PHARMACOLOGY: A REVIEW

PHARMACOLOGY - most simply defined as study of drug.Fundamentals of Pharmacology 1. Pharmacokinetics - study of drug’s changes as it enters and passes through the body.

a. absorptionb. distributionc. biotransformationd. excretion

2. Pharmacodynamics - mechanism by which drugs produce changes in body tissue.

a. desired effect - intended action of drugs b. adverse effect - harmful unintended reactionsc. side effects – consequence reactionsd. toxicity – the degree which something is poisonous

Digoxin = 0.5 – 2.0 ng/mL Lithium = 0.5 – 1.5 mEq/L Digoxin Toxicity: nausea, vomiting, anorexia, diarrhea, halo vision

SAFETY AND EFFICACYNursing Principles

1. Always verify the Five Rightsa. Right Medicationb. Right Amountc. Right Patientd. Right Manner and Routee. Right Timef. Right Documentationg. Right Assessmenth. Right Educationi. Right Evaluationj. Right to Refuse to Medication

2. Chart drug administration only after it has been given, never before.

3. Never leave the medication on cart or tray unattended.4. Chart observed therapeutic and adverse effects accurately and fully.5. Check history for allergies and potential drug interactions before administering a newly ordered drug. 6. Inform the prescribing physician of any observed adverse effects; if cannot be located, inform the nursing supervisor7. Question drug orders that are unclear, that appear to contain errors, or that have potential to harm.8. Take the following actions if an error occurs: immediately notify the nursing supervisor, the prescribing physician, and the pharmacist. Assess the client’s condition and provide any necessary care.9. For postpartum women, advice to take drugs after breastfeeding.

Administration of Drugs Routes and Nursing Considerations:

1. Enteral – oral, sublingual, rectal, gastric tubes-capsulated pill, sustained release and enteric coated should

not be crushed.2. Parenteral – IV, IM, SQ, ID, IT, IA, epidural.Vastus lateralis (safest site for IM)Deltoid- less than 2mlDorsogulteal (gluteus maximus)- not use for patient less than 3 years old3. Topical – skin, inhalants, mucus membrane.

Eye medicationsoadminister eyedrops first then ointment.ouse a separate bottle for each client.oinstruct the client to tilt the head backward, open eyes and look up.oavoid contact of medication bottle to the eyeball. oplace prescribed dose in the lower conjunctival sac.oinstruct the client to press the inner canthus for 30-60 seconds.oinstruct the client to close the eye gently.

Ear drops

oin infant and children younger than 3 y.o, pull pinna downward and backward.oin older children and adult, upward and backward.odirect the solution on the wall of the ear canal, not directly on the ear drum.

CLASSIFICATIONS OF DRUGS

A. DRUGS AFFECTING THE CENTRAL AND AUTONOMIC SYSTEMCholinergic Agents (Parasympathomemitics)

Prototype-synthetic acetylcholine, pilocarpine, carbachol, bethanecol (Urocholine), edrophonium (Tensilon), neostigmine (Prostigmine), pyridostigmine (Mestinon).

Mechanism of action-stimulates cholinergic receptors by mimicking acetylcholine or inhibition of enzyme cholinesterase

Indications-glaucoma, urine retention, Myasthenia Gravis -antidote to neuromuscular blocking agents : tricyclic antidepressants and atropine

Adverse effects-blurring of vision, miosis -increase in salivation, intestinal cramps-bronchoconstriction, wheezing, DOB-hypotension and bradycardia

Nursing considerations1. Warn & monitor clients of the side effects2. Have atropine available for use as antidote

Cholinergic Blocking Agents (Parasympatholytics, Anticholinergics)

Prototype-atropine, scopalamine (Triptone), dicyclomine (Bentyl), propantheline (Pro-Banthine).

Mechanism of actions-block the binding of acetylcholine in the receptors of parasympathetic nerves.

Indication-use preoperatively to dry up secretions.

-treat spasticity of GI or urinary tract.-use for treatment of bradycardia, asthma, Parkinsonism.-use for antidote in organophosphate poisoning.

Adverse effects -dry mouth, dilatation of pupils, tachycardia-urinary retention, ileus, heat stroke

Nursing considerations 1. Keep clients in cool environment. 2. Watch out for signs of heatstroke and dehydration. 3. Encourage clients to increase fluid intake and use of sugarless um/candy for dry mouth. 4. For GI spasticity, administer 30 minutes before meals and at bed time.

Adrenergic Agents (Sympathomimetics)Prototype

-epinephrine, norepinephrine, ephedrine, dopamine, dobutamine, henylephrine, terbutaline, albuterol, isoproterenol.

Mechanism of actions-stimulate alpha and beta adrenergic receptor directly or trigger the release of catecholamines indirectly causing sympathetic effects.

Indications-cardiopulmonary arrest, hypotension-COPD and asthma, nasal congestions-allergic reaction, anaphylactic shock

Adverse effects-restlessness, insomnia, tremors, nausea-palpitations, angina, tachycardia, HPN

Nursing considerations 1. Contraindicated in clients w/ hyperthyroidism, pheochromocytoma & cardiovascular disease. 2. Monitor vital signs and advice precautions. 3. Should be taken with food.

Adrenergic Blocking AgentsPrototype

a. Alpha blockers -phentolamine (Regintine), phenoxybenzamine, prazosin (Minipress), reserpine (Serpasil), terazosin (Hytrin) -clonidine (Catapress), methyldopa (Aldomet)

b. Beta blockers -atenolol (Tenormin), esmolol (Brevibloc), metoprolol (Lopressor), nadolol (Corgard), propanolol (Inderal), timolol ( Blocadren)

Mechanism of actionsa. alpha blockers

-inhibits action of a-receptors in vascular smooth muscle to cause vasodilatation.

b. beta blockers -compete with epinephrine in b-receptors in heart, pulmonary airways, peripheral circulation and CNS.

Indications-Raynaud’s disease, hypertension, pheochromocytoma.-angina, arrhythmias, mitral valve prolapse, glaucoma

Adverse effects-orthostatic hypotension, bradycardia, CHF-depression, insomnia and vertigo-bronchospasm and dyspnea, nasal stuffiness, cold extremities

Nursing considerations1. Administer oral alpha-blockers with milk to minimize GI side effects.2. Administer oral beta-blockers before meals and at a.m. if insomnia occurs.3. Check client’s apical pulse rate before drug administration, refer if below 60 bpm.4. Hypotensive precautions.5. Warn clients not to drive or operate dangerous machinery until he/she has adjusted to medications.

Skeletal Muscle Relaxants AgentsPrototype

-methacarbamol (Robaxin), baclofen (Lioresal), dantrolene (Dantrium), metaxalone (Skelaxin), orphanedrine (Norgesic), chlorzoxazone

Mechanism of actions-depress CNS-inhibit calcium ion release in the muscle-enhance the inhibitory action of GABA (gamma-amino butyric acid)

Indications

-for acute musculoskeletal pain-for muscle spasticity associated with multiple sclerosis, cerebral palsy, CVA, and spinal cord injury

Adverse effects-hypotonia, ataxia, hypotension, drowsiness-blurred vision, bradycardia, depression, urine retention

Nursing considerations1. Caution clients that mental alertness may be impaired. 2. Monitor neuromuscular status, bowel and bladder functions.3. Inform clients that maximum benefit of baclofen is attained for 1-2 months.4. Reduce baclofen dosage gradually because of associated withdrawal symptoms: Confusion, hallucinations, paranoia & rebound spasticity.

Anticonvulsants Prototype

a. Hydantoins-phenytoin (Dilantin)b. Barbiturates-phenobarbital ( Luminal)c. Miscellaneous

- carbamazepine (Tegretol), diazepam, clorazepate (Tranxene), valproic acid (Dapakene), ethosuximide (Zarontin)

Mechanism of action-treat seizures by depressing abnormal neuronal activity in motor cortex

Adverse effects-sedation & drowsiness, gingival hyperplasia-diplopia, nystagmus, vertigo, dizziness-thrombocytopenia, aplastic anemia

Nursing considerations1. Advise female clients to use contraceptives.2. Inform clients taking phenytoin that harmless urine discoloration is common.3. Warn clients with diabetes that hydantoins may increase blood sugar level and that valproic acid may produce a false positive result in urine ketone test.4. Teach clients receiving carbamazepine to identify symptoms of bone marrow depressions.5. Reassure that barbiturates are not addictive at a low dosage.6. Avoid taking alcohol with barbiturates.

7. Administer IV phenytoin slowly to avoid cardiotoxicity.8. Avoid mixing other drugs in same syringe with phenytoin.

Antiparkinsonian AgentsPrototype

a. Anticholinergic agents -trihexyphenidyl (Artane), benztropine (Congentin)

b. Dopaminergic agents-Levodopa, carbidopa-levodopa (Sinemet), amantidine (Symmetrel), pergolide (Permax), selegiline (Eldepryl), bromocriptine.

Mechanism of actionsa. anticholinergic agents

-inhibit cerebral motor centersb. dopaminergic agents

-increasing dopamine concentrations or enhancing neurotransmitter functioning.

Adverse effects of dopaminergic agentsa. levodopa–nausea, vomiting, anorexia, orthostatic hypotension, dark-colored urine and sweatb. amantidine–ankle edema, constipationc. bromocriptine–palpitations, tachycardia

Nursing considerations1. Give dopaminergic agents after meals to reduce GI symptoms.2. Reassure client that levodopa may cause harmless darkening of urine and sweat.3. Avoid taking Vit B6 (pyridoxine) with levodopa because it speed up metabolism. 4. Educate clients to minimize orthostatic hypotension.5. Elevate leg to reduce ankle edema.

Central Nervous System StimulantsPrototype

-amphetamines, methylphenidate (Ritalin)Mechanism of actions

-increase excitatory CNS neurotransmitter activity and blocks inhibitory impulses

Indications-for obesity (amphetamines)-attention deficit hyperactivity disorders

-narcolepsy-drug-induced respiratory depressions.

Adverse effects-nervousness, insomnia, restlessness-hypertension, tachycardia, headache-anorexia, dry mouth

Nursing considerations1. Should be given at morning.2. Don’t stop amphetamine abruptly to avoid withdrawal symptoms.3. Monitor blood pressure and pulse.4. Ice chips or sugarless gum for dry mouth.5. Watch out for growth retardation in children taking methylphenidate

B. DRUGS AFFECTING MENTAL FUNCTIONINGSedatives, Hypnotics, and Anxiolytics

Prototypea. Benzodiazepines

-diazepam (Valium), lorazipam (Ativan), alprazolam (Xanax), flurazepam (Dalmane)

b. Barbiturates-amobarbital, phenobarbital, secobarbital

c. Miscellaneous-chloral hydrate (Noctec), buspirone (Buspar), paraldehyde (Paral)

Mechanism of actionsa. Benzodiazepines

-increase the effect of inhibitory neuro transmitter GABA (gamma-amino butyric acid)

b. Barbiturates and Miscellaneous agents-depress CNS

Indications-induce sleep, sedate and calm clients

Adverse effects-hangover-effect, dizziness, CNS depression-respiratory depression, drug-dependence

Nursing considerations1. Warn clients of injuries and falls.

2. Brief period of confusion and excitement upon waking up is common with benzodiazepines.3. Warn clients not to discontinue medications abruptly without consulting a physician.4. Avoid alcohol while taking these drugs.5. Rotate and don’t shake the ampules of barbiturates. Don’t mix with other drugs.6. Warn female clients that diazepam is associated with cleft lip.

Antidepressants and Mood Disorder DrugsPrototype

a. Tricyclic antidepressants-amitriptyline (Elavil), protriptyline (Vivactil), imipramine (Tofranil), desipramine

b. MAO (monoamine oxidase inhibitors)-isocarboxazid (Marplan), phenelzine (Nardil), tranylcypromine (Pernate)

c. Second-generation antidepressants-fluoxetine (Prozac), trazodone (Desyrel)

d. Lithium Mechanism of actions

a. Tricyclic antidepressants-increase receptor sensitivity to serotonin and/or norepinephrine.

b. MAO inhibitors-inhibit the enzyme MAO that metabolizes the neurotransmitters norepinephrine and serotonin.

c. Second – generation antidepressants-inhibits the reuptake of serotonin.

d. Lithium-increase serotonin & norepinephrine uptake

Adverse effects-dry mouth, blurred vision, urine retention, constipation (anticholinergic effects) -orthostatic hypotension, insomnia-hypertensive crisis (MAO)-dehydration (Lithium)

Nursing considerations

1. Caution client to rise slowly to reduce the effects of orthostatic hypotension.2. Take antidepressant with food to enhance absorption3. Explain to client that full response may take several weeks (2 weeks).4. Assess client for constipation resulting from tricyclic antidepressant use.5. Client taking MAO inhibitors should avoid tyramine-rich foods to avoid Hypertensive crisis.-aged cheese, sour cream, yogurt, beer, wine, chocolate, soy sauce and yeast-pentholamine (Regintine) is the drug of choice for hypertensive crisis.6. Inform physician and withhold fluoxetine if client develop rashes. 7. Take lithium with food to reduce GI effects

->1.5 mEq/L blood level may cause toxicity manifested by: confusion, lethargy, seizures,hyperreflexia. -maintain salt and adequate fluid intake -tremors may occur but it is temporary-monitor white blood cell count (increase)

Antipsychotic drugs (Neuroleptics)Prototype

a. Phenothiazines-chlorpromazine (Thorazine), -trifluoperazine (Stelazine),-thioridazine (Mellaril)

b. Other Agents-clozapine (Clozaril), haloperidol (Haldol)

Mechanism of action-block dopamine receptor in the limbic system, hypothalamus, and other regions of the brain.

Adverse effects-Extra pyramidal symptoms such as dystonia, pseudoparkinsonism, and an irreversible tardive dyskinesia as manifested by :

a. lip smackingb. fine wormlike tongue movementc. involuntary movements of arms and leg.

-Neuroleptic malignant syndromea. fever, tachycardia, tachypnea, diaphoresis, cardiovascular collapseb. muscle rigidity, seizures.

-orthostatic hypotensionNursing considerations

1. Teach family members the signs of EPS and NMS, and report to physician immediately.2. Normalization of symptoms may not occur for several weeks after beginning of therapy.3. Avoid administering haloperidol intravenously4. Watch out of neutropenia with clozapine.5. Watch out for orthostatic hypotension and photosensitivity with phenothiazine.6. Be sure that oral doses are swallowed, and not hoarded.

C. DRUGS USED IN PAIN MANAGEMENTGeneral Anesthetics

Prototypea. Inhalation anesthetics

-enflurane (Ethrane), halothane-isoflurane (Forane), nitrous oxide

b. Injection anesthetics-fentanyl (Sublimaze), ketamine (Ketalar), thiopental Na (Penthotal), etomidate (Amidate)

Mechanism of actions-cause CNS depression, by producing loss of consciousness, unresponsiveness to pain stimuli, and muscle relaxation

Nursing considerations1. Instruct client NPO for 8 hours before administration.2. Monitor cardio pulmonary depression and hypotension.3. Monitor urinary retention.4. Monitor body temperature

-malignant hyperthermic crisis: dantrolene (antidote)5. Avoid alcohol or CNS depressants for 24 hours after anesthesia6. In patient who received halothane, monitor signs of hepatic fatal side effects:

-rash, fever, nausea, vomiting

-jaundice and altered liver functionLocal and Topical Anesthetic

PrototypeLocal: bupivacaine, lidocaine, tetracaine, procaine, mepivacaine, prilocaineTopical: benzocaine, butacaine, dibucaine,lignocaine

Mechanism of action-block transmission of impulses across nerve cell membrane.

Adverse effects-cardiac dysrhythmias

Nursing considerations1. lignocaine + prilocaine (EMLA cream) should be applied topically 60 minutes before procedure.2. administer cautiously to the areas of large broken skin.3. observe for fetal bradycardia in pregnant clients.

Analgesics Prototype

a. Narcotic analgesics -codeine, meperidine (Demerol) morphine, butorphanol (Stadol) nalbuphine (Nubain)

b. Non – narcotic analgesic NSAIDs – aspirin (aminosalicylic acid), mefenamic acid (Ponstan),ibuprofen (Motrin), naproxen, ketoprofen (Orudis), ketorolac. paracetamol and acetaminophen (Tylenol)

Mechanism of actionsa. Narcotic analgesics

-alter pain perception by binding to opiod receptors in CNSb. Non- narcotic analgesic

-relieves pain and fever by inhibiting the prostaglandin pathway.

Nursing considerations1. Monitor respiratory depression & hypotension in clients taking narcotic analgesic.2. Injury and accident precautions in clients taking narcotic analgesic.3. Warn clients about possibility of dependency, and do not discontinue narcotics abruptly in the narcotic-dependent clients.4. Naloxone is antidote for narcotic overdose.5. Advice clients to take NSAIDs with food and monitor bleeding complications.6. Aspirin is contraindicated in clients below 18 years old with flu-like symptoms.7. Monitor hearing loss in clients taking aspirin.8. Monitor liver function in clients taking acetaminophen. 9. N-acetylcysteine is antidote for paracetamol overdose.

D. DRUGS AFFECTING THE CARDIOVASCULAR SYSTEM Anticoagulants

Prototype-Heparin (SQ and IV), Warfarin (Orally)

Mechanism of actionsa. Heparin

-prevents thrombin from converting fibrinogen to fibrin.b. Warfarin

-suppress coagulation by acting as an antagonist of vitamin K after 4-5 days.

Indications-thrombosis, pulmonary embolism, myocardial infarction

Adverse effect-bleeding

Nursing considerations1. HEPARIN sodium

-if given SQ don’t aspirate or rub the injection site (above the scapula - best site).-therapeutic level 1.5-2.5 times normal PTT; normal PTT is 20-35 sec. = 50-85 sec.-antidote: (protamine sulfate)

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

Hemostasis:

Bleeding/injury I

Vasoconstriction PlasminogenI I

Platelet aggregation Plasmin(temporary plug) I

I I Clotting factor activation ---------------------------- I

I I I IIntrinsic pathway (8, 9, 10, 11, 12) Extrinsic pathway (3, 7, 10) I

I I I(PTT) (PT) Vit K depletion I

` I I I Prothrombin activation I I I

Thrombin I I I I

Fibrinogen ------------Fibrin threads ------------- Fibrin split products (Coagulation) (Removed by liver & spleen) Thrombolytic

PrototypeStreptokinase, Urokinase

Mechanism of actions -activates plasminogen to generates plasmin (enzyme that dissolve clots).

Indications-use early in the course of MI (within 4-6 hours of the onset)

Nursing considerations1. monitor bleeding2. antidote : Aminocarpic acid

Antiplatelet MedicationsPrototype

Aspirin, Dipyridamole (Persantin), Clopidoigrel (Plavix), TiclopidineMechanism of action-inhibit the aggregation of platelet thereby prolonging bleeding time.

Indications-used in the prophylaxis of long-term complication following M.I, coronary revascularization, and thrombotic CVA.

Nursing considerations1. Monitor bleeding time (NV = 1-9 mins)2. Take the medication with food.

Cardiac GlycosidesPrototype

-digoxin (Lanoxin) and digitoxin (Crystodigin)Mechanism of actions

-increase intracellular calcium, which causes the heart muscle fibers to contract more efficiently, producing positive inotropic & negative chronotropic action.

Indications-use for CHF, atrial tachycardia and fibrillation

Nursing considerations1. Monitor for toxicity as evidence by : nausea, vomiting, anorexia, halo vision, confusion, bradycardia and heart blocks .2. Do not administer if pulse is less than 60 bpm.3. Should be caution in patient with hypothyroidism and hypokalemia.4. Antidote : Digi-bind5. Phenytoin is the drug of choice to manage digitalis-induced arrhythmia.

NitratesPrototype

-sosorbide dinitrate (Isordil)-nitroglycerine (Deponit, Nitrostat)

Mechanism of action-produce vasodilatation including coronary artery.

Indications-angina pectoris, MI, peripheral arterial occlusive disease

Adverse effects-headache, orthostatic hypotension

Nursing Considerations1. Transdermal patch

-apply the patch to a hairless area using a new patch and different site each day.-remove the patch after 12-24 hours, allowing 10-12 hours “patch free” each day to prevent tolerance.

2. Sublingual medications-note the BP before giving the medication

-offer sips of water before giving because dryness may inhibit absorption-one tablet for pain and repeat every 5 minutes for a total of three doses; if not relieved after 15 minutes seek medical help.-stinging or burning sensation indicates that the tablet is fresh. -instruct patient not to swallow the pill-sustained release medications should be swallowed and not to be crush-protect the pills from light

Anti-arrhythmic DrugsClass I (block Na channels)

IA - quinidine, procainamideIB – lidocaineIC - flecainamide

Class II (Beta-blockers)propanolol, esmolol

Class III (block K channels)amiodarone, bretylium

Class IV (block Ca channels)verapramil, diltiazem

Nursing considerations1. Watch out for signs of CHF.2. Have client weigh themselves and report weight gain.3. Watch out for signs of lidocaine toxicity: confusion and restlessness

AntilipemicsPrototype

a.cholesterol-lowering agents-cholestyramine, colestipol, lovastatin

b.triglyceride-lowering agents-gemfibrozil, clofibrate

Mechanism of action-interfere with cholesterol synthesis as well as decreasing lipoprotein & triglyceride synthesis.

Nursing considerations1. monitor liver functions while using statins.2. prevent constipation, flatulence, cholelithiasis

3. encourage increase fluid and fiber intake.

E. ANTI – HYPERTENSIVE MEDICATIONSAngiotensin-Converting Enzyme (ACE) Inhibitors “PRIL”

Prototype captopril (Capoten), enalapril (Vasotec), quinapril, lisinopril

Mechanism of actions-prevent peripheral vasoconstriction by blocking conversion of angiotensin I to angiotensin II decreasing peripheral resistance

Adverse effect-it cause hyperkalemia-induce chronic cough

Nursing considerations1. not to discontinue medications because it can cause rebound hypertension.2. avoid using K+ sparing diuretics.

Calcium-Channel BlockersPrototype

-Nifedipine (calcibloc, adalat), Amlodipine (norvasc), Felodipine (Plendil) Verapramil (Isoptin)

Mechanism of action-decrease cardiac contractility and the workload of the heart, thus decreasing the need for O2.-it also promotes vasodilatation of the coronary and peripheral vessels.

Indications-hypertension, angina, arrhythmia

Adverse effects-bradycardia, hypotension, headache-reflex tachycardia, constipation

Nursing considerations1. Administer between meals to enhance absorption.2. Take client’s pulse rate before each dose, withhold if pulse is below 60 bpm.3. Refer for signs of congestive heart failure.

F. DIURETICS-usually given at morning

Carbonic Anhydrase Inhibitors

-Acetazolimide (Diamox)-Increase Na+, K+, & Hco3 Secretion, Along With It Is H2o-Metabolic Acidosis

Osmotic Diuretic -Mannitol -Increase Osmotic Pressure Of The Glomerular Filtrate. -Hypotension

Thiazide Diuretics -Hydrochlorothiazide -Blocks Na and K Reabsorption; Reabsorb Ca -Hypercalcemia

Loop Diuretics -Furosemide (Lasix)-Blocks Na, K, and Ca Reabsorption -Hypocalcemia

Potassium Sparing Diuretics -Spironolactone (Aldactone)-Excrete Na and Water but it reabsorbs K-Hyperkalemia

F. RESPIRATORY MEDICATIONSBronchodilators

Prototype:Symphatomimetic Xanthines-albuterol, salbutamol -aminophylline-isoproterenol, salmeterol -theophylline-terbutaline

Mechanism of actions:-sympathomimetic (b-receptor agonist) bronchodilators, dilate airways.-xanthine bronchodilators, stimulate CNS for respiration.

Indications: -bronchospasm, asthma, bronchitis, COPD

Adverse effects:-palpitations and tachycardia -restlessness, nervousness, tremors-anorexia, nausea and vomiting, headache, dizziness

Nursing considerations:

1. Contraindicated hyperthyroidism, cardiac dysrhythmia, or uncontrolled seizure disorder.2. It should be used with caution in patient with HPN and narrow-angle glaucoma.

Glucocorticoids (Corticosteroids)Prototype:

-dexamethasone, budesonide, fluticasone, prednisone, beclomethasone

Mechanism of actions:-act as anti-inflammatory agents and reduce edema of the airways, as well as pulmonary edema.

Adverse effects: -Cushing’s syndrome, neutropenia. osteoporosis

Nursing considerations:1. Take drugs at meal time or with food.2. Eat foods high in potassium, low in sodium.3. Instruct client to avoid individuals with RTI.4. Instruct client not to stop medication abruptly, it should be tapered to prevent adrenal insufficiency5. Avoid taking NSAID while taking steroids.6. Take inhaled bronchodilators first before taking inhaled steroids, and rinse mouth after using.

Mast Cell StabilizersPrototype:

-cromolyn sodium (Intal)Mechanism of action:

-stabilize mast cells that release histamine triggering asthmatic attacks.

Nursing Consideration: 1. It should be given before asthmatic attacks.2. Administer oral capsule at least 30 mins before meals for better absorption.3. Drink a few sips of water before & after inhalation to prevent cough & unpleasant taste4. Assess for lactose-intolerance.

Anti-histamines (H-1 blockers)Prototype:

-Astemizole (Hismanal), Loratidine (Claritin), Brompheniramine (Dimetapp), Diphenhydramine (Benadryl), Cetirizine (Iterax), Celestamine (Tavist)

Mechanism of action:-decrease nasopharyngeal secretions and decrease nasal itching by blocking histamine in H1-receptor.

Indications:-common colds, rhinitis, nausea and vomiting, urticaria, allergies and as sleep aid

Nursing Considerations:1. Administer with food and drink.2. Given IM via Z-track method or orally.3. Precautions in handling machine and driving while taking these drugs.4. Ice chips or candy for dry mouth

Anti-tuberculosisPrototype:

First line Second line-Isoniazid (INH) -Cycloserine-Rifampicin (Rifadin) -Kanamycin-Ethambutol -Ethonamide-Pyrazinamide -Para-aminosalicylic acid-Streptomycin

-active tuberculosis is treated with drug combination for 6-9 mos.-multidrug-resistant strain (MDR-TB) are medicated for 1 year up to 2 years -given before mealsIsoniazid

-should be given 1 hr before or 2 hrs after meals because food may delay absorption.-should be given at least 1 hr before antacids.-instruct to notify physician for signs of hepatoxicity (jaundice), and neurotoxicity, numbness of extremities.-administer with Vitamin B6 to counteract the neurotoxic side effects.-avoid alcohol.

Rifampicin-given on an empty stomach with 8 0z. of water, 1 hour before or 2 hours after meals and avoid taking antacids with medications.-hepatotoxic thus avoid alcohol.

-instruct the client that urine, feces, sweat, and tears will be red-orange in color.

Pyrazinamide-given for 2 months.-increase serum uric acid and cause photosensitivity.

Ethambutol-contraindicated in children under 13 years old.-obtain a baseline visual acuity because it can cause optic neuritis.-instruct the client to notify the physician immediately if any visual problems occurs.

Streptomycin-aminoglycoside antibiotic given IM-nephrotoxic and ototoxic-obtain baseline audiometric test and repeat every 1-2 months because the medications impairs the CN VIII

G. DRUGS AFFECTING GASTROINTESTINAL SYSTEMAntacids

Prototype:-Aluminum/magnesium compounds (Maalox)-Sodium bicarbonate (Alka-Seltzer)-Calcium carbonate (Tums)-Magnesium hydroxide (Milk of Magnesia).

Mechanism of actions:-neutralize the stomach acidity.

Adverse effects:-metabolic alkalosis, stone formation-electrolyte imbalance-diarrhea (magnesium), constipation (aluminum)

Nursing considerations:1. Give 1 hr after meals.2. Avoid giving medications within 1-2 hrs of antacid administration (decreases absorption).3. Take fluids to flush after intake of antacid suspensions.4. Monitor for changes of bowel patterns.

Histamine – 2 blockersPrototype:

-cimetidine (Tagamet), ranitidine (Zantac), famotidine (Pepcid), nizatidine (Axid)

Mechanism of action:-blocks H2 receptors in the stomach, reducing acid secretions

Nursing considerations:1. Given before or with meals2. Avoid giving other drugs with cimetidine3. Gynecomastia may develop with chronic use of cimetidine.

Proton – Pump Inhibitors (PPI)Prototype:

-omeprazole (Losec), Lansoprazole (Lanz), pantoprazole (Pantoloc).

Mechanism of action:-inhibit the proton H+ to combine with Cl- toform hydrochloric acid.

Nursing considerations:1. Given before meals preferably at morning

Mucosal Barriers Prototype:

-sucralfate (Carafate), misoprostol (Cytotec).Mechanism of action:

-coats the mucosa to prevent ulcerationsNursing consideration:

2. Given before meals3. Misoprostol is contraindicated for pregnants.4. Sucralfate cause constipation.

Anti-diarrheal AgentsPrototype:

-diphenoxylate (Lomotil), loperamide (Imodium), kaolin/pectin mixture (Kaopectate)

Mechanism of actions:-decrease stomach motility and peristalsis

Nursing considerations:1. Monitor for rebound constipation.2. Be cautious taking if with infectious diarrhea.3. Monitor atropine toxicity with diphenoxylate.4. Clay, white or pale stool is common with kaopectate.

LaxativesA. lactulose (Cephulac), Na biphosphate (Fleet enema) & magnesium salt (Milk of Magnesia)

-retain fluid and distend intestine

B. ducosate (Dialose)-emulsify fecal fat and water

C. bisacodyl (Dulcolax) & senna (X-prep)-irritates intestinal mucosa and stimulate intestinal smooth muscles

D. bulk-forming laxative (Metamucil) -increase fecal bulk and water content

E. mineral oil-lubricates & prevent colon absorption

EmeticsPrototype:

-ipecac syrup, apomorphineMechanism of actions:

-induce vomiting through stimulation of vomiting center of medulla.

Indications:-ingestion of poisonous or toxic substances

Nursing considerations:1. Consult poison control center before induction of vomiting.2. Administer ipecac syrup with large amount of fluid.