PHARMACOLOGYGreek termpharmakon – drug or medicineLogos – the truth about or rational discussionClinical pharmacology is the study of drugs in humans. A drug is any chemical that can effect living processes.

Pharmacology –Study of the biological effects of chemicalsPharmacotherapeutics – Clinical pharmacology involving drugs use to treat, prevent, or diagnose a disease

NURSING PROCESS AND MEDICATION ADMINISTRATION 1. ASSESSMENTAllergiesPattern of health careUnderstanding of the disease processFinancial support2. Physical Assesment Age and weightSocial support at homeChronic condition3. Diagnostic test, laboratory test4. Medication HistoryPrescriptionsOTCS HerbalsResponse to medications

Nursing DiagnosisHuman response to illnessDrug therapy may only be a part of the total pictureDrug therapy is incorporated in the total picture

PLANNING1. identify possible intractions 2. client and family education3. gather equipment, review procedures, safety measures, timing and frequency of drugs4. storage of drugs

IMPLEMENTATION1. Maximising therapeutic effects2. Minimizing adverse effects3. SIX rights of medication administration

EVALUATIONMonitor the patient response to drug therapy expected outcomeUnexpected outcome

The 5 RIGHTS of Medication Administration Right drugRight doseRight timeRight routeRight patient

WHAT OTHER RIGHTS TO ENSURE SAFETY IN GIVING DRUGS?Right to:Consistent system AnalysisA “ double checkThe entire system of medication administrationOrdering, preparing, dispensing, documenting

RIGHT TO: Proper drug storage Proper documentation Actual dosage preparation Accurate dosage calculation and

preparation Careful checking of orders Patient’s safety

SIX ELEMENTS OF A DRUG ORDER1. Name of the patient2. Date order is written3. Name of medication4. Dosage which includes size, frequency and

number of doses5. Route of delivery6. Name and signature of the prescriber

DRUG NAMES1. Chemical NameDescribe the chemical structure and composition2. Generic NameNon propriety name given by USANC 3.Brand NameRegistered trademarkEXAMPLESChemical NamePropionic acidGeneric NameIbuprofenBrand NameMotrin

Pharmacologic PrinciplesDRUGAny chemical that affects the physiologic mechanism of a living organismPHARMACOLOGYThe study or science of drugsPharmacologic Principles

1.PHARMACEUTICSStudy of Drug formsDeals with the delivery systemThe rate at which drug is dissolved and absorbed a.1. Pharmaceutical phase Dose of formulated drug

↓ Administration

↓Disintegration and dissolution

of the drug in the body a.2. Pharmacokinetic phase

drug available for absorption↓

Absorption, distribution, metabolism, excretion

a.3. Pharmacodynamic PhaseDrug available for action

↓Drug receptor interaction

↓Effect

2. PharmacokineticsThe study of what actually happens to a drug from the time it enters the body until it has left the bodyA. Absorption- movement of drug from the site of administration

B. Distribution transport of a drug to the bloodstreamC. Metabolism alteration of a drug in the bodyD. Elimination elimination of the drug or its compound in the body

PHARMACOKINETICS 1. Absorption the route of administration affects the rate and extent of absorption of that drug A. Enteral B. Parenteral C. TopicalThe extent of drug is called Bioavailability A. Absorption of oral drugsVaries according to the dosage form and routeStatus of the absorptive surface portions of the small intesines may be missing or damagedRate of blood flow to the intestinessepsis ,excersise labor Activity of the stomachfood increases gastric acid production leading to decreased Ph . Status of gastric motilityfast or slow transmit time due to pathology, conditions which might delay transmissionSome drugs are taken with an empty stomach with a full glass of waterOther drugs should be taken with a full stomach to avoid gastric irritation or to enhance absorption

Drugs that are given by the oral route →Mesenteric blood system → Liver for

biotransformation before travelling into general circulation and this is called

↓FIRST PASS EFFECT

FACTORS AFFECTING DRUG ACTION1. ABSORPTION - refers to the time the drug enters the body to the bloodstream.Factors:

A. Dosage FormB. Route of administration

a) Parenteral – generally rapidb) Intravenous and Intra-arterial – most

rapidc) Intramuscular and Subcutaneous

- Absorption is fast when given in aqueous base

-Depends on condition of blood flow-Impaired peripheral circulation and shock will delay absorption

d) Intradermal – absorption is slow and confined to area of injection only

e) Oral – rate and degree of absorption -depends on G.I. motility, presence of foods, gastric pH and other drugs taken

C. Lipid Solubility – affects absorption as it passes the G.I. mucosa

D. G.I. Motilitya. Stomach empties slowly with food and delay absorptionb. Most oral drugs are best absorbed if given before meals or between meals

c. Diarrhea can cause drugs not to be absorbedd. Constipation may delay absorption

2. DISTRIBUTIONDrugs are distributed first to areas that have extensive blood supplies

heart kidney liver brainAreas of slower distributions are:

muscles, skin, fatsSites like Bone and Brain might be very difficult for drugs to reach due to barriers or poor blood supply

FACTORS THAT AFFECT DISTRIBUTION 1. Protein Bindingalbumin is the main protein to bind with drugsdrugs that are bound to protein are not available for use and called PROTEIN BOUNDDrugs not bound to protein are available to act at the intended site of action and excert their effects and this is called: FREE DRUG IF THE PATIENT HAS LOW ALBUMIN More drugs is available and the patient may have increased adverse effects2. Water soluble VS Fat solubleWater soluble: tend to stay in the blood stream and have a slow absorption in the tissuesFat Soluble: distributed to the tissues more quickly3. Blood Brain Barrier difficult for drugs to pass thru and will allow some fat soluble drugs to pass thru4. Placental Barrier

MetabolismAlso known as BIOTRANSFORMATIONIt takes place mainly in the liver and produces:A. Inactive metaboliteB. More soluble compoundC. A more potent metabolite

ORGANS RESPONSIBLE FOR METABOLISM LIVER KIDNEYS SKELETAL MUSCLES LUNGS PLASMA INTESTINAL MUCOSA

FACTORS AFFECTING METABOLISM1. Age elderly has decreased hepatic enzymes neonates has immature liver functions2. Foods grapefruits and other foods3. DiseasesCardiovascular or renal dysfunction. Illness – pathologic condition: shock = decrease peripheral vascular circulation = slow absorption

patients who are vomitingnephrotic syndrome or malnutrition = decrease protein (for distribution)kidney failure = decrease dose

5. Psychological aspectPlacebo – drug dosage form such as tablet or capsule; has no pharmacologic activity; has no active ingredient6. Tolerance – person begins to require higher dose to produce the same effect

7. Dependence – addiction or habituationwithdrawal symptoms

8. Cumulative effect = drug accumulation =drug toxicity

-rate of consumption > rate of metabolism and excretion

DECREASED METABOLISM RESULTS IN: Accumulation of drugs Prolonged action of drugs Possible toxic effects

FACTORS THAT INCREASED METABOLISM Drugs that stimulate the formation of new

enzymes Barbiturates Rifampicin Drugs may leave the system more quickly or

diminished therapeutic effects.

3. METABOLISMProcess of metabolism is a sequence of chemical events that change a drug as it enters the body.Liver is the principal siteOral medications

- go directly into the liver via portal before entering systemic circulation- many medications become entirely inactivated by the liver the first time they go through it.

Age – infants and elderly has reduced ability to metabolized some drugsNutrition – Liver enzymes involved in metabolism rely on adequate amounts of lipids, vitamins etc.Insufficient amounts of hormones such as insulin can affect metabolism of drug in the liver.

4. EXCRETIONKidney is the main organLiverBowel

MORE PHARMACOKINETIC PRINCIPLES 1. OnsetThe time the drug takes it therapeutic effect2. PeakThe time the drug takes its full therapeutic responseTime to change dressings or do painfull procedures 3. DurationThe time the drug concentration is sufficient to elicit a therapeutic responseHow long it is going to last to anticipate the next dose4. TroughThe lowest blood level of a drug 5. Half life The time it takes for the original amount of the drug in the body to be removedExample:Short ½ life – need to be taken frequentlyCompliance maybe a problemAcyclovir 5x dailyLong half life – may have adverse effects . It will stay in the body for long

Pharmacodynamics The mechanism of drug action in living tissueHow the drug alter the system

A. Therapeutic effect – positive changeDrugs excert their actions in 3 ways:Receptor interactionsEnzyme interactions

NON SPECIFIC INTERACTIONS1. Receptor interactionKey in a lockAgonistDrugs that fit well and elicit their own responseExa.Beta 2 drug agonistAntagonistDrugs that attach to the cell and block other drugs from attaching to the cell Benadryl is an antagonist

2. Enzyme interactionsAlters the enzyme necessary for a certain body functionAce Inhibitors – alters the enzyme pathway

3. Non specific interactionsAlters the cell structure after some crucial processAntibiotics

Pharmacotherapeutics The use of drugs and its clinical indications to prevent and treat a diseaseAcute therapy –stroke, heart attackMaintainance therapy – HPN, lipidemia Supplemental/replacement therapy – insulin, iron, thyroid drugsPalliative – high dose opioids for cancerSupportive – fluids and electrolytesProphylactic – antibiotics during surgeryEmpiric – experience shows it works, no evidence

1.Therapeutic drug monitoringSome drug have a very narrow range oftherapeutic and toxic effectsDigoxin and gentamycin are closely monitored2. Peak level – highest blood level3. trough – lowest blood levelBlood is drawn at specific times before and after administration to know the amount of drug in the body

Factors of Monitoring1. Therapeutic index

Ratio of safety A low therapeutic index indicates a greater

chance of adverse reaction2. Drug concentrationConsider pathologic conditions3. Patient’s conditionStress and anxiety 4. toleranceA decreasing response to repeated doses5. DependencePhysiologic and psychologic need for a drug6. Interactions

a. Additive effect – smaller doses can be given with the same effect ie. Tylenol and codeine

b. Synergestic effect – 2 drugs have better effect than given alone

HCTZ plus enalapril c. Antagonistic – 2 drugs have lesser effect

than with either drug alone

Antacids with tetracycline d. incompatibility – when given together one

deteriorates Furosemide and heparin Hazy color of parenteral drugs can occur

when incompatible with i.v tubings

7. Adverse effects2 broad categories1. medication errors2. Adverse reactions

a. Hypersensitivity reactions b. Pharmacologic reactions

8. Contraindications Should not be given if contraindicated Aspirin with gastric ulcer Allergic to drug Pregnant Impaired liver or kidney function

5. Psychological aspect Placebo – drug dosage form such as tablet

or capsule; has no pharmacologic activity; has no active ingredient

6. Tolerance – person begins to require higher dose to produce the same effect7. Dependence – addiction or habituation

-withdrawal symptoms8. Cumulative effect = drug accumulation =drug toxicity

-rate of consumption > rate of metabolism and excretion

Drug Interactionsaction of one drug is altered by the action of another drug Drug 1 + Drug 2 = increase activity of drug 1 and drug 2.Drug 1 + Drug 2 = decrease activity of drug 1 and drug 2.Ex: Antacids inhibit the dissolution of ketoconazole Aluminum containing antacids inhibit the absorption of tetracycline

Only unbound drug is pharmacologically ACTIVE

ADDITIVE EFFECT- 2 drugs with similar action are taken for a doubled effect ex: propoxyphene + aspirin=added analgesic effect

SYNERGISTIC EFFECT- the combined effect of 2 drugs is greater than the sum of the effect of each drug given alone

ex. Aspirin + codeine=increased analgesic effect

Examples of drug destroyed by the acidity of the stomach

INSULIN and GENTAMYCIN Brownish discoloration of the teeth-TetracyclineGRAY BABY SYNDROME- bone marrow toxicity----Chloramphenicol

Drug AdministrationPrinciples of drug administration

1. Observe the 7 rights of drug administration: Give the right dose of the right drug to the right client at the right time by the right route and approach, then record it right.

2. Verify all now or questionable orders with physician or nurse-in-charge. Be knowledgeable about meds you administer

3. i.e. know drug’s purpose, action, side effects, etc.

4. Use only medications in clearly labeled containers and check label 3x (from pharmacy/ cabinet, before and after preparation)

5. Check expiry date and look for any changes that may indicate decomposition(color, odor, and clarity)

6. Practice aseptic techniques: wash hands, do not contaminate containers, place caps upside down.

7. Be sure meds are identified for each client. Confirm or ask client’s name and counter check with ID bracelet/tag

8. Check for any allergies(skin tenting prior to administration)

9. Inform client of medication, technique and purpose.

10. Stay with client until meds are taken. Do not leave meds at bedside. Dispose all used items in sink or toilet.

11. Assist client as needed. If client vomits, report to physician.

12. Record administration of drug immediately and accurately/ chart any omission, initial it, and give rationale.

13. For errors in administration, report immediately.

14. For safety, give only meds that you personally prepared.

Common Dosage Forms

Form DescriptionCaplet Solid form for oral use;

shaped like a capsule and coated for ease of swallowing

Capsule Solid form for oral use; meds in powder, liquid, or oil form encased by gelatin shell

Elixir Clear fluid containing water and/or alcohol; designed for oral use; usually has sweetener

Enteric tablet

Tablet coated with materials that dissolve in intestine, where medication is absorbed

Extract Concentrated form made by removing active portion of meds from its other components

Glycerite Solution of medication combined with glycerin (at least 50%) external use

Intraocular disk

Small, flexible oval when moistened by ocular fluid, releases medication for up to 1 week

Liniment Preparation usually containing alcohol, oil, or

soapy emollient that is applied to the skin

Lotion Medication in liquid suspension applied externally to protect skin

Pill Solid form containing 1 or more meds, shaped into globules, ovoid, or oblong shapes

Solution Liquid that may be used orally, parenterally, or externally; can also be instilled into body

Suppository Pellet-shaped solid with gelatin, for insertion into body cavity(rectum or vagina)

Suspension Fine drug particles dispersed in liquid medium which settles on standing, so shake before using

Syrup Medication dissolved in concentrated sugar solution; may contain flavoring for palatability

Tablet Powder form pressed into hard disks or cylinders; also contains binders(adhesive), disintegrators(for tablet dissolution), lubricants, and fillers(for convenient tablet size)

Tincture Alcohol or water-alcohol medication solution

Transdermal patch

Meds in semipermeable membrane disk or patch absorbed thru skin slowly over long period

Troche/ lozenge

Flat & round form dissolved in mouth to release meds; contains flavoring, sugar, and mucilage

Routes of administrationVia the mouth

Oral Take with 50-100 ml of cold fluid unless contraindicatedContraindications: GI dysfxn(vomiting), unconscious or unable to swallow, NPO pre- or post-opDisadvantages: gastric irritation, inactivation by gastric acid, unpleasant taste or odor, teeth discoloration.

Remember

Sit client upright to enhance swallowingWhen preparing solid meds: only scored tablets may be brokenCrush tables only when appropriate( e.g. for children, elderly, dysphagia); otherwise consider a liquid preparationFor enteric-coated tablets: don’t crush or give with antacids, milkWhen preparing liquid meds:Shake suspensions & pour away from label to prevent dirtying itRead amount at meniscus & at eye levelWipe lip and neck of bottle before re-capping itEvaluate client’s response to meds after 30 min. if client vomits after taking meds, inform physician. Do not give again.

Major Routes of Administration ORAL ADMINISTRATION OF MEDICATIONS

Advantages Convenient Inexpensive to administer

Disadvantages: Absorption varies from person to person Oral meds may irritate GI tract Client must cooperate

Absorption: two gates of absorption Gastrointestinal tract Capillary walls

Most of an oral dose is absorbed in the small intestine Rate and degree of absorption depends on

pH of stomach contents Food in stomach Gastric emptying time Coating on medication preparation

Topical medications(skin, nose, eye, ear, vagina, rectum)

Via skinUse gloves, gauze or sterile applicatorsCleanse skin with soap & warm water to remove encrustation that blocks contact and absorption of new meds.

Remember

Lotion and creams: applied lightly, not rubbed

Liniment: rubbed into skin gently but firmlyPowder: dusted lightly to cover affected area thinlyTransdermal patches: remove backing and place patch in area with little hair; use gloves to avoid drug absorptionNitroglycerin patch: take blood pressure before and after application

Via noseHave client blow nose, lie supine and breath thru mouthPosition head as follows for 5 min (to ensure absorption)

RememberPosterior pharynx: head tilted or extended

backwardEthmoid and sphenoid sinus: head hyper extended or tilted over edge of bed (Parkinson’s position)Frontal & maxillary sinus: hyper extended and side wards (Proetz’s)

- Place dropper or atomizer 1 cm above nares &squeeze quickly, being careful not to touch nose with applicator

- Client may wipe but not blow nose.- Meds may produce unpleasant taste or coughing- Contraindications to decongestants (most common

nasal med): Heart dse, DM, and hypertension

Via eyeRecall: O.D.= right eye, O.S.=left eye, O.U.= both eyesGently clean eyelid of crusts or discharge using gauze in saline. Always wipe from inner to outer canthus.

For eye drops- While client looks up, use thumb/ forefinger to

pull down cheekbone and pull up lid exposing lower conjunctiva

- Drop prescribed meds and ask client to blink or close eyes

- Repeat if client closes eyes prematurely

For eye ointment- Squeeze thin stream along inner edge of lover

conjunctiva from inner to outer canthus. Don’t touch eye with container; twist tube to break stream.

- Client closes eyes, then lightly rub lid in circular motion

Via ear- Recall: A.D. = right ear, A.S.= left ear;

A.U.= both ears- With client side-lying, straighten ear canal by

pulling ear up and backward(adult & older children); down and backward (infants)

- Assess eardrum perforation( contraindication to irrigation) or discharge (clean if present)

- Warm meds in hands (to avoid vertigo). Hold dropper 1 cm above the ear & instill meds. Maintain for 2-3 min.

- For irrigation: place towel under client’s head and have client hold basin under ear. Slowly irrigate with ≈50ml of fluid & allow all fluid to drain out

Via vagina- Decrease client anxiety: explain procedure,

may prefer self administration, provide privacy, have her void prior

- Position: dorsal recumbent, over bedpan if for irrigation

- Use gloves; then retract labia with non-dominant hand.

For suppositories:- With dominant hand, apply water-based

lubricant on rounded end of suppository & insert 3-4 inches down along posterior wall of the vaginal canal

- Store suppositories in the ref to avoid melting

For creams, foams, jelly or irrigating solutions (douche)- Insert applicator 2-3 inches down and deposit

meds.- Client remains in position for 15-20minutes

Via rectum- Provide privacy. Use gloves. Explain

procedure- Ask client to lie on side& breathe slowly thru

the mouth- Apply lubricant, insert tapered end past internal

anal sphincter (kids≈ 2 in; adults ≈ 4 in) and hold buttocks together as client may expel suppository.

Inhalant medications (Metered-dose Inhalers, MDI)

These clients depend on meds for adequate control of airway obstruction & must learn self-administration.Position: upright (sitting or standing)Shake inhaler then have client inhale & exhale deeply-3 point or lateral hand position: client holds inhaler, thumb at bottom of mouthpiece & index & middle finger at the top.-Place inhaler in mouth or 1-2 in away with spacer (ensures drug is inhaled & not just deposited on tongue or throat)-Simultaneously, client inhales deeply & presses canister.-Hold breath for 10 sec then exhale thru pursed lips.

PARENTERAL MEDICATIONSAMPULE PREPARATION

- Tap neck to move fluid down ampule then snap off neck towards self. Hold ampule upside down, quickly draw meds without needle touching rim

- Also, keep tip of needle under fluid to avoid aspirating bubbles. If aspirated, do not expel air in ampule

- To expel bubbles, tap syringe to move bubbles up & draw back plunger slightly then push to expel air

VIAL PREPARATION (SOLUTION)Multi-dose vials: Wipe off rubber stopper with alcohol pledget Without contaminating plunger, draw up air equal to amount of meds needed & inject air into vial. This prevents negative pressure buildup & aids in drawing up meds.Insert needle thru center (thinnest part) of rubber seal. Keep tip below fluid level & allow pressure in vial to fill syringe.Before injecting into client, change dulled needle

Vial Preparation (Powder for Reconstitution)Prepare diluent & inject into vial. Remove needle & roll vial in palms. Do not shake.Use a filter needle when drawing up reconstituted meds

Mixing Medications2 Vials:

Inject air into vial A & withdraw needle (tip must not touch the solution)Inject air into vial B & withdraw meds. Change needle.Inject new needle into vial A & withdraw meds

Vial to Ampule: Draw meds from vial first then from ampule

Administering Injections- Select Appropriate site, avoiding bruised or

tender areas & rotating sites as much as possible for repeated injections.

- Clean site with alcohol swab, let dry. Always use gloves to prevent contact with client blood.

- Insert needle quickly, bevel up, then release hold to decrease pain

- Aspirate for blood. Re-insert if with blood- Inject slowly. Press swab over site before

removing needle.- Massage area except for Z-track or heparin

injection- Most common site for heparin injection is the

abdomen

INTRAMUSCULAR INJECTION SITES

Absorbed across capillary wall Rate of absorption depends on

How water soluble is the medication? How much blood flows to site of injection?

Adverse effects: discomfort, possible local tissue injury

INTRAMUSCULAR INJECTION SITE VENTROGLUTEALPosition: Supine lateralAdvantages: Anatomic landmarks well defined; muscle mass suited for deep IM or Z-track injections; free of major nervesDisadvantages: in the event of hypersensitivity reaction, medication absorption cannot be delayed by tourniquet

DORSOGLUTEAL Position: ProneAdvantages: muscle mass suited for deep IM or Z-track injectionsDisadvantages: Requires correct/accurate site and technique to avoid injury to major nerves and vascular structures; in the event of hypersensitivity reaction, medication absorption cannot be delayed by tourniquet

DELTOIDPosition: lateral, prone, sitting, supineAdvantages: readily accessible; in the event of hypersensitivity reaction, medication absorption can be delayed by tourniquetDisadvantages: small muscle mass; limited to small volume doses; close to nerves; requires accurate technique

VASTUS LATERALIS Position: sitting, supineAdvantages: good site for infants; size acceptable for multiple injections; free of major nerves

Disadvantages: special attention required to avoid sciatic nerve or femoral structures if long needle is used

INTRAVENOUS THERAPYuse - replace fluid, electrolytes and other nutrients for clients who cannot eat or drink adequately types of IV therapy solutions

osmotic pressure similar to that of plasma examples: normal saline 0.9%; lactated Ringer's solution; 5% dextrose in water

hypotonic exerts less osmotic pressure than plasma examples: 2.5% dextrose in water; half strength normal saline 0.45%

hypertonic exerts higher osmotic pressure than plasma (draws water out of the cells) examples: 5% dextrose in normal saline 0.9%; 5% dextrose in lactated Ringer's solution

INTRAVENOUS ADMINISTRATION Venipuncture

Prepare infusion set. Place roller clamp 1-2 inches below drip chamber & move to “off” position. Insert spike to fluid bag.

Prime or fill drip chamber & tubing with solution Remove any air bubbles by tapping tubing. Apply tourniquet & select a vein large enough

for the catheter Use the most distal site in the non-dominant

arm. Dilate vein: Open / close client’s fist or milk

arm towards site Cleanse site then anchor vein using the thumb

and stretch skin opposite the direction of insertion

For both butterfly needle and over-the-needle catheter: Insert at 20-30 degree angle, bevel up, slightly distal to the site. Look for blood return then fully lower needle or catheter ( remove stylet if ONC before lowering)

Stabilize catheter, connect to infusion set & secure with tape

IV PUSH VIA HEPARIN LOCKUse SASH methodS: flush with 2 ml salineA: administer medsS: flush with 2 ml salineH: flush with 10-100 units heparin

IV PUSH VIA EXISTING LINEOcclude primary IV line by pinching tubing just above injection port closest to patient, give meds & release tubing.

IV INFUSIONInject meds thru port in IV bag with rubber stopper not thru air vent or port for IV tubing. Label rate and time

PIGGYBACKAdd med solution bag to an existing line

Connect IV tubing to medication bag. Hang med bag higher than primary fluid bag if piggyback, same height if tandem.

SUBCUTANEOUS ADMINISTRATIONAbsorbed across capillary wall Rate of absorption depends on

How water soluble is the medication? How much blood flows to site of injection?

Adverse effects: discomfort, possible local tissue injury

SUCCESS IS TAKEN ONE STEP AT A TIME

I CAN Did is a word

of achievement,Won’t is a word

of bereavement,Can’t is a word

of defeat,Ought is a word

of duty,I CANTry is a word each hour,Will is a word

of beautyCan is a word

of power

MEDICATION CALCULATIONSMetric System

To convert within the metric system, simply divide or multiply multiples of 101000mg= 1 g, 1= 1000ml, 0.45L= 450 ml

Apothecary SystemSystem rarely used; basic unit is grainUses small Roman numerals (gr xvi= 16 grains);

Fractions (1/3 gr)

Weight60 grains= 1 dram8 grains= 1 ounce12 grains= 1 pound

Volume60 minims= 1 fluidram16 fluidram= 2 fluidounce= 1 pint1 gallon= 4 quarts= 8 pints

Household SystemFamiliar to most people but not as accurate as metric system

Household Metric Apothecary

1 drop 0.06 ml 1 minim

15 drops1 tsp1 tbsp1 ounce1 glass= 1 measuring cup2 measuring cups1 quart1 gallon2.2 pounds1 inch

1ml5 ml15 ml30 ml240 ml480 ml= 500 ml960 ml= 1 L3840 ml= 4 L1 kg2.54 cm60 mg

15 minims1 fluidram= 60 min4 fluidram1 fluidounce8 fluid ounce1 pint1 quart1 gallon1 grain

CALCULATIONSDrug Dosage

Remember to convert the same unit before calculatingBasic formula for unknown volume (ml) of drug needed(x):X(ml)= D/S X known quantity

For drugs that need to be diluted, use the following diluents:IM= use 2ccIV=/<500mg= use 5 ccIV> 500mg= use 10 cc

Parenteral Injection

Pediatric Drug Dosage1. Based on Body Surface Area (BSA)- most accurate2. Based on kg Body Weight (BW)3. Based on Age:

Site syringe needle method remarks

ID Ventral forearm, scapula, chest

0.1- 1 ml (max) tuberculin

G: 26L: 3/8”, 5/8”

Stretch skin, insert needle bevel up, at 5- 15 degrees 2-3 mm deep to form a wheal

don’t massage.Encircle the site

SC Lateral upper arm, ant thigh, abdomen ( 1 inch from umbilicus), scapula

Kids: 0.5- 1 mlAdults: 1- 3 ml

G: 25- 27L: 3/8”, 5/8”,½”

Pinch skin to form SC fold (needle should be ½ width of fold). Hold syringe like a dart, palm down. Insert at 45 deg for ext & thin client, 90 deg for abdomen, obese and emaciated

Don’t aspirate or massage heparin or insulin injections

IM Gluteus, anterior & medial thigh

Kids: 0.5- 1 mlAdult: 2- 3 ml

G: 21- 23L: 1” (kids);1- ½” (adult)

Hold like dart, palm down. Insert at 90 deg. Aspirate. If no back flow, inject slowly, wait 10- 20 secs, remove needle and release

Z-track: used to decrease irritation

Fried’s Rule (birth to 12 months):Infant’s dose= age in months/150 x adult dose

Young’s rule (1- 12 years):Child’s dose= age in years/age in yrs + 12 x adult dose

Clark’s Rule:Child’s dose= wt of child in lbs/150 lb x adult dose

BSA (m2)= square root ofweight (kg) x height (cm)

3600

Child’s dose= child’s BSA x adult doseadult BSA (average is 1.73 m2)

Example: 3 year old child weighs 15 kg with a height of 92 cm is to be given Demerol; adult dose for Demerol is 100 mg/ doseSolution:Child’s BSA= square root of (15 kg x 92 =1380/ 3600 =0.619.1392 or 0.62 m2Child’s dose = 0.62 m2 x 100 mg Demerol= 62/1.73 = 35.8 0r 36mg

1.73 m2Answer:36 mgBased on kg Body Weight (BW)X (ml)= mg/kg/dose x wt in kg x known quantity

stock doseExample:Paracetamol 15 mg/kg/dose for child weighing 20 kg. Stock dose: 250/ 5 mlSolution:Child’s dose= 15 mg x 20 kg x 5 ml = 1500

kg/dose / 250 mg= 6mgAnswer:6 ml/ doseExample:Amoxicillin 30 mg/kg/day for a child weighing 20 kg. Preparation is 250 mg/ 5 ml; to be given 3x a daySolution: 30 mg/kg/day x 20 kg x 5 ml/250 mg= 12 ml/day12 ml/ 3= 4ml/ doseAnswer:4 ml/ doseExample:Cefalexin 50 mg/ kg/ day for a child weighing 30 kg. Preparation is 250 mg/ 5 ml; to be given every 6 hoursSolution:50 mg/kg/day x 30 kg x 5 ml/ 250 mg = 30 ml/ day30 ml/ 4= 7.5 ml/ doseAnswer:7.5 ml/ doseExample:Salbutamol 0.15 mg/kg/ dose for a child weighing 20 kg. Stock dose is 2 mg/5 mlSolution:

0.15 mg/kg/dose x 20 kg x 5 ml/ 2mg = 7.5 ml/ dose

Answer:7.5 ml/ dose

IV Fluid Flow Rate/ RegulationBasic formula: Macrodrip Gtts/min= amount of solution in ml/min x drop factorDrop factor ( 10, 15, 20 gtts/ml) depends on manufacturerUnless specified, use drop factor 15 gtts/ml (most common)Example:LRS 1L to consume in 8 hours; drop factor 15 gtts/mlSolution:1 L/ 8 hrs x 1000 ml/ 1L x 1 hour/60 mins x 15 gtts/ ml= 31 gtts/ minAnswer:31 gtts/ minShort Cut Formula: Microdrip Ugtts/min= ml/ hr since drop factor is always 60 ugtts/min & 1 hr= 60 mins Drop conversion: 1 gtt= 4 ugtts Example:LRS 1 L in 24 hoursAnswer:42 ugtts/ minSolution:1 L/ 24 hours x 1ooo ml/ 1 L x 1 hour/ 60 mins x 60 ugtts/ ml= 42 ugtts/ min or 1000 ml/ 24 hrs= 42 ugtts/ min therefore,ml/ hr= ugtts/minTitration:Desired mg/volume in gtts= delivery rate/regulation1 cc= 15 gtts Example:1 gram Lidocaine in 500 cc D5 water at 2 mg/ minSolution:1 gm = 2mg/min 500 cc X 1000 mg = 2mg/min (1 cc= 15 gtts ) 7500 gtts X 1000 mgX= 2mg/min (7500 gtts) X= 2mg/min (7500 gtts) 1000 mg X= 15 gtts/min = 60 ugtts/ min ( 1 gtt= 4 ugtts)Answer:15 gtts/ min

SOLUTIONSElectrolyte Solutions:Hypertonic: D5 LRS, D5 0.9% NaCl, D5 0.45% NaCl, D5 NM, D5 NRIsotonic: 0.9 NaCl, LRS Hypotonic: D5 water, D10 waterNutrient Solutions/ TPN hyperalimentation- provides high calorie IV nutrition; 1 kcal/ ml with amino acids, dextrose, electrolytes, vitamins and minerals

PARENTERAL NUTRITIONFor clients who are unable to digest or absorb enteral nutrition ( GI obstruction, ileus, surgery, trauma)If less than 10% dextrose solutionCatheter inserted in peripheral vein & threated into subclavian/ SVCIf more than 10% dextrosecentral venous catheter direct to SVC

TPN Requires monitoring of glucose, electrolytes, lipids, proteins

Don’t increase rate if infusion lags behind

NARCOTIC ANALGESICS Case Study

Mrs. Linda Boyd, age 48, is admitted to the local hospital for an abdominal hysterectomy. PostoperatiVely she is placed on meperidine (Demerol) 100 mg IM every 4 hours prn.

PROTOTYPE-MORPHINE SULFATE Action. Acts on opioid receptors in CNS and induces sedation,analgesia, and euphoria. Use. Relief of moderate to severe pain, preoperative medication,pain relief in Ml, relief of dyspnea occurring in pulmonary edema oracute left ventricular failure.

Adverse Effect. respiratory depression

Nursing Implications Assess client's pain before giving

medication.. The first sign of tolerance is usually a

decreased duration of effect of the analgesic. Monitor respiratory rate and depth before

giving drug, and periodically thereafter. . CNS Agents6 D’s:D- depressed respirationsD- dizzyD- drowsyD- decreased GI peristalsis and urine outputD- decreased BPD- drug dependence

Narcotic Antagonist:Naloxone hydrochloride ( Narcan )

action : Occupies receptor sites and reverse effects of agonist drugs

Use : Postoperative respiratory depression

Adverse effects: hypertension, tremors, reversal of analgesia

Nursing implications:Rescucitative equipments readily availablemonitor clients for bleeding

Narcotic Antagonists-reverses narcotic induced respiratory depression: Naloxone (Narcan)

5 P’sP- perspiration increasedP- pulse increasedP- puke increasedP- pressure increasedP- pain increased

NEUROLOGICAL (INCLUDING ANESTHETICS)- Anticonvulsives - Antiparkinson Agents - Cholinesterase Inhibitors - Antidepressants- Antimanic Agents

- Antipsychotic- Hypnotics- Antianxiety (Anxiolytic)- General Anesthetics - Local Anesthetics

ANTICONVULSANTS action - modifies bioelectric activity at subcortical and cortical areas examples

diazepam (Valium) magnesium sulfate phenytoin (Dilantin) phenobarbital (Luminal)

use: prevents seizures adverse effects

blood dyscrasias gastric effects - nausea, vomiting CNS depression - dizziness, drowsiness phenytoin: ataxia, hirsutism, hypotension

nursing interventions - give medication with food - wiith phenytoin: monitor condition of oral

mucosa, don't mix with other IV fluids, monitor blood lab results, monitor urine

- renal, liver, and blood studies - teach clients - avoid alcohol - notify physician of unusual symptoms - carry medical alert information - take medication on schedule; do not

discontinue - avoid driving and other potentially hazardous

activities - phenytoin: good oral hygiene, frequent dental

visits

Phenytoin: adverse effects: PHENYTOIN: P-450 interactions Hirsutism Enlarged gums Nystagmus Yellow-browning of skin Teratogenicity Osteomalacia Interference with B12 metabolism (hence anemia) Neuropathies: vertigo, ataxia, headache Anticonvulsant AgentsPhenytoin (Dilantin)G- gingival hyperplasiaU- use alternate birth controlM- mouth care- preventive dental check-upS- soft tooth brush, don’t use abruptly

ANTIPARKINSON AGENTS action

anticholinergics: block or compete at central acetylcholine receptors dopamine agonists: activation of dopamine receptors

Parkinsonism: drugs SALAD: Selegiline Anticholinenergics (trihexyphenidyl, benzhexol, ophenadrine) L-Dopa + peripheral decarboxylase inhibitor (carbidopa, benserazide)

Amantadine Dopamine postsynaptic receptor agonists (bromocriptine, lisuride, pergolide)  

Nursing responsibilities- reinforce client education - do not stop taking antiparkinsonian meds

suddenly: may precipitate parkinsonian crisis - take with meals - caution with hazardous activities- levodopa - minimize Vitamin B6 in diet, because it hinders

drug's effectiveness - sweat and urine may be dark colored - toxicity: personality changes, increased

twitching, grimacing, tongue protrusion

CHOLINESTERASE INHIBITORS action

prevents breakdown of acetylcholine at nerve endings facilitates transmission of impulses across myoneural junction strengthens muscle contractions including respiratory muscles

examples edrophonium chloride (Tensilon) for diagnostic purposes neostigmine bromide (Prostigmin) ambenonium chloride (Mytelase)

use: treat myasthenia gravis Adverse effects

gastric irritation: nausea, vomiting, diarrhea hypersalivation CNS disturbances orthostatic hypotension toxicity: pulmonary edema, respiratory failure, bronchospasm

Contraindications intestinal obstruction, renal obstruction peritonitis

nursing interventions - monitor client response to medication; may

need to adjust dosage - monitor vital signs during period of dosage

adjustment - keep atropine sulfate available for overdosage - administer medication with food - administer medication as per schedule - teach client - wear medic alert jewelry and ID

- change position cautiously; sit at first feeling of faintness.

ANTIDEPRESSANTSaction: increase norephinephrine at subcortical neuroeffector sites

examples norepinephrine blockers (tricyclic, TCAs): amitriptyline (Elavil), imipramine (Tofranil) monoamine oxidase inhibitors (MAOIs): isocarboxazid (Marplan), phenelzine sulfate (Nardil) selective serotonin reuptake inhibitors: fluoxetine (Prozac), sertraline (Zoloft)

use: treat melancholia, depression adverse effects

norepinephrine blockers potentiate anticholinergics and CNS depressants orthostatic hypotension drowsiness, dizziness, confusion CNS stimulation

MAOIs potentiate alcohol, barbiturates, antihistamines hypertensive crisis with ingestion of foods high in tyramine (pickled herring, beer, wine, cheese, chocolate) orthostatic hypotension

SELECTIVE SEROTONIN REUPTAKE INHIBITORS

may interact with tryptophan insomnia headache sexual dysfunction gastric irritation

contraindications acute schizophrenia mixed mania and depression suicidal tendencies narrow angle glaucoma

nursing interventions - monitor effect of medication - maintain suicide precautions especially as

depression lifts - give SSRIs in morning; TCAs at bedtime - teach client - do not take OTC medication without physician

approval - avoid hazardous activities - effect of medication may take up to four weeks - MAOIs: teach client to avoid food containing

tyramine; monitor client for hypertensive crisis - SSRIs and MAOIs should not be given

concurrently or close together

General Concepts for Antidepressants:D- driving is out until response to drug is determinedE- effect has a delayed onset of 7- 21 daysP- planning pregnancy- consult physicianR- relieves symptoms, not a cure!E- evaluate vital signs

S- stopping drug abruptly is out!S- safety measuresI- instruct client to report undesirable effectsO- observe for suicidal tendenciesN- no alcohol or CNS depressants

Psychiatric AgentsAntidepressants: SSRI, TCA, MAOI 1. SSRI’s: Paxil, Celexa, Prozac, Luvox, Zoloft

CNS- side effectC- CNS stimulationN- nauseaS- Sexual/ changes in libido; Skin: photosensitivity

3. MAOI’s : Mar Par Nar: Marplan, Parnate, Nardil Avoid Tyramine rich foods: may cause hypertensive crisis

-aged cheese, beer, ale, red wine, pickled foods, smoked fish, beef, liver, avocado

ANTIMANIC AGENTS action: reduces adrenergic neurotransmitter levels in cerebral tissue examples

antimanic agents: lithium carbonate (Lithane) alternative antimanic agents: carbamazepine (Tegretol), clonazepam (Klonopin)

use: control of manic phase of mood disorders; bipolar disorder adverse effects

- metallic taste - hand tremors - excess voiding and extreme thirst - slurred speech - disorientation - cogwheel rigidity - renal failure - respiratory depression

nursing interventions - monitor blood levels - avoid concurrent administration of adrenergic

drugs - evaluate client's response to medication

teach client - effect of medication may take several weeks - high intake of fluids and normal sodium - toxicity signs: diarrhea, vomiting, weak

muscles, confusion etc. - take medication with meals

L- level- therapeutic (0.6- 1.2 meq/ml)I- increased urinationT- thirst increasedH- headache & tremorsI- increase fluidsU- unsteadyM- monitor salt ( decrease lithium level with excess sodium)

ANTIPSYCHOTICS action blocks dopamine hydrochloride receptors in the CNS and sympathetic nervous system examples

phenothiazines: chlorpromazine (Thorazine), thioridazine (Mellaril) – can cause skin irritation or contact dermatitis

benzisoxazole: risperidone (Risperdal) thioxanthenes: chlorprothixene (Taractan) butyrophenones: haloperidol (Haldol)

adverse effects - excessive sedation - jaundice - orthostatic hypotension - urinary retention - anorexia - dry mouth - hypersensitivity reactions (such as photoallergic

reaction, impotence, cardiac toxicity) - blood dyscrasias - agranulocytosis - extrapyramidal side effects: dystonia,

pseudoparkinsonism, akathisia, akinesia, tardive dyskinesia

- neuroleptic malignant syndrome: fever, muscle rigidity, agitation, confusion, deliruim, respiratory failure

AntipsychoticsS- sedation & sunlight sensitivityT- tardive dyskinesia, tachycardia, tremorsA- anticholinergic,agranulocytosis, addictionN- neuroleptic malignant syndromeC- cardiac arrhythmias, orthostatic hypotensionE- extrapyramidal (akathisia), endocrine (libido)

A nurse is preparing a plan regarding home care instructions for the parents of a child with generalized tonic-clonic seizures who is being treated with oral phenytoin (Dilantin). The nurse instructions in the plan regarding:a) Monitoring the child’s intake and output dailyb) Checking the child’s blood pressure before the

administration of the medicationc) Providing oral hygiene, especially care of the

gumsd) Administering the medication one hour before

food intake

ANTIANXIETY (ANXIOLYTIC) action: depress CNS examples

benzodiazepines: alprazolam (Xanax), chlordiazepoxide (Librium):physical dependency and withdrawl finsings after long term use azapirones: buspirone (Buspar)

uses: anxiety, sleep disorders, alcohol withdrawl adverse reactions - CNS disturbances: dizziness drowsiness,

lethargy, orthostatic hypotension - skin rash - blood dyscrasias contraindications

hypersensitivity acute narrow angle glaucoma liver disease

A- avoid abrupt discontinuation after prolonged useN- not given if w/HPN, renal/liver dysfxn, drug abuseX- xanax, ativan, serax, diazepam, librium, midazolam I- increase in 3D’s: drowsiness, dizziness, dec BPE- enhances axn of GABA

T- teach to rise slowly from supineY- yes, alcohol shld be avoided

GENERAL ANESTHETICSaction: depresses the CNS through a progressive sequence  

PROGRESSIVE SEQUENCE OF GENERAL ANESTHESIA

examples inhalation anesthetics: cyclopropane, enflurane (Ethrane), ether, nitrous oxide IV barbiturates: thiopental sodium (Pentothal), methohexital sodium (Brevital) IV and IM nonbarbiturates: midazolam HCL (Versed), ketamine HCL (Ketaject)

use: used in combination for surgical anesthesia adverse effects - inhalation anesthetics: excitement and

restlessness, nausea and vomiting, respiratory distress

- IV barbiturates: respiratory depression, hypotension, tachycardia, laryngospasm

- IV and IM nonbarbiturates: respiratory failure, hyper/hypotension, rigidity, psychiatric disturbances

contraindications - CVA - increased intracranial pressure - severe hypertension - cardiac decompensation -

nursing interventions - have oxygen and emergency treatment

available - monitor vital signs - use precautions if agent flammable - use safety precautions when client induced

Helium – brownO2- greenCo2 – grayAir- yellowNitrogen – blackNitrous oxide – blue

Abbocath:White – 27g25- yellow21 – blue19 – pink18 – greenLOCAL ANESTHETICS action: decreases nerve membrane permeability to sodium ion influx

examples topical: benzocaine, cocaine, lidocaine HCL (Xylocaine) spinal: dibucaine (Nupercaine), procaine HCL (Novocaine)

nerve block: bupivacaine HCL (Marcaine), mepivacaine HCL (Carbocaine)

use: pain control while client is conscious adverse effects

- allergic reactions - respiratory arrest - arrhythmias, cardiac arrest - convulsions - hypotension

nursing interventions - have oxygen and emergency equipment

available - monitor vital signs during local anesthesia - if spinal anesthesia, keep client flat for 6-12

hours to prevent headaches

WOMEN’S HEALTH RELATED AGENTS

OXYTOCIN ( PITOCIN)P- pressure is elevatedI- intoxication with waterT- tetanic contractionsO- oxygen decrease in fetusC- cardiac arrhythmiaI- irregularity in fetal heart rateN- nausea and vomiting

Magnesium Sulfate- for control of convulsion inpreeclampsia or eclampsia Mg SO4 Toxicity: decreased BURPB- BP decreasedU- urine output decreasedR- respiratory rate decreasedP- patellar reflex decreasedNSAIDs N- no alcoholS- S.E. “BIRTH” bone marrow depression, inc.GI distress, renal toxicity, tinnitus, hepato-toxicity aspirin sensitivity- do not giveinhibits prostaglandinD- do take with foodS- stop 5- 7 days before surgery Antineoplastic AgentsC- CBC, platelets- monitorA- antiemetics before drugN- nephrotoxicity- undesirable effectC- couselling regarding reproductive issuesE- encourage handwashing, avoid crowdsR- recommend a wig for alopecia

A 40-year-old patient who’s receiving chemotherapy for breast cancer develops nausea and vomiting. For this patient, the nurse should give the highest priority to which action in the care plan?a) Serve small portions of bland food.b) Encourage rhythmic breathing exercises.

c) Administer metoclopramide (Reglan) and dexamethasone (Decadron), as prescribed.

d) Withhold fluids for the first 4 to 6 hours after chemotherapy administration.

Respiratory DrugsBronchodilatorsMucolytics Antitussives Antituberculosis agentsAntihistaminesAnti-inflammatory

BRONCHODILATORS action:

dilate air passages in the lungs, specific action dependent on type of drug. increase heart rate act on the autonomic nervous system

examples beta-adrenergic: abuterol (Proventil, Ventolin), metaproterenol (Alupent) xanthines: aminophylline, theophylline (Theo-Dur) acts on bronchial smooth muscle epinephrine HCL (Adrenalin) - increases the rate and strength of cardiac contraction through the sympathetic nervous system isoproterenol HCL (Isuprel) - increases the heart rate by stimulating the beta-adrenergic blocking agent of the sympathetic nervous system

use: bronchospasms, asthma adverse effects

- dizziness - tremors - anxiety - palpitations - gastric disturbances - headache - tachycardia - dysrhythmias

contraindications

- hypersensitivity - narrow angle glaucoma - tachydysrhythmias - severe cardiac disease

nursing interventions - monitor theophylline levels (normal ten to 20

mcg/dl) - monitor intake and output, and vital signs - monitor EKG, vital signs during therapy - teach clients - take medication as prescribed only - report adverse effects - stop smoking during therapy - take with meals - avoid OTC drugs

MUCOLYTICS/EXPECTORANTS action

mucolytics: disrupt molecular bonds and thins mucus expectorants: stimulate a gastric mucosal reflex to increase production of lung mucous

examples

mucolytic: acetylcysteine (Mucomyst) expectorant: guaifenesin (Robitussin)

uses: asthma acute or chronic bronchopulmonary disease cystic fibrosis mucomyst: acetaminophen toxicity

adverse side effects - oropharyngeal irritation - bronchospasm - gastric effects

contraindications increased intracranial pressure status asthmaticus

nursing interventions - monitor respiratory status - teach client - take no fluids directly after oral administration - do take plenty of fluids - encourage coughing and deep breathing,

especially before treatment

ANTITUSSIVES action: to supress coughs through medullary cough center or indirect action on sensory nerves

examples narcotic: codeine, hydrocodone bitartrate (Hycoda) nonnarcotic - dextromethorphan (Robitussin)

use: colds, respiratory congestion, pneumonia, bronchitis, TB, cystic fibrosis, emphysema adverse effects

- drowsiness - nausea - dry mouth - dizziness

contraindications hypothyroidism iodine sensitivity

nursing interventions - monitor blood counts with long term therapy - increase fluid intake - humidify client's room - teach client - increase fluid intake if not contraindicated - do not to take fluids immediately after

medication - avoid driving and other hazardous activity

especially if taking narcotic type - antitussives add to the effects of alcohol

Respiratory AgentsB- breathing and coughing techniquesR- relaxation techniquesE- evaluate heart rate and blood pressureA- arm identification (asthma)T- tremorsH- have 8 or more glasses of fluids

E- emphasize no smoking

ANTITUBERCULOSIS AGENTSaction: appears to inhibit RNA synthesis, so stops tubercle bacilli from multiplying (first line) or functioning (second line)

examples first line

ethambutol (Myambutol) decreases mycobacterial RNA synthesis isoniazid (INH) - suppresses mycobacterial cell-wall synthesis

second line capreomycin (Capastat) pyrazinamide (PZA)

adverse effects - gastric irritation - CNS disturbances - liver disturbances - blood dyscrasias - streptomycin - ototoxicity - ethambutol - visual disturbances - isoniazid - suppressed absorption of fat and

vitamin B complex contraindications

severe renal disease hypersensitivity

nursing interventions - monitor client response to therapy - monitor blood work during therapy - if CNS disturbances are evident, take safety

precautions - teach client - to take medication as ordered - to eat foods rich in B-complex vitamins - avoid use of alcohol - report if become pregnant - ethambutol: report eye problems, have regular

eye exams

Just know yourR.I.P.E.S

Managing gastrointestinal conditions

Antacids action

neutralizes gastric acid coats stomach lining

examples aluminum hydroxide gel (Amphojel) aluminum and magnesium hydroxides (Maalox) magaldrate (Riopan)

use: peptic ulcers, reflux esophagitis, hiatal hernia adverse reactions - aluminum compounds - constipation, intestinal

obstruction - magnesium compounds - diarrhea - reduced absorption of calcium and iron

nursing interventions - shake oral suspension well - monitor client's response to treatment - administer with 8 oz glass of water - teach client - avoid overuse of antacids

- dietary restrictions for ulcers - need for diet high in calcium and iron - for clients on low sodium diets: antacids

contain sodium - may color stools whitish

Antiulcers actions

decrease acetylcholine release block release of histamines inhibit secretion of pepsin inhibit proton pump

examples anticholinergics; belladonna tincture, chlorodiazepoxide (Librax) h2 blockers - cimetidine (Tagamat), ranitidine (Zantac) pepsin inhibitor - sucralfate (Carafate) proton pump inhibitor - lansoprazole (Prevacid), omeprazole (Prilosec)

uses: management of peptic ulcer disease, gastroesophageal reflux disease(GERD), protects gastric mucosa from hydrochloric acid production

adverse reactions - dry mouth, decreased secretions, constipation,

tachycardia, & urinary retention - headaches, dizziness, constipation, skin reash,

pruritis, impotence - sucralfate is nonabsorbable, occasional

constipation

contraindications anticholinergics - narrow- angle glaucoma renal failure liver disease

nursing interventions - administer on empty stomach - avoid antacids within 30 minutes of sucralfate - avoid antacids within one to two hours of other

antiulcer drugs - administer other drugs one to two hours after

sucralfate - teach clients - avoid alcohol, spicy food, and caffeinated

beverages - eliminate smoking - increase fluid intake - medication can take up to two weeks for full

effect - report increasing abdominal pain, vomiting of

blood, or passage of bloody stools

Gastrointestinal AgentsAnti-ulcer: H2 receptor antagonists: tidine drugs: NO WINE JUST DINED- don’t take with antacidsI- inform physician of bleedingN- no smoking, alcohol or NSAIDs E- elevate head of bed

A patient with peptic ulcer is about to begin a therapeutic regiment that includes a bland diet, antacids, and ranitidine (Zantac). Which instruction should the nurse provide before this patient is discharged?

a) Eat three balanced meals every day.b) Stop taking the drugs when the symptoms

subside.

c) Avoid aspirin and products that contain aspirin. d) Increase the intake of fluids containing

caffeine.

Cardiovascular DrugsCardiac glycosidesAntihypertensives Thrombolytics Lipid-lowering agents Antianginals Hypotension and shock Anticoagulants Antidysrhythmics  Cardiac Glycosides

CARDIAC GLYCOSIDES action: makes heart beat slower but stronger improves pumping ability of heart increases force of heart's contraction decreases rate of contraction increases cardiac output

examples digitoxin (Crystodigin) digoxin (Lanoxin)

Use congestive heart failure atrial flutter atrial fibrillation

Contraindications ventricular tachycardia ventricular fibrillation second and third degree heart block

Adverse Side Effects - gastrointestinal effects such as nausea and

vomiting, diarrhea, and anorexia - bradycardia - xanthopsia - muscle weakness - dysrhythmia

Nursing Interventions - before giving glycoside, check apical pulse and

heart rhythm. Report if < 60 bpm - Report for toxicity- in children - cardiac arrhythmias - in adults - visual disturbances, nausea and

vomiting, anorexia - older clients more prone to toxicity - monitor drug levels - therapeutic range 0.8 to 2.0 mg/ml - toxic range > 2 mg/ml - diuretics may increase chance of toxicity - monitor intake and output

Client teaching - identify and report signs of toxicity - for atrial fibrillation: take pulse and report if

below 60 or above 100 or changes in rhythm

- daily weights: report two pound increase -

ANTIHYPERTENSIVES action: dilates peripheral blood vessels examples

hydralazine HCL (Apresoline) enalapril maleate (Vasotec) reserpine (Serpasil) prazosin HCL (Minipress) methyldopa (Aldomet)

clonidine (Catapres) contraindications

heart block children

adverse side effects - orthostatic hypotension - dizziness - bradycardia - tachycardia - sexual dysfunction - deterioration in renal function - agranulosis

Nursing interventions - monitor vital signs and blood pressure,

sitting and standing - monitor for hearing changes, renal

functioning - if hypotension, closely monitor client - encourage intake of foods high in vitamin B

teach client

- low sodium diet - change positions slowly - take medication as instructed - avoid hazardous activities - protect medication from heat and light

THROMBOLYTICS action: binds with plasminogen to dissolve thrombi (clots) in coronary arteries within four to six hours of myocardial infarction. Activates conversion of plasminogen to plasmin. Plasmin is able to break down clots (fibrin). examples

streptokinase (Streptase) urokinase (Abbokinase)

uses: myocardial infarction deep venous thrombosis, pulmonary emboli

contraindications active bleeding cerebral embolism/thrombosis/hemorrhage recent intraarterial diagnostic procedure or surgery recent major surgery neoplasms of the CNS severe hypertension

nursing interventions - monitor for bleeding - monitor coagulation studies - monitor for allergic reactions - keep available: aminocaproic acid

(fibrinolysis inhibitor)

LIPID-LOWERING AGENTS (ANTILIPEMIC)action and use: lower LDL levels by reducing the synthesis of cholesterol and/or triglycerides. Use: primary hypercholesterolemia

examples cholestyramine (Questran) atorvastatin (Lipitor)

colestipol (Colestid) nicotinic acid (Niacin)

contraindications: hypersensitivity pregnancy/lactation active liver disease

adverse side effects

skin flushing gastric upset niacin: temporary, intense flushing of face, neck and ears reduced absorption of fat-soluble vitamins disruption of liver function muscle tenderness or weakness (rhabdomyolysis)

nursing interventions - monitor cholesterol levels - monitor liver function tests - teach client - blood work and eye exams will be necessary

during treatment - to report blurred vision, severe GI symptoms,

or headache - about low-cholesterol high-fiber diet - to report muscle weakness or tenderness - with cholestyramine, colestipol: Give other

medications (e.g., such as thiazide diuretics, digoxin, warfarin, and certain antibiotics) one hour before or four hours after administration of cholestryramine and colestipol, so that they will not react with bile-acid-binding resins

ANTIANGINALS: NITRATESexamples: nitroglycerin, isosorbide dinitrate (Isordil) action: dilate arterioles which lowers peripheral vascular resistance (afterload) uses: treatment and prevention of acute chest pain caused by myocardial ischemia adverse effects: postural hypotension, headache, flushing, dizziness

contraindications hypersensitivity severe anemia hypotension hypovolemia

nursing Interventions - monitor for orthostatic hypotension - monitor for tolerance with long term use - administer every five minutes but not more

than three tablets in 15 minutes - if pain not relieved after 15 minutes and three

tablets, notify physician immediately

instruct client - take pulse before taking medication - take oral preparations without food - when to seek medical attention - not to chew or swallow sublingual tabs - make position changes slowly - carry drug so that it is always within reach but

avoid exposure to body heat and light - replace drug approximately every six months - avoid alcohol ingestion

- With nitroglycerin patch, never go near the microave

ANTIANGINALS: BETA – ADRENERGIC AGENTSexamples: propranolol (Inderal), metoprolol (Lopressor) action: inhibit sympathetic stimulation of beta receptors in the heart decreases heart rate and force of myocardial contraction thus decreasing myocardial oxygen consumption

uses: reduces frequency and severity of acute anginal attacks, dysrhythmias

side effects: blood dyscrasias, hypotension, GI disturbances, flushing of the skin

contraindications - hypersensitivity - cardiogenic shock - cardiac failure

nursing interventions - weigh daily. Report weight gain of five

pounds or greater - monitor ECG if using for dysrhythmia - administer on an empty stomach - protect injectable solution from light

Beta-blockers: main contraindications ABCDE: Asthma Block (heart block) COPD Diabetes mellitus Electrolyte (hyperkalemia

contraindications - hypersensitivity - cardiogenic shock - cardiac failure

nursing interventions - weigh daily. Report weight gain of five

pounds or greater - monitor ECG if using for dysrhythmia - administer on an empty stomach - protect injectable solution from light-

ANTIANGINALS: CALCIUM CHANNEL BLOCKERS

examples: verapamil (Isoptin), nifedipine (Adalat), diltiazem (Cardizem)

action: prevent the movement of extracellular calcium into the cell resulting in coronary and peripheral artery dilation

uses: stable angina, dysrhythmias, hypertension side effects: headache, drowsiness, dizziness, GI disturbances, flushing of the skin

contraindications: hypersensitivity

nursing interventions - monitor chest pain - monitor ECG if used for dysrhythmia - administer with food

- instruct client - increase fluids to counteract constipation - take pulse before taking drug - avoid hazardous activities until stabilized

on drug - limit caffeine consumption - avoid alcohol - change position slowly -

ACE INHIBITORSCaptopril (an ACE inhibitor): side effects CAPTOPRIL: Cough Angioedema/ Agranulocystosis Proteinuria/ Potassium excess Taste changes Orthostatic hypotension Pregnancy contraindication/ Pancreatitis/ Pressure drop (first dose hypertension) Renal failure (and renal artery stenosis contraindication)/ Rash Indomethacin inhibition Leukopenia/ Liver toxicity Hypotension and shock

NATURAL AND SYNTHETIC CATECHOLAMINES

examples: epinephrine, dopamine (Intropin), dobutamine (Dobutrex)

actions: increase cardiac output, (+) inotrope, (+) chronotrope

uses: dopamine and dobutamine: hypovolemic and cardiogenic shock, epinephrine: anaphylactic shock Hypotension and shock

adverse effects: dysrhythmias, hypotension, tissue necrosis if extravasation occurs. Tremors, anxiety, dizziness with epinephrine

contraindications - hypersensitivity - ventricular fibrillation - tachydysrhythmias - safety in children not known - Hypotension and shock

nursing interventions - correct hypokalemia before administering - monitor vital signs frequently - monitor ECG continuously during

administration - administer with infusion pump - start drug slowly and increase according to

health care provider's orders - monitor injection site for extravasation - protect solution from light - do not use discolored solution - stop the drug gradually

Anticoagulantsaction: disrupt the blood coagulation process, thereby suppressing the production of fibrin examples

heparin: parenteral administration coumadin (Warfarin): oral administration

use

pulmonary embolism deep vein thrombosis myocardial infarction atrial fibrillation

adverse side effects - allergic responses such as chills, fever and

urticaria - use cautiously if client tends to bleed

(hemophilia, peptic ulcer) - GI disturbances- nausea and vomiting,

diarrhea, abdominal cramps

contraindications hemophilia leukemia peptic ulcer blood dyscrasias

nursing interventions - heparin: monitor APTT (activated partial

thromboplastin time) - normal 40 seconds - at therapeutic levels, APTT increases by

a factor of 1.5 to 2 - coumadin - monitor PT (prothrombin

time) - normal 12 seconds - INR (International normalized ratio) two

to three - do baseline blood studies before therapy - have antidote ready - heparin: protamine sulfate - coumadin: vitamin K - monitor client for symptoms of

hemorrhage such as increased pulse, decreased BP

- avoid salicylates (such as aspirin) - avoid IM injections

teach client - take medication at same time every day - wear medical alert jewelry: wearer takes

anticoagulants - use a soft toothbrush - do not use a straight razor; use an electric

razor - avoid alcohol and smoking - report any signs of bleeding, red or black

bowel movements, headaches, rashes, red or pink-tinged urine, sputum

- avoid trauma - blood levels of the anticoagulant may be

monitored - do not take over-the-counter (OTC)

medications without health care provider's approval

ANTIDYSRHYTHMICS 

Action : prevent abnormal heart rhythms action depends on type of antidysrhythmics drug

examples class I:sodium channel blockers quinidine (Quinidex), lidocaine; decreases myocardial excitability and contractility class II: beta blockerspropranolol (Inderal); stabilizes cell membrane class III: conduction delayers

bretylium (Bretylol); decreases conduction and excitability of myocardial cells class IV: calcium channel blockers- verapamil (Isoptin);inhibits influx of calcium ions across cell membrane during cardiac contraction; reduces cardiac excitability and dilates main coronary arteries others - digoxin (Lanoxin), adenosine (Adenocard); slows heart rate, improves pumping ability of the heart

CARDIOVASCULAR AGENTSP- pressure (blood) monitorR- rise slowly E- eating must be consideredS- stay on medicationsS- skipping or stopping is a n0- n0U- undesirable responses: drowsiness, dizzinessR- remind to exercise, dec alcoholE- eliminate smoking

Medical surgical planning, the nurse is discussing the medication regime with a patient who takes nitroglycerin (Nitrostat) for angina, as needed. Which statement from the patient indicates that further teaching is necessary?

a) “I store the tablets in a dark bottle.”b) “I take the tablet with a full glass of water.” c) “I wait for my tongue to tingle when I take a

tablet.”d) “I’ll go to the hospital if three tablets, minutes

apart, don’t relieve the pain.”

A nurse has completed diet teaching for a client on a low-sodium diet for the treatment of hypertension. The nurse determines that further teaching is necessary if the client makes which statement?

a) “This diet will help lower my blood pressure.”b) “The reason I need to lower my salt intake is to

reduce fluid retention.”c) “This diet is not a replacement for my

antihypertensive medications.”d) “Frozen foods are lowest in sodium.”

A patient with an arteriovenous malformation has been admitted with a hemorrhagic stroke. The physician prescribes several drugs for this patient. Which drug order should the nurse question?

a) Heparin b) Dexamethasone (Decadron)c) Methyldopa (Aldomet) d) Phenytoin (Dilantin)

A patient with heart failure has been receiving an I.V. infusion at 125 ml/hour. Now the patient is short of breath, and the nurse notes bilateral crackles, jugular vein distention, and tachycardia. What should the nurse do first?

a) Notify the physician.b) Discontinue the I.V. access device.c) Administer the prescribed diuretic.d) Slow the infusion and notify the physician .

ANTIBIOTICSM- monitor superinfections E- evaluate renal/ liver dysfxn D- diarrhea- take yogurtI- inform provider prior to taking other medsC- cultures prior to initial dose

A- alcohol is out; ask about allergyT- take full courseE- evaluate cultures, WBC, temperature

A patient with a urinary tract infection (UTI) receives a prescription for cotrimoxazole (Septra) 2 tablets by mouth daily for 10 days. Which observation best demonstrates that the patient followed the prescribed regimen?

a) Increased urine output to 2,000 ml in 24 hoursb) Decreased flank and abdominal discomfortc) Absence of bacteria on urine culture d) Normal red blood cell (RBC) output

TERATOGENS 1.Androgen- masculinization of female infants2. Thalidomide- phocomelia, cardiac and lung defect3. Anticonvulsant (Dilantin)- cleft lip and palate, cogenital heart defects4. Lithium- congenital heart defects5. Tetracycline- yellow staining of teeth, inhibit bone growth, not given to children below 76. Vitamin K- hyperbilirubinemia 7. Salicylates(aspirin)- neonatal bleeding, decreased intrauterine growth8. Sodium bicarbonate- fetal metabolic alkalosis9. Streptomycin- nerve deafness10.Vitamin A- CNS defects11. Iodides- goiter, mental retardation12. Steroids, cortisone- cleft lip and palate13. Barbiturates- bleeding disorder

ENDOCRINE AGENTS

CORTICOSTEROIDS (end in one: prednisone, dexamethasone, betamethasone, hydrocortisone)C- cushing- like symptomsb U- ffalo humpS- sodium increase, sweatingH- headache, hyperglycemia

increase in BP, HR, appetiteN- not healing quicklyG- GI upset

CORTICOSTEROIDSSome People Get ColdS- Sodium increasedP- Potassium decreasedG- Glucose increasedC- Calcium decreased

The nurse is preparing a care plan for a 35-year-old patient with Addison’s disease. Which nursing diagnosis is most appropriate for this client?

a) Risk for infection b) Excess fluid volumec) Urinary retentiond) Hypothermia

A patient with diabetes insipidus has been receiving intranasal administration of a synthetic vasopressin. Which outcome indicates that treatment has been effective?

a) Fluid intake of less than 85 oz (2,500 ml) in 24 hours.

b) Urine output of more than 200 ml/hour .c) Blood pressure of 90/50 mm Hg.

d) Pulse rate of 126 beats/minute.

The nurse should expect to administer which of these drugs to a patient with diabetes insipidus?

a) Desmopressin (DDAVP) b) Furosemide (Lasix)c) Regular insulind) 10% dextrose

A 55-year-old female with Addison’s disease has been admitted to the nursing unit with dehydration. Your initial assessment confirms a nursing diagnosis of deficient fluid volume. Which of the following etiologic factors establishes this nursing diagnosis?

a) Glucocorticoid excess.b) Mineralocorticoid deficiency c) Melanocyte-stimulating hormone excessd) Melanocyte-stimulating hormone deficit

Thyroid PreparationsFor Hypothyroidism: Levothyroxine T4 (synthroid), Liothyronine T3 (Cytomel)T- TSH, T3, T4- monitorH- Hypo/hyperthyroidism- monitorR- review how to take a pulseO- observe clinical improvement in 3-4 daysI- increase metabolic rate- actionD- do not change brands of drugs

A patient with hypothyroidism is receiving levothyroxine (Levothroid), 50 mcg by mouth daily. Which of these findings should the nurse recognize as an adverse drug effect?

a) Dysuriab) Leg crampsc) Tachycardia d) Blurred vision

ANTITHYROID PREPARATIONSFor hyperthyroidism: methimazole (tapazole), propylthiouracil (PTU)B- bleedingI- InfectionG- give with food

When assessing the ear canal of a 1-year-old client, which direction should the pinna be pulled to straighten the ear canal?

a) Up and backb) Down and back c) Laterallyd) The pinna should never be pulled.

ANTINEOPLASTICS (CYTOTOXIC, ANTIPROLIFERATIVE AGENTS)

Action Highly toxic agents that attack all rapidly dividing cells, both normal and malignant Represents a systemic approach that bases its action on disruption of the cell life cycle Most agents modify or interfere with DNA synthesis

Examples Alkalyting agents: mechlorethamine HCl (Nitrogen Mustard), cyclophosphamide (Cytoxan): produce breaks in DNA molecule and cross-linking of strands

thus interfering with DNA replication; most effective in hematologic malignancies Antitumor antibiotics: Biomycin; bind directly with DNA changing its configuration and inhibiting replication Antimetabolites: methotrexate, 5-fluorouracil, floxuridine, cytosine arabinoside, 6-mercaptopurine, 6-thioguanine: inhibit DNA synthesis; most effective against rapidly growing tumors enzymes necessary for cell function and replication Plant alkaloids: Vinblastine, Vincristine, Etoposide: Bind to substances needed to form mitotic spindle, thus preventing cell division Hormones and hormone inhibitors: Tamoxifen alters the endocrine environment to make it less conducive to cell growth; used in cancers of the breast, prostate, and other reproductive organs

Routes of administration Intravenous (peripheral or central venous access) Oral Intraarterial Intraperitoneal Intrapleural Intrathecal Via ventricular reservoir

Use:

To cure, control or palliate results of neoplasm May be used as an adjunct to surgery and radiation

Adverse effects: result from the damage to normal cells

Nausea/ vomiting, stomatitis, alterations in taste, anorexia

Diarrhea, constipation Alopecia, dermatitis, pruritus,

paresthesia, rash, bruising Hemorrhagic cystitis Cardiomyopathy Fatigue, dyspnea, fever, chills Sterility, amenorrhea Depression, anxiety Myelosuppression

Nursing interventions Monitor lab studies as ordered Monitor IV administration site for

extravasation Maintain strict asepsis Administer antiemetic agents as ordered

and prophylactically before chemotherapy. Give antihistamines as ordered Withhold food and fluids for four to six

hours before treatment Between treatments, give small, frequent,

bland meals Give antidiarrheals as ordered Monitor for signs of dehydration and

encourage fluids as tolerated Provide frequent oral hygiene, lubricate lips

as indicated For stomatitis, use topical anesthetics

before eating and as indicated Apply lotion to skin as indicated; avoid

harsh, drying soaps

Provide a restful environment, emotional support and anxiolytics as ordered

Teach client medications and side effects alopecia is temporary avoid bruising, aspirin products, and persons

with infections conserve energy recognize signs of bleeding; anemia,

infection use a soft-bristle toothbrush avoid use of razors

Guidlines for reducing risks when handling cytotoxic antineoplastic drugs wear a mask to avoid inhaling powder when

handling a powder form of a drug. do not prepare drugs in eating places Wear

gloves, eye protectors and protective clothing when in contact with injectable solutions.

dispose of contaminated materials in puncture-proof containers labeled as hazardous material.

wear gloves when handling linens contaminated with drugs for at least 48 hours after contamination.

wash hands thoroughly before and after exposure to drugs.

follow organizational procedure to clean-up after chemical spill.