprotinin

Topical hemostatic agent•Absorbable gelatin (P)•Microfibrillar collagen•Thrombin

DRUGS USED TO TREAT ANEMIAS

Erythropoietin•Darbopoetin alfa•Epoetin alfaIndication & Action•Acts like the natural glycoprotein erythropoietin to stimulate the production of RBCs in the bone marrow

•Tx of anemia in RF & for pts. on dialysis•To decrease need of BT•Tx of anemia associated w/ AIDS therapy•Tx for anemia associated w/ cancer chemotherapy

Contraindication & Caution•Uncontrolled HPN

•w/ allergy to mammalian-cell derived product/human albumin• lactation

Adverse Effects•CNS effects – asthenia, potential for seizure•GI sx•CV: HPN, edema, possible chest pain

•Possible clotting of access line r/t direct cellular effects of the drug

Iron preparations•Ferrous fumarate•Ferrous gluconate•Ferrous sulfate (P)• Iron dextran

Indications•Elevate serum iron concentration•Tx of IDA•Adjunctive therapy for pt. receiving epoetin alfa

Contraindication & Caution•w/ known allergy

•Hemochromatosis (excessive iron)•Hemolytic anemias•Peptic ulcer, colitis, regional enteritis

Adverse Effects•GI irritation/upset: + dark stools constipation•CNS toxic

• Parenteral Iron: anaphylactic reaction, local irritation, staining of the tissues, phlebitis

Folic acid derivatives•Folic acid (P)•Leucovorin

Indication & Action•Essential for cell growth & division•Production of strong stoma in RBCs•Necessary for maintenance of myelin sheath in nerve tissue•Dietary deficiencies•Pregnancy & lactation

Contraindication & Caution•w/ caution to pregnant & lactating patients

Adverse effects•Pain & discomfort at injection sites•Nasal irritation w/ the use of nasal spray

Vitamin b12•Cyanocobalamin•Hydroxocobalamin (P)

DRUGS ACTING ON THE RENAL SYSTEM

DIURETIC AGENTS

Thiazide Diuretics (DCT)•Hydrochlorothiazide (P)

Thiazide-Like Diuretics•Chlorthalidone (P)

Loop Diuretics (LoH)•Furosemide (P)

Carbonic Anhydrase Inhibitors (PT)•Acetazolamide (P)

Potassium-Sparing Diuretics (DT & collecting duct)•Spironolactone (P)

Osmotic Diuretic (glomerulus, tubule)•Mannitol (P)• Isosorbide

General Action & Indication•Prevents reabsorption of excessive proportion of sodium ions in glomerular filtrate

•Cause increased intravascular volume & hydrostatic pressure, w/c could result in leaking of fluids at capillary level•For tx of edema (CHF)•Acute pulmonary edema•Liver/renal disease•Tx of HPN

•Decrease fluid pressure in the eye (intraocular pressure; glaucoma)•Tx of hyperkalemia

Contraindication & Caution•Allergy•w/ fluid & electrolyte imbalance•severe renal d’se

•Systemic lupus erythematosus (SLE)•DM (glucose-elevating effects)•Gout (abnormality in renal tubule reabsorption & secretion)•Liver d’se•Pregnancy & lactation

Adverse Effects•GI upset•Fluid & electrolyte imbalances•Hypotension•Electrolyte disturbances

DRUGS AFFECTING THE URINARY TRACT & THE BLADDER

Urinary Tract Anti-Infectives•Methylene blue•Nalidixic acid•Norfloxacin

Urinary Tract Antispasmodics•Oxybutynin

Urinary Tract Analgesic•Phenazopyridine

Bladder Protectant – protect from irritation r/t solutes in the urine; has anticoagulant & fibrinolytic effects•Pentosan Polysulfate Sodium

Drug Used to Treat BPH (a- adrenergic blocking agent) – used to block dilation of arterioles in bladder & urinary tract

•Doxazosin (P)•Finasteride•terazosin

DRUGS ACTING ON THE RESPIRATORY SYSTEM

DRUGS ACTING ON THE UPPER RESPIRATORY TRACT

Antitussive•Codeine•Dextromethorphan•Hydrocodone

DecongestantsTopical Nasal Decongestants•Ephedrine (P)•PhenylephrineOral Decongestants•Pseudoephedrine (P)Topical Nasal Steroid Decongestants•Beclomethasone•Dexamethasone flunisolide

Antihistamines•Azatadine•Brompheniramine•Cetirizine•Desloratadine•Diphenhydramine (P)

Expectorants•Guaifenesin•Terpin hydrate

Mucolytics•Acetlycysteine (P)•Domase alfa

DRUGS USED TO TREAT OBSTRUCTIVE PULMONARY DISORDERS

• Asthma• COPD; emphysema; RDS

Bronchodilators/Antiasthmatics, Xanthines•Aminophylline

• Theophylline (P)

Action & Indication• Directly affects smooth muscle of RT both in bronchi & blood vessels• Increase vital capacity that has been impaired by bronchospasm or air trapping

Contraindication•w/ GI problems•coronary d’se, respiratory dysfunction•Renal/hepatic d’se,alcoholism•Hyperthyroidism

Adverse Effects•Normal level: 10-20 mcg/ml•GI upset, irritability, tachycardia

•Seizure, brain damage, death

Sympathomimetics•Terbutaline•Ephedrine•Epinephrine (P)

Indication•Bronchospasm in reversible obstructive airway d’se

Contraindication•Cardiac/vascular d’se, arrhythmias•Diabetes. Hyperthyroidism•Pregnancy, lactation

Adverse Effects•CNS stimulation•GI upset•Cardiac arrhythmias, HPN

• Bronchospasm, sweating• Pallor, flushing

Anticholinergics• Ipratropium

Inhaled Steroids•(P) flunisolide

Action & Indication•Used to decrease inflammatory response in airway• Increase airflow & facilitate respiration

• Promotes B-adrenergic receptor activity w/c may promote smooth muscle relaxation & inhibit bronchoconstriction

• Prevention & tx of asthma

Contraindications•Not for use during acute asthma attack/status asthmaticus

• Pregnancy/lactation• w/ active infection of Resp. sys.

Adverse Effects•Sore throat, hoarseness, coughing, dry mouth•Pharyngeal/laryngeal fungal infection

Leukotriene Receptor Antagonists•Zafirlukast (P)•Montelukast

Indication•Blocks s/s of asthma (eg. neutrophil & eosinophil migration, smooth muscle contraction)

•For prophylaxis & chronic tx of bronchial asthma in adults & <12y/o•Not indicated for acute asthmatic attacks

Contraindications•w/ hepatic/renal impairment•Pregnancy & lactation

Adverse Effects•h/a, dizziness, myalgia•Nvd, abd. Pain, elevated liver enzymes•Generalized pain, fever

Lung Surfactants•Beractant (P)• Calfactant

Indication•Reduces surface tension w/n the alveoli allowing expansion & gas exchange•Prophylactic tx for those at risk for RDS

Adverse Effects•Patent ductus arteriosus, hypotension

• Intraventricular hemorrhage, pneumothorax•Hyperbilirubinemia, sepsis

Mast Cell Stabilizers•(P) Cromolyn•Nedocromil

Action/Indication•Prevent release of inflammatory & bronchoconstricting substances•Prevents allergic asthmatic response•Tx of chronic bronchial asthma, exercise-induced asthma, allergic rhinitis

Contraindication•Known allergy to drug•Cannot be used during an acute attack•Cromolyn not recommended for <2y/o children•Nedocromil not recommended for >12y/o

Adverse Effects•Swollen eyes, h/a, dizziness, fatigue•dry mucosa, nausea, cough•Should not be discontinued abruptly

DRUGS ACTING ON THE GI SYSTEM

Drugs Affecting GI secretions

5 types of drugs used to treat ulcers:

1. Histamine-2 (H2) antagonists – block the release of HCL acid in response to gastrin

•Cimetidine (P)•Famotidine•Ranitidine

Action/Indication•Block histamine-2 receptor sites w/c leads to reduction in gastric acid secretion & reduction in overall pepsin production•H2 receptor sites – heart – cardiac arrhythmias•Short-term tx of active doudenal ulcer or benign gastric ulcer

•Tx of pathological hypersecretory conditions (Zollinger-Ellison syndrome)•Prophylaxis of stress-induced ulcers, acute upper GI bleeding•Tx of erosive GER•Relief of symptoms of heartburn, acid indigestion, & sour stomach (OTC prep.)

Contraindications/Cautions•Known allergy•Caution w/ pregnancy/lactation•Hepatic/renal dysfunction

Adverse Effects•Diarrhea/constipation•Dizziness, h/a, somnolence, confusion, hallucination

•Cardiac arrhythmias, hypotension•Gynecomastia (w/ long-term use w/ cimetidine), impotence

2. Antacids – interact w/ acids at the chemical level to neutralize them

•Aluminum•Sodium bicarbonate (P)•Magnesium/Ca salts•Magaldrate

Action/Indication•Symptomatic relief of upset stomach associated w/ hyperacidity (w/ peptic ulcer, gastritis, peptic esophagitis, hiatal hernia)

hernia of upper stomach: a hernia in which the part of the stomach around the esophagus entrance is forced up into the chest cavity through the normal opening in the diaphragm for the esophagus. Hiatal hernia is associated with heartburn and can usually be corrected by surgery.

Microsoft® Encarta® 2009. © 1993-2008 Microsoft Corporation. All rights reserved.

Contraindication/Caution•Known allergy•Caution w/ electrolyte imbalance, GI obstruction

Adverse Effects•Rebound acidity•Alkalosis w/ resultant metabolic changes (n/v, neuromuscular changes, h/a, irritability, muscle twitching, coma)

• Hypercalcemia & milk-alkali syndrome (seen as alkalosis, renal Ca deposits, severe electrolyte disorders)

• Constipation/diarrhea• Hypophosphatmeia (due to

Al salts)• Fluid retention, CHF (Na

HCO3)

3. Proton Pump Inhibitors (PPI) – suppress the secretion of HCL acid into the lumen of the stomach•Omeprazole (P)• lansoprazole

Indication/Action•Act at specific secretory surface receptors to prevent final step of acid production

•For short-term tx of active doudenal ulcers, GERD, erosive esophagitis, benign active gastric ulcer•Long-term tx of pathological hypersecretory conditions•As maintenance therapy for healing of erosive esophagitis & ulcers

Contraindications/Cautions•w/ known allergy•Pregnant/lactating women

Adverse Effects•Dizziness, h/a asthenia (loss of strength), vertigo, insomnia, apathy•Diarrhea, abd. pain, n/v, dry mouth, tongue atrophy

•Cough, stuffy nose, hoarseness, epistaxis•Rash, pruritus

4. Antipeptic Agents – coat any injured area in the stomach to prevent further injury from acid•Sucralfate

Action/Indication•Protect sites against acid, pepsin, & bile salts•prevents furhter beakdown of the area & promotes ulcer healing• Inhibits pepsin activity in gastric juices•Short-term tx of doudenal ulcers

5. Prostaglandins – inhibit the secretion of gastrin & increase the secretion of mucus lining of the stomach, providing a buffer•Misoprostol

Action/Indication•Prevent NSAID-induced gastric ulcers

Contraindication•Abortifacient

Adverse Effects•Nvd, dyspepsia•Miscarriages, excessive bleeding, spotting, cramping, hypermenorrhea, dysmenorrhea

6. Digestive Enzymes – suffered strokes, salivary gland disorders, surgery of head/neck, cystic fibrosis, pancreatic dysfunction•Pancrelipase•Pancreatin (P)•Saliva substitute

Action/Indication•Contains electrolytes & carboxymethylcellulose to act as thickening agent in dry mouth conditions•Help digestion & absorption of fats, proteins, & CHO•Replacement therapy in pts. w/ cystic fibrosis, chronic pancreatitis, ductal obstruction,

• pancreatic insuffciency, steatorrhea, malabsorption syndrome, after pancreatectomy, gastrectomy

Contraindication/Caution•Known allergy to parabens or any component of the drug•w/ pt. w/ CHF, HPN, RF•Known allergy to the product or to pork products

Adverse Effects•Cx from abnormal electrolyte absorption (eg. increased level of Mg, Na, or K•GI irritation

LAXATIVE & ANTIDARRHEAL AGENTS

•Speed up or improve movement of intestinal contents along GIT• Increase tone of GIT & to stimulate motility throughout the system

• Used to decrease mov’t along GIT when rapid mov’t decreases the time for absorption of nutrients, leading to loss of H2O & nutrient

LAXATIVES Chemical stimulants•Bisacodyl

•Cascara•Castor oil (P)

Bulk Laxatives•Lactulose•Mg citrate (P)•Mg hydroxide

Lubricants•Mineral oil (P)

GI Stimulants•Metoclopramide (P)•Dexpanthenol

Antidiarrheal Agents•Bismuth subsalicylate•Loperamide (P)•Opium

EMETIC & ANTIEMETIC AGENTS

Emetic Agent• Ipecac syrup (P)

Indication/Action• In cases of overdose or poisoning•Gastric lavage

• Irritates GI mucosa w/c stimulates CTZ

Contraindication/Caution• Ingestion of caustic alkali or corrosive mineral acids – potential for upper GI & airway serious damage•When volatile petroleum distillate (kerosene) have been swallowed - aspiration

•Comatose/semi-comatose pt.; s/s of convulsion

Adverse Effects•GI upset, mild CNS depression•Cardiotoxicity

Antiemetic – decrease or prevent nausea or vomiting•Reduces hyperactivity of the vomiting reflex either decrease local response to stimuli or block CTZ

Phenothiazine•Chlorpromazine•Prochlorperazine (P)•Promethazine

Nonphenothiazines•Metoclopramide

Anticholinergics/Antihistamines•Meclizine (P)•Cyclizine•Buclizine

5-HT3 receptor blockers•Ondansetron•Dolasetron

Miscellaneous•Dronabinol•Hydroxyzine• trimethobenzamide

Contraindication/Caution•w/ coma/severe CNS depression•Brain damage/injury•Hypo/hypertension•Severe liver dysfxn/renal•Active eptic ulcer•Prenancy/lactation

Adverse Effect• interference w/ normal CNS response•Cardiac arrhythmias•Autonomic effects – dry mouth, anorexia, pallor, photosensitivity